Physical Examination and Health Assessment 9th Edition by Carolyn Jarvis & Ann L. Eckhardt ISBN-10 0323809847 ISBN-13 978-0323809849 Test Bank for Physical Examination and Health Assessment 9th Edition by Carolyn Jarvis & Ann L. Eckhardt
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Physical Examination and Health Assessment 9th Edition by Carolyn Jarvis & Ann L. Eckhardt
Chapter 1: Evolution of Nursing My Nursing Test Banks Chapter 1: Evolution of Nursing Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What is a nursing program considered when certified by a state agency? a. Accredited b. Approved c. Provisional d. Exemplified ANS: B Approved means certified by a state agency for having met minimum standards; accredited means certified by the NLN for having met more complex standards. Provisional and exemplified are not terms used in regard to nursing program certification. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 10 OBJ: 5 TOP: Nursing programs KEY: Nursing Process Step: N/A
MSC:NCLEX: N/A 2. Which of the following must the nurse recognize regarding the health care delivery system? a. It includes all states. b. It affects the illness of patients. c. Insurance companies are not involved. d. The major goal is to achieve optimal levels of health care. ANS: D The nurse must recognize that in the health care delivery system, the major goal is to achieve optimal levels of health care. The health care system consists of a network of agencies, facilities, and providers involved with health care in a specified geographic area. Insurance companies do have involvement in the health care system. The illness of patients is not necessarily affected by the health care system. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 7 TOP: Health care systems KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 3. What is required by the health care team to identify the needs of a patient and to design care to meet those needs? a. The Kardex b. The physicians order sheet c. An individualized care plan d. The nurses notes ANS: C An individualized care plan involves all health care workers and outlines care to meet the needs of the individual patient. The Kardex, physicians order sheet, and nurses notes do not identify the needs of the patient nor are they designed to assist all members of the health care team to meet those needs. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 13, 16 OBJ: 8 | 9 TOP: Care plan KEY: Nursing Process Step: Planning MSC:NCLEX: N/A 4. Patient care emphasis on wellness, rather than illness, begins as a result of: a. increased education concerning causes of illness.
b. improved insurance payments. c. decentralized care centers. d. increased number of health care givers. ANS: A The acute awareness of preventive medicine has resulted in todays emphasis on education about issues such as smoking, heart disease, drug and alcohol abuse, weight control, and mental health and wellness promotion activities. This preventive education has resulted in an emphasis on wellness, rather than illness. Improved insurance payments, decentralized care centers, and increased numbers of health care givers did not influence an emphasis on wellness. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 4 | 8 TOP: Wellness KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 5. What is the most effective process to ensure that the care plan is meeting the needs of the patient? a. Documentation b. Communication c. Evaluation d. Planning ANS: B Communication is the primary essential component among the health care team to evaluate and modify the care plan. Documentation, evaluation, and planning are not primary essential components to ensure the care plan is meeting the needs of the patient. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 16 OBJ: 8 TOP: Communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 6. How does an interdisciplinary approach to patient treatment enhance care? a. By improving efficiency of care b. By reducing the number of caregivers c. By preventing the fragmentation of patient care d. By shortening hospital stay
ANS: C An interdisciplinary approach prevents fragmentation of care. An interdisciplinary approach does not improve the efficiency of care, reduce the number of caregivers, or shorten hospital stay. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 16 OBJ: 8 | 9 TOP: Interdisciplinary approach KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 7. How may a newly licensed LPN/LVN practice? a. Independently in a hospital setting b. With an experienced LPN/LVN c. Under the supervision of a physician or RN d. As a sole practitioner in a clinic setting ANS: C An LPN/LVN practices under the supervision of a physician, dentist, OD, or RN. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 13, 19 OBJ: 11 TOP: Vocational nursing KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 8. Whose influence on nursing practice in the 19th century was related to improvement of patient environment as a method of health promotion? a. Clara Barton b. Linda Richards c. Dorothea Dix d. Florence Nightingale ANS: D The influence of Florence Nightingale was highly significant in the 19th century as she fought for sanitary conditions, fresh air, and general improvement in the patient environment. Clara Barton developed the American Red Cross in 1881. Linda Richards is known as the first trained nurse in America, was responsible for the development of the first nursing and hospital records, and is credited with the development of our present-day documentation system. Dorothea Dix was the pioneer crusader for elevation of standards of care for the mentally ill and superintendent of female nurses
of the Union Army. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 2, 17 Table 1-2 OBJ: 2 | 4 TOP: Nursing leaders KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 9. What document identifies the roles and responsibilities of the LPN/LVN? a. NLN Accreditation Standards b. Nurse Practice Act c. NAPNE Code d. American Nurses Association Code ANS: B The LPN/LVN functions under the Nurse Practice Act. NLN Accreditation Standards, the NAPNE Code, and the American Nurses Association Code do not identify the roles and responsibilities of the LPN/LVN. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 13 OBJ: 11 TOP: Roles and Responsibilities KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 10. What is a cost-effective delivery of care used by many hospitals that allows the LPN/LVN to work with the RN to meet the needs of patients? a. Focused nursing b. Team nursing c. Case management d. Primary nursing ANS: C Case management is a cost-effective method of care. Focused nursing, team nursing, and primary nursing are not cost-effective methods of delivering care that allow the LPN/LVN to work with the RN to meet patient needs. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 14 OBJ: 7 | 9 TOP: Patient care delivery systems KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 11. What is the title of the American Hospital Associations 1972 document that outlines the patients expectations to be treated with dignity and compassion?
a. Code of Ethics b. Patients Bill of Rights c. OBRA d. Advance directives ANS: B Patient expectations are outlined by the Patients Bill of Rights. Patient expectations are not outlined in the Code of Ethics, OBRA, or advance directives. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 15 OBJ: 4 | 8 TOP: Patients rights KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 12. The relationships among nursing, patients, health, and the environment are the basis for: a. care plans. b. nursing models. c. physicians orders. d. evaluation of patient care. ANS: B Nursing models are theories based on the relationship between nursing, patients, health, and environment. Care plans, physicians orders, and evaluation of patient care are not based on the relationships among nursing, patients, health, and environment. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 17 OBJ: 1 TOP: Nursing models KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 13. What system reduces the number of employees but still provides quality care for patients? a. Team nursing b. Cross-training c. Use of critical pathways d. Case management ANS: B Cross-training reduces the number of employees but does not alter the quality
of patient care. Team nursing, use of critical pathways, and case management do not reduce the number of employees while continuing to provide quality care for patients. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 14-15 OBJ: 8 TOP: Patient care KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 14. What is the purpose of licensing laws for LPN/LVNs? a. To limit the number of LPN/LVNs. b. Prevention of malpractice c. Protection of the public from unqualified people d. To increase revenue for the state board of nursing ANS: C The purpose of licensing laws for LPN/LVNs is to protect the public from unqualified practitioners. Licensing laws purpose is not to limit the number of LPNs/LVNs, prevent malpractice, or increase revenue for the state board of nursing. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 4-5 OBJ: 4 | 9 | 10 TOP: Licensure KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 15. What premise is Maslows hierarchy of needs based on? a. All needs are equally important. b. Basic needs must be met before the next level of needs can be met. c. Self-actualization is a primary need. d. Individuals prioritize needs the same way. ANS: B Maslows hierarchy of needs is based on the premise that basic needs must be met first. It is not based on all needs being equally important or that individuals prioritize needs the same way. Self-actualization is not a primary need according to Maslow. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 8 TOP: Maslows hierarchy of needs KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 16. What must the nurse realize when assessing physical and social
environmental factors affecting health and illness? a. They affect one another. b. They cause illness. c. They cause patients to react similarly. d. They can be separated. ANS: A Physical and social factors affect each other, cannot be separated, and cause each patient to react in a unique manner. They do not necessarily cause illness or cause patients to react similarly, and they cannot be separated. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 12 OBJ:4 | 8TOP:Environmental factors KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 17. What organization, established during World War II, provided nursing education and training? a. Nightingale school b. Cadet Nurse Corps c. Public health department d. Frontier Nursing Service ANS: B The Cadet Nurse Corps was established during World War II to provide nursing education and training. The Nightingale school, public health department, and Frontier Nursing Service are not organizations established during World War II to provide nursing education and training. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 5 OBJ: 1 | 4 TOP: Nursing education KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 18. What is a modern educational advancement program for the LPN/LVN to enter RN education? a. Repetition b. Exclusion c. Articulation d. Coexistence
ANS: C Most states have some type of articulation program in which the LPN/LVN can achieve advanced standing in an RN program without having to enroll in the entire curriculum. Repetition, exclusion, and coexistence do not refer to educational advancement. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 10 OBJ: 1 | 9 TOP: Nursing education KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 19. Where did Florence Nightingales original nursing education take place? a. Saint Thomas b. Kings College Hospital c. Crimean Hospital d. Kaiserswerth School ANS: D Florence Nightingale trained at Kaiserswerth School. Florence Nightingales original training was not at Saint Thomas, Kings College Hospital, or Crimean Hospital. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 2 TOP: Nursing programs KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 20. What system of comprehensive patient care considers the physical, emotional, and social environment and spiritual needs of a person? a. Interdependent care b. Holistic health care c. Illness prevention care d. Health promotion care ANS: B Holistic health care encompasses the physical, emotional, social, and spiritual aspects of the patient. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 13 OBJ: 8 TOP: Health care KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 21. What official agency exists exclusively for LPN/LVN membership and
promotes standards for the LPN/LVN? a. NFLPN b. ANA c. NLN d. NAPNES ANS: A The NFLPN exists solely for the LPN/LVN. The other options have membership that includes RNs and the lay public. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 9 OBJ: 5 | 6 | 9 TOP: Nursing organizations KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 22. What score does the graduate practical nurse require to be issued a license upon completion of the computerized examination? a. 70% or better b. This is defined and set by each state c. Designated as pass d. Within the 75th percentile ANS: C Currently graduates of an approved vocational school are eligible to take the licensing examination and be awarded a license with a score of pass that is recognized by all states. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 11 OBJ: 3 TOP: Licensure examination KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 23. What document, published in 1965 by the ANA, clearly defined two levels of nursing practice? a. Licensing standards b. Position paper c. Smith-Hughes Act d. Nurse practice act ANS: B The ANAs position paper of 1965 defined two levels of nursing: registered nurse and technical nurse. Licensing standards, the Smith-Hughes Act, and
the nurse practice act were not documents defining two levels of nursing practice published in 1965. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 11 OBJ: 3 | 4 | 9 TOP: Position paper KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 24. What is the wellness/illness continuum defined as? a. A concept that never changes b. The range of a persons total health c. A continuum influenced only by ones physical condition d. An idea that focuses strictly on an individuals social well-being ANS: B The wellness/illness continuum is defined as the range of a persons total health. This continuum is ever-changing, and it is influenced by the individuals physical condition, mental condition, and social well-being. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 8 TOP: Wellness/Illness continuum KEY: Nursing Process Step: N/A MSC:NCLEX: N/A MULTIPLE RESPONSE 25. Florence Nightingale established a nursing school at Saint Thomas Hospital in London. What was it characterized by? (Select all that apply.) a. Allowing all applicants who applied to be enrolled b. Offering formal and practical educational experiences c. Keeping records of students progress d. Focusing on sanitation and hygiene e. Retaining a registry of all graduates ANS: B, C, D, E The nursing school established by Florence Nightingale rigorously screened its applicants. The curriculum, which included both formal education and practical experiences, was focused on hygiene and sanitation. The school kept records of the students progress during their school years, and also kept a registry of the graduates. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 3 OBJ:1 | 2TOP:School established by Florence Nightingale
KEY:Nursing Process Step: N/AMSC:NCLEX: N/A COMPLETION 26. Primitive medical interventions were based on the belief that illness was caused by the presence of . ANS: evil spirits Illness was thought to be caused by the inhabitation of the body by evil spirits. Medical interventions were designed to drive out the evil spirits by introducing good spirits. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1 OBJ: 1 TOP: Primitive health care KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 27. During early civilization performed witchcraft and rituals to induce the bad spirits to leave the body of the ailing person. ANS: medicine men Medicine men performed witchcraft and rituals to induce the bad spirits to leave the body of the ailing person during early civilization. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 1 TOP: Primitive health care KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 28. The National Council of State Boards of Nursing (NCSBN) performs a job analysis every years to determine the scope of practice of LPN/LVNs. ANS: 3 three The National Council of State Boards of Nursing performs a job analysis every 3 years to measure the scope of practice for LPN/LVNs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 18 OBJ: 6 | 9 TOP: National Council analysis KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 29. Graduates of the first school for training the practical nurse were referred to as nurses.
ANS: attendant The first school for training the practical nurse started in Brooklyn, New York in 1892 and was conducted under the auspices of the Young Womens Christian Association (YWCA). The Ballard School, as it was known, was approximately 3 months in duration and trained its students to care for the chronically ill, invalids, children, and the elderly. The main emphasis was on home care and included cooking, nutrition, basic science, and basic procedures. Graduates of this program were referred to as attendant nurses. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 9 OBJ: 1 TOP: Attendant nurses KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 30. In 1949, the National Federation of Licensed Practical Nurses (NFLPN) was founded by . ANS: Lillian Kuster In 1949 the National Federation of Licensed Practical Nurses (NFLPN) was founded by Lillian Kuster. This association is the official membership organization for licensed practical nurses/licensed vocational nurses (LPN/LVNs), and membership is limited to LPNs and LVNs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 9 OBJ: 2 TOP: National Federation of Licensed Practical Nurses KEY:Nursing Process Step: N/AMSC:NCLEX: N/A OTHER 31. What is the order of Maslows hierarchy of needs beginning with the most basic? a. Safety and security b. Love/belongingness c. Physiological d. Self-actualization e. Esteem ANS: C, A, B, E, D Abraham Maslow believed that an individuals behavior is formed by the
individuals attempts to meet essential human needs, which he identified as physiological, safety and security, love and belongingness, and esteem and self-actualization. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 8 TOP: Maslows Hierarchy of Needs KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 2: Legal and Ethical Aspects of Nursing My Nursing Test Banks Chapter 2: Legal and Ethical Aspects of Nursing Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. When a nurse becomes involved in a legal action, the first step to occur is that a document is filed in an appropriate court. What is this document called? a. Deposition b. Appeal c. Complaint d. Summons ANS: C A document called a complaint is filed in an appropriate court as the first step in litigation. A deposition is when witnesses are required to undergo questioning by the attorneys. An appeal is a request for a review of a decision by a higher court. A summons is a court order that notifies the defendant of the legal action. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 23 OBJ: 1 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 2. The nurse caring for a patient in the acute care setting assumes responsibility for a patients care. What is this legally binding situation? a. Nurse-patient relationship b. Accountability c. Advocacy d. Standard of care ANS: A
When the nurse assumes responsibility for a patients care, the nurse-patient relationship is formed. This is a legally binding contract for which the nurse must take responsibility. Accountability is being responsible for ones own actions. An advocate is one who defends or pleads a cause or issue on behalf of another. Standards of care define acts whose performance is required, permitted, or prohibited. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 24 OBJ: 3 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 3. What are the universal guidelines that define appropriate measures for all nursing interventions? a. Scope of practice b. Advocacy c. Standard of care d. Prudent practice ANS: C Standards of care define actions that are permitted or prohibited in most nursing interventions. These standards are accepted as legal guidelines for appropriateness of performance. The laws that formally define and limit the scope of nursing practice are called nurse practice acts. An advocate is one who defends or pleads a cause or issue on behalf of another. Prudent is a term that refers to careful and/or wise practice. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 25 OBJ: 4 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 4. An LPN/LVN is asked by the RN to administer an IV chemotherapeutic agent to a patient in the acute care setting. What law should this nurse refer to before initiating this intervention? a. Standards of care b. Regulation of practice c. American Nurses Association Code d. Nurse practice act ANS: D
It is the nurses responsibility to know the nurse practice act in his or her state. Standards of care, regulation of practice, and the American Nurses code are not laws that the nurse should refer to before initiating this treatment. PTS: 1 DIF: Cognitive Level: Application REF: Page 25 OBJ: 5 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 5.A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be found guilty of: a. malpractice. b. harm to the patient. c. negligence. d. failure to follow the nurse practice act. ANS: A The nurse can be held liable for malpractice for acts of omission. Failure to meet a legal duty, thus causing harm to another, is malpractice. The nurse practice act has general guidelines that can support the charge of malpractice. PTS: 1 DIF: Cognitive Level: Application REF: Pages 22-23 OBJ: 2 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 6. Patients have expectations regarding the health care services they receive. To protect these expectations, which of the following has become law? a. American Hospital Associations Patients Bill of Rights b. Self-determination act c. American Hospital Associations Standards of Care d. The Joint Commissions rights and responsibilities of patients ANS: A Patients have expectations regarding the health care services they receive. In 1972, the American Hospital Association (AHA) developed the Patients Bill of Rights. The Self-determination act, American Hospital Associations Standards of Care, and The Joint Commissions rights and responsibilities do not address patients expectations regarding health care. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 26 OBJ: 3 | 4 TOP: Legal KEY: Nursing Process Step: N/A
MSC:NCLEX: N/A 7. The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed? a. Physical assessment b. Interview c. Informed consent d. Surgical checklist ANS: C The doctrine of informed consent refers to full disclosure of the facts the patient needs to make an intelligent (informed) decision before any invasive treatment or procedure is performed. A physical assessment, interview, and surgical checklist are not required before this procedure. PTS: 1 DIF: Cognitive Level: Application REF: Pages 26-27 OBJ: 8 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 8. When a nurse protects the information in a patients record what ethical responsibility is the nurse fulfilling? a. Privacy b. Disclosure c. Confidentiality d. Absolute secrecy ANS: C The nurse has an ethical and legal duty to protect information about a patient and preserve confidentiality. Some disclosures are legal and anticipated, and may not be subject to the rules of confidentiality. None of the information in a chart is considered secret. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 28 OBJ: 9 TOP: Confidentiality KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 9. An older adult is admitted to the hospital with numerous bodily bruises, and the nurse suspects elder abuse. What is the best nursing action? a. Cover the bruises with bandages. b. Take photographs of the bruises.
c. Ask the patient if anyone has hit her. d. Report the bruises to the charge nurse. ANS: D The law stipulates that the health care professional is required to report certain information to the appropriate authorities. The report should be given to a supervisor or directly to the police, according to agency policy. When acting in good faith to report mandated information (e.g., certain communicable diseases or gunshot wounds), the health care professional is protected from liability. PTS: 1 DIF: Cognitive Level: Application REF: Page 29 OBJ: 9 TOP: Elder abuse KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 10. What is the best way for a nurse to avoid a lawsuit? a. Carry malpractice insurance b. Spend time with the patient c. Provide compassionate, competent care d. Answer all call lights quickly ANS: C The best defense against a lawsuit is to provide compassionate and competent nursing care. Carrying malpractice insurance is prudent, but it will not avoid a lawsuit. Spending time with patients and answering call lights quickly will not necessarily help avoid a lawsuit. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 29-30 OBJ: 8 TOP: Avoiding a lawsuit KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 11. The nurse is caring for a patient with a do-not-resuscitate (DNR) order. Although the nurse may disagree with this order, what is his or her legal obligation? a. To question the doctor b. To seek advice from the family c. To discuss it with the patient d. To follow the order ANS: D
When a DNR order is written in the chart, the nurse has a duty to follow the order. Questioning the doctor, seeking advice from the family, and discussing it with the patient are not legal obligations of the nurse. PTS: 1 DIF: Cognitive Level: Application REF: Page 35 OBJ: 10 | 14 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 12. The nurse has strong moral convictions that abortions are wrong. When assigned to assist with an abortion, what is the most appropriate action for the nurse to take? a. Ask for another assignment b. Leave work c. Transfer to another floor d. Protest to the supervisor ANS: A The nurse should not abandon the patient, but ask for another assignment. PTS: 1 DIF: Cognitive Level: Application REF: Page 35 OBJ: 9 | 16 TOP: Ethics KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 13. The new LPN/LVN is concerned regarding what should or should not be done for patients. What resource will best provide this information? a. Nurse practice act b. Standards of care c. Scope of nursing practice d. Professional organizations ANS: B Standards of care define what should or should not be done for patients. The nurse practice act, scope of nursing practice, and professional organizations do not provide the best information as to what should or should not be done for patients. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 25 OBJ: 5 TOP: Standards of care KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 14. What role is the nurse who diligently works for the protection of patients
interests playing? a. Caregiver b. Health care administrator c. Advocate d. Health care evaluator ANS: C A nurse accepts the role of advocate when, in addition to general care, the nurse protects the patients interests. Caregiver, health care administrator, and health care evaluator are not terms for the nurse who diligently works for the protection of patients. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 24 OBJ: 9 | 12 TOP: Advocate KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 15. When asked to perform a procedure that the nurse has never done before, what should the nurse do to legally protect himself or herself? a. Go ahead and do it b. Refuse to perform it, citing lack of knowledge c. Discuss it with the charge nurse, asking for direction d. Ask another nurse who has performed the procedure ANS: C The nurse cannot use ignorance as an excuse for nonperformance. The nurse should ask for direction from the charge nurse, explaining she has never performed the procedure independently. PTS: 1 DIF: Cognitive Level: Application REF: Page 25 OBJ: 8 TOP: Legal KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 16. The nurse is assisting a patient to clarify values by encouraging the expression of feelings and thoughts related to the situation. What is the most appropriate action for the nurse? a. Compare values with those of the patient b. Make a judgment c. Withhold an opinion d. Give advice
ANS: C The nurse can assist the patient in values clarification without giving an opinion. PTS: 1 DIF: Cognitive Level: Application REF: Pages 33-34 OBJ: 3 | 8 TOP: Values clarification KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 17. What fundamental principle must the nurse first observe when confronted with an ethical decision? a. Autonomy b. Beneficence c. Respect for people d. Nonmaleficence ANS: C The first fundamental principle is respect for people. Autonomy, beneficence, and nonmaleficence are not the first fundamental principles to observe when confronted with an ethical decision. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 34 OBJ: 13 | 15 TOP: Ethics KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 18.A nurse working on an acute care medical surgical unit is aware that his or her first duty is to the patients health, safety, and well-being. Given this knowledge, which of the following is most necessary for the nurse to report? a. Unethical behavior of other staff members b. A worker who arrives late c. Favoritism shown by nursing administration d. Arguments among the staff ANS: A A member of the nursing profession must report behavior that does not meet established standards. Unethical behavior involves failing to perform the duties of a competent caring nurse. PTS: 1 DIF: Cognitive Level: Application REF: Page 35 OBJ: 13 TOP: Unethical behavior KEY: Nursing Process Step: N/A MSC:NCLEX: N/A
19.A nurse is considering purchasing malpractice insurance. What should the nurse be aware of regarding malpractice insurance provided by the hospital? a. Only offers protection while on duty b. Is limited in the amount of coverage c. Is difficult to renew d. Can be terminated at any time ANS: A Most institutional insurance only provides liability coverage if the nurse is on duty at that facility. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 30 OBJ: 2 TOP: Malpractice insurance KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 20. Which is a nursing care error that violates the Health Insurance Portability and Accountability Act (HIPAA)? a. Administering a stronger dose of drug than was ordered b. Refusing to give a patients daughter information over the phone c. Informing the patients medical power of attorney of a medication cha d. Leaving a copy of the patients history and physical in the photocopie ANS: D Leaving the document in the photocopier could expose it to the public. Inappropriate drug administration is possible malpractice. Sharing information with the power of attorney is legal. Refusing to give a patients daughter information over the phone is appropriate practice. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 26, 28 OBJ: 7 TOP: Health Insurance Portability and Accountability Act (HIPAA) KEY:Nursing Process Step: N/AMSC:NCLEX: N/A 21. Which of the following could cause a nurse to be cited for malpractice? a. Refusing to give 60 mg of morphine as ordered b. Giving prochlorperazine (Compazine) to a patient allergic to phenoth c. Dragging an injured motorist off the highway and causing further inj d. Informing a visitor about a patients condition ANS: B Standards of care dictate that a nurse must be aware of all the properties of
drugs administered. Prochlorperazine (Compazine) is a phenothiazine. Providing confidential information or refusing to give an excessively large narcotic dose is not considered malpractice. Good Samaritan laws generally protect a person giving aid to an injured motorist. PTS: 1 DIF: Cognitive Level: Application REF: Pages 22-23 OBJ: 2 TOP: Malpractice KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 22.A lumbar puncture was performed on a patient without a signed informed consent form. This patient might sue for: a. punitive damages. b. civil battery. c. assault. d. nothing; no violation has occurred. ANS: B Civil battery charges can be brought against someone performing an invasive procedure without the patients informed consent legally documented. This patient could not sue for punitive damages or an assault. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 28 OBJ: 6 | 8 TOP: Informed consent KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 23.A physician instructs the nurse to bladder train a patient. The nurse clamps the patients indwelling urinary catheter but forgets to unclamp it. The patient develops a urinary tract infection. What do the nurses actions exemplify? a. Malpractice b. Battery c. Assault d. Neglect of duty ANS: A A nurse is liable for acts of commission (doing an act) and omission (not doing an act) performed in the course of their professional duty. A charge of malpractice is likely when a duty exists, there is a breach of that duty, and harm has occurred to the patient. PTS: 1 DIF: Cognitive Level: Application REF: Pages 22-23
OBJ: 2 TOP: Malpractice KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 24. What is true about nurse practice acts? a. They informally define the scope of nursing practice. b. They provide for unlimited scope of nursing practice. c. Only some states have adopted a nurse practice act. d. The nurse must know the nurse practice act within his or her state. ANS: D The laws formally defining and limiting the scope of nursing practice are called nurse practice acts. All state, provincial, and territorial legislatures in the United States and Canada have adopted nurse practice acts, although the specifics they contain often vary. It is the nurses responsibility to know the nurse practice act that is in effect for her geographic region. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 25 OBJ: 1 TOP: Nurse practice acts KEY: Nursing Process Step: N/A MSC:NCLEX: N/A MULTIPLE RESPONSE 25. How can the medical record be used in litigation? (Select all that apply.) a. Public record b. Proof of adherence to standards c. Evidence of omission of care d. Documentation of time lapses e. Evidence by only the plaintiff ANS: A, B, C, D The information when used in court becomes a public record. The information can be used as proof of adherence to standards, omission of care, and documentation of time lapses. Both plaintiff and defendant can use the document. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 28 OBJ: 4 TOP: Legal properties of medical record KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 26. During a lunch break, an emergency department (ED) nurse truthfully tells
another nurse about the condition of a patient who came to the ED last night. What is the ED nurse guilty of? (Select all that apply.) a. HIPAA violation b. Slander c. Libel d. Invasion of privacy e. Defamation ANS: A, D The disclosure is an invasion of privacy and a violation of HIPAA. Because the information is true and verbal, it cannot be considered slander or libel. PTS: 1 DIF: Cognitive Level: Application REF: Pages 26, 28 OBJ: 7 TOP: Disclosure of information KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 27.A nurse failed to monitor a patients respiratory status after medicating the patient with a narcotic analgesic. The patients respiratory status worsened, requiring intubation. The patients family claimed the nurse committed malpractice. What must be present for the nurse to be held liable? (Select all that apply.) a. A nurse-patient relationship exists. b. The nurse failed to perform in a reasonable manner. c. There was harm to the patient. d. The nurse was prudent in her performance. e. The nurse did not cause the patient harm. f. Duty does not exist. ANS: A, B, C For the court to uphold the charge of malpractice, and to find the nurse liable, the following elements must be present: duty exists, there is a breach of duty, and harm must have occurred. PTS: 1 DIF: Cognitive Level: Application REF: Page 24 OBJ: 2 TOP: Malpractice KEY: Nursing Process Step: N/A MSC:NCLEX: N/A COMPLETION 28. Personal beliefs about the worth of an object, idea, custom, or attitude that
influence a persons behavior in a given situation are referred to as . ANS: values Values are personal beliefs about the worth of an object, an idea, a custom, or an attitude. Values vary among people and cultures; they develop over time and undergo change in response to changing circumstances and necessity. Each of us adopts a value system that will govern what we feel is right or wrong (or good and bad) and will influence our behavior in a given situation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 33 OBJ: 11 | 12 TOP: Values KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 29. Acts whose performance is required, permitted, or prohibited are defined by of . ANS: standards, care Standards of care define acts whose performance is required, permitted, or prohibited. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 25 OBJ: 4 TOP: Standards of care KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 3: Documentation My Nursing Test Banks Chapter 3: Documentation Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What does documentation of type of care, time of care, and signature of the person prove? a. The person who signed the documentation did all the work noted. b. No litigation can be brought against the person who signed. c. Interventions were implemented to meet the patients needs. d. The patients response to the intervention was positive. ANS: C Documenting type of care, time of care, and signature of the person results in
recording the interventions that are implemented to meet the patients needs. Many charting entries include doctors visits, presence of family, or interventions by other departments. Patient response to some interventions is not always positive. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 38 OBJ:1TOPocumentation KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 2.Why is documentation especially significant in managed care? a. The hospital needs to show that employees care for patients. b. Institutions are reimbursed only for patient care that is documented. c. Patients might bring lawsuits if care was not given. d. Documents may become part of a lawsuit. ANS: B Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the prospective payment system of diagnosis-related groups (DRGs); a system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 40 OBJ: 1 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 3. The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is this system of documentation? a. SOAP b. Block c. CBE d. Focus ANS: C Charting additional treatments done, changes in a patients condition, and new concerns during the shift is charting by exception (CBE). PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 46 OBJ: 1 | 5 | 7 TOP: Documentation KEY: Nursing Process Step: N/A
MSC:NCLEX: N/A 4. What form explains the lapse when events are not consistent with facility or national standards of expected care? a. Subjective data b. Focus chart c. Incident report d. Nursing assessment ANS: C An incident report is completed when patient care was not consistent with facility or national standards. The form explains the event, time, extent of injury, and who was notified. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 47 OBJ: 1 | 7 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 5. The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This is known as a: a. nursing order. b. Kardex. c. nursing care plan. d. critical pathway. ANS: D Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 51 OBJ:8TOPocumentation KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 6.What makes home health care documentation unique? a. Some charting is retained at the hospital. b. The physicians office needs separate charting. c. Different health care providers need access. d. The physician is the pivotal person in the charting. ANS: C
Home health care documentation has unique problems because of the need for different health care workers to access the medical record. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 53 OBJ: 9 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 7. What regulates standards for long-term care documentation? a. OBRA b. Title XXII c. Nursing diagnoses d. The care plan ANS: A OBRA (Omnibus Budget Reconciliation Act) was a significant Medicare and Medicaid legislation for long-term health care documentation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 53 OBJ: 10 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 8. What is the nurse required to do to adhere to the concept of confidentiality for the patients medical record? a. Provide information only to another nurse b. Provide information only to an attorney c. Share information only with the family d. Have a clinical reason for reading the record ANS: D The nurse should not read the patients medical record unless there is a clinical reason for doing so. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 54 OBJ: 4 TOP: Confidentiality KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 9. Documentation is necessary for the evaluation of patient care. Of which phase of the nursing process is this an integral part? a. Assessment b. Planning c.
Implementation
d. Evaluation ANS: C Documentation is part of the implementation phase of the nursing process. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 38 OBJ: 1 | 4 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 10. What does the nurse use as a basis for documentation in focus charting? a. Problem list b. Nursing orders c. Nursing diagnoses d. Evaluation ANS: C In focus charting, instead of using the problem list, modified nursing diagnoses are used as an index for nursing documentation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 45 OBJ: 7 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 11. What is the purpose of QA (quality assurance)? a. To screen employment applications b. To evaluate care results against accepted standards c. To conduct in-services for quality documentation d. To report deviation from standards to the state health department ANS: B QA is an in-house department that evaluates care services and results against accepted standards. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 39 OBJ: 1 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 12. What is the process used to appraise the practice of an individual nurse known as? a. Quality assurance b. Incident reporting c.
OBRA
d. Peer review ANS: D Peer review is an in-house department study that may appraise the nursing practice of individual nurses. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 4 TOP: Peer review KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 13. What is the documentation format that uses the acronym SOAPE? a. Problem-oriented b. Focused c. Traditional d. Crisis ANS: A The problem-oriented medical record uses the acronym SOAPE to format and for focus charting on a list of patient problems/nursing diagnoses. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 45 OBJ:7TOProblem-oriented medical record (POMR) KEY:Nursing Process Step: N/AMSC:NCLEX: N/A 14.Who is the legal owner of the patients medical record? a. Patient b. Physician c. Institution d. State ANS: C Ownership of a medical record belongs to the institution in the case of a hospitalized patient, or the physician in the case of private office visits. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 53 OBJ:4TOP:Legal ownership KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 15. When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered?
a. Charting in code b. Logging off c. Charting in privacy d. Signing on with a password ANS: B Logging off closes the computer file that was opened with the nurses password. Any other data entry will require that person to sign on with their password. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 54, 55 Box 3-5 OBJ: 2 TOP: Computer documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 16. What is the system that classifies patients by age, diagnosis, and surgical procedure and produces 300 different categories used for predicting the use of hospital resources? a. Quality assurance b. Resource assessment c. Quality improvement d. Diagnosis-related groups ANS: D Cost reimbursement rates under government plans are based on diagnosisrelated groups (DRGs), which is a system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 5 TOP: Diagnostic-related groups KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 17.A nurse is using the data, action, response, education (DARE) system of charting, and is completing the data portion. What data are the nurses focus? a. Planning b. Assessment c. Implementation d. Patient teaching ANS: B
DARE is the acronym for four different aspects of charting using the focus format. Data (D) is both subjective and objective and is equivalent to the assessment step of the nursing process. Action (A) is a combination of planning and implementation. Response (R) of the patient is the same as evaluation of effectiveness. Some facilities include education/patient teaching (E). PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 45 OBJ: 7 TOP: Charting KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 18.A new patient is being admitted to a long-term care facility. Who has primary responsibility for each patients initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified? a. Physician b. Registered nurse c. Nursing assistant d. Licensed practical nurse/licensed vocational nurse ANS: B The registered nurse (RN) has primary responsibility for each patients initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 41 OBJ: 4 | 10 TOP: Scope of practice KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 19. What will the nurse implement when an error is made when documenting in a patients chart? a. Scratch out the error b. Apply correction fluid c. Erase the error completely d. Draw a single line through the error ANS: D A nurse should not erase, apply correction fluid, or scratch out errors made while recording in a patients chart. Instead, the nurse should draw a single
line through the error, write the word error above it, and sign her name or initials. PTS: 1 DIF: Cognitive Level: Application REF: Pages 42, 43 Table 3-2 OBJ: 6 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 20. What should the nurse be sure to do when documenting in a patients chart? a. Include speculation b. Chart consecutively c. Leave blank spaces d. Include retaliatory comments ANS: B A nurse should not write retaliatory or critical comments about a patient or care by other health care professionals. The nurse should not leave blank spaces in the nurses notes. The nurse should be certain the entry is factual and not speculate or guess. The nurse should chart consecutively, line by line. PTS: 1 DIF: Cognitive Level: Application REF: Pages 42, 43 Table 3-2 OBJ: 6 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A MULTIPLE RESPONSE 21. What are categories of inadequate documentation that may lead to a malpractice claim? (Select all that apply.) a. Incorrectly recording the time of an event b. Failing to record verbal orders c. Charting events in advance d. Documenting an incorrect date e. Marking out and initialing charting errors ANS: A, B, C, D Marking out with a single line and initialing is an acceptable method to indicate a charting error. PTS: 1 DIF: Cognitive Level: Application REF: Pages 42, 43 Table 3-2 OBJ: 4 TOP: Inadequate documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A
22. When documenting an incident in the nurses notes, what should the nurse
include? (Select all that apply.) a. Description of injury, including diagrams of injury placement b. Date, time, and location of incident c. Name of physician and family members notified d. Chronologic order of events of the incident e. Confirmation that an incident report was initiated ANS: A, B, C, D The documentation of the initiation of an incident report should not be included in the nurses notes. Nurses notes are part of the legal medical record; the incident report is not. To note that an incident report was initiated is a red flag that a problem has occurred. PTS: 1 DIF: Cognitive Level: Application REF: Pages 42, 47 OBJ: 4 | 6 TOP: Documenting incident reports KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 23. What are some problems associated with electronic (or computerized) charting? (Select all that apply.) a. Security b. Expense of training staff c. Legibility d. Easy retrieval e. New terminology ANS: A, B, E Security, expensive staff training, and learning new terminology are all problems of electronic charting. Legibility and easy retrieval are advantages. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 40, 41, 54 OBJ: 1 TOP: Computer charting KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 24. What are the basic purposes of written patient records? (Select all that apply.) a. Teaching b. Legal record of care
c. Written communication d. Research and data collection e. Permanent record for accountability f. Temporary record of hospitalization ANS: A, B, C, D, E There are five basic purposes for written patient records: (1) written communication, (2) permanent record for accountability, (3) legal record of care, (4) teaching, and (5) research and data collection. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 39 OBJ: 1 TOP: Medical record KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 25. What should a medical record provide for all health care providers? (Select all that apply.) a. Care given to the patient b. Care planned for the patient c. A patients nursing problems d. A patients medical problems e. Details about any incident reports f. The patients response to treatment ANS: A, B, C, D, F A medical record should furnish all health care providers with a concise, accurate, written picture of a patients medical and nursing problems, care planned and given, and the patients response to treatments. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 39 OBJ: 1 TOP: Medical record KEY: Nursing Process Step: N/A MSC:NCLEX: N/A COMPLETION 26. The best defense against malpractice claims associated with nursing care is accurate . ANS: documentation Accurate documentation can guard against malpractice claims because it should describe when, what, and how events occurred.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 42 OBJ: 4 TOP: Documentation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 27. Twenty-fourhour charting is designed to establish levels to help determine staffing needs. ANS: acuity Patient acuity, which is reflected in 24-hour charting compilation, can dictate staffing needs. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 47 OBJ: 7 TOP: 24-hour charting KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 28. Documentation using the DARE format (Data, Action, Response, Education) includes elements of the charting system. ANS: focused Focused charting uses the acronym DARE to direct and formalize charting. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 45 OBJ: 7 TOP: Focused charting KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 29.A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as . ANS: quality assurance quality assessment quality improvement Quality assurance/assessment/improvement is an audit in health care that evaluates services provided and the results achieved compared with accepted standards. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 39 OBJ:1TOP:Quality assurance/assessment/improvement KEY:Nursing Process Step: N/AMSC:NCLEX: N/A OTHER
30.A nurse is receiving a telephone order from a physician. The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals. What is the correct order of this method? a. Read back b. Background c. Recommendation d. Situation e. Assessment ANS: D, B, E, C, A SBAR (Situation, Background, Assessment, and Recommendation) is a method of communication among health care workers and a part of documentation (Kaiser Permanente, 2007). SBAR is considered a safety measure in preventing errors from poor communication during hand-off or handover interactions, the communication that occurs from one shift to the next or when a nurse phones a health care provider with information about a patient. An additional R is added. The additional R (SBARR) represents read back when the nurse reads back the order for clarification. PTS: 1 DIF: Cognitive Level: Application REF: Page 41 Box 3-1 OBJ: 3 TOP: SBARR KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 4: Communication My Nursing Test Banks Chapter 4: Communication Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. Although the patient denies pain, the nurse observes the patient breathing rapidly with clenched fists and facial grimacing. What is the nurses best response to these observations? a. I am glad you are feeling better and have no discomfort. b. Where do you hurt? c. What you are saying and what I am observing dont seem to match. d. It makes me uncomfortable when you are not honest with me.
ANS: C The nonverbal communication should be clarified to prevent miscommunication. PTS: 1 DIF: Cognitive Level: Application REF: Pages 59-61 OBJ:2 | 3TOP:Communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse considers the feelings and needs of a patient by stating, I know you are concerned about your surgery tomorrow. How can I help you? What type of communication is this? a. Intrusive b. Aggressive c. Closed d. Assertive ANS: D Assertive communication takes a patients feelings and needs into account, yet honors the patients rights as an individual. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 61 OBJ:4TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 3. If the nurse aggressively says to a patient, Why couldnt you have asked me to give you your pain medication when I was in here earlier? what feeling is the patient most likely to demonstrate? a. Anger b. Satisfaction that his needs are met c. Humiliation and worthlessness d. Confidence that his request will be granted ANS: C Aggressive communication is highly destructive. Although anger may eventually come, the patient most likely feels humiliated first. PTS: 1 DIF: Cognitive Level: Application REF: Page 62 OBJ:7TOP:Communication
KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 4. What does therapeutic communication accomplish? a. Facilitates the formation of a positive nurse-patient relationship b. Manipulates the patient c. Assigns the patient a passive role d. Requires the patient to accept what the nurse says ANS: A A positive nurse-patient relationship is facilitated by therapeutic communication. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 62 OBJ: 10 TOP: Communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 5. The nurse is sitting in a chair near the patients bed, leaning forward to hear what the patient is saying, and does not interrupt. What is the nurse demonstrating? a. Support b. Caring c. Active listening d. Interest ANS: C When demonstrating active listening, the nurse must give his or her full attention and make an effort to understand both the verbal and nonverbal message. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 63 OBJ:5TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 6. What therapeutic communication technique requires a great deal of skill and is not used as frequently as other communication techniques? a. Touch b. Silence c. Listening
d. Summarizing ANS: B Silence is an extremely effective therapeutic communication skill that is frequently underused because the nurse feels uncomfortable applying it. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 63 OBJ: 5 TOP: Communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 7.A patient does not speak English; therefore, the nurse cannot use words to provide comfort during a painful procedure. What is another intervention that may provide comfort to this patient? a. Silence b. Listening c. Touch d. Restating ANS: C Holding the hand of a nonEnglish-speaking patient is effective and comforting. PTS: 1 DIF: Cognitive Level: Application REF: Page 63 OBJ:9TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 8.A patient states, I do cocaine when I feel things are out of my control. The nurse responds by asking, What else does cocaine do for you? What communication skill does this exemplify? a. Summarization b. Restating c. Showing acceptance d. Stating observations ANS: C Acceptance is the willingness to listen and respond to what the patient is saying without passing judgment. PTS: 1 DIF: Cognitive Level: Application REF: Page 64-65 OBJ:5TOP:Communication
KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 9.A patient states, Im really strung out about this pregnancy. The nurse responds by asking, What about this pregnancy worries you? What communication technique is this? a. Closed inquiry b. Restating c. Open-ended question d. Minimal encouraging ANS: C Open-ended questions convey interest and do not require a specific response. PTS: 1 DIF: Cognitive Level: Application REF: Pages 65 OBJ:5TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 10.A grieving young widow cries out, Why was my husband killed? Why wasnt it me? What is the nurses best response? a. Stating You need to be strong for your children. b. Silently placing her hand on the widows arm. c. Asking if there is anyone the widow needs to have notified. d. Stating You are feeling overwhelmed about your husbands death. ANS: B The ability to listen and assist those who are newly grieving through the use of silence and a quiet presence is very effective. Stating You need to be strong for your children is a clich. Asking if there is anyone the widow needs to have notified and stating You are feeling overwhelmed about your husbands death are not therapeutic in this immediate grieving time. PTS: 1 DIF: Cognitive Level: Application REF: Pages 63-64 OBJ:5TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 11.A nurse is assessing a patient with a nursing diagnosis of impaired verbal communication. What is the lowest number of defining characteristics for this
diagnosis? a. One b. Two c. Three d. Four ANS: A If one or more of the defining characteristics is present, a nursing diagnosis of impaired verbal communication can be determined. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 72 OBJ:9TOP:Communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 12. What communication technique should the nurse use when communicating with an unresponsive patient? a. Avoid speaking directly to the patient b. Assume verbal stimuli are heard c. Speak in a loud voice d. Use simple words ANS: B A person interacting with an unresponsive patient should assume all sounds and verbal stimuli have the potential of being heard by the patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 75 OBJ:10TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 13. If in response to the patient statement, I am upset about all this lab work the nurse responds, Youre upset? What is this is an example of? a. An open-ended question b. Reflecting c. Restating d. Paraphrasing ANS: C Restating is one of the most effective methods of therapeutic communication
to encourage the patient to offer more information. PTS: 1 DIF: Cognitive Level: Application REF: Pages 65-66 Table 4-3 OBJ:5TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 14. What is one of the main characteristics of therapeutic communication? a. It allows the patient a passive role. b. It uses only verbal communication. c. It involves the patient as a person. d. It is directive. ANS: C Therapeutic communication actively involves the patient in all areas of the nursing process. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 64-65 OBJ: 1 TOP: Communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 15.A nurse is standing at the bedside with the patient lying in bed. What can the nurse be construed as demonstrating? a. Interest b. Power c. Caring d. Support ANS: B Standing at the bedside with the patient in bed may imply that the nurse has power. PTS: 1 DIF: Cognitive Level: Application REF: Page 68 OBJ:6 | 7TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 16.A nurse actively avoids the use of one-way communication. What is the major problem with one-way communication? a. The receiver is in control. b. Feedback is provided to the sender.
c. Participation is not equal. d. The communication is unstructured. ANS: C One-way communication is seldom effective because the sender is in control and gets very little feedback from the receiver. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 59 OBJ:7TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 17.A nurse must violate the personal space of a patient to perform an invasive procedure. How can the nurse reduce the discomfort of the patient? a. By approaching the interaction in a professional manner b. By distracting the patient with jokes and humor c. By asking another nurse to be present at the bedside d. By assuring the patient that all people dislike invasion of personal sp ANS: A The intimate zone can cause uneasiness for both patient and nurse; therefore, approach the interaction in a professional manner. PTS: 1 DIF: Cognitive Level: Application REF: Page 69 OBJ:6TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 18. What would be the best method for a literate, English-speaking patient on a ventilator to communicate his or her needs? a. Eye blinking for yes and no b. Magic slate or paper and pencil c. Computer d. Message board or cards ANS: B Writing devices are preferred as they do not limit the patients messages compared to a message board or cards. Eye blinks are tiring and timeconsuming. Computers require space and the ability to type. PTS: 1 DIF: Cognitive Level: Application REF: Page 74
OBJ:10TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 19.A patient roughly asks the nurse to bring him some ice cream. What would be considered an assertive response by the nurse? a. You are hungry and want a snack. b. I can do that in 10 minutes when I finish my rounds. c. Maybe I can get one of the aides to bring you something in a while. d. Call the nursing station and ask them to have the kitchen bring whate ANS: B Assertiveness is the most effective style of communication to be responsive to the patient and set limits. PTS: 1 DIF: Cognitive Level: Application REF: Pages 61 OBJ:4TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 20.A nurse tells a patient, This PM you are going for an abdominal A&P, an H&H, as well as an IV pyelogram. Please sign these consent forms. What may this use of medical jargon cause? a. Understanding b. Speed in communication c. Misinterpretation d. Clarity in the message ANS: C Jargon is terminology unique to people in a special type of work and is not understood by everyone. Although jargon does speed communication and is clear to those who know it, it may be misinterpreted and not understood by all people. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 59 OBJ:7TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 21. During a complete assessment, which type of questioning is not usually
conducive to fostering communication? a. Open-ended b. Focused c. Closed d. Clarifying ANS: C Closed questions are types of questions that the nurse may choose to use that are not usually conducive to fostering communication. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 65 OBJ:7TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 22.A patient states, My husband has told me how he feels about my having a mastectomy. The nurse nods and says, Go on. This is an example of: a. clarifying. b. restating. c. focusing. d. minimal encouraging. ANS: D The nurse uses minimal encouragement to lead the patient to provide more information. PTS: 1 DIF: Cognitive Level: Application REF: Page 65 OBJ:5TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 23.A nurse is communicating with an older adult. How might the nurse enhance communication? a. Speak in a rapid manner to accommodate the patients short attention b. Speak in a lower voice tone to accommodate hearing loss. c. Speak in a simple manner as if speaking to a child. d. Speak in a loud voice directly at ear level. ANS: B Older adults lose their ability to hear higher frequency sound. Speaking in a
lower tone enhances communication. Speaking overly loud and as if to a child may be irritating and demeaning. Rapid speech may be difficult for older adults to understand. PTS: 1 DIF: Cognitive Level: Application REF: Page 70 OBJ: 6 TOP: Physiologic factors affecting communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 24. What does maintaining eye contact for 2 to 6 seconds during communication with a patient do? a. Keeps the nurses attention on the conversation b. Counteracts shyness in the patient c. Indicates continuous focused attention d. Assesses if the patient is involved in the conversation ANS: C Maintaining eye contact for 2 to 6 seconds involves the person in what is being said, is indicative of continued interest, and conveys to the patient an accepting attitude. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 59 OBJ:2TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 25. The nurse recognizes that a patient experiencing stress feels vulnerable. What would be the most appropriate way for the nurse to intervene? a. Use technical language b. Direct the conversation c. Modify communication methods d. Offer all the information ANS: C When the patient is experiencing stress, the nurse should modify communication methods. PTS: 1 DIF: Cognitive Level: Application REF: Pages 61-63 OBJ:6TOP:Communication KEY:Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity 26.A nurse communicates with a patient by maintaining eye contact and through the use of touch. What type of communication technique is the nurse demonstrating? a. Verbal b. Persuasive c. Directive d. Nonverbal ANS: D Messages transmitted without the use of words (either oral or written) constitute nonverbal communication. Nonverbal cues include tone and rate of voice, volume of speech, eye contact, physical appearance, and use of touch. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 59 OBJ:5TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 27.A nurse frequently looks at her watch when giving a patient a bed bath. What message is most likely conveyed to the patient from the nurse? a. She desires to spend more time with the patient. b. She is anxious to listen to the patients concerns. c. She is feeling hurried. d. She likes her watch. ANS: C Frequently looking at ones watch while interacting with a patient conveys to the patient that the nurse is in a hurry and really has no desire to spend time with him or her. PTS: 1 DIF: Cognitive Level: Application REF: Page 60 OBJ: 8 TOP: Gestures KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 28. When listening to a patient, what action by the nurse demonstrates disinterest and coldness? a. Tightly crossing her arms b. Uncrossing her arms
c. Uncrossing her legs d. Facing the patient ANS: A The way that an individual sits, stands, and moves is called posture. Posture has the potential to convey warmth and acceptance, or distance and disinterest. An open posture is demonstrated with a relaxed stance with uncrossed arms and legs while facing the other individual. A slight shift in body position toward an individual, a smile, and direct eye contact are all consistent with open posturing and convey warmth and caring. Closed posture is a more formal, distant stance, generally with the arms, and possibly the legs, tightly crossed. A person will often interpret closed posture as disinterest, coldness, and even nonacceptance. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 60 OBJ: 1 | 7 | 8 TOP: Posture KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 29. How can the nurse demonstrate warmth and acceptance when listening to a patient? a. Tightly crossing her arms b. Uncrossing her arms c. Tightly crossing her legs d. Facing away from the patient ANS: B The way that an individual sits, stands, and moves is called posture. Posture has the potential to convey warmth and acceptance, or distance and disinterest. An open posture is demonstrated with a relaxed stance with uncrossed arms and legs while facing the other individual. A slight shift in body position toward an individual, a smile, and direct eye contact are all consistent with open posturing and convey warmth and caring. Closed posture is a more formal, distant stance, generally with the arms, and possibly the legs, tightly crossed. A person will often interpret closed posture as disinterest, coldness, and even nonacceptance. PTS: 1 DIF: Cognitive Level: Application REF: Page 60 OBJ: 1 | 5 | 8 TOP: Posture KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
30. How may a nurse caring for a pediatric patient best be perceived as
nonthreatening? a. Tightly crossing her arms b. Maintaining an open posture c. Maintaining a tense posture d. Standing at the bedside ANS: B Standing at the bedside looking down at the patient in the bed places the nurse in a position of authority and control. The patient is likely to experience this as intimidating and condescending. Whenever possible, the nurse should be level with the patient; this is especially important with pediatric patients. Sitting at the bedside in a relaxed and open posture is one example. PTS: 1 DIF: Cognitive Level: Application REF: Page 60 OBJ: 1 | 5 TOP: Posture KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 31.A nurse is caring for a patient who is experiencing excruciating pain and requires frequent administration of analgesics. What statement would be anexample of the nurse demonstrating aggressive communication? a. Please let me know when you start to have pain. b. Lets practice some guided imagery. c. Lets try repositioning you. d. I will only medicate you every 4 hours. ANS: D Aggressive communication is when a person interacts with another in an overpowering and forceful manner to meet his or her own personal needs at the expense of the other. By only medicating a patient every 4 hours for excruciating pain, the nurse meets his or her own needs at the expense of the patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 62 OBJ:7TOP:Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 32.A nurse is caring for a newly admitted diabetic patient and is performing
the initial assessment. What statement made by the nurse demonstrates use of a closed question? a. What time do you take your insulin? b. How do you feel about taking insulin? c. Tell me about your support system. d. How do you feel about having diabetes? ANS: A Much of the information gathered from a patient comes from questioning them directly. A closed question is focused and seeks a particular answer. For example, when interviewing a newly admitted patient with diabetes, the nurse asks, What time do you take your insulin? A specific question with a specific answer is a typical closed question, which generally requires only one or two words in response. PTS: 1 DIF: Cognitive Level: Application REF: Page 65 OBJ:7TOP:Closed questioning KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 33.A nurse is caring for a patient experiencing respiratory distress. The physician places an endotracheal tube. What is the most appropriate nursing diagnosis for this patient? a. Ineffective coping b. Risk for infection c. Altered nutrition: less than body requirements d. Impaired verbal communication ANS: D Because of the placement of an endotracheal tube, the patient is unable to speak. The nursing diagnosis of impaired verbal communication is most appropriate. PTS: 1 DIF: Cognitive Level: Application REF: Page 72 OBJ:9TOP:Nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 34.A nurse examines whether patient interventions have been appropriate and
expected outcomes have been met. The nurse is demonstrating which step in the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation ANS: D A nurse evaluates the effectiveness of interventions based on the patients ability to meet established goals and outcomes. PTS: 1 DIF: Cognitive Level: Application REF: Page 72 OBJ:9TOP:Nursing process KEY:Nursing Process Step: EvaluationMSC:NCLEX: Evaluation 35.Which question below is open-ended? a. Are you going to Europe this fall? b. Are you sailing to Europe? c. What are you most looking forward to in Europe? d. Have you been to Europe before? e. Where in Europe are you going? ANS: C Only the question What are you most looking forward to in Europe? allows an unlimited answer. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 65 OBJ: 5 TOP: Open-ended communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A MULTIPLE RESPONSE 36. Which are true regarding communicating while using eye contact? (Select all that apply.) a. Eye contact is responsible for much communication. b. Eye contact is responsible for much miscommunication. c. Making eye contact generally indicates an intention to interact. d. Eye contact always results in a positive outcome. e. Extended eye contact can imply aggression. f. Extended eye contact can lead to heightened anxiety.
ANS: A, B, C, E, F Eye contact is responsible for much communication and much miscommunication. Generally, making eye contact communicates an intention to interact. However, the nature of the interaction and the results of eye contact are not necessarily always positive. Extended eye contact sometimes implies aggression and arouses anxiety. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 59 OBJ: 3 TOP: Eye contact KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 37. Which are examples of passive listening? (Select all that apply.) a. The nurse nods frequently while the patient speaks. b. The nurse maintains eye contact while listening to the patient. c. The nurse occasionally interjects, I see, when listening to the patient. d. The nurse gives verbal feedback to the patient. e. The nurse verbally interprets the meaning of what the patient has sai ANS: A, B, C, D Listening is sometimes active and sometimes passive. Active listening requires full attention to what the patient is saying. The message is heard, its meaning is interpreted, and the patient is given feedback, indicating understanding of the message. Verbally interpreting the meaning of what the patient has said is an example of active listening. In passive listening, the nurse indicates that they are listening to what the patient is saying either nonverbally, through eye contact and nodding, or verbally through encouraging phrases such as Uh-huh and I see. All of the other options are examples of passive listening. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 63 OBJ: 5 TOP: Listening KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 38. What is true about the use of touch in therapeutic communication? (Select all that apply.) a. Touch is a form of nonverbal communication. b. Touch is a form of verbal communication. c. Touch should be used with indiscretion.
d. Touch can convey warmth and caring. e. Touch can convey support and understanding. f. Touch should be used sincerely and genuinely. ANS: A, D, E, F Touch is a form of nonverbal communication that is inherent in the practice of nursing. Nearly every nursing intervention for the purpose of providing physical care calls for touch. Touch is frequently highly personal or of an intimate nature (e.g., giving a bed bath, assisting a patient on or off a bedpan, inserting a urinary catheter). Because of the intimate nature of touch in the nursing context, it is necessary to use it with great discretion to fit into sociocultural norms and guidelines. Some nurses are uncomfortable with touch because of a fear of it seeming inappropriate or being misinterpreted. When a nurse feels comfortable with physical contact with a patient, touch has great potential for conveying warmth, caring, support, and understanding. For the nurse to convey warmth, it is absolutely necessary for the nature of their touch to be sincere and genuine. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 62 OBJ: 5 TOP: Touch KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 39. When speaking to a person of a different culture, how should the nurse consider modifying his or her communication style? (Select all that apply.) a. Speak slowly and with increased volume b. Use of touch c. Use of eye contact d. Reference of address e. Meaning of gestures ANS: B, C, D, E Use of touch, eye contact, reference of address, and meaning of gestures all may have cultural significance and connotation. Slow, loud speech would not assist with speaking to a person of a different culture. PTS: 1 DIF: Cognitive Level: Application REF: Pages 70 OBJ: 7 TOP: Culture KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
40. Which defining characteristics support the nursing diagnosis of impaired
verbal communication? (Select all that apply.) a. Aphasia b. Geriatric patients c. Profoundly deaf d. Legally blind e. Severe COPD ANS: A, C, D, E Difficulty speaking, attending, disorientation, dyspnea, and sensory deficits are all defining characteristics that warrant a diagnosis of impaired verbal communication. Being a geriatric patient does not necessarily support the nursing diagnosis of impaired verbal communication. PTS: 1 DIF: Cognitive Level: Application REF: Page 72 OBJ:9TOP:Impaired communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 41. What is true about the use of silence in therapeutic communication? (Select all that apply.) a. Maintaining silence is an effective therapeutic communication techni b. Maintaining silence is generally overused in therapeutic communicat c. The sender often becomes uncomfortable when using silence. d. The ability to use silence effectively requires skill and timing. e. Prolonged periods of misunderstood silence can cause tension. f. Purposeful use of silence often conveys lack of respect. ANS: A, C, D, E Maintaining silence is an extremely effective therapeutic communication technique, and yet tends to be quite underused. Because silence often feels awkward in American society, people tend to feel the need to fill it. This impulse does not always allow the people involved in an interaction time to organize their thoughts sufficiently to communicate what they would like. It is common for a person to need several seconds after hearing a verbal message to interpret what has been stated and to formulate the most appropriate response. Unfortunately, the receiver often does not get this
amount of time before a response is necessary. In many cases, the sender becomes uncomfortable with the silence and begins speaking again before the receiver has had an opportunity to formulate a response and is really ready to deliver it. The ability to use silence effectively requires skill and timing. It is easy for prolonged periods of misunderstood silence to cause uneasiness and tension. However, in many cases, purposeful use of silence conveys respect, understanding, caring, and support, and it is often used in conjunction with therapeutic touch. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 63 OBJ: 5 TOP: Silence KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity COMPLETION 42. The nurse explains to a patient that based on the description of personal space, the area within 18 inches of the patient is designated as the zone. ANS: intimate Personal space zones: 0 to 18 inches = intimate, 18 inches to 4 feet = personal zone, 4 to 12 feet = social zone, more than 12 feet = public zone. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 69 OBJ:8TOP:Space and territoriality KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 43.A patient with aphasia who cannot understand a spoken or written message is said to have aphasia. ANS: receptive Aphasic patients who do not understand verbal exchanges are classified as receptive aphasics. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 75 OBJ: 7 TOP: Aphasia KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 44. The term that describes an individuals perception or understanding of a particular word or phrase is .
ANS: connotation Connotation is the meaning an individual applies to a word or phrase. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 59 OBJ: 2 TOP: Connotation KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 45. When a nurse lectures to a large group, the method of communication is usually in the form of communication. ANS: one-way One-way communication allows the sender to be in control with little expectation of or desire for feedback. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 59 OBJ: 5 TOP: Communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 46. As the nurse listens to a supervisor, the nurse has a smile on her face but has crossed her arms in front of her chest and has crossed her legs. This is an example of a posture. ANS: closed A posture with crossed limbs frequently is indicative of nonacceptance. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 60 OBJ: 6 | 7 TOP: Posture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 47. is the reciprocal process in which messages are sent and received between people. ANS: communication Communication is essential to the delivery of nursing care. It is the reciprocal process in which messages are sent and received between people. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 58 OBJ: 1 TOP: Communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 48. The is the person conveying the message, whereas the
is the individual or individuals to whom the message is conveyed. ANS: sender, receiver For communication to occur, a sender and a receiver of a message are both necessary. The sender is the person conveying the message, whereas the receiver is the individual or individuals to whom the message is conveyed. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 58 OBJ: 1 TOP: Communication KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 5: Nursing Process and Critical Thinking My Nursing Test Banks Chapter 5: Nursing Process and Critical Thinking Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What best defines the nursing process? a. A method to ensure that the physicians orders are implemented corre b. A series of assessments that isolate a patients health problem.
c. A framework for the organization of individualized nursing care. d. A preset formula for the design of nursing care. ANS: C The nursing process is a framework by which to organize individualized nursing care. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 78 OBJ: 1 TOP: Nursing process KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 2. All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment? a. 53-year-old admitted with a perforated ulcer b. 5-year-old admitted for the implant of grommets in the middle ear c. 76-year-old admitted for a knee replacement d. 40-year-old admitted for possible bowel obstruction ANS: A A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should receive a focused assessment. The remaining options are not considered critical illnesses. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ: 2 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. What subjective data does the nurse record following a head-to-toe examination? a. Rash on back b. Prolonged nausea c. Blood pressure of 190/100 d. White blood cell count of 19,000 ANS: B Another term for subjective data is symptoms, which cannot be observed or measured. This data must come from the patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:3TOP:Subjective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological
Integrity 4. What objective data should the nurse include after a patient assessment? a. Headache of 3 days duration b. Severe stomach cramps c. Flatulence d. Anxiety ANS: C Objective data are observable and measurable by people other than the patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:3TOP:Objective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. What is classified as information provided by the family when a patient is unable to provide data during assessment? a. Primary b. Secondary c. Unreliable d. Biased ANS: B Secondary sources include family members. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 79-80 OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 6. What are the two primary methods used to collect data? a. Written report by patient and family b. Review of the chart and the nurses notes c. Interview and physical examination d. Review of the physicians orders and the Kardex ANS: C The two primary methods of collecting data are interviewing and physical examination. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 79-80
OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 7. The nurse writes two nursing diagnoses: (1) inadequate nutritional intake related to vomiting as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition. What is the major difference between these diagnoses? a. The second diagnosis needs no defined nursing interventions. b. The second diagnosis needs medical intervention. c. The second diagnosis will not need to be evaluated. d. The second diagnosis reflects a problem that does not yet exist. ANS: D The actual nursing diagnosis represents a condition that is currently present. Risk for diagnoses are those that the patient is susceptible to, but not yet troubled by. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83 OBJ:4TOP:Nursing diagnosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. What framework does the establishment of priorities of care during the planning phase of the nursing process often use? a. Eriksons developmental tasks b. Piagets cognitive table c. Maslows hierarchy of needs d. Freuds classifications ANS: C A useful framework to guide prioritization is Maslows hierarchy of needs. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 85 OBJ:9TOPriorities of care KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 9.What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions? a. The patient will increase intake to 1000 mL daily to liquefy secretion b. The patient will cough more frequently within 3 days.
c. The patient will breathe better within 3 days. d. The patient will perform deep-breathing exercises four times daily. ANS: A The patient goal would be to improve airway clearance. Coughing more frequently within 3 days and performing deep-breathing exercises four times daily do not directly relate to the problem of thick secretions. Breathing better within 3 days is too vague. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 84 OBJ:6TOP:Nursing diagnosis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 10.What is the primary purpose of nursing orders? a. To support physicians orders b. To provide direction for all caregivers c. To provide broad, general statements d. To clarify nursing principles ANS: B Nursing orders are necessary to provide instructions for all caregivers. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 85-86 OBJ:7TOP:Nursing orders KEY:Nursing Process Step: PlanningMSC:NCLEX: N/A 11.What documentation reflects implementation? a. Patient selected low-sugar snacks independently. b. Patient was medicated with Tylenol 500 mg PO for pain. c. Patient was ambulated for 15 minutes after lunch. d. Patient participated in group therapy session without reminder. ANS: C Implementation is the nurse carrying out nursing orders to promote outcome achievement. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 87-88 OBJ:2TOP:Implementation KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 12.Which nursing order is complete and correct? a. May 10: Nursing assistants will ambulate patient. A. Nurse
b. Day nurse will cleanse wound and change dressings every day. May 1 c. Nursing assistants will serve 8 oz glass of juice at each meal, 5/10. d. P.M. nurse will ensure that heel protectors are in place before bedtime ANS: B Nursing orders must be signed, dated, and have specific designation as to who will perform intervention and specifics about time or frequency of the intervention. PTS: 1 DIF: Cognitive Level: Application REF: Pages 85-86 OBJ:7TOP:Nursing orders KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13.A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date, it is determined that what has occurred? a. Omission b. Variance c. Failure d. Error ANS: B A variance occurs when a projected outcome is not met. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 90 OBJ:8 | 11TOP:Critical pathways KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 14. During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a nursing diagnosis plan. What does this data represent? a. Symptoms b. Data clustering c. Signs of fluid overload d. Urinary retention ANS: B
The nurse organizes data, and those that are related are referred to as clustering. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 80 OBJ: 3 | 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. What type of assessment is performed continuously throughout nursepatient contact? a. Complete b. Body systems c. Focused d. Subjective ANS: C Focused assessments are performed continuously throughout nurse-patient contact based on the nursing care plan. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 79 OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 16. What assists the nurse in the identification of nursing diagnoses? a. Objective data b. Subjective data c. Data clustering d. Validated data ANS: C Data clustering assists the nurse in determining nursing diagnoses. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83 OBJ:4TOP:Nursing diagnosis KEY:Nursing Process Step: AssessmentMSC:NCLEX: N/A 17.What organized approach might the nurse use when performing a complete physical examination? a. Maslows hierarchy of needs b. A head-to-toe assessment c. Subjective data collection d.
Objective data collection
ANS: B A head-to-toe format provides a systematic approach. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 18. Who is the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis? a. Physician b. LPN/LVN c. RN d. Technician ANS: C The RN is responsible for analyzing and interpreting data. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 80 OBJ: 4 TOP: Role responsibility KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 19. What is the basis for designing and selecting nursing interventions to meet patient needs? a. Nursing diagnosis b. Care plan c. Physicians orders d. Nurses notes ANS: A The nursing diagnosis is the basis for developing nursing interventions. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 80 OBJ:4TOP:Nursing diagnosis KEY:Nursing Process Step: PlanningMSC:NCLEX: N/A 20. The patient is confined to bed rest, which contributes to immobility. What is bed rest considered in this situation? a. Contributing to the patients recovery b. A risk factor c. Difficult to maintain d.
A nursing responsibility
ANS: B Risk factors are those that increase the susceptibility of a patient to a problem. PTS: 1 DIF: Cognitive Level: Application REF: Page 82 OBJ: 5 TOP: Risk factors KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 21. What is a nursing diagnosis considered when a problem is suspected but data to support it are lacking? a. A syndrome nursing diagnosis b. An actual nursing diagnosis c. A risk for diagnosis d. A possible nursing diagnosis ANS: D A possible nursing diagnosis requires additional data to confirm a problem or to complete a data cluster so that it can be related to a NANDA-I label. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83 OBJ:4 | 10TOP:Nursing diagnosis KEY:Nursing Process Step: AssessmentMSC:NCLEX: N/A 22. When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation ANS: B During the planning phase, the nurse connects nursing interventions to nursing orders. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 85 OBJ:2TOP:Nursing process KEY:Nursing Process Step: PlanningMSC:NCLEX: N/A 23. What is an important consideration when developing the care plan? a. Ensure the number of interventions is limited b. Ensure the patient is involved in the process
c. Ensure interventions will be easy to implement d. Ensure evaluation of the nursing diagnoses is possible ANS: B Plans are more effective when the patient is involved in the process. The care plan is not limited in terms of the number of interventions, nor do they have to be easy. The nursing diagnoses are not evaluated; the patients progress toward the outcome is. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 85 OBJ: 6 | 9 TOP: Care plan KEY: Nursing Process Step: Planning MSC:NCLEX: N/A 24. From where are the risk for nursing diagnoses identified? a. The care plan b. The interventions c. The assessment d. The evaluation ANS: C Nursing diagnoses should be identified from the assessment. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 82-83 OBJ:2TOP:Nursing process KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. What expected outcome exemplifies accepted criteria? a. Nurse will assess vital signs every day b. Resident will observe safety guidelines while smoking c. Resident will take part in one activity daily for the next 90 days d. Nurse will monitor O2 saturation to maintain at gr ANS: C Expected outcomes must be patient-centered, measurable, and refer to a time frame. PTS: 1 DIF: Cognitive Level: Application REF: Page 84 OBJ:6TOP:Nursing process KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 26.During an admission assessment, the nurse collects objective and
subjective data. What is an example of subjective data? a. The patient complains of nausea. b. The patient is vomiting. c. The patient experiences tachycardia. d. The patent is pacing the halls. ANS: A Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of nausea is an example of subjective data. All other options are examples of objective data. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:1 | 3TOP:Subjective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 27. During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data? a. The patient is asleep. b. The patient is tearful. c. The patient has facial grimacing. d. The patient states, I hurt all over. ANS: D Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Stating I hurt all over is an example of subjective data. All other options are examples of objective data. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:1 | 3TOP:Nursing process KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 28.During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data? a. The patient is coughing. b. The patient has cyanosis of the lips. c. The patient experiences tachypnea.
d. The patient complains of generalized discomfort. ANS: D Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of generalized discomfort is an example of subjective data. All other options are examples of objective data. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:1 | 3TOP:Subjective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data? a. The patient complains of chest pain. b. The patient states, I feel nauseous. c. The patient complains of feeling faint. d. The patient is short of breath on exertion. ANS: D Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Shortness of breath on exertion is an example of objective data. All other options are examples of subjective data. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:1 | 3TOP:Objective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data? a. The patient is jaundiced. b. The patient states, I am nervous. c. The patient complains of palpitations. d.
The patient denies dizziness when ambulating.
ANS: A Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. The patient is jaundiced is an example of objective data. All other options are examples of subjective data. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:1 | 3TOP:Objective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data? a. The patient complains of feeling depressed. b. The patient states, I hear voices in my head. c. The patient complains of auditory hallucinations. d. The patient is pacing back and forth while chanting. ANS: D Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Pacing back and forth while chanting is an example of objective data. All other options are examples of subjective data. PTS: 1 DIF: Cognitive Level: Application REF: Page 79 OBJ:1 | 3TOP:Objective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 32. What is an example of an appropriate nursing diagnosis? a. Impaired skin integrity b. Skin breakdown noted c. Turn patient every 2 hours d.
The patient has scabies on his back
ANS: A Impaired skin integrity is an example of a nursing diagnosis. Skin breakdown noted is an example of a charting entry, turn patient every 2 hours is a nursing intervention, and scabies is a medical diagnosis. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83 OBJ:4TOP:Nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 33. What is an example of an appropriate nursing diagnosis? a. Constipation b. Patient complains of constipation c. Need for laxatives d. Patient has a duodenal ulcer ANS: A Constipation is an example of a nursing diagnosis, a patient complaining of constipation is an example of a charting entry, a need for laxatives is an example of a patient need, and a patient has a duodenal ulcer is an example of a medical diagnosis. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83 OBJ:4TOP:Nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 34.A nurse is formulating a nursing diagnosis. What is an example of an appropriately written nursing diagnosis? a. Risk for impaired skin integrity related to physical immobilization b. Physical immobilization secondary to risk for impaired skin integrity c. Risk for impaired skin integrity related to diagnosis of decubitus ulce d. Physical immobilization secondary to decreased cognitive ability ANS: A Risk for impaired skin integrity related to physical immobilization is the only appropriately written nursing diagnosis. All other options are not listed as NANDA-I approved nursing diagnoses. PTS: 1 DIF: Cognitive Level: Application REF: Pages 81-83
OBJ:4TOP:Nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 35. Which is an example of a nursing diagnosis? a. Pneumonia b. Diabetes mellitus c. Impaired skin integrity d. Congestive heart failure ANS: C Impaired skin integrity is the only example of a nursing diagnosis; all other options are examples of medical diagnoses. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83 OBJ:4TOP:Nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 36. Which is an example of a medical diagnosis? a. Constipation b. Diabetes mellitus c. Impaired skin integrity d. Altered nutrition: less than body requirements ANS: B Diabetes mellitus is the only example of a medical diagnosis; all other options are examples of nursing diagnoses. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 83 OBJ:4TOP:Medical diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 37. Which is an example of a medical diagnosis? a. Pain b. Anxiety c. Pneumonia d. Impaired skin integrity ANS: C
Pneumonia is the only example of a medical diagnosis; all other options are examples of nursing diagnoses. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 83 OBJ:4TOP:Medical diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 38. Which are acceptable secondary sources for data? (Select all that apply.) a. Patient b. Family members c. Other health professionals d. Diagnostic reports e. Textbooks ANS: B, C, D, E A patient is not a secondary source. The patient is the primary data source. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 79-80 OBJ: 3 TOP: Data sources KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 39. Which are official categories of nursing diagnoses? (Select all that apply.) a. Actual b. Risk c. Wellness d. Syndrome e. Potential ANS: A, B, C, D Actual, risk, wellness, and syndrome are the four categories of nursing diagnoses. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83 OBJ: 4 TOP: Nursing diagnosis KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 40. Which are considered phases of the nursing process? (Select all that apply.) a. Diagnosis
b. Prediction c. Assessment d. Evaluation e. Implementation f. Outcome identification ANS: A, C, D, E, F The nursing process consists of six dynamic and interrelated phases: diagnosis, assessment, outcome identification, planning, implementation, and evaluation. Prediction is not a phase of the nursing process. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 78 OBJ: 2 TOP: Nursing process KEY: Nursing Process Step: All MSC:NCLEX: N/A COMPLETION 41. NANDA International meets to reorganize diagnosis labels and language every years. ANS: 2 NANDA meets every 2 years to revise language, form, and diagnosis labels. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 81 OBJ: 10 TOP: NANDA KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 42. The standards that name and measure patient outcomes are referred to as . ANS: NOC (Nursing Outcome Classification) NOC Nursing Outcome Classification NOC sets up outcome criteria based on a patient problem. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 88-89 OBJ: 10 TOP: NOC KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 43. The document that outlines a multidisciplinary plan for care interventions over a specified time frame is a . ANS:
clinical pathway critical path A clinical pathway is an organized multidisciplinary plan over a specified time frame, which outlines aspects of patient care. They are also called critical paths, action plans, and care maps. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 90 OBJ: 11 TOP: Clinical pathways KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 44.A systematic method by which nurses plan and provide care for patients is known as the . ANS: nursing process The nursing process serves as the organizational framework for the practice of nursing. It is a systematic method by which nurses plan and provide care for patients. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 78 OBJ: 2 TOP: Nursing process KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 45.A systemic, dynamic process by which the nurse, through interaction with the patient, significant others, and health care providers, collects and analyzes data about the patient is known as . ANS: assessment The American Nurses Association (ANA) defines assessment as a systemic, dynamic process by which the nurse, through interaction with the client, significant others, and health care providers, collects and analyzes data about the client. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 78 OBJ:2TOP:Nursing process KEY:Nursing Process Step: AssessmentMSC:NCLEX: N/A 46.Any health care condition that requires diagnostic, therapeutic, or educational actions is known as a . ANS: problem
A problem is any health care condition that requires diagnostic, therapeutic, or educational actions. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 81 OBJ: 2 TOP: A problem KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 47.A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes is known as a . ANS: nursing diagnosis A nursing diagnosis is a type of health problem that can be identified. It is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 81 OBJ:4TOP:Nursing diagnosis KEY:Nursing Process Step: DiagnosisMSC:NCLEX: N/A 48. The human responses to health conditions/life processes that exist in an individual, family, or community are known as a(n) . ANS: actual nursing diagnosis An actual nursing diagnosis is described as the human responses to health conditions/life processes that exist in an individual, family, or community. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 81-83 OBJ:4TOP:Actual nursing diagnosis KEY:Nursing Process Step: DiagnosisMSC:NCLEX: N/A 49. Human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community are known as a(n) . ANS: risk nursing diagnosis A risk nursing diagnosis is defined as the human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 81-83 OBJ:4TOP:Risk nursing diagnosis KEY:Nursing Process Step: DiagnosisMSC:NCLEX: N/A 50.Human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement are known as a . ANS: wellness nursing diagnosis A wellness nursing diagnosis is defined as human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 83 OBJ:4TOP:Wellness nursing diagnosis KEY:Nursing Process Step: DiagnosisMSC:NCLEX: N/A 51.The identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures is known as a . ANS: medical diagnosis A medical diagnosis is the identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 83 OBJ: 4 TOP: Medical diagnosis KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 52.A health care system that provides control over health care services for a specific group of individuals in an attempt to control cost is known as . ANS: managed care Managed care is a health care system that provides control over health care services for a specific group of individuals in attempts to control cost. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 90 OBJ: 6 | 11 TOP: Risk Managed care KEY: Nursing Process Step: N/A
MSC:NCLEX: N/A 53.A multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases is known as a . ANS: critical pathway A critical pathway is a multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 90 OBJ: 11 TOP: Clinical pathways KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 6: Cultural and Ethnic Considerations My Nursing Test Banks Chapter 6: Cultural and Ethnic Considerations Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. Culture varies from patient to patient. Why is it important that the nurse understand and accept each person as an individual? a. To develop a plan of care b. To provide holistic care c. To identify differences d. To support each patient ANS: B Accepting each person as an individual is the first step in providing holistic care. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 95 OBJ: 2 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 2. What is a fixed concept of how all members of an ethnic group act or think? a. Variations within a cultural group b. Identical practices c. Holistic nursing
d. Ethnic stereotypes ANS: D Ethnic stereotypes are fixed concepts of how all members of an ethnic group act or think. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 95 OBJ: 4 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 3. All nurses should work to provide culturally appropriate nursing care. What is the integration of cultural knowledge into all aspects of care? a. Cultural competence b. Transcultural nursing c. Nursing process d. Team nursing ANS: B All nurses should provide transcultural nursing, which is the integration of cultural knowledge into all aspects of care. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 95-96 OBJ: 1 | 2 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 4. What is the term for when members of a particular ethnic group believe that their beliefs and practices are the best? a. Prejudice b. Separatism c. Ethnocentrism d. Bias ANS: C When members of a particular ethnic group believe that their practices and beliefs are the best, it is referred to as ethnocentrism. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 95 OBJ: 4 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 5. What is the term used to describe cultures in which women make decisions about health care and provide the care and discipline to the children?
a. Biologic b. Matriarchal c. Cultural d. Patriarchal ANS: B In a matriarchal society, women make the decisions about health care. In patriarchal society, the men make decisions about health care. There is no such thing as biologic or cultural cultures. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 100 OBJ: 4 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 6. What basic philosophy in the United States is relevant to health care? a. Folk remedies b. Biomedical therapy c. Holistic therapy d. Spiritual intervention ANS: B Most people in the United States believe biomedical therapy is the best way to treat disease. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 106 Table 6-2 OBJ: 4 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 7. What is a set of learned values, beliefs, customs, and practices shared by a group? a. Race b. Ethnicity c. Culture d. Religion ANS: C Culture is a set of learned values, beliefs, customs, and practices shared by a group. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 94 OBJ: 4 TOP: Culture KEY: Nursing Process Step: N/A
MSC:NCLEX: N/A 8.A nurse is American-born and works in a large hospital with patients from many cultures. What must this nurse develop to provide the best care? a. Another language b. Assessment skills c. Cultural competence d. Care planning ability ANS: C To provide care to patients from different cultures, the nurse must develop cultural competence. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 95 OBJ: 3 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 9. The nurse from New York City is caring for a patient from Atlanta, Georgia. What difference between the nurse and patient may cause them to experience difficulty in communicating? a. Race b. Subculture c. Ethnic group d. Culture ANS: B Subcultures have characteristic patterns that distinguish them from the rest of the culture. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 94 OBJ: 2 TOP: Subculture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 10. The father of an American Indian has just died. What should the nurse do immediately after death? a. Provide privacy so that the family may touch and kiss the deceased g b. Ask about providing help with the death ceremony c. Carefully wrap the deceaseds clothing for the family to take home d. Mention the deceased by name frequently ANS: B
In the American Indian culture it is taboo to touch the deceased or any of the belongings of the deceased. After death, the name of the deceased is not spoken. PTS: 1 DIF: Cognitive Level: Application REF: Page 112 Table 6-4 OBJ:1 | 4 | 6TOP:American Indian KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 11. What is the term for a generalization about a form of behavior, an individual, or a group? a. Dialect b. Religion c. Ethnicity d. Stereotype ANS: D A stereotype is a generalization about a form of behavior, an individual, or a group. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 95 OBJ: 4 TOP: Stereotype KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 12. What is the term for a group of people who share biologic physical characteristics? a. Race b. Culture c. Religion d. Social organization ANS: A A race is a group of people who share biologic physical characteristics. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 96 OBJ: 4 TOP: Race KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 13. What is the term for a group of people who share a common social and cultural heritage based on shared traditions, national origin, and physical and biologic characteristics?
a. Race b. Culture c. Religion d. Ethnicity ANS: D Ethnicity refers to a group of people who share a common social and cultural heritage based on shared traditions, national origin, and physical and biologic characteristics. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 96 OBJ: 4 TOP: Ethnicity KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 14.A nurse is caring for a neonate born to observant Orthodox Jewish parents. Who can the nurse anticipate will name the neonate? a. Father b. Mother c. Grandfather d. Grandmother ANS: A For observant Jews, babies are named by the father. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 103 Box 6-4 OBJ: 2 | 3 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 15.A nurse is caring for a male neonate born to observant Orthodox Jewish parents. Who will the nurse anticipate will circumcise the neonate? a. A bishop b. A mohel c. His father d. His physician ANS: B Male children are named 8 days after birth, when ritual circumcision is done. A mohel performs the circumcision. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 103 Box 6-4 OBJ: 2 | 4 TOP: Religious practices KEY: Nursing Process Step: N/A
MSC: NCLEX: Psychosocial Integrity 16.A nurse is caring for a female neonate born to observant Orthodox Jewish parents. What book does the nurse know will be used when naming this neonate? a. Bible b. Koran c. Holy Torah d. Book of Mormon ANS: C For observant Jews, female babies are usually named during a reading of the Holy Torah. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 103 Box 6-4 OBJ: 2 | 4 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 17.A nurse is caring for an Orthodox Jewish woman immediately after she has given birth. What can the nurse expect regarding the spouses participation in his wifes care? a. He will share a bed with the patient. b. He will ask to bathe with the patient. c. He will touch the patient frequently. d. He will avoid physical contact with the patient. ANS: D For observant Jews, a woman is considered to be in a ritual state of impurity whenever blood is coming from her uterus, such as during menstrual periods and after the birth of a child. During this time, her husband will not have physical contact with her. When this time is completed, she will bathe herself in a pool called a mikvah. Nurses need to be aware of this practice and be sensitive to the husband and wife because the husband will not touch his wife. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 103 Box 6-4 OBJ: 4 | 5 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 18.A nurse is caring for an Orthodox Jewish patient. What is the most
appropriate dietary requirement for the nurse to implement? a. Mixing of milk and meat at a meal b. Use of separate cooking utensils for meat and milk products c. Use of one set of cooking utensils for meat and milk products d. Consumption of food not slaughtered in accordance with Jewish law ANS: B For observant Jews, Kosher dietary laws include the following: no mixing of milk and meat at a meal; no consumption of food or any derivative thereof from animals not slaughtered in accordance with Jewish law; use of separate cooking utensils for meat and milk products; if a patient requires milk and meat products for a meal, the dairy foods should be served first, followed later by the meat. PTS: 1 DIF: Cognitive Level: Application REF: Page 103 Box 6-4 OBJ: 4 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 19. The nurse is preparing an Orthodox Jewish patients tray during Passover. What intervention is appropriate for this patient? a. Avoid fish dishes b. Encourage time for prayer c. Offer the patient leavened products d. Encourage the use of loud music in celebration ANS: B Orthodox Jews say prayers over the bread and wine before meals. Time and a quiet environment should be provided for this. During Passover, no leavened products are eaten. PTS: 1 DIF: Cognitive Level: Application REF: Page 103 Box 6-4 OBJ: 4 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 20.A nurse is preparing to discuss birth control options for a Roman Catholic patient. What is the most appropriate method for the nurse to discuss with this patient? a. Abstinence b. Vasectomy
c. Tubal ligation d. Oral contraceptives ANS: A Birth control for Roman Catholics is prohibited except for abstinence or natural family planning. Referral to a priest for questions about this can be of great help. Nurses can teach the techniques of natural family planning if they are familiar with them; otherwise, this should be referred to the physician or to a support group of the Church that instructs couples in this method of birth control. Sterilization is prohibited unless there is an overriding medical reason. PTS: 1 DIF: Cognitive Level: Application REF: Page 104 Box 6-4 OBJ: 3 | 5 | 7 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 21.A nurse is preparing a meal tray for a patient who is a Latter-Day Saint. What beverage should the nurse prepare? a. Tea with all meals b. Coffee each morning c. Cola beverages d. Fruit juice ANS: D For observant Latter-Day Saints, beverages with caffeine such as cola, coffee, and tea; alcohol; and other substances are considered injurious. PTS: 1 DIF: Cognitive Level: Application REF: Pages 101-102 Box 6-4 OBJ: 4 | 7 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 22.A nurse is caring for a patient who is a Latter-Day Saint. The nurse is aware members of this faith may wear sacred undergarments. What intervention is appropriate for the nurse caring for this patient? a. Instruct the patient to remove the undergarments b. Allow the patient to wear the undergarments only at night c. Allow the patient to wear the undergarments only during the day d. Remove the undergarments in emergency situations only ANS: D
For observant Latter-Day Saints, a sacred undergarment may be worn at all times and should be removed only in emergency situations. PTS: 1 DIF: Cognitive Level: Application REF: Page 101 Box 6-4 OBJ: 4 | 5 TOP: Religious practices KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 23. Which statement about the biomedical health belief system is true? a. Life processes can be manipulated by human beings by mechanical in b. Life processes cannot be manipulated by human beings by mechanica c. Disease has a nonspecific cause, onset, course, and treatment. d. Disease is only caused by failure of body parts and chemical imbalanc ANS: A Characteristic of the biomedical health belief system include the beliefs that life is regulated by biomedical and physical processes. Life processes can be manipulated by human beings by mechanical interventions. Health is the absence of disease or signs and symptoms of disease. Disease is an alteration of the structure and function of the body. Disease has a specific cause, onset, course, and treatment. It is caused by trauma, pathogens, chemical imbalances, or failure of body parts. Treatment focuses on the use of physical and chemical treatments. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 106 Table 6-2 OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 24. Which health belief system is commonly referred to as third-world beliefs and practices? a. Folk health belief system b. Holistic health belief system c. Biomedical health belief system d. Alternative/complementary belief system ANS: A The folk health belief system is commonly referred to as third-world beliefs and practices. It is often called strange or weird by nurses and other health professionals who are unfamiliar with folk medicine beliefs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 106 Table 6-2
OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 25. Which health belief system includes a belief of a supernatural force exerting influence to cause health or illness? a. Folk b. Holistic c. Biomedical d. Alternative/complementary ANS: A The folk health belief system is commonly referred to as third-world beliefs and practices. It is often called strange by nurses and other health professionals who are unfamiliar with folk medicine beliefs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 106 Table 6-2 OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 26. Which health belief system focuses on restoring balance with physical, social, and metaphysical worlds? a. Folk health belief system b. Holistic health belief system c. Biomedical health belief system d. Alternative/complementary belief system ANS: B The treatment based on the holistic health belief system is designed to restore balance with physical, social, and metaphysical worlds. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 106 Table 6-2 OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 27. The nurse is caring for a patient who fasts during daylight hours during Ramadan. The nurse recognizes that the patient is adhering to the cultural beliefs of which culture? a. Muslims b. African Americans c. Chinese Americans
d. Mexican Americans ANS: A Muslims practice fasting during daylight hours during Ramadan. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 101-102 Box 6-4 OBJ: 4 | 5 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 28. The nurse is caring for a Muslim patient. What dietary selection should the nurse serve to this patient? a. Bacon, eggs, and toast b. Pork fried rice c. Ham and cheese sandwich d. Chicken and rice ANS: D Muslims practice avoidance of foods that include pork products. Bacon, pork, and ham are all pork products. Only the chicken and rice meal does not include a pork product. PTS: 1 DIF: Cognitive Level: Application REF: Pages 101-102 Box 6-4 OBJ: 1 | 2 | 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 29.A patient requests a consultation between the physician and a religious leader known as an Imam. What is this patients cultural belief? a. Muslim b. African American c. Chinese American d. Mexican American ANS: A Muslims may wish to have their doctor consult with an Imam, a religious leader. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 112 Table 6-4 OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 30. The nurse is delivering a meal tray to a female Muslim patient. What intervention is most appropriate for this patient?
a. Offering her a ham and cheese sandwich b. Providing her with a male nurse c. Providing her with a female nurse d. Offering her bacon and eggs ANS: C When caring for Muslims, same-sex health care providers should be used if at all possible. Ham and bacon are not appropriate items to offer a Muslim patient, since they do not consume pork products. PTS: 1 DIF: Cognitive Level: Application REF: Page 112 Table 6-4 OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 31. The nurse is caring for a Chinese American patient. How should this nurse demonstrate cultural awareness? a. Maintain eye contact with the patient b. Hold the patients hand while conversing c. Touch the patients arm when speaking to the patient d. Sit side-to-side when speaking with the patient ANS: D Chinese Americans view maintaining eye contact as ill-mannered and disrespectful. They are uncomfortable when face-to-face, and prefer to sit side-to-side or at a right angle to carry on conversation. Touching is not usual during conversation; it is regarded as disrespectful or impolite. PTS: 1 DIF: Cognitive Level: Application REF: Page 111 Table 6-4 OBJ: 4 | 5 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 32. The nurse is caring for a Mexican American patient. What nursing intervention would best demonstrate cultural sensitivity? a. Encouraging consultation of male members of the family regarding he b. Discouraging consultation of male members of the family regarding h c. Insisting on providing all personal care required by the patient d. Asking only female family members about health care decisions ANS: A When caring for Mexican Americans, families may expect to help care for
the patient. Male family members usually are consulted before health care decisions are made. PTS: 1 DIF: Cognitive Level: Application REF: Page 112 Table 6-4 OBJ: 4 | 5 | 7 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 33. The nurse is caring for an African American patient. Who would the nurse expect to be the primary decision maker in the patients family? a. Men b. Women c. Clergy d. Grandparents ANS: B When caring for African Americans, women are primarily the decision makers in the family and are frequently the head of the household. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 112 Table 6-4 OBJ: 1 | 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 34. The nurse is caring for a Mexican American patient who is in labor. How can this nurse best demonstrate cultural sensitivity? a. Encouraging female family members to be present for the delivery b. Encouraging the patients spouse to be present for the delivery c. Asking the patients spouse to see his baby before cutting the umbilic d. Asking the patients spouse to hold the neonate before bathing the neo ANS: A When caring for Mexican Americans, it is considered inappropriate for the husband to be present during birth. The father is not expected to see his wife or baby until both are cleaned and dressed. PTS: 1 DIF: Cognitive Level: Application REF: Page 112 Table 6-4 OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 35. The nurse is caring for a postpartum patient who requests to dry and bury the umbilical cord near an object or in a place that symbolizes what the parents want for the childs future. Which cultural beliefs does the nurse
recognize this patient adhering to? a. American Indian b. African American c. Chinese American d. Mexican American ANS: A After delivery, American Indians practice taking the umbilical cord from the newborn, drying and burying it near an object or place that symbolizes what the parents want for the childs future. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 112 Table 6-4 OBJ: 4 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 36. What are some characteristics that cultures have in common? (Select all that apply.) a. Economic practices b. Survival modes c. Transportation systems d. Language e. Family systems ANS: A, B, C, E Language may differ within cultures; the rest are shared characteristics. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 95 Box 6-1 OBJ: 1 | 4 TOP: Common traits KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 37. What should the culturally sensitive nurse do for a Muslim woman being treated in the hospital? (Select all that apply.) a. Assign only female staff to care for her. b. Keep her head and extremities covered as much as possible. c. Arrange for family to bring specially prepared pork dishes. d. Let her make decisions relative to her care. e. Allow privacy for prayer. ANS: A, B, E
Muslim women are not accustomed to making decisions, leaving it to the head of the house or the family as a whole. Muslims do not eat pork. PTS: 1 DIF: Cognitive Level: Application REF: Page 102 Box 6-4 OBJ: 4 | 5 TOP: Muslims KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 38.A nurse working in a long-term care facility is admitting an 85-year-old resident of Hispanic descent diagnosed with Alzheimer disease. What should this nurse take into consideration when caring for the resident? (Select all that apply.) a. Cultural background has an important role in determining the residen b. The resident will be culturally sensitive to caregivers c. Home remedies may have value even if harmful d. The resident will have a strong sense of trust for health care workers e. Communication should involve gesturing whenever possible ANS: A, C Cultural background has an impact on family dynamics and plays an important role in determining the role and the status of the older person. Some older adults are less tolerant of other cultures as a result of influences or experiences early in their lives, which raises the possibility of misunderstandings and distrust when the caregiver is of a cultural group different than that of the older person. Communication should suit the individual needs of the resident and does not necessarily involve gesturing. PTS: 1 DIF: Cognitive Level: Application REF: Page 96 OBJ: 6 TOP: Older Adult KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity COMPLETION 39. The nurse should not maintain eye contact with a Korean patient because many Asians believe prolonged eye contact is . ANS: impolite rude Many Asians avoid eye contact, believing it to be impolite or rude. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 111 Table 6-4 OBJ: 2 | 4 TOP: Asians KEY: Nursing Process Step: Implementation
MSC:NCLEX: N/A 40. The cultural characteristic of unwillingness to leave a current activitywhich may result in late or missed appointmentsis called . ANS: elasticity Elasticity is the ethnic characteristic of being late or missing an appointment altogether because of involvement in a current activity. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 100 OBJ: 4 TOP: Elasticity KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 41. Following the death of a Presbyterian infant, the nurse should help arrange for . ANS: baptism Presbyterians believe in infant baptism. PTS: 1 DIF: Cognitive Level: Application REF: Page 104 Box 6-4 OBJ:4TOP:Infant baptism KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 42. While caring for a Mexican American family in the home, the home health nurse recognizes that the family may also consult the for health advice. ANS: curandero, folk healer curandero folk healer The curandero or folk healer is an important figure in the health care of MexicanAmericans. PTS: 1 DIF: Cognitive Level: Application REF: Page 107 Figure 6-2 OBJ:4TOP:Mexican Americans KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 43.A nation, community, or broad group of people who establish particular
aims, beliefs, or standards of living and conduct is known as a . ANS: society A society is a nation, community, or broad group of people who establish particular aims, beliefs, or standards of living and conduct. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 94 OBJ: 4 TOP: Society KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 44.A set of learned values, beliefs, customs, and practices that are shared by a group and are passed from one generation to another is known as . ANS: culture Culture is a set of learned values, beliefs, customs, and practices that are shared by a group and are passed from one generation to another. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 94 OBJ: 4 TOP: Culture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 45.A generalization about a form of behavior, an individual, or a group is known as a . ANS: stereotype A stereotype is a generalization about a form of behavior, an individual, or a group. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 95 OBJ: 4 TOP: Stereotype KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 7: Asepsis and Infection Control My Nursing Test Banks Chapter 7: Asepsis and Infection Control Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What is true regarding surgical asepsis?
a. It inhibits growth of pathogenic organisms. b. It is known as a cleaning technique. c. It includes hand hygiene. d. It is known as a sterile technique. ANS: D Surgical asepsis is known as a sterile technique. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 117 OBJ: 1 TOP: Infection KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 2. What action exemplifies a nurse practicing medical asepsis in performing daily care? a. Lifting a sterile swab from a sterile field b. Using disposable sterile gowns c. Washing hands for 5 minutes between patients d. Keeping bed linens off the floor ANS: D Keeping the bed linens off the floor is an example of medical asepsis; all other options are examples of surgical asepsis. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 117 OBJ: 1 | 2 TOP: Infection KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 3. What bacteria can lie dormant when conditions for growth are not favorable? a. Residue b. Capsules c. Spores d. Flagella ANS: C Spore formation occurs when conditions are unfavorable, causing the bacteria to take a dormant form. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 118 OBJ: 2 | 4 TOP: Bacteria KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment
4.A patient with a respiratory infection reports that he is not yet on an antibiotic. The nurse explains that the physician is waiting on the results of the culture and sensitivity. What does this test determine? a. What media the bacteria requires to grow b. How fast the bacteria grow c. Which antibiotics stop bacterial growth d. When the bacteria colonize ANS: C Sensitivity tests are done to determine which antibiotics will stop growth. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 118 OBJ:6TOP:Laboratory tests KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. What bacterium is responsible for more diseases than any other organism? a. Staphylococcus b. Pseudomonas aeruginosa c. Haemophilus influenzae d. Streptococcus ANS: D The Streptococcus bacterium is responsible for more diseases than any other organism. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 118 OBJ: 3 TOP: Bacteria KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 6. What additional complication does a disease caused by a virus have compared to a disease caused by bacteria? a. Multiplies rapidly b. Returns frequently c. Is not killed by antibiotics d. Is unable to be cultured ANS: C Antibiotics do not alter the course of a disease caused by a virus. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 119
OBJ: 3 TOP: Virus KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 7.A patient with ringworm asks the nurse if she has worms. What does the nurse inform the patient about the cause of ringworm? a. Bacteria b. Protozoa c. Virus d. Fungi ANS: D Ringworm is caused by fungi. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 121 OBJ: 3 TOP: Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. What should the nurse be diligent in to provide a safe environment for the patient? a. Keeping a light on at night to prevent falls b. Hand hygiene between patient contacts c. Regulating the temperature to avoid drafts d. Changing the bed linen to diminish microorganisms ANS: B One of the most important actions is hand hygiene before caring for another patient. PTS: 1 DIF: Cognitive Level: Application REF: Pages 126 OBJ:5 | 8 | 9TOP:Safe environment KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 9. What does the nurse describe when giving an example of a fomite vehicle? a. Rabid dog b. Person with AIDS c. Contaminated stethoscope d. Infected wound ANS: C If a vehicle is an inanimate (nonliving) object, it is called a fomite.
PTS: 1 DIF: Cognitive Level: Application REF: Page 122 OBJ: 2 TOP: Infection KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 10. The nurse observes a patient demonstrating wound cleaning. What action indicates the need for further instruction? a. Using sterile gloves to perform the cleaning b. Applying an antiseptic to the area c. Cleaning the area from the outside in d. Washing hands with soap ANS: C Cleaning away from the wound prevents entrance of microorganisms. PTS: 1 DIF: Cognitive Level: Application REF: Pages 123-125, 141 OBJ: 13 TOP: Wounds KEY: Nursing Process Step: Evaluation MSC:NCLEX: Safe, Effective Care Environment 11. The nurse is concerned when a patient admitted with a diagnosis of pneumonia suddenly develops a urinary tract infection (UTI). What type of infection is this UTI considered? a. Viral infection b. Bacterial infection c. Health careassociated infection d. Spore infection ANS: C More than 40 million people are admitted to hospitals each year and as many as 10% of them acquire a health careassociated infection while there. Criteria for health careassociated infections require that the infection manifest at least 48 hours after hospitalization or contact with another health agency. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 124 OBJ:2TOP:Health careassociated infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse prioritizes the care of four patients. Which patient has a systemic infection? a. 14-year-old with acute appendicitis
b. 80-year-old with a urinary tract infection c. 40-year-old with AIDS d. 50-year-old with arthritis ANS: C AIDS is a systemic viral infection. Acute appendicitis and urinary tract infections are local infections. Arthritis is not an infection. PTS: 1 DIF: Cognitive Level: Application REF: Pages 119-120; 126 OBJ:6TOP:Systemic infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. What assessment does the nurse recognize as an inflammatory response in a surgical wound on the leg of a patient? a. A foul drainage is coming from the wound b. The affected leg is cooler than the other leg c. There are raised, red, pruritic welts on the leg d. Rubor and edema appear around the wound ANS: D Rubor and edema are two of the cardinal signs of an inflammatory response. Foul drainage suggests infection, the affected leg being cooler than the other leg suggests circulatory disorder, and raised, red, pruritic welts on the leg suggest allergy. PTS: 1 DIF: Cognitive Level: Application REF: Page 124 OBJ:7TOP:Inflammatory response KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. The infection control practitioner plans an in-service on control of health care-associated infections. What should be the focus of this program? a. Observing nurses caring for patients b. Screening patients who are admitted to the hospital c. Educating hospital personnel about aseptic practices d. Discharging infectious patients from the hospital ANS: C Duties of the infection control practitioner include staff education on
infection control. PTS: 1 DIF: Cognitive Level: Application REF: Page 124 OBJ: 5 | 13 TOP: Infection KEY: Nursing Process Step: Planning MSC:NCLEX: Safe, Effective Care Environment 15.A health care worker is stuck by a needle left on the patients bedside table. The staff member appropriately reports the needlestick. What will the indicated treatment be combatting? a. Hepatitis B b. Streptococcal infections c. Staphylococcal infections d. Influenza ANS: A Workers who have had a needlestick need to complete an injury report and seek treatment in the event of exposure to hepatitis B. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 126 OBJ: 3 | 5 TOP: Needlesticks KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 16. What technique should the nurse use when disposing of linens contaminated with feces? a. Don gown, gloves, and mask b. Wash hands for 5 minutes after disposal c. Don gloves only d. Double-bag the sheets ANS: C All health care workers should follow Standard Precautions to prevent infection from pathogens. Standard Precautions for the disposal of ordinary feces require only that the nurse don gloves. PTS: 1 DIF: Cognitive Level: Application REF: Page 135 OBJ:13TOP:Standard Precautions KEY: Nursing Process Step: Analysis MSC: NCLEX: Safe, Effective Care Environment 17. The nurse is instructing a patient about the most important preventive technique for breaking the chain of infection. What technique is the patient
learning about? a. Sterilization b. Standard Precautions c. Hand hygiene d. Medical asepsis ANS: C Hand hygiene is the most important preventive measure for interrupting the infection process. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 126 OBJ: 2 | 9 TOP: Infection KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 18. How long should the nurse perform hand hygiene before beginning care of a patient? a. 5 minutes b. 2 minutes c. 1 minute d. 30 seconds ANS: D The nurse should wash hands after using the bathroom, after contact with any secretions, before eating, and before and after patient care. The nurse should use warm water, soap, and friction for 15 to 30 seconds, and dry hands thoroughly. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 126 OBJ: 9 TOP: Infection KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 19.A nurse is observing isolation precautions by wearing a mask while performing complex patient care. How often should the nurse change masks? a. 5-10 minutes b. 10-20 minutes c. 20-30 minutes d. 30-40 minutes ANS: C The mask should be changed every 20 to 30 minutes.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 134 OBJ: 8 TOP: Mask KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 20.A major threat to health care workers is blood-contaminated sharps. What should the nurse use to discard the used syringe? a. Wastebasket b. Sink c. Puncture-proof container d. Disinfecting soap ANS: C All patient care areas where sharps are used require puncture-proof containers. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 135 OBJ: 8 TOP: Sharps KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 21. The nurse is transporting a patient in respiratory isolation to the radiology department. What intervention should the nurse implement? a. Cover the patient with a sheet b. Take the patient down the service elevator c. Apply a mask to the patient d. Call x-ray to come and get the patient ANS: C If a patient requiring respiratory isolation must be transported to another area, the patient must don a mask. PTS: 1 DIF: Cognitive Level: Application REF: Pages 135-136 OBJ: 5 | 8 TOP: Isolation KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 22. The patient in isolation may experience psychological or emotional deprivation. What should the nurse do to help minimize these feelings? a. Be cheerful b. Spend extra time with the patient c. Protect the patient from additional infection d. Answer the call light quickly
ANS: B To minimize feelings of psychological or emotional deprivation, the nurse should spend extra time with the patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 137 OBJ: 13 TOP: Isolation KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 23. The infection control officer is observing hospital staff for appropriate use of aseptic technique. What observation demonstrates the need for more instruction on surgical asepsis? a. Facing the sterile field b. Placing a sterile dressing on a sterile field c. Touching the edges of the sterile field with sterile gloves d. Keeping gloved hands above the waist ANS: C The edges of a sterile field are not considered sterile. PTS: 1 DIF: Cognitive Level: Application REF: Pages 139-141 OBJ:1TOP:Sterile technique KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment 24. The nurse is pouring a sterile solution from a bottle. What direction should the label on the bottle be in for appropriate technique? a. Facing outward b. Covered c. Facing downward d. In the palm of the hand ANS: D The bottle should be held with the label in the palm of the hand. PTS: 1 DIF: Cognitive Level: Application REF: Page 146 OBJ:11 | 12TOP:Sterile technique KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 25. What is a method used to kill all microorganisms, including spores? a. Disinfecting
b. Using an antiseptic c. Using chlorine bleach d. Sterilizing ANS: D Sterilization refers to methods used to kill all microorganisms and spores. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 152 OBJ: 12 TOP: Pathogens KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 26. The nurse accidently spills blood from a specimen container. The first action the nurse takes is to don gloves. What should the nurse then spray the fluid with? a. Liquid detergent b. 20% bleach solution c. 10% bleach solution d. Warm soapy water ANS: C Any accidental body fluid spill should be cleaned up as soon as possible. The person cleaning the spill should wear gloves. One cup of bleach diluted with 10 cups of water should be used as a disinfectant to spray over the spill and clean up with paper towels. The paper towels should then be placed in the plastic-lined waste container. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 153 OBJ: 12 TOP: Body fluids KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 27. When assessing a patient for signs of an infection, the nurse recognizes which laboratory result as indicative of an infection? a. Lowered red blood cell count b. Increased white blood cell count c. Lowered white blood cell count d. Increased red blood cell count ANS: B Increased white blood cell count may indicate an infection. PTS: 1 DIF: Cognitive Level: Application REF: Page 124
OBJ: 3 | 4 TOP: Lab results KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. What can result from the nurse consistently performing hand hygiene and using sterile supplies when caring for patients in the hospital setting? a. Hospital stay is shortened b. Sense of self-worth is improved c. Risk of infection is reduced d. Nursing care needed is reduced ANS: C Hand hygiene is the most important measure for interrupting the infectious process. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 125 OBJ: 5 TOP: Infection KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 29. Recognizing the stages of an infection assists the nurse in identifying the progression of an infection. What is the nonspecific to specific symptom stage of an infection? a. Convalescent b. Illness c. Prodromal d. Incubation ANS: C The prodromal stage progresses from onset of nonspecific signs and symptoms to more specific signs and symptoms. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 124 Box 7-3 OBJ: 4 | 6 TOP: Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. What is the most dependable and practical method to use when sterilizing instruments for the operating room? a. Chemical solution b. Boiling water c. Steam under pressure d. Dry heat
ANS: C Steam under pressure is the most practical and dependable method for destruction of all microorganisms. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 152 box 7-3 OBJ: 12 TOP: Sterilization KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 31. What contribution did Joseph Lister introduce to medical practice? a. Isolation of infected patients b. Iodine and alcohol use as disinfectants c. The autoclave d. Aseptic technique ANS: D Joseph Lister contributed to medical practice through the introduction of the aseptic technique. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 116 OBJ: 1 TOP: Joseph Lister KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 32. The nurse is providing instruction to an anxious mother of a child with Rocky Mountain spotted fever. When discussing this diagnosis what information will the nurse relay about this disease? a. It is extremely contagious among humans. b. It is contracted from handling unvaccinated animals. c. It is a hemolytic B Streptococcus infection spread by droplet transmi d. It is a serious disease contracted from the bite of a tick. ANS: D Rocky Mountain spotted fever is contracted through the bite of a tick vector. It is not contagious among humans. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 119 OBJ:2 | 3TOP:Vector transmission KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. The emergency department nurse is assessing a puncture wound of the foot. What is the most likely type of infection in this wound?
a. Aerobic bacterial infection b. Anaerobic bacterial infection c. Viral infection d. Fungal infection ANS: B An anaerobic bacterial infection is one that grows in an oxygenated environment. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 118 OBJ:6TOP:Anaerobic infections KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 34. The nurse is instructing a bioterrorism class regarding anthrax. How can anthrax be transmitted? a. From person to person b. Through microscopic skin punctures c. Through inhalation of the spores d. By exposure to animals that have anthrax ANS: C Anthrax is contracted by inhaling the spores. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 119 OBJ: 3 TOP: Anthrax KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 35. The nurse is providing teaching to elementary students regarding vectors. What example will the nurse provide as an example of a vector? a. Child with measles giving it to his sister b. Tick whose bite causes Lyme disease c. Woman with syphilis infecting her partner d. Dog whose bite causes rabies ANS: B A vector is a person or animal not sick with the disease harboring an organism that is contagious. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 121 OBJ: 3 TOP: Vector KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 36.What type of organism causes malaria? a. Bacterium b. Virus c. Protozoan d. Fungus ANS: C Malaria is caused by the introduction of protozoa from the bite of a mosquito. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 121 OBJ:4TOProtozoan infections KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 37.A nurse is performing an admission assessment on a patient with suspected tuberculosis. What assessment findings by the nurse are consistent with tuberculosis? a. Hemoptysis b. Weight gain c. Night terrors d. Hypothermia ANS: A Suspicious symptoms consistent with tuberculosis include fatigue, unexplained weight loss, dyspnea, fever, night sweats, and hemoptysis (a cough that can be productive of blood). PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 137-138 OBJ:6TOP:Tuberculosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 38.A nurse is performing an admission assessment on a patient with suspected tuberculosis. What is the greatest risk of exposure to tuberculosis? a. After a diagnosis is made b. Before a diagnosis is made c. After the patient has begun medication therapy d. After implementation of isolation precautions
ANS: B The risk of exposure to tuberculosis is greatest before a diagnosis is made and isolation precautions are implemented. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 137-138 OBJ:8TOP:Tuberculosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 39. Which numbered portion of the illustration below depicts the bacterial class bacilli? a.1 b.2 c.3 d.4 e.5 ANS: E Bacilli are elongated microorganisms. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 119, Figure 7-3 OBJ: 3 TOP: Microorganisms KEY: Nursing Process Step: N/A MSC:NCLEX: N/A MULTIPLE RESPONSE 40.A person can spread a bacterial infection by which actions? (Select all that apply.) a. Kissing others b. Sneezing at work c. Donating blood d. Coming in contact with blood products e. Leaving used tissue on the lavatory ANS: A, B, E Bacteria can be spread by direct, indirect, or airborne transmission. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 118 OBJ:14TOP:Bacterial transmission KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
41. What are some characteristics of microorganisms? (Select all that apply.)
a. Involved in a life process of their own b. Pathogens that cause disease c. Nonpathologic organisms that cause disease d. May be infectious e. Can enter the body via skin, air, or blood ANS: A, B, D, E Microorganisms are involved in a life process of their own, pathogens cause disease, may be infectious, and can enter the body via skin, air, or blood. Nonpathologic organisms do not cause disease. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 116-117 OBJ:3TOP:Characteristics of microorganisms KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment COMPLETION 42.A patient is distressed that an antibiotic has not been effective for the control of the infection. The nurse explains that some bacteria are capable of defending against antibiotics by the formation of a . ANS: capsule Some bacteria can protect themselves by the formation of a capsule of sticky protein that prevents antibiotics from entering the cell. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 118 OBJ:4TOP:Bacterial capsules KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 43.The nurse reminds a group of nursing students that the type of asepsis that destroys all microorganisms and their spores is asepsis. ANS: surgical Surgical asepsis destroys all microorganisms and their spores. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 117 OBJ:1TOP:Surgical asepsis KEY:Nursing Process Step: Implementation
MSC:NCLEX: Safe, Effective Care Environment Chapter 8: Body Mechanics and Patient Mobility My Nursing Test Banks Chapter 8: Body Mechanics and Patient Mobility Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse instructs a nursing assistant to use large muscle groups when lifting. What is the rationale for this instruction? a. Workers compensation claims will be prevented b. Big muscles work more effectively c. It guarantees no muscle strain d. It distributes workload more evenly ANS: D Proper body mechanics provide for even distribution of workload. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 161 OBJ:1 | 2TOP:Body mechanics KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 2. What should the nurse do to reduce the effort of moving a heavy object? a. Bring the feet close together and flex the knees b. Keep the back straight and bend at the waist c. Widen the base of support in the direction of movement d. Broaden the base of support and twist toward the direction of movem ANS: C The base of support should be broadened in the direction of movement. PTS: 1 DIF: Cognitive Level: Application REF: Page 161 OBJ:1 | 2TOP:Body mechanics KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 3. What should the nurse do to protect his or her back when lifting or moving a patient? a. Lowering the height of the bed b. Holding the back straight with locked knees
c. Bending knees and hips d. Getting the patient to the side of the bed ANS: C The nurses back can be well protected when he or she bends knees and hips. PTS: 1 DIF: Cognitive Level: Application REF: Page 161 OBJ:11TOP:Body mechanics KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 4. Where should the nurse place the load when carrying heavy objects? a. In a low position b. To the side of the body c. Close to the body midline d. With anothers assistance ANS: C The nurse should carry objects close to the midline of the body. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 162 OBJ:11TOP:Body mechanics KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 5. The nurse is educating a patient on ways to regain the ability to perform ADLs and maintain normal physiological activities. What will the nurse relay as a requirement? a. Strength b. Wellness c. Alertness d. Mobility ANS: D The purpose of mobility is completing ADLs and maintaining physiological activities. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 166 OBJ: 4 TOP: Mobility KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse counsels the immobilized patient in regard to prevention of
muscle atrophy and contractures. What will the nurse be sure to include when counseling this patient? a. The need for additional calcium b. The need for additional protein c. The need for some type of exercise d. The need for a special protective bed ANS: C The immobilized patient must receive some type of exercise to prevent atrophy and contractures. PTS: 1 DIF: Cognitive Level: Application REF: Page 169 OBJ: 6 TOP: Immobility KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. What is the term for range of motion (ROM) when it is performed by the patient? a. Assisted b. Passive c. Active d. Coordinated ANS: C ROM performed actively by the patient is designated as active ROM.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 169 OBJ:9TOP:Range of motion (ROM) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse is performing passive range of motion (ROM) for the patient. How will the nurse move the joint through ROM? a. The fullest extent b. Place the joint in normal position c. The point of pain d. Relax the patient ANS: C The joints are moved to the point of resistance or pain. PTS: 1 DIF: Cognitive Level: Application REF: Pages 173 OBJ:9TOP:Range of motion (ROM) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. How should the nurse assist the patient with moving when pain is anticipated? a. Be supportive b. Apply heat before moving them c. Administer medication before ambulation d. Obtain assistance if the patient is heavy ANS: C The nurse may want to administer medication before an activity that may be painful. PTS: 1 DIF: Cognitive Level: Application REF: Page 174 Skill 8-3 OBJ:6TOP:Body mechanics KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The 125-pound nurse assesses the weight of a patient. What weight is the heaviest the nurse may safely lift by herself? a. 158.75 lb b. 168.75 lb
c. 178.75 lb d. 188.75 lb ANS: B Nurses should never attempt to lift more than 35% above their own body weight. 125 0.35 = 43.75 125 + 43.75 = 168.75 PTS: 1 DIF: Cognitive Level: Analysis REF: Page 182 OBJ:11TOP:Body mechanics KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 11. What is the site of the most common strain injury acquired by the nurse when working? a. Trapezius muscle group b. Thoracic muscle group c. Lumbar muscle group d. Thigh muscle group ANS: C The most common back injury is strain of the lumbar muscle group. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 159 OBJ: 2 TOP: Body mechanics KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 12. What implementation might the nurse use to improve safety during a transfer? a. Weighing the patient first b. Using a transfer belt c. Putting shoes on the patient d. Supporting a flaccid arm ANS: B As a general rule, the nurse should use a transfer belt. PTS: 1 DIF: Cognitive Level: Application REF: Page 182 OBJ:5TOP:Body mechanics KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment
13. What is considered to be the minimum number of hours of daily activity
necessary to prevent the negative consequences of immobility? a. 2 hours b. 4 hours c. 6 hours d. 8 hours ANS: A The amount of exercise required to prevent physical disuse syndrome is 2 hours in 24 hours. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 167 Box 8-2 OBJ: 6 TOP: Immobility KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse is performing passive range-of-motion exercises on a patient following a traumatic injury. What is the number of times the nurse should move each joint when performing passive range-of-motion (ROM) exercises? a. Three b. Four c. Five d. Six ANS: C Each movement should be repeated five times. PTS: 1 DIF: Cognitive Level: Application REF: Page 173 Skill 8-2 OBJ:6TOP:Range of motion (ROM) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. What profession has the highest workers compensation claim rates of any occupation or industry? a. Firefighters b. Truck drivers c. Law enforcement d. Nursing personnel ANS: D Studies of workers compensation claims show that nursing personnel have
the highest claim rates of any occupation or industry. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 159 OBJ: 2 TOP: Workers compensation KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 16.A nurse instructs a nursing assistant about moving older adult patients in bed. When should the nurse intervene when observing the nursing assistant perform a return demonstration? a. The nursing assistant is using simple language. b. The nursing assistant is avoiding jerky movements. c. The nursing assistant is avoiding sudden movements. d. The nursing assistant is pulling the patient across bed linens. ANS: D The skin of older adults is more fragile and susceptible to injury. When moving or transferring older adults, it is essential to avoid pulling them across bed linens because this may cause shearing or tearing of the skin. The nurse should explain each step in simple language and avoid jerky, sudden movements. PTS: 1 DIF: Cognitive Level: Application REF: Page 174 Skill 8-3 OBJ:10 | 11TOP:Moving patients KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The LPN/LVN assists a patient into the semi-Fowler position per physician order. What would indicate that this patient is in the correct position? a. Patient is leaning over the bedside table b. Head of bed is at a 30-degree angle c. Knee is drawn toward the chest d. Arms are flexed toward the head ANS: B The semi-Fowler position is when the head of the bed is raised approximately 30 degrees. Orthopneic position is when the patient is leaning over the bedside table. Sims position is when the knee is drawn toward the chest. Arms are not flexed toward the head in the semi-Fowler position.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 164 Skill 8-1 OBJ:7TOPositioning patients KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 18.A newly hired group of graduate practical/vocational nurses are attending orientation at a long-term care facility. What information will be included regarding considerations of mobility and the older adult? (Select all that apply.) a. The skin of older adults is more fragile and susceptible to injury. b. Always support older adults under the soft tissue when moving them i Weakness and hypertension are common signs and symptoms noted in c. bed rest. d. Aging tends to result in loss of flexibility and joint mobility. e. Older adults sometimes become fearful when hydraulic lifts are used f ANS: A, D, E The skin of older adults is more fragile and susceptible to injury. Aging tends to result in the loss of flexibility and joint mobility and older adults sometimes do become fearful with use of hydraulic lifts. Older adults should be supported under the joints when moving in bed. Weakness and hypotension are common signs and symptoms noted in an older adult on bed rest. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 160 OBJ: 3 TOP: Older adult KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 19. The nurse receives a patient from the recovery room following total hip replacement surgery. What will the nurse include when assessing neurovascular status on this patient? (Select all that apply.) a. Pupils b. Pain c. Sensation d. Color e. Skin temperature
ANS: B, C, D, E One of the responsibilities of the nurse is to frequently monitor the patients neurovascular function, or circulation, movement, and sensation (CMS) assessment. The LPN/LVN checks for skin color, temperature, movement, sensation, pulses, capillary refill, and pain. Pupil assessment is part of a neurologic assessment. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 166 OBJ:8 | 13TOP:Neurovascular function KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION 20. The most common cause of musculoskeletal disorders in nurses involves a movement that requires the nurse to and at the same time. ANS: twist, lift lift, twist The motion of twisting and lifting at the same time frequently strains the muscles of the lower back. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 162 OBJ: 1 | 2 TOP: Muscle strain KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 21. To maintain a wide base of support, the nurse should stand with the feet separated by the distance of times the length of the nurses shoe. ANS: 1.5 one and one half A wide base of support of 1.5 times the length of the nurses shoe is recommended. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 161 OBJ:1TOP:Base of support KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 22. When a fall occurs, the nurse should document the incident and initiate
a(n) report. ANS: incident The nurse must initiate an incident report describing the events of a patients fall. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 167 Box 8-2 OBJ:6TOP:Incident report KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 23. machines flex and extend joints to mobilize them passively without the strain of active exercises. ANS: Continuous passive motion (CPM) Continuous passive motion CPM Continuous passive motion (CPM) machines flex and extend joints to mobilize them passively without the strain of active exercises. It is imperative that the CPM machine be set according to the health care providers orders for the degree and the speed of flexion and extension for each individual patient to prevent damage to the joint or surgical site. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 172 OBJ:12TOP:Continuous passive motion machines KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. The nurse points to the X in the illustration below and describes this point as the of . ANS: center, gravity The center of gravity is the centermost point from the base of support. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 161 OBJ:2TOP:Center of gravity KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity OTHER
25. Place the nursing activities in priority order for the preparation of a patient
to ambulate. Put a comma and space between each answer choice (A, B, C, D, etc.). a. Dangle the patient at the side of the bed b. Apply a gait belt c. Assist the patient to stand d. Inform the patient of activity e. Roll up the head of the bed ANS: D, E, A, B, C The order that is most organized is inform, roll up head of bed, dangle, apply belt, and assist to stand. PTS: 1 DIF: Cognitive Level: Application REF: Page 167 box 8-2 OBJ:6TOPreparation to ambulate KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment Chapter 9: Hygiene and Care of the Patients Environment My Nursing Test Banks Chapter 9: Hygiene and Care of the Patients Environment Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is preparing to bathe a patient. What should the room temperature be set at? a. No warmer than 67 F b. No cooler than 68 F c. No cooler than 70 F d. 75 F or warmer ANS: B The recommended room temperature is 68 to 74 F. PTS: 1 DIF: Cognitive Level: Application REF: Page 186 OBJ:1 | 2 | 4TOPatients environment KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
2. The nurse explains that the purpose of a sitz bath is to reduce inflammation
in the perineal and anal area. What is the least amount of time the nurse will instruct for a sitz bath? a. 10 to 15 minutes b. 20 to 30 minutes c. 30 to 40 minutes d. 1 hour ANS: B The sitz bath should last 20 to 30 minutes. PTS: 1 DIF: Cognitive Level: Application REF: Page 191 OBJ:2 | 3TOP:Therapeutic baths KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3.A patient is recovering from a hemorrhoidectomy and experiences dizziness within 5 minutes when taking a sitz bath. What action should the nurse implement? a. Cover the patient to prevent chilling b. Stay with the patient until the full time for the bath has elapsed c. Remove the patient from the sitz bath and return to bed d. Assess vital signs every 5 minutes during the remainder of the sitz ba ANS: C The patient may become dizzy during a sitz bath due to dilation of the large vessels in the abdomen. If this occurs, the patient should be removed from the sitz bath and returned to bed. Vital signs should be assessed until they return to normal. PTS: 1 DIF: Cognitive Level: Application REF: Page 191 OBJ: 3 TOP: Sitz bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. What should the water temperature be when preparing a tepid bath for a patient? a. 98.6 F b. 100.2 F c. 104.8 F
d. 110.4 F ANS: A The tepid bath is taken in water that is 98.6 F. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 191 OBJ: 4 TOP: Tepid bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is assessing a patients skin for signs of impaired skin integrity. Which finding by the nurse is considered a major manifestation? a. Burn b. Laceration c. Pressure ulcer d. Infection ANS: C A major manifestation of impaired skin integrity is a pressure ulcer. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 200 OBJ:5TOPressure ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6.A nurse assesses an area of sustained redness on the coccyx area of a resident in long-term care. What is the most likely cause of this pressure area? a. Heat from pressure b. Collapse of blood vessels c. Friction from pressure d. Collapse of skin tissue ANS: B A pressure ulcer occurs when there is sufficient pressure to collapse the blood vessels. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 200 OBJ:5TOPressure ulcers KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 7. The nurse is caring for an unconscious patient with a risk for skin
impairment. How often will the nurse plan to change the position of this patient? a. Every 30 minutes b. Every 60 minutes c. Every 120 minutes d. Every 180 minutes ANS: C The bedfast patient should have a position change every 2 hours (120 minutes) because skin compromise can occur if there is unrelieved pressure during that amount of time. PTS: 1 DIF: Cognitive Level: Application REF: Page 202 Box 9-5 OBJ:5TOPressure ulcers KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse assesses a red blister over the right superior iliac area of a patient. What stage is this decubitus ulcer? a.I b.II c.III d.IV ANS: B A pressure ulcer demonstrating blisters is a stage II decubitus ulcer. PTS: 1 DIF: Cognitive Level: Application REF: Page 202 OBJ:5TOPressure ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. The nursing assessment of a pressure ulcer includes size, depth, pain, odor, and color of tissue. What does this evaluate? a. Treatment needed b. Effectiveness of implementation c. Whether improvement is occurring d. Need for additional interventions ANS: C
Ongoing assessment of a pressure ulcer will evaluate whether improvement is occurring. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 201 OBJ:5TOPressure ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. The nurse attempts to avoid a pressure ulcer for a bedridden patient by turning the patient frequently. What is the most favorable position for the nurse to move this patient into? a. Back-lying b. Full lateral c. 30-degree lateral d. Full prone ANS: C It is preferable to use the 30-degree lateral incline position. PTS: 1 DIF: Cognitive Level: Application REF: Page 202 Box 9-5 OBJ:5TOPressure ulcers KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. One reason the nurse focuses on oral hygiene is to maintain a healthy state of the oral cavity. What is another reason to promote oral hygiene? a. To improve self-esteem b. To stimulate appetite c. To restore tooth destruction d. To assist with periodontitis ANS: B A sense of well-being can stimulate appetite. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 204 OBJ:6TOP:Oral hygiene KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. How will the nurse correctly replace a patients dentures after cleaning? a. Inserting the lower denture first
b. Asking the patient to insert them c. Inserting both dentures together d. Inserting the upper denture first ANS: D When reinserting dentures, replace the upper dentures first. PTS: 1 DIF: Cognitive Level: Application REF: Page 206 Skill 9-2 OBJ:6TOP:Oral hygiene KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. Proper hair care is important for the patients self-image. What is the proper water temperature when shampooing a patients hair? a. 101 F b. 105 F c. 110 F d. 120 F ANS: C Water at 110 F should be used to shampoo a patients hair. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 208 Skill 9-3 OBJ: 6 TOP: Hair care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. When must the nurse remember to use an electric razor when shaving a patient? a. When a bleeding tendency is present b. When there is a risk for suicide c. When the facial hair is fine d. When speed is essential ANS: A A patient with a bleeding disorder should use an electric razor. PTS: 1 DIF: Cognitive Level: Application REF: Page 207 OBJ: 6 TOP: Shaving KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is bathing a patient with a deep vein thrombosis in the left leg. What modification will the nurse make when attending to the left leg?
a. Washing the leg with long, firm strokes and drying with a towel b. Omitting washing the leg at all c. Gently washing the leg and patting dry with a towel d. Applying lotion in long, smooth strokes ANS: C The lower extremities of people with circulatory disorders are gently washed and patted dry, omitting any stroking or massaging. PTS: 1 DIF: Cognitive Level: Application REF: Page 194 Skill 9-1 OBJ: 3 TOP: Bathing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is providing hand and foot care to a patient and notices the patient has extremely hard nails. Who is the person best prepared to provide nail care for patients with extremely hard nails? a. Physician b. RN c. CNA d. Podiatrist ANS: D If the patients nails are extremely hard, a podiatrist should provide care. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 207, 210 Skill 9-3 OBJ: 6 TOP: Foot care KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 17. How often should the nurse cleanse the meatal-catheter junction of a patient with an indwelling catheter? a. At least once a day b. At least twice a day c. At bedtime d. Each shift ANS: B Catheter care should be performed at least two times daily. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 207 OBJ:8TOP:Catheter care KEY:Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 18. The nurse is preparing to perform perineal care for the female patient. What is the best method for using a bath blanket to drape the patient? a. Square position b. Long position c. Diamond position d. Rectangular position ANS: C Drape the patient with a bath blanket in the diamond position. PTS: 1 DIF: Cognitive Level: Application REF: Page 211 Skill 9-4 OBJ:8TOPerineal care KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. Clear water is used to cleanse the eyes. It is important to use proper technique when cleansing the eyes to prevent infection. What direction will the water flow when cleansing a patients eyes? a. Upward toward the forehead b. Downward toward the chin c. From the outer toward the inner canthus d. From the inner toward the outer canthus ANS: D The eye is cleansed from the inner to outer canthus. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 213 OBJ: 6 TOP: Eye care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. How frequently should the nurse clean the nares of patients who have a nasogastric tube or are receiving oxygen by nasal cannula? a. At least every 2 hours b. At least every 6 hours c. At least every 8 hours d. At least every 10 hours ANS: C When receiving oxygen by a nasal cannula or when a nasogastric tube is in
place, the nurse should cleanse the nares every 8 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 214 OBJ: 6 TOP: Nasal care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse must follow the principles of medical asepsis while making a patients bed, including procedures for handling linens. How should the nurse handle soiled linens? a. Place on the floor b. Fan in the air c. Hold away from the uniform d. Place at the end of the bed ANS: C Soiled linen should not come into contact with a uniform. PTS: 1 DIF: Cognitive Level: Application REF: Page 215 Skill 9-5 OBJ: 10 TOP: Bed making KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 22. How should the nurse cleanse the meatal opening when performing male perineal care? a. From the meatus outward b. With an alcohol swab c. In a circular motion d. With a cotton-tipped applicator ANS: A The nurse should cleanse the meatal opening from the meatus outward. PTS: 1 DIF: Cognitive Level: Application REF: Page 212 Skill 9-4 OBJ:8TOPerineal care KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse lowers the bed to place the patient on the bedpan. The angle of the head of the bed should be raised to: a. 20 degrees. b. 45 degrees. c. 90 degrees.
d. 30 degrees. ANS: D Elimination is facilitated with the head of the bed elevated 30 degrees. PTS: 1 DIF: Cognitive Level: Application REF: Page 221 Skill 9-6 OBJ: 12 TOP: Elimination KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. What does the nurse recognize is important to consider when using the nursing process to plan hygiene care of the patient? a. Nurses orders b. Physicians orders c. Patients preferences d. Outcome goals ANS: C Individual patients will have individual desires and choices. PTS: 1 DIF: Cognitive Level: Application REF: Page 222 OBJ: 2 TOP: Hygiene KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 25. The nurse is providing personal hygiene for a Hindu patient from India. What intervention should the nurse implement? a. Not serve meat b. Shampoo the patients hair weekly c. Give a daily bath d. Cut nails monthly ANS: C A daily bath is part of the religious duty of Indian Hindus. PTS:1DIF:Cognitive Level: Application REF: Page 186, Cultural Considerations OBJ: 2 TOP: Hygiene KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. The nurse is assisting a patient to perform personal hygiene. What is the most important focus of the nurse when assisting this patient? a. Nursing care b. Independence
c. Repetition d. Performance ANS: B The nurse should encourage the patients independence as much as possible. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 185 OBJ: 2 TOP: Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The nurse discovers a reddened area over a patients hip. What should be the nurses first intervention? a. Cover the area with an occlusive dressing b. Apply mild ointment with a cotton-tipped applicator c. Press the area gently to assess for blanching d. Rub gently to increase circulation ANS: C If the area is a stage I decubitus ulcer, the area will not blanch. PTS: 1 DIF: Cognitive Level: Application REF: Page 201 OBJ:5TOPressure ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. The nurse is educating a patient regarding a tub bath. What is the maximum length of time the nurse should instruct the patient to remain in the water? a. 5 to 10 minutes b. 10 to 20 minutes c. 20 to 30 minutes d. 30 to 40 minutes ANS: B A patient should not stay in the water for more than 20 minutes. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 195 Skill 9-1 OBJ: 3 TOP: Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. Where should a nurse performing a backrub begin? a. Shoulder
b. Base of the neck c. Sacral area d. Lumbar area ANS: C The nurse should begin a massage in the sacral area. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 199 Skill 9-1 OBJ: 7 TOP: Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. The nurse is caring for a patient experiencing presbycusis. What intervention should the nursing personnel be instructed to implement? a. Speak quickly to the patient b. Speak in loud tones to the patient c. Speak slowly and clearly to the patient d. Tell the patient they must purchase a hearing aid ANS: C Age-related hearing loss, presbycusis, is a common finding in older adults. It is important to speak slowly and clearly to the patient with presbycusis. Not all patients with this type of hearing loss require a hearing aid. PTS: 1 DIF: Cognitive Level: Application REF: Page 214 OBJ: 6 TOP: Hearing loss KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 31.A physician orders a patient to be placed in the Trendelenburg position. How will the nurse position the bed? a. On the floor b. Parallel with the floor c. Tilted with the head of the bed down d. Tilted with the foot of the bed down ANS: C The entire bed is tilted downward with the head of the bed down when placing a patient in the Trendelenburg position. PTS: 1 DIF: Cognitive Level: Application REF: Page 189 Table 9-1 OBJ: 1 TOP: Positioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
32. The physician orders a patient to be placed in the reverse Trendelenburg
position. How should the nurse place the bed? a. On the floor b. Parallel with the floor c. Tilted with the head of the bed down d. Tilted with the foot of the bed down ANS: D The entire bed is tilted downward with the foot of the bed down when placing a patient in the reverse Trendelenburg position. PTS: 1 DIF: Cognitive Level: Application REF: Page 189 Table 9-1 OBJ: 1 TOP: Positioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. Which guideline should be followed when giving a backrub? a. Observing the skin for abnormalities b. Massaging for at least 10 minutes c. Following massage with a brisk alcohol rub d. Conversing with patient continually throughout the backrub e. Using alcohol-based lotion for disinfection ANS: A The backrub should last for about 3 to 5 minutes, giving the nurse an opportunity to observe for skin abnormalities. Conversation should be kept to a minimum to enhance relaxation. Alcohol either as a rub or used as disinfectant is drying to the skin. PTS: 1 DIF: Cognitive Level: Application REF: Page 199 Skill 9-1 OBJ: 7 TOP: Backrub KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 34. The nurse is preparing to make an occupied bed. What procedure will the nurse follow to correctly complete this task? (Select all that apply.) a. Remove spread and blanket separately b. Place soiled sheet at end of bed c. Place bath blanket over patient on top sheet d. Slide mattress to bottom of bed
e. Position patient to far side of bed ANS: A, C, E When making an occupied bed the nurse will remove the spread and blanket separately. The bath blanket is placed over the patient on the top sheet and the patient is positioned to the far side of the bed. Soiled linen is placed in the laundry bin, not at the end of the bed. The mattress is slid to the top of the bed. PTS: 1 DIF: Cognitive Level: Application REF: Pages 215-216 Skill 9-5 OBJ:11TOP:Making occupied bed KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment COMPLETION 35. The nurse avoids dragging the patient across the bed linen to decrease the potential risk of skin injury by . ANS: friction Dragging the patient across bed linen rather than lifting can cause skin damage from friction. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 201-202 OBJ: 5 | 9 TOP: Friction KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 36. Because of its effect on epithelization, the LPN/LVN should confirm the order to use or on a stage III pressure ulcer. ANS: peroxide, alcohol alcohol, peroxide Peroxide and alcohol have a negative effect on epithelization of a pressure ulcer. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 202 Box 9-5 OBJ:5TOPressure ulcers KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 37. To prevent skin breakdown in a wheelchair-bound patient, the nurse teaches the patient to shift the patients weight every minutes.
ANS: 15 fifteen People who are wheelchair-bound should shift their weight by pushing on the arms of their chair every 15 minutes to prevent skin breakdown. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 202 Box 9-5 OBJ:5TOP:Skin breakdown KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 38. As a safety precaution against breakage of dentures, the nurse should place in the emesis basin before cleaning the dentures. ANS: water Water in the basin will break the fall of the dentures if they are dropped. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 206 Skill 9-2 OBJ:6TOP:Oral hygiene KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment Chapter 10: Safety My Nursing Test Banks Chapter 10: Safety Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse manager is providing an in-service regarding a safe hospital environment. What will this education mainly focus on preventing? a. Falls b. Exposure to contaminants c. Injury d. Electrical hazard ANS: C A safe environment implies freedom from injury. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 228 OBJ: 6 TOP: Safety KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment
2. What is important for the nurse to determine in order to decrease the risk
for injury to a patient? a. If patient can read English b. If patient is left-handed c. If patient is able to eat unassisted d. If patient can dress independently ANS: B A left-handed patient will twist to accommodate, which places them at risk for injury. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 229-230 OBJ: 1 TOP: Safety KEY: Nursing Process Step: Assessment MSC:NCLEX: Safe, Effective Care Environment 3. What skills should health care workers frequently attend in-services about to ensure that staff has competent skills and risk for falls can be decreased? a. Bathing b. Feeding c. Transferring d. Ambulating ANS: C The majority of patient falls occur during transfer. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 229-230 OBJ: 3 TOP: Falls KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 4. What important safety precaution should the home health nurse teach parents in order to prevent burns to small children? a. Never leave them unattended b. Turn pot handles on stoves away from reach c. Turn hot water on first when filling the bathtub d. Keep side rails up on the crib ANS: B To protect infants and children from burns, turn the pot handles on stoves away from the childs reach. PTS: 1 DIF: Cognitive Level: Application REF: Page 230
OBJ: 2 TOP: Safety KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 5. What must the nurse do before applying a safety reminder device (SRD)? a. Get permission from the family b. Assess patients skin condition c. Get a physicians order d. Explain the SRD to the patient ANS: C Initially, an order is necessary that specifies the type of SRD and the duration of its application. PTS: 1 DIF: Cognitive Level: Application REF: Page 232, Box 10-4 OBJ:4TOP:Safety reminder devices (SRDs) KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 6. What should the nurse do when offering a cup of hot coffee to a frail, older adult patient? a. Give the patient a straw b. Dilute the coffee with cold water c. Fill the cup half full d. Offer a bib or an apron ANS: C Filling the cup half full promotes safety and does not change the flavor of the beverage, nor does it demean the patient as would making him or her wear a bib or apron. PTS: 1 DIF: Cognitive Level: Application REF: Page 230-231 OBJ: 2 TOP: Safety KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 7. What type of fire extinguisher should the nurse use when the oxygen concentrator machine malfunctions and causes an electrical fire? a. Type A b. Type B c. Type C d. Type D
ANS: C Electrical fires require type C fire extinguishers. PTS: 1 DIF: Cognitive Level: Application REF: Page 241 OBJ: 7 TOP: Fires KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 8.A disaster situation occurs and involves an explosion in a hospital laundry. What would this be classified as ? a. Active b. External c. Life-threatening d. Internal ANS: D Internal disaster often threatens the safety of patients and staff. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 244 OBJ: 9 TOP: Disaster KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 9. The emergency department nurse admits a victim of poisoning. Who should the nurse call to receive the best assistance for dealing with this victim? a. American Red Cross b. Fire department paramedics c. Poison control center d. Civil defense office ANS: C The nurse can access the local poison control center for assistance in caring for a victim of poisoning. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 244 OBJ: 8 TOP: Poisoning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10.A nurse instructs a nursing assistant about the proper use of a gait belt and is observing a return demonstration. What action by the nursing assistant should cause the nurse to intervene? a. Nursing assistant is walking on the patients strong side b. Nursing assistant is walking to the side of the patient
c. Nursing assistant is securing the gait belt securely around the patients d. Nursing assistant is grasping the handles of the gait belt while the pati ANS: A A gait belt should be securely applied around the patients waist. It has handles attached for the nurse to grasp while the patient ambulates. The nurse should walk on the patients weaker side so that assistance may be given if the patient starts to fall. PTS:1DIF:Cognitive Level: Application REF: Pages 230, 234-235 Skill 10-1 OBJ: 4 TOP: Gait belt KEY:Nursing Process Step: N/AMSC:NCLEX: N/A 11. What should a nurse do when encountering a mercury spill? a. Vacuum the spill b. Open interior doors c. Close all outside windows d. Open any outside windows ANS: D In the event of a mercury spill, interior doors should be closed and outside windows should be opened. The spill should not be vacuumed. PTS: 1 DIF: Cognitive Level: Application REF: Pages 238-239 Box 10-6 OBJ: 9 TOP: Mercury spill KEY: Nursing Process Step: N/A MSC:NCLEX: N/A MULTIPLE RESPONSE 12. When the nurse ambulates with a patient who has left-sided weakness, what actions should the nurse take? (Select all that apply.) a. Walk on the patients right side b. Keep the patient away from heavy furniture c. Hold the patients arm securely d. Keep the leg nearest the patient behind the patients knee e. Use a gait belt ANS: D, E Ambulating with a person who has an identified weakness requires that the nurse walk on the same side as the weakness, slightly behind the patient, with the nurses near leg behind the patients knee. The nurse should use a gait belt
and hold the patient at the waist and the gait belt. Furniture can be used as support. PTS: 1 DIF: Cognitive Level: Application REF: Page 230 OBJ: 3 TOP: Ambulating KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 13. The nurse assesses a patient in a Posey safety reminder device (SRD) for which problem(s) that may increase because of the use of SRDs? (Select all that apply.) a. Immobility b. Lethargy c. Risk for impaired circulation d. Risk for skin impairment e. Incontinence ANS: A, C, D, E The use of SRDs increases a patients immobility, risk for skin impairment, risk for impaired circulation, and incontinence. A SRD would not increase lethargy. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 231 OBJ:4TOProblems associated with SRDs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14.A long-term care facility is committing to a restraint-free environment. What will the health care workers implement to encourage this environment? (Select all that apply.) a. Frequent orientation to surroundings b. Explain all procedures and treatments c. Discourage visitors d. Maintain toileting routines e. Minimize exercise and ambulation ANS: A, B, D To encourage a restraint-free environment health care workers should provide frequent orientation to surroundings, thoroughly explain all procedures and treatments, and maintain toileting routines. Visitors should be
encouraged so they may sit with the residents, and frequent exercise and ambulation also should be encouraged. PTS: 1 DIF: Cognitive Level: Application REF: Page 232 Box 10-3 OBJ:5TOP:Restraint-free environment KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe: Effective Care Environment COMPLETION 15. is a violent or dangerous act used to intimidate or coerce a person or government to further a political or social agenda. ANS: Terrorism Terrorism is a violent or dangerous act used to intimidate or coerce a person or government to further a political or social agenda. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 245 OBJ: 9 TOP: Terrorism KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 16. When reinforcing the PASS acronym for fire extinguisher use, the nurse reminds the staff that the final S stands for . ANS: sweep The acronym stands for: P = pull pin, A = aim, S = squeeze, S = sweep. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 241, 243 Box 10-10 OBJ:7TOP:Fire extinguisher use KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 17. The nurse conducting a seminar on bioterrorism reviews several types of agents that may be used as weapons. An agent that does not seriously damage or kill the target population but only impairs it is classified as . ANS: incapacitating The agent that only impairs the target rather than killing or seriously damaging it is classified as an incapacitating agent. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 246-249
OBJ: 11 TOP: Bioterrorism KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse explains that the measurement of radiation exposure is in multiples of Gy. The number of Gy an individual may absorb before becoming ill with radiation syndrome is . ANS: 0.75 The amount of radiation absorbed is measured by the Gy. 1 Gy is equal to 100 rad. Absorption of 0.75 Gy will cause the individual to develop acute radiation syndrome. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 248 OBJ:11TOP:Radiation syndrome KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity Chapter 11: Vital Signs My Nursing Test Banks Chapter 11: Vital Signs Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What part of the body maintains a balance between heat production and heat loss, regulating body temperature? a. Thymus b. Thyroid c. Hypothalamus d. Adrenal glands ANS: C Body temperature is regulated by the hypothalamus. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 257 OBJ: 9 | 13 TOP: Vital signs KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 2. What type of body temperature remains relatively constant? a. Surface b. Rectal c. Oral
d. Core ANS: D The core body temperature remains relatively constant. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 257 OBJ: 2 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse uses cooling techniques to keep the body temperature below 105 F. What can result from an elevated temperature? a. Excessive thirst b. Excessive perspiration c. Damage to body cells d. Increased heart rate ANS: C If the temperature exceeds 105 F, normal body cells may be damaged. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 258 OBJ: 8 TOP: Vital signs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures. What temperature is the nurse aware of that can lead to death? a. 95.2 F b. 93.0 F c. 93.2 F d. 90.8 F ANS: C Death can occur if the temperature falls below 93.2 F. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 258 OBJ: 9 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. What is the term for a fever that rises and falls but does not return to normal until the patient is well? a. Constant b. Intermittent
c. Remittent d. Elevated ANS: C A remittent fever does not return to normal until the patient becomes well. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 258 OBJ:9TOP:Remittent fever KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. How should the nurse position the ear pinna when using the tympanic thermometer on a child? a. Upward and back b. Parallel c. Downward and back d. Upward and forward ANS: C Using the tympanic thermometer for a child, the nurse will tug the ear pinna down and back. PTS: 1 DIF: Cognitive Level: Application REF: Page 262, Skill 11-1 OBJ:3 | 9TOP:Tympanic thermometer for a child KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. How should the nurse position the earpieces on a stethoscope to ensure optimum reception? a. Backward b. Parallel to the ears c. Toward the face d. Downward ANS: C To ensure the best reception of sound, place earpieces pointing toward the face. PTS: 1 DIF: Cognitive Level: Application REF: Page 264 OBJ: 9 | 12 TOP: Vital signs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
8. What does the nurse use the diaphragm of the stethoscope to best assess?
a. Carotid sounds b. Lung sounds c. Vascular sounds d. Low-pitched sounds ANS: B Lung sounds are auscultated by using the diaphragm of the stethoscope. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 265 OBJ:6 | 9TOP:Stethoscope use KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. What is the pulsethe expansion and contraction of an artery produced by? a. Contraction of the right atrium b. Contraction of the right ventricle c. Contraction of the left atrium d. Contraction of the left ventricle ANS: D Expansion and contraction of an artery is caused by the ejection of blood from the left ventricle. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 265 OBJ: 4 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of 120. What is this pulse interpreted as by the nurse? a. Normal b. Bradycardic c. Arrhythmic d. Tachycardic ANS: D If the pulse is faster than 100 bpm on an adult patient, it is considered to be tachycardic. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 265 OBJ: 5 TOP: Tachycardia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 11. The patients pulse is below 60. The nurse is aware that the patient is not receiving digoxin. What does the nurse suspect is causing the bradycardia? a. Low exercise tolerance b. Unrelieved severe pain c. Excessive bed rest d. A prone position ANS: B Bradycardia can result from unrelieved severe pain. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 265 OBJ: 5 TOP: Bradycardia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. What site should be selected if a peripheral pulse needs to be assessed quickly? a. Radial pulse b. Brachial pulse c. Carotid pulse d. Pedal pulse ANS: C The carotid site is the best for finding a pulse quickly. PTS: 1 DIF: Cognitive Level: Application REF: Page 266 OBJ: 5 TOP: Carotid KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. What is the term for the exchange of carbon dioxide and oxygen that takes place at the alveolar level? a. Tachypnea b. Internal respiration c. External respiration d. Bradypnea ANS: B Internal respiration is the exchange of gas at the alveolar level. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 269 OBJ:6TOP:Internal respiration
KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14.A patient is suspected of having a cardiac arrhythmia. The nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. What is the term for the difference between these two rates? a. Pulse pressure b. Unequal pulses c. Pulse deficit d. Tachycardia ANS: C The difference between radial and apical pulses is called a pulse deficit. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 268-269 Box 11-10 OBJ: 5 TOP: Pulse deficit KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. The nurse is alarmed when a patient with a severe head injury of the occipital lobe has a respiratory rate of 10 breaths per minute. Where might this finding indicate that there is an injury? a. Cerebellum b. Medulla oblongata c. Cortex d. Cerebrum ANS: B Rate of respiration is controlled by the medulla oblongata. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 270 OBJ:6TOP:Respiratory rate KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse assesses respirations of a patient demonstrating pursed-lip breathing, flared nostrils, and retractions. How will the nurse describe these respirations? a. Tachypnea b. Stertorous c. Dyspnea
d. Cheyne-Stokes ANS: C The patient who is using ancillary muscles to breathe is exhibiting dyspnea. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 271 OBJ: 6 TOP: Dyspnea KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17.A nurse assesses a neonates temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonates temperature is 96 F? a. Record the findings b. Notify the physician c. Check the axillary temperature d. Check the tympanic temperature ANS: A The neonates temperature normally ranges from 96 to 99.5 F (35.5 to 37.5 C). Temperature regulation is labile (unstable) during infancy because of immature physiological mechanisms. Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic membrane thermometer. Tympanic thermometer readings are suitable for patients of all ages, except infants. PTS: 1 DIF: Cognitive Level: Application REF: Page 258, Box 11-4 OBJ: 8 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18.A nurse assesses a neonates temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonates temperature is 99.5 F? a. Record the findings b. Notify the physician c. Check the axillary temperature d. Check the tympanic temperature ANS: A The neonates temperature normally ranges from 96 to 99.5 F (35.5 to 37.5 C). Temperature regulation is labile (unstable) during infancy because of
immature physiological mechanisms. Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic membrane thermometer. Tympanic thermometer readings are suitable for patients of all ages, except infants. PTS: 1 DIF: Cognitive Level: Application REF: Page 258, Box 11-4 OBJ: 8 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19.A nurse assesses a patients dorsalis pedis pulse. The pulse is difficult to feel and not palpable when only slight pressure is applied. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse ANS: C A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied. A bounding pulse feels full and springlike even under moderate pressure. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3 OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20.A nurse assesses a patients dorsalis pedis pulse. The pulse is not palpable when light pressure is applied. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse ANS: A A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt
but not palpable when moderate pressure is applied. A bounding pulse feels full and springlike even under moderate pressure. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3 OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21.A nurse assesses a patients dorsalis pedis pulse. The pulse is easily felt but not palpable when moderate pressure is applied. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse ANS: B A normal pulse is easily felt but not palpable when moderate pressure is applied. A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A bounding pulse feels full and springlike even under moderate pressure. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3 OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22.A nurse assesses a patients dorsalis pedis pulse. The pulse feels full and springlike even under moderate pressure. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse ANS: D A bounding pulse feels full and springlike even under moderate pressure. A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not
palpable when moderate pressure is applied. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3 OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 23. When instructing a primary caregiver about keeping a daily log of blood pressure readings, what instructions should the nurse include? (Select all that apply.) a. Take the reading at different times during the day. b. Apply the cuff approximately 2 inches above the antecubital fossa. c. If unable to get a reading the first time, immediately reinflate the cuf d. Assess pulse with the bell of the stethoscope. e. Apply the cuff snugly. ANS: B, E Readings for a blood pressure log should be taken at the same time every day on the same arm. The cuff should be applied 2 inches above the antecubital fossa and snugly secured. The pulse should be assessed with the diaphragm of the stethoscope. If unable to get a reading the first time, the cuff should be deflated completely and reinflated after several minutes. PTS: 1 DIF: Cognitive Level: Application REF: Pages 276-278, Skill 11-5 OBJ:7TOP:Blood pressure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. When assessing factors that may influence the patients pulse rate, what should the nurse take into consideration? (Select all that apply.) a. Age b. Sex c. Emotion d. Temperature e. Religion ANS: A, B, C, D All the options listed can affect the pulse rate except religion. PTS: 1 DIF: Cognitive Level: Application REF: Page 265
OBJ:5TOP:Influences on pulse rate KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25.A patient is admitted to a medical surgical unit. What factors will determine how frequently vital signs will be assessed? (Select all that apply.) a. Desire of the patient b. Judgment of need by the nurse c. Discretion of the family d. Orders of the health care provider e. Patients condition ANS: B, D, E Whether and how frequently vital signs are measured depends on the nurses judgment of need, orders of the health care provider, and patients condition. Desire of the patient and family members cannot override these factors, but can be taken into consideration within reason of these factors. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 254-255, Box 112 OBJ:11TOP:Frequency of vital signs measurement KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. The home health nurse is preparing to educate a patient regarding electronic self-blood pressure measurement. What information should the nurse provide regarding this procedure? (Select all that apply.) a. Expect precise values b. Proper measurement techniques are necessary c. Cuff fits over clothing d. Stethoscope is not required e. Recalibration is not necessary ANS: B, C, D Self-blood pressure monitoring requires proper measurement techniques, cuff is made to fit over clothing, and stethoscopes are not required. Values may be inaccurate and recalibration is necessary at least once a year. PTS: 1 DIF: Cognitive Level: Application REF: Pages 278-279
OBJ:14TOP:Self-Blood Pressure Measurement KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The physician orders daily weights on a patient residing in a long-term care setting. What actions should the nurse implement to assess weight accurately? (Select all that apply.) a. Weigh patient at the same time each day b. Schedule weighing immediately after breakfast c. Encourage patient to void before being weighed d. Ensure same amount of clothing is worn by patient e. Calibrate by setting scale at zero after each weight ANS: A, C, D Accurate assessment of weight should occur at the same time each day, preferably at 6 AM before breakfast. The patient should be encouraged to void before being weighed and the same amount of clothing should be worn each day. The scale should be calibrated to zero before (not after) each weight is taken. PTS: 1 DIF: Cognitive Level: Application REF: Page 281-282, Skill 11-6 OBJ:10TOP:Weight measurement KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 28. The nurse assesses for the fifth vital sign, which is . ANS: pain Pain is considered the fifth vital sign. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 253 OBJ:1TOPain as a vital sign KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. If a patient has an axillary temperature of 96.2 F, the nurse understands that the true temperature is . ANS: 97.2 F
Axillary temperatures are considered to be 1 F below core temperature. PTS:1DIF:Cognitive Level: Comprehension REF: Page 257-259, 261 Skill 11-1 OBJ: 3 TOP: Axillary temperature KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. The nurse assesses the blood pressure as 192/86, noting that the patient has a pulse pressure of . ANS: 106 one hundred six The pulse pressure is the difference between the diastolic and systolic readings. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 273 OBJ:7TOPulse pressure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity Chapter 12: Physical Assessment My Nursing Test Banks Chapter 12: Physical Assessment Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is collecting data during an initial assessment. What can be seen, heard, measured, or felt and is objective? a. Symptom b. Observation c. Sign d. Assessment ANS: C A sign can be seen, heard, measured, or felt. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 286 OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 2. As part of an assessment, the nurse asks the patient for subjective information related to the present illness. What are the subjective findings
perceived by the patient? a. Assessments b. Symptoms c. Signs d. Observations ANS: B Symptoms are subjective indications of illness that are perceived by the patient. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 287 OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 3. Any disturbance of a structure or function of the body is a pathologic condition. What is the term for this condition? a. Injury b. Condition c. Disease d. Pathology ANS: C A disease is any disturbance of a structure or function of the body. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 287 OBJ: 2 TOP: Disease KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 4. The nurse is assessing a patient for collection of subjective and objective data. What will this data provide the basis for making? a. Care plan b. Medical diagnosis c. Nursing assessment d. Nursing diagnosis ANS: D Nurses rely on assessment of signs and symptoms to formulate a nursing diagnosis. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 287 OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment
MSC:NCLEX: N/A 5. The nurse is discussing the origin of diabetes with a diabetic patient. What will the nurse discuss as the most appropriate explanation for the cause of this disease? a. Pituitary b. Adrenals c. Pancreas d. Thyroid ANS: C Diabetes mellitus results from dysfunction of the pancreas. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 287 OBJ: 2 TOP: Disease KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 6. There are four categories of factors that increase an individuals vulnerability to develop a disease: genetic, physiological, age, and lifestyle. What is the term for these factors? a. Risk factors b. Causative factors c. Etiologic factors d. Hazardous factors ANS: A Risk factors are placed into four categories. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 288 OBJ: 3 TOP: Disease KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 7. When discussing diabetes with a patient, the nurse describes this disease as falling into which group in terms of duration? a. Acute b. Organic c. Chronic d. Functional ANS: C Diabetes mellitus is an example of a chronic disease.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 288 OBJ: 4 TOP: Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. What is the term used to describe a disease where there has been a partial or complete disappearance of clinical and subjective characteristics of the disease? a. Acute b. Functional c. Chronic d. Remission ANS: D Remission means there has been partial or complete disappearance of the clinical and subjective characteristics. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 288 OBJ: 4 TOP: Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. What type of disease results in a structural change in an organ that interferes with its functioning? a. Functional disease b. Organic disease c. Acute disease d. Chronic disease ANS: B An organic disease results in a structural change in an organ. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 288 OBJ: 2 TOP: Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. The signs and symptoms of both infection and inflammation include erythema, edema, and pain. What is considered the major difference between infection and inflammation? a. Inflammation is a result of bacteria. b. Inflammation is a protective response. c. Inflammation is a disease process.
d. Inflammation produces tissue damage. ANS: B Inflammation is a protective response. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 288 OBJ: 5 TOP: Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11.A nursing assessment is a process of collecting data to establish a database. The information contained in the database is a basis for: a. a complete physical examination. b. a medical assessment. c. an individualized plan of care. d. writing nursing orders. ANS: C The information contained in the database is the basis for an individualized plan of care. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 290 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 12. The nurse is meeting a patient for the first time. What is the first thing the nurse will do to initiate a nurse-patient relationship? a. Appear interested b. Introduce herself/himself c. Provide support d. Communicate trust ANS: B The first step in a nurse-patient relationship is for the nurse to introduce herself/himself. PTS: 1 DIF: Cognitive Level: Application REF: Page 293-294 OBJ:9TOP:Nurse-patient relationship KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 13. What should a patient interview being conducted by the nurse convey to the patient?
a. The nurse has feelings of concern. b. The nurse has limited time. c. The nurse is very intelligent. d. The nurse has answers to problems. ANS: A The nurse must convey feelings of concern. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 294 OBJ: 9 TOP: Interview KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. What does the nurse recognize as the initial step in conducting an assessment of a patient? a. A body systems review b. The nursing health history c. Biographical data d. The present illness ANS: B The nursing health history is the initial step in the assessment process. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 295 OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. When collecting data related to the present illness, the nurse must obtain detailed and comprehensive data. What does this data help to establish? a. A nursing diagnosis b. A nursing care plan c. Appropriate interventions d. Nursing orders ANS: C The data collected related to the present illness must be detailed and comprehensive to allow planning of appropriate interventions. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 296 OBJ: 10 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. During the nursing interview, several histories are taken. What is the
history that involves data concerning habits and lifestyle patterns? a. Family history b. Environmental history c. Past health history d. Psychosocial history ANS: C The nurse identifies habits and lifestyle patterns under the past health history. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 296 OBJ: 10 TOP: Interview KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. The nurse uses a systematic method for collecting data on all body systems, including normal functioning and any noted changes. What is this method? a. Nursing interview b. Review of systems c. Nursing assessment d. Health history ANS: B A review of systems is a systematic method. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 296-297, Box 12-1 OBJ: 11 TOP: Interview KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18. The nurse is developing a nursing care plan for a newly admitted patient. What is the first step the nurse will take in developing this care plan? a. Health history b. Review of systems c. Family history d. Nursing assessment ANS: D The nursing assessment is the critical step in forming the nursing care plan. PTS: 1 DIF: Cognitive Level: Application REF: Page 298 OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
19. The patient should be assessed as soon as possible after admission. Who
performs this initial assessment? a. Physician b. Charge nurse c. LPN/LVN d. RN ANS: D The initial assessment is done by the registered nurse. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 298 OBJ: 8 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20.A patient was admitted with a complaint of abdominal pain. Later, the nurse observed the patient demonstrating dyspnea. What type of assessment does this change in condition require? a. Individualized b. Focused c. Specialized d. Systematic ANS: B When the nurse observes a change in the patients condition, the assessment is focused. PTS: 1 DIF: Cognitive Level: Application REF: Page 298 OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. When performing a nursing physical assessment, the nurse uses a head-totoe approach. Where will the nurse begin when using this method? a. Skin assessment b. Neurologic assessment c. Circulatory assessment d. Respiratory assessment ANS: B When performing a head-to-toe assessment, the nurse begins with a neurologic assessment.
PTS: 1 DIF: Cognitive Level: Application REF: Page 300, Box 12-8, 301 OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22. An older adult patient is being assessed for skin turgor. The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised. What can the nurse conclude is responsible for this assessment? a. Dehydration b. Edema c. Skin breakdown d. Malnutrition ANS: A Dehydration results in decreased skin turgor. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 302 OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 23. During a physical assessment, the nurse listens for adventitious lung sounds. Crackles are classified as fine, medium, or coarse. When are these sounds most often auscultated? a. During expiration b. Following expiration c. During inspiration d. Following inspiration ANS: C Crackles are usually heard during inspiration. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 304 OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. Auscultating the heart sounds should result in a lubb-dupp sound when using the bell and the diaphragm of the stethoscope. What causes the lubb sound? a. Opening of the AV valves b. Opening of the semilunar valves
c. Closing of the AV valves d. Closing of the semilunar valves ANS: C The lubb-dupp sound of the heart is caused by the closing of the AV and semilunar valves, respectively. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 305-306 OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. The nurse assesses a patient for capillary refill after the fingernail is compressed for 5 seconds. What should the nurse expect the refill time to be? a. 1 second b. 2 seconds c. 3 seconds d. 4 seconds ANS: C Capillary refill should take fewer than 3 seconds. PTS: 1 DIF: Cognitive Level: Application REF: Page 308 OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope. What is the normal rate of bowel sounds per min-ute? a. 2-10 b. 3-20 c. 4-32 d. 5-40 ANS: C The normal rate of bowel sounds per minute is 4 to 32. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 308 OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 27.A patient has edema of the lower extremities. The nurse is assessing whether it is pitting and to what degree. After pressing the skin against a
bony prominence for 5 seconds, the nurse identifies 2+ pitting edema. When did the edema disappear? a. 10-15 seconds b. 20-25 seconds c. 30-35 seconds d. 40-45 seconds ANS: A The 2+ pitting edema is identified because the pitting edema disappears in 10 to 15 seconds. PTS: 1 DIF: Cognitive Level: Application REF: Page 110, Box 12-10 OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. Various techniques are used by the nurse when performing a physical assessment. One of these techniques is percussion. What is percussion used to determine? a. Sounds for auscultation b. Data about physical features c. Changes in structural integrity d. Density of underlying tissue ANS: D The sounds indicate the density of the underlying tissue. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 293, Box 12-4 OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. The nurse is obtaining a history of a patients present illness. The PQRST system is used for the interview. What does the R stand for in this system? a. Random b. Region c. Result d. Recent ANS: B In the PQRST system, the R stands for region. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 295, Box 12-6
OBJ: 10 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. When performing a physical examination of a patient, the nurse uses a technique that is particularly useful in identifying areas of tenderness or masses of the abdomen. What is this technique? a. Auscultation b. Deep palpation c. Light palpation d. Percussion ANS: B Deep palpation is used to detect tenderness or masses of the abdomen. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 309 OBJ: 8 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31. The nurse is performing auscultation of breath sounds on a respiratory patient. The sounds heard on inspiration and expiration are low-pitched, coarse, gurgling, and have a snoring sound. What best identifies these sounds? a. Crackles b. Plural friction rub c. Rhonchi d. Sonorous wheezes ANS: D Sonorous wheezes have a low-pitched, coarse, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and large airways. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 304 OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 32. What is the suggested sequence for a systematic approach to begin auscultating the thorax? a. Anterior thorax b. Apices c. Left lateral thorax
d. Right lateral thorax ANS: B The suggested sequence for a systematic auscultation of the thorax is to begin with the apices. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 304 OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 33.A nurse is gathering objective data when admitting a patient. Which assessment finding reported by the patient is considered objective? a. Complains of nausea b. States, I hurt all over. c. Complains of feeling anxious d. Appears to be anxious ANS: D Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Anxiety is the only objective assessment finding. All other options are examples of subjective data. PTS: 1 DIF: Cognitive Level: Application REF: Page 286 OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 34.A nurse is gathering objective data when admitting a patient. Which assessment finding is considered objective data? a. The patient complains of chest pain. b. The patient states, I am having trouble breathing. c. The patient complains of coughing up sputum. d. The patient expectorates red-tinged sputum. ANS: D Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Expectoration of red-tinged sputum is the only objective assessment finding. All other options are examples of subjective data. PTS: 1 DIF: Cognitive Level: Application REF: Page 286
OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 35.A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data? a. Complains of chest pain b. Is experiencing dyspnea c. Appears to be anxious d. Expectorates red-tinged sputum ANS: A Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Chest pain is the only subjective assessment finding. All other options are examples of objective data. PTS: 1 DIF: Cognitive Level: Application REF: Pages 287 OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 36.A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data? a. Complains of pruritus b. Is experiencing erythema c. Appears to be experiencing pruritus d. Has a generalized rash ANS: A Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Pruritus is the only subjective assessment finding. All other options are examples of objective data. PTS: 1 DIF: Cognitive Level: Application REF: Pages 287 OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 37.A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data? a. Complains of diplopia b. Is experiencing nystagmus c. Demonstrates facial grimacing d. Has a generalized rash ANS: A Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Diplopia is the only subjective assessment finding. All other options are examples of objective data. PTS: 1 DIF: Cognitive Level: Application REF: Pages 287 OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 38. What should the nurse begin by assessing when performing a head-to-toe assessment? a. Support system b. Skin integrity c. Pain level d. Neurologic status ANS: D When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 300, Box 12-8 OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 39. During a head-to-toe assessment, the nurse assesses the patients abdomen. Which area should the nurse assess next?
a. Chest b. Arms c. Legs and feet d. Perineal area ANS: D When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order. PTS:1DIF:Cognitive Level: Application REF: Pages 300, Box 12-8; 309-310 OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 40. During a head-to-toe assessment, the nurse assesses the patients perineal area. Which area should the nurse assess next? a. Chest b. Arms c. Abdomen d. Legs and feet ANS: D When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order. PTS: 1 DIF: Cognitive Level: Application REF: Page 300, Box 12-8; 310 OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 41. During a neurologic assessment, the nurse notes a patient has a unilateral, dilated, and nonreactive pupil. This is a sign that the patient is experiencing pressure on which cranial nerve? a.I b.II c.III
d.IV ANS: C The third cranial nerve runs parallel to the brainstem. The function of the oculomotor nerve is essential for eye movements. A traumatic brain injury can result in increased intracranial pressure, edema to the brainstem with pressure on cranial nerve III, causing the ominous sign of a unilateral, dilated, and nonreactive pupil. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 301 OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 42.A physician needs to insert a vaginal speculum into a patient for a vaginal examination. In what position should the nurse place the patient? a. Sims b. Prone c. Lithotomy d. Dorsal recumbent ANS: C The lithotomy position provides maximal exposure of genitalia and facilitates insertion of a vaginal speculum. PTS: 1 DIF: Cognitive Level: Application REF: Page 292, Table 12-2 OBJ: 6 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 43.A physician needs to assess extension of a patients hip joint. In what position should the nurse place the patient? a. Sims b. Prone c. Lithotomy d. Dorsal recumbent ANS: B Prone position is used to assess extension of a patients hip joint. PTS: 1 DIF: Cognitive Level: Application REF: Page 292, Table 12-2 OBJ: 6 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
44.A physician needs to assess a patient for a heart murmur. In what position should the nurse place the patient? a. Sims b. Prone c. Lithotomy d. Lateral recumbent ANS: D The lateral recumbent position aids in detecting heart murmurs. PTS: 1 DIF: Cognitive Level: Application REF: Page 292, Table 12-2 OBJ: 6 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 45.A physician needs to assess a patients rectal area. In what position should the nurse place the patient? a. Sims b. Prone c. Lithotomy d. Knee-chest ANS: D Knee-chest position provides maximum exposure of the rectal area. PTS: 1 DIF: Cognitive Level: Application REF: Page 292, Table 12-2 OBJ: 6 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 46.A nurse needs to auscultate a patients lung sounds. In what position should the nurse place the patient? a. Sims b. Prone c. Sitting d. Lithotomy ANS: C Sitting upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts. PTS: 1 DIF: Cognitive Level: Application REF: Page 292, Table 12-2 OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 47. During a physical assessment, the nurse notes a patient has a bluish discoloration of the skin and mucous membranes. How should the nurse document this finding? a. Dyspnea b. Cyanosis c. Diaphoresis d. Ecchymosis ANS: B Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 48. During a physical assessment, the nurse notes a patient has a lack of appetite resulting in an inability to eat. What should the nurse document that the patient is experiencing? a. Dyspnea b. Asthenia c. Anorexia d. Ecchymosis ANS: C Anorexia is a lack of appetite resulting in the inability to eat. This symptom can occur in many disease conditions. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 49. During a physical assessment, the nurse notes a patient has a loss of strength and energy. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Asthenia
d. Ecchymosis ANS: C Asthenia is a condition of debility, loss of strength and energy, and depleted vitality. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 50. During a physical assessment, the nurse notes that a patients heart rate is 56 beats per minute. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Diaphoresis d. Bradycardia ANS: D Bradycardia is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute. PTS: 1 DIF: Cognitive Level: Application REF: Page 289, Table 12-1 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 51. During a physical assessment, the patient complains of difficulty in passing stools. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Constipation d. Ecchymosis ANS: C Constipation is difficulty in passing stools or an incomplete or infrequent passage of hard stools. There are many causes, both organic and functional. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
52. During a physical assessment, the nurse observes a patient experiencing a
sudden audible expulsion of air from the lungs. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Coughing d. Ecchymosis ANS: C Coughing is a sudden audible expulsion of air from the lungs. Coughing is an essential protective response that serves to clear the lungs, bronchi, or trachea of irritants and secretions or to prevent aspiration of foreign material into the lungs. It is a common sign of diseases of the larynx, bronchi, and lungs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 53. During a physical assessment, the nurse notes a patient has profuse secretions of sweat. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Diaphoresis d. Ecchymosis ANS: C Diaphoresis is the secretion of sweat, especially the profuse secretion associated with an elevated body temperature, physical exertion, exposure to heat, and mental or emotional stress. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 54. During a physical assessment, the nurse notes a patient passes frequent loose liquid stools. What should the nurse document that the patient is experiencing? a. Dyspnea
b. Cyanosis c. Diaphoresis d. Diarrhea ANS: D Diarrhea is the frequent passage of loose liquid stools. It generally results from increased motility in the colon. This is usually a sign of an underlying disorder. The characteristics of the diarrhea give evidence as to the source. Dark black, tarry stools can mean there is bleeding in the intestines. Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 55. During a physical assessment, the nurse notes that a patient has bright red blood in the feces. What does the nurse recognize as the most likely cause of this bleeding? a. Bleeding in the upper intestinal tract b. Bleeding in the lower intestinal tract c. Bleeding in the entire intestinal tract d. Consumption of cranberry juice ANS: B Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract. PTS: 1 DIF: Cognitive Level: Application REF: Page 289, Table 12-1 OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 56.A nurse is caring for a patient with congestive heart failure. During the physical assessment, the nurse notes the patient is experiencing difficulty breathing. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Diaphoresis d. Ecchymosis
ANS: A Dyspnea is shortness of breath or difficulty in breathing that may be caused by certain heart and lung conditions, strenuous exercise, or anxiety. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 57.A patient has discoloration of an area of their mucous membrane caused by extravasation of blood into the subcutaneous tissue. What should the nurse document that the patient has? a. Dyspnea b. Cyanosis c. Diaphoresis d. Ecchymosis ANS: D Ecchymosis is discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls (also called a bruise). PTS: 1 DIF: Cognitive Level: Application REF: Page 289, Table 12-1 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 58. When admitting a patient to the hospital, the nurse notes the patient has mild sunburn. How should the nurse document this finding? a. Dyspnea b. Cyanosis c. Erythema d. Ecchymosis ANS: C Erythema is redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries; erythema is seen in mild sunburn. PTS: 1 DIF: Cognitive Level: Application REF: Page 289, Table 12-1 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 59. When assessing a patient with hepatitis, the nurse notes a yellow tinge to the patients skin. What does the nurse understand as the most likely cause of the jaundice? a. Heart b. Liver c. Brain d. Intestines ANS: B Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 289, Table 12-1 OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 60. When assessing a patient, the nurse notes a yellow tinge to the patients skin. How should the nurse document this finding? a. Dyspnea b. Cyanosis c. Jaundice d. Ecchymosis ANS: C Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver. PTS: 1 DIF: Cognitive Level: Application REF: Page 289, Table 12-1 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 61. When assessing a patient, the nurse notes that the patient is unable to lie flat to breathe. When the nurse assists the patient into a sitting position, the patient is able to breathe more easily. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Jaundice
d. Orthopnea ANS: D Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably. It occurs in many disorders of the respiratory and cardiac systems. PTS: 1 DIF: Cognitive Level: Application REF: Page 289, Table 12-1 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 62. When assessing a patient, the nurse notes that the patient has an unnatural paleness of color to the skin. How should the nurse document this finding? a. Skin pallor b. Pruritus c. Sallow skin d. Jaundice ANS: A Pallor is an unnatural paleness or absence of color in the skin; it may result from a decrease in hemoglobin and erythrocytes. PTS: 1 DIF: Cognitive Level: Application REF: Page 290, Table 12-1 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 63. When assessing a patient, the patient complains of an uncomfortable sensation leading to an urge to scratch. The nurse notes the patient scratches frequently. How should the nurse document this finding? a. Dyspnea b. Cyanosis c. Jaundice d. Pruritus ANS: D Pruritus is a symptom of itching and an uncomfortable sensation leading to an urge to scratch. Some causes are allergy, infection, jaundice, elevated serum urea, and skin irritation. PTS: 1 DIF: Cognitive Level: Application REF: Page 290, Table 12-1 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 64.A physician documents that a patient is having purulent drainage from a wound. What does the nurse understand is most likely the cause? a. Ringworm b. Viral infection c. Fungal infection d. Bacterial infection ANS: D Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues. Bacterial infection is the most common cause. The character of the pus, including its color, consistency, quantity, or odor, may be of diagnostic significance. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 290, Table 12-1 OBJ: 5 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 65.A physician documents that a patient has a sallow complexion. How does the nurse interpret this information? a. Yellow color to the skin b. Blue color to the skin c. Red color to the skin d. Gray color to the skin ANS: A Sallow is an unhealthy, yellow color; usually said of a complexion or skin. PTS: 1 DIF: Cognitive Level: Application REF: Page 290, Table 12-1 OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 66.A physician documents that a patient has a scleral icterus. How does the nurse describe the color of the patients sclera? a. Red b. Blue c. Green d. Yellow
ANS: D Scleral icterus means the color of the sclera is yellow. The jaundice is due to coloring of the sclera with bilirubin that infiltrates all tissues of the body. PTS: 1 DIF: Cognitive Level: Application REF: Page 290, Table 12-1 OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 67.A physician documents that a patient has a scleral icterus. What is the cause of this coloring? a. Bilirubin b. Hemoglobin c. Serum potassium d. Serum magnesium ANS: A Scleral icterus means the color of the sclera is yellow. The jaundice is due to coloring of the sclera with bilirubin that infiltrates all tissues of the body. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 290, Table 12-1 OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 68. When assessing a female for risk factors associated with coronary artery disease, what information should the nurse include? (Select all that apply.) a. Family history of illness b. Diet c. Smoking d. Exercise e. Number of pregnancies ANS: A, B, C, D With the exception of information relative to pregnancies, all options would be informative about risk for heart disease. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 288 OBJ: 3 TOP: Risk factors KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 69. Which are infectious diseases? (Select all that apply.)
a. Measles b. Pneumonia c. Hay fever d. Tuberculosis e. Osteoarthritis f. Acquired immunodeficiency syndrome ANS: A, B, D, F Infectious diseases result from the invasion of microorganisms into the body. Examples of infectious diseases include acquired immunodeficiency syndrome (AIDS), tuberculosis, measles, and pneumonia. Hay fever is a manifestation of an allergic reaction, and osteoarthritis is an example of a degenerative disease. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 287 OBJ:2TOP:Infectious disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 70. The nurse is preparing to perform a physical assessment. What essential supplies should this nurse gather? (Select all that apply.) a. Flashlight b. Gloves c. Red pen d. Thermometer e. Scissors ANS: A, B, D, E Items essential to the nurses assessment are a penlight or flashlight, a stethoscope, a blood pressure cuff, a thermometer, gloves, gait belt, watch with second hand, scissors, black pen, and a tongue blade. PTS: 1 DIF: Cognitive Level: Application REF: Page 291, Box 12-2 OBJ:7TOPhysical assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION 71. The nurse notes that a patient has difficulty breathing in the supine
position, and the patient admits that he sleeps in a recliner at home. These are cardinal signs of disease. ANS: COPD pulmonary Long-term pulmonary disease makes it difficult for the patient to breathe without distress in the supine position. These patients frequently sleep in a recliner chair. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 304-305 OBJ:12TOP:Chest assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 72. When auscultating the chest, a nurse hears crackles in both lower lobes. To further assess this finding, the nurse should ask the patient to . ANS: cough It is a useful assessment to determine that the patient can clear the secretions by coughing. PTS: 1 DIF: Cognitive Level: Application REF: Page 305 OBJ: 11 TOP: Crackles KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 73. The nurse observes that an older adult patient has no hair on the lower legs. The nurse should assess further for the sufficiency of . ANS: arterial flow Reduced arterial flow causes lack of hair on the lower extremities due to inadequate blood flow. PTS: 1 DIF: Cognitive Level: Application REF: Page 302 OBJ:12TOP:Vascular assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 74. Signs that are perceived by an examiner and can be seen, heard, measured,
or felt are known as . ANS: objective data Objective data is a sign that can be seen, heard, measured, or felt by the examiner. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 286 OBJ:2TOP:Objective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 75. Symptoms that are perceived by the patient are known as . ANS: subjective data Symptoms are subjective indications of illness that are perceived by the patient. Symptoms are referred to as subjective data. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 287 OBJ:2TOP:Subjective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 76.A condition in which there is a lack of appetite resulting in the inability to eat is known as . ANS: anorexia Anorexia is a lack of appetite resulting in the inability to eat. It can occur in many disease conditions. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 4 TOP: Anorexia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 77.A condition of debility, loss of strength and energy, and depleted vitality is known as . ANS: asthenia Asthenia is a condition of debility, loss of strength and energy, and depleted vitality.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 4 TOP: Asthenia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 78.A circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute is known as . ANS: bradycardia Bradycardia is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 4 TOP: Bradycardia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 79.A condition in which a patient experiences bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood is known as . ANS: cyanosis Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 4 TOP: Cyanosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 80. Discoloration of an area of the skin or mucous membrane that is caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls is known as . ANS: ecchymosis Ecchymosis is discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 4 TOP: Ecchymosis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 81. Redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries is known as . ANS: erythema Erythema is redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 4 TOP: Erythema KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 82.A yellow tinge to the skin that may indicate obstruction in the flow of bile from the liver is known as . ANS: jaundice Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 4 TOP: Jaundice KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 83.An abnormal condition in which a person must sit or stand to breathe deeply or comfortably is known as . ANS: orthopnea Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1 OBJ: 4 TOP: Orthopnea KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 84.A symptom of itching and an uncomfortable sensation leading to an urge to scratch is known as . ANS: pruritus Pruritus is a symptom of itching and an uncomfortable sensation leading to
an urge to scratch. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 290, Table 12-1 OBJ: 4 TOP: Pruritus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 85.A creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues is known as . ANS: purulent drainage Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 290, Table 12-1 OBJ:4TOPurulent drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 86. An abnormal condition in which the heart contracts regularly but at a rate greater than 100 beats per minute is known as . ANS: tachycardia Tachycardia is an abnormal condition in which the heart contracts regularly but at a rate greater than 100 beats per minute. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 290, Table 12-1 OBJ: 4 TOP: Tachycardia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 87. An abnormally rapid rate of breathing that is seen in many disease conditions is known as . ANS: tachypnea Tachypnea is an abnormally rapid rate of breathing that is seen in many disease conditions. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 290, Table 12-1 OBJ: 4 TOP: Tachypnea KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 88.A condition in which there is a temporary loss of consciousness associated
with an increased rate of respiration, tachycardia, pallor, perspiration, and coolness of the skin is known as . ANS: syncope Syncope is a temporary loss of consciousness (partial or complete) associated with an increased rate of respiration, tachycardia, pallor, perspiration, and coolness of skin. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 301, Table 12-3 OBJ: 4 TOP: Syncope KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 89. and personal characteristics determine health behavior in individuals and families. More than half of all health problems are the result of behavior and lifestyle. ANS: Cultural beliefs Cultural beliefs and personal characteristics determine health behavior in individuals and families. More than half of all health problems are the result of behavior and lifestyle. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 298 OBJ:14TOP:Cultural sensitivity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity OTHER 90. Arrange these assessment techniques in correct order of a standard physical examination. Put a comma and space between each answer choice (A, B, C, D, etc.). a. Auscultation b. Percussion c. Inspection d. Palpation ANS: C, D, A, B The usual sequence of assessment is inspection, palpation, auscultation, and lastly percussion.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 293, Box 12-4 OBJ:11TOPhysical examination series KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity Chapter 13: Admission, Transfer, and Discharge My Nursing Test Banks Chapter 13: Admission, Transfer, and Discharge Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. When admitting a patient to the hospital, the nurse observes that the patient is distracted and tense. What does this behavior suggest as a common reaction to hospitalization? a. Relief about being cared for b. Fear of the unknown c. Feeling of powerlessness d. Concern about cost ANS: B Fear of the unknown may be the most common reaction to hospitalization. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 313 OBJ: 3 | 5 TOP: Admission KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 2.A nurse is admitting a patient to an acute care facility. During the admission procedure, what nursing intervention would best help reduce patient anxiety? a. Transport the patient by wheelchair. b. Inform the physician that the patient is admitted. c. Greet the patient by name. d. Collect financial information during the interview. ANS: C Greeting the patient by name is one of the most important aspects of admission. PTS: 1 DIF: Cognitive Level: Application REF: Page 316 OBJ: 1 | 4 | 5 TOP: Admission KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
3. What essential part of the admission procedure is performed by the RN?
a. Securing the patients valuables b. Confirming the type of insurance coverage c. Obtaining a health history d. Familiarizing the patient with the room ANS: C Admission assessment is performed by the RN. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 318 OBJ: 5 | 6 TOP: Admission KEY: Nursing Process Step: Assessment MSC:NCLEX: Safe, Effective Care Environment 4. When should discharge planning begin? a. The day before discharge b. On the first day postoperatively c. Shortly after admission d. When the doctor orders it ANS: C Discharge planning begins shortly after admission. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 323 OBJ: 5 | 8 TOP: Discharge KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 5. Where can a nurse refer the family of a patient to find a source of financial aid to meet medical expenses? a. A local bank b. A clinical nurse specialist c. The hospital administration d. Social services ANS: D Often a patient will require services of various disciplines within the hospital. Social services can assist with meeting medical financial obligations. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 326 Health Promotion OBJ:8TOP:Social services KEY:Nursing Process Step: Implementation
MSC:NCLEX: Safe, Effective Care Environment 6. When a patient demands to be discharged without a physicians order and is leaving the unit with his belongings, what should the nurse ask the patient to sign? a. A form exercising the patients rights b. A discharge against medical advice form c. An informed consent d. An advanced directive ANS: B If a doctor cannot convince the patient to stay, the patient should sign an against medical advice form. PTS: 1 DIF: Cognitive Level: Application REF: Page 327, Box 13-6 OBJ: 10 TOP: Discharge KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 7. The nurse must be sensitive to an older adult patient experiencing separation anxiety when admitted to the hospital. When a child experiences separation anxiety they will usually cry. What will an older adult often demonstrate when experiencing separation anxiety? a. Withdrawal b. Anger c. Depression d. Regression ANS: C The older adult may demonstrate depression as a result of separation anxiety entering the hospital. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 314 OBJ: 3 TOP: Admission KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 8. Upon admission, the nurse notes that a patient without family members present has a billfold filled with cash. Where can the nurse suggest the money be placed? a. In a sealed envelope in the bedside table b. In the care of hospital security
c. Locked in the narcotic cupboard d. In the hospital safe ANS: D Valuables should be locked in the hospital safe. PTS: 1 DIF: Cognitive Level: Application REF: Page 316 OBJ:6TOP:Care of valuables KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 9. If a patient has an order for an interagency transfer where does the nurse explain that the patient will be moved? a. A double room to a private room b. One unit of the hospital to another c. One room of the unit to another d. One facility to another ANS: D The interagency transfer moves a patient from one health care agency to another. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 322 OBJ: 7 TOP: Transfer KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 10. Before the actual discharge occurs, what must the nurse ensure ? a. The patient is well enough to go home. b. The patient has not been overly medicated. c. The patient understands the discharge instructions. d. The patient has adequate transportation. ANS: C It is essential that the patient be fully aware of the discharge instructions before being discharged. PTS:1DIF:Cognitive Level: Application REF: Pages 323, 325-326, 328 Skill 13-3 OBJ: 5 | 9 TOPischargeKEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 11.A patient who is alert and oriented is threatening to leave the hospital
against medical advice (AMA). What action should the nurse take? a. Forcibly detain and restrain the patient. b. Administer a sedative hypnotic medication. c. Prevent patient from leaving until an AMA form is signed. d. Notify the physician that the patient is threatening to leave AMA. ANS: D When a patient threatens to leave AMA, the physician should be notified immediately. If the physician fails to convince the patient to remain in the facility, the physician will ask the patient to sign an AMA form releasing the facility from legal responsibility for any medical problems the patient may experience after discharge. If the physician is not available, the nurse should discuss the discharge form with the patient and obtain the patients signature. If the patient refuses to sign the AMA form, the patient should not be detained. This violates the patients legal rights. After the patient leaves, the nurse should document the incident thoroughly in the nurses notes and notify the physician. A rational adult patient who will not sign the AMA form cannot be forcibly detained. PTS: 1 DIF: Cognitive Level: Application REF: Page 327, Box 13-6 OBJ:10TOP:Against medical advice KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 12. How can the nurse demonstrate cultural sensitivity to a Haitian American patient? a. By providing a well-lit room 24 hours a day b. By writing out all instructions given to the patient c. By allowing the patient to keep leaves in her room d. By asking the physician to provide all directions to the patient ANS: C Many Haitians believe that leaves have a special significance in healing. Leaves may be found in the clothes and on various parts of the body. Leaves are thought to have mystical power related to regaining or keeping health. PTS:1DIF:Cognitive Level: Application REF: Page 315, Cultural Considerations OBJ: 4 TOP: Cultural awareness
KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychological Integrity 13.A nurse is caring for a Haitian American patient. How might the nurse demonstrate cultural sensitivity? a. Discarding any leaves the patient may have brought with them b. Assigning the patient to a room with any Haitian American patient c. Instructing the patient to ride in a wheelchair when discharged d. Allowing the patient to walk out of the hospital when discharged ANS: D Some Haitian Americans associate wheelchairs with being sick. Therefore, on discharge, the patient who is allowed to walk out of the hospital will be more likely to feel that care has been effective. A poor patient with a Haitian background and a wealthy patient with a Haitian background, although from the same country, may find the same room assignment together in the hospital very distasteful. PTS:1DIF:Cognitive Level: Application REF: Page 315, Cultural Considerations OBJ: 4 TOP: Cultural awareness KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychological Integrity MULTIPLE RESPONSE 14. How can the nurse help reduce the stress of a hospital admission? (Select all that apply.) a. Show the patient how bedside equipment works. b. Explain the need to establish a clear source of reimbursement. c. Give simple explanation of policies. d. Involve the patient in the plan of care. e. Keep family interventions to a minimum. ANS: A, C, D An empathic reception reduces anxiety of admission; for instance, demonstrating how bedside equipment works, explaining hospital policies, and involving the patient in the plan of care from the start all help to reduce the stress of a hospital admission. Securing financial information is not a role of the nurse, and family interventions are frequently helpful in reducing
stress. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 314-318 OBJ:4 | 5TOP:Stress reduction KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 15. The nurse adheres to the discharge standards set by The Joint Commission (TJC), which include that patients will receive instruction regarding which aspect(s) of care? (Select all that apply.) a. Medications b. Rehabilitation techniques c. Referral to community agencies d. Medical equipment to be used e. Obtaining health insurance ANS: A, B, C, D The Joint Commission (TJC) standards require that a patient have information pertinent to medication, rehabilitation instructions, referral to community agencies, instruction in using any medical equipment, family care responsibility, diet, and how to obtain further treatment if necessary. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 324 OBJ:9TOP:TJC standards for discharge KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment COMPLETION 16. The nurse completes thorough documentation before, during, and after a transfer to ensure of . ANS: continuity, care Clear documentation before, during, and after a transfer ensures that the patients condition is being monitored and maintains the continuity of care. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 322 OBJ:5 | 7TOPocumentation KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 17. Some patients consider sundown Friday to
sundown Saturday to be the Sabbath, which is a time of rest. ANS: Orthodox Jewish Some Orthodox Jewish patients consider sundown Friday to sundown Saturday to be the Sabbath, which is a time of rest. These patients may avoid the use of any electronic equipment, so the nurse should find alternatives to the use of this equipment if possible. PTS:1DIF:Cognitive Level: Knowledge REF: Page 315, Cultural Considerations OBJ: 3 TOP: Orthodox Jewish culture KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 18. Because of the stress caused by hospitalization, the nurse assesses a newly admitted older adult patient for . ANS: disorientation In a normally alert and oriented older adult, medical conditions that necessitate hospitalization often result in some level of disorientation. PTS:1DIF:Cognitive Level: Application REF: Page 314, Life Span Considerations OBJ: 3 | 5 TOP: Disorientation in older adults KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity Chapter 14: Surgical Wound Care My Nursing Test Banks Chapter 14: Surgical Wound Care Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is instructing a patient who has a drain in a surgical wound. How will the nurse indicate that the wound will heal? a. Primary intention b. Secondary intention c. Tertiary intention d. Deliberate intention ANS: C
When wounds are kept open by a drain, they heal by tertiary intention. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 335 OBJ:4TOP:Tertiary intention KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. What technique will the nurse implement to assist the postoperative patient to cough? a. Support the patients back b. Offer an antitussive c. Splint the abdomen with a pillow d. Lean patient against the bedside table ANS: C To assist a postoperative patient to cough, splinting the abdomen with pillow, hands, or a towel roll is helpful to relieve stress on the suture line. PTS: 1 DIF: Cognitive Level: Application REF: Page 335 OBJ: 8 TOP: Suture lines KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The day following surgery, the nurse notes bloody drainage on the dressing. How will the nurse describe this drainage when documenting? a. Serosanguineous b. Sanguineous c. Serous d. Purulent ANS: B The term sanguineous means bloody. It is indicative of active bleeding. PTS: 1 DIF: Cognitive Level: Application REF: Page 337, Table 14-2 OBJ: 1 TOP: Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. What is the advantage of an occlusive dressing? a. Allows air to the incision b. Keeps the incision moist c. Delays epithelialization d. Does not have to be changed
ANS: B Occlusive dressings keep the incision moist and increase epithelialization. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 338 OBJ:7TOP:Occlusive dressings KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. When removing the dressing on a patient, the nurse discovers that the gauze dressing has adhered to the wound. What intervention should the nurse implement? a. Call the RN b. Gently remove the gauze with sterile forceps c. Cover with occlusive dressing d. Moisten the dressing with sterile water ANS: D When a dressing has adhered to the wound, the nurse may moisten the dressing with sterile water or sterile normal saline to loosen it. PTS: 1 DIF: Cognitive Level: Application REF: Page 339 OBJ:7TOPry dressings KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is providing instruction to a patient regarding home wound irrigation. How far should the patient hold the hand-held showerhead from the wound when irrigating the wound? a. 2.5 inches b. 6 inches c. 12 inches d. 18 inches ANS: C When wound irrigation is done at home with a hand-held showerhead, the showerhead should be held approximately 12 inches from the wound. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 346 OBJ:11TOP:Wound irrigation KEY:Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 7. The nurse is irrigating a leg wound of a patient on the trauma unit. Where should the nurse direct the flow of the irrigant? a. From the area of least contamination to the area of most contaminati b. Forcefully into the wound c. Gently over the skin into the wound d. From a distance of about 12 inches ANS: A The irrigant should flow from the least contaminated area to the most contaminated area to prevent microorganisms from entering the wound. PTS: 1 DIF: Cognitive Level: Application REF: Page 343 OBJ:11TOP:Wound irrigation KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement? a. Call the RN b. Cover the bowel with a sterile saline dressing c. Turn the patient to the side of the evisceration d. Raise the patient up to a high Fowler position ANS: B Although the RN must be notified, covering the loop of the bowel takes priority. The patient may be raised to a semi-Fowler position to relieve strain on the suture line. PTS: 1 DIF: Cognitive Level: Application REF: Page 347, Box 14-3 OBJ: 8 TOP: Evisceration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse is removing every other staple from a surgical wound, which has been closed with 15 staples. The wound begins to separate after removal of 3 of the 15. What nursing action should be implemented? a. Remove 7 more alternate staples and securely tape with Steri-Strips b. Cover with moist dressing and apply a binder c. Continue to remove staples as ordered because this is an expected ou
d. Leave the 12 staples in place and record the separation ANS: D If the wound separates during the removal of staples, cease the removal, cover with a dry dressing, and record the separation. PTS: 1 DIF: Cognitive Level: Application REF: Page 348 OBJ:9TOP:Staple removal KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The physician has not ordered a dressing change for a draining wound on a patient in an acute care setting. How should the nurse assess the amount of drainage? a. Weigh the patient to estimate the weight of the saturated dressing b. Reinforce the dressing c. Circle and date the outline of the exudate on the dressing d. Count each dressing as 1 mL of drainage ANS: C Without an order to change the dressing, the drainage should be circled and dated. Should the dressing become saturated, the dressing can be reinforced but the exudate should still be circled. PTS: 1 DIF: Cognitive Level: Application REF: Page 351 OBJ:7TOPraining wounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. The Centers for Disease Control and Prevention (CDC) classifies wounds according to the amount of contamination. What is the classification for an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively? a. Dirty wound b. Clean-contaminated wound c. Contaminated wound d. Clean wound ANS: D A clean wound is an uninfected surgical wound with less than a 5% chance of
becoming infected postoperatively. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 333 OBJ: 5 TOP: Wounds KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 12. Hemostasis begins as soon as the injury occurs and a clot begins to form. What is the substance in the clot that holds the wound together? a. Fibrin b. Thrombin c. Protime d. Calcium ANS: A Fibrin in the clot begins to hold the wound together. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 334 OBJ: 1 TOP: Wounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. What phase is a wound in when blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain? a. Healing b. Inflammatory c. Reconstruction d. Maturation ANS: B During the inflammatory phase, blood and fluid leak out of the blood vessels into the vascular space. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 335, 337 OBJ: 1 TOP: Wounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. What marked advantage does primary intention have over other phases of wound healing? a. Healing is rapid b. Healing rarely becomes infected c. Minimal scarring results d. Healing is painless
ANS: C Wounds that heal by primary intention have minimal scarring. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 334 OBJ: 4 TOP: Wounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is caring for a patient during the first 24 hours following surgery. How often will the nurse assess for bleeding under the dressing? a. Every 30 minutes b. Every 60 minutes c. Every 2 to 4 hours d. Every 5 to 8 hours ANS: C The nurse inspects the dressing every 2 to 4 hours for the first 24 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 335 OBJ: 6 TOP: Wounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse is preparing to perform a dressing change on a patient following a total hip replacement. When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change? a. After the dressing change b. At least 15 minutes before the dressing change c. At least 30 minutes before the dressing change d. At least 1 hour before the dressing change ANS: C It may help to give an analgesic at least 30 minutes before exposing the wound. PTS: 1 DIF: Cognitive Level: Application REF: Page 339 OBJ: 7 TOP: Wounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound. What is the result of this intervention when the dressing is removed? a. Destruction of tissue
b. Bleeding c. Mechanical debridement d. Prevention of infection ANS: C The primary purpose of a wet-to-dry dressing is to debride a wound mechanically. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 339 OBJ: 7 TOP: Wounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse assessing a postoperative patient discovers that the pulse is rapid, blood pressure has decreased, urinary output has decreased, and the dressing is dry. What can the nurse determine is indicated by these findings? a. Pain shock b. Dehydration c. Internal hemorrhage d. Acute infection ANS: C If a patient has a rapid pulse, decreased blood pressure, decreased urinary output, and the dressing is dry, then the diagnosis is most likely an internal hemorrhage. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 347 OBJ:3TOPostoperative KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. What is the usual length of time before suture removal? a. 2 to 3 days b. 4 to 5 days c. 5 to 6 days d. 7 to 10 days ANS: D Sutures are generally removed within 7 to 10 days. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 348 OBJ: 9 TOP: Wounds KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 20. The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain. What is the maximum amount of drainage considered normal? a. 50 mL b. 100 mL c. 200 mL d. 300 mL ANS: D Drainage greater than 300 mL in 24 hours is considered abnormal. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 351 OBJ: 3 TOP: Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. What is the classification for the Jackson-Pratt drainage removal system? a. Sterile drainage system b. Closed drainage system c. Open drainage system d. Self-measuring drainage system ANS: B The Jackson-Pratt removal system is a type of closed drainage system. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 351 OBJ: 10 TOP: Drainage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The nurse is caring for a patient with a surgical wound. How can the nurse promote healing? a. Offer fluids every 4 hours b. Encourage the consumption of large meals c. Encourage up to 1000 mL of daily fluid intake d. Encourage the consumption of small frequent meals ANS: D To promote wound healing, dietary services can provide small frequent feedings. Fluids, when tolerated, should be offered hourly. Unless contraindicated, the nurse should encourage an intake of 2000 to 2400 mL in
24 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 335 OBJ:2TOP:Wound healing KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse is instructing a patient about the effects of smoking. What accurate information does the nurse provide? a. Smoking increases the amount of tissue oxygenation. b. Smoking increases the amount of functional hemoglobin in blood. c. Smoking may decrease platelet aggregation and cause hypercoagulabi d. Smoking interferes with normal cellular mechanisms that promote rel ANS: D Smoking reduces the amount of functional hemoglobin in blood, thus decreasing tissue oxygenation. Smoking may increase platelet aggregation and hypercoagulability. Smoking interferes with normal cellular mechanisms that promote release of oxygen to tissues. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 336, Table 14-1 OBJ: 6 TOP: Smoking KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. The nurse is preparing a presentation regarding the effects of diabetes mellitus. What will the nurse include regarding the effects of diabetes mellitus? a. Improves overall tissue perfusion b. Promotes release of oxygen to tissues c. Causes hemoglobin to have a greater affinity for oxygen d. Causes hemoglobin to have a decreased affinity for oxygen ANS: C Diabetes mellitus is a chronic disease that causes small blood vessel disease that impairs tissue perfusion. It also causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 336, Table 14-1 OBJ:6TOPiabetes mellitus KEY:Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 25. The nurse assessing a patients wound notes a clear watery drainage. How will the nurse most accurately document this finding? a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage ANS: A Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is bright red and indicates active bleeding. Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 337, Table 14-2 OBJ: 5 TOP: Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. The nurse assessing a patients wound notes thick, yellow drainage. How will the nurse most accurately document this finding? a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage ANS: B Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Serous drainage has the appearance of clear, watery plasma. Sanguineous drainage is bright red and indicates active bleeding. Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 337, Table 14-2 OBJ: 5 TOP: Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 27. The nurse assessing a patients wound notes pale red watery drainage. How will the nurse most accurately document this finding?
a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage ANS: D Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage. Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is bright red and indicates active bleeding. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 337, Table 14-2 OBJ: 5 TOP: Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. The nurse assessing a patients wound notes bright red drainage. How will the nurse most accurately document this finding? a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage ANS: C Sanguineous drainage is bright red and indicates active bleeding. Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 337, Table 14-2 OBJ: 5 TOP: Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. What does the nurse recognize that this indicates? a. Cellulitis b. Dehiscence
c. Evisceration d. Extravasation ANS: B Dehiscence is separation of a surgical incision or rupture of a wound closure. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 347, Table 14-3 OBJ: 8 TOP: Dehiscence KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. The nurse is preparing to redress a wound and will secure the dressing using a gauze bandage as ordered by the physician. What is an advantage of gauze bandages? a. Provision of warmth b. Applies strong pressure c. Antibacterial effects d. Prevents skin maceration ANS: D Gauze bandages are lightweight and inexpensive, mold easily around contours of the body, and permit air circulation that helps prevent skin maceration (the softening and breaking down of skin from prolonged exposure to moisture). Flannel bandages provide warmth. Elastic bandages are effective for pressure application. Gauze bandages do not have antibacterial effects. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 338 OBJ:13TOP:Bandages and binders KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31.A patient with a diagnosis of insulin dependent diabetes mellitus is being treated for a stage II foot ulcer. The patient refuses to follow an ADA diet as ordered by a physician and is morbidly obese. The nurse assesses the ulcer to be healing, free from signs and symptoms of infection, with a positive pedal pulse and warm to touch. What nursing diagnosis will be identified as a priority? a. Infection b. Altered nutrition: more than body requirements c. Impaired skin integrity
d. Altered peripheral tissue perfusion ANS: B The nurses assessment identifies no signs of infection, that the wound is healing with positive pedal pulse and skin warm to touch ruling out infection, impaired skin integrity, and altered peripheral tissue perfusion as priorities at this time. The priority nursing diagnosis for this patient is Altered Nutrition: more than body requirements related to diet noncompliance. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 361 OBJ:14TOP:Nursing Diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 32. The nurses employed at a wound therapy clinic are preparing an educational in-service about the vacuum-assisted closure (VAC) device for hospital nurses. What accurate information will be included in this inservice? (Select all that apply.) a. Positive pressure is applied by this device b. Healing is facilitated by decrease in drainage c. Promotes formulation of granulation tissue d. Reduces local and peripheral edema e. Drops bacterial level in wound ANS: C, D, E Vacuum-assisted closure (VAC) devices apply negative pressure and increase drainage. Healing is facilitated by promotion of granulation tissue, decreased local and peripheral edema, and in 3 to 4 days following application a drop in bacterial level in the wound should be observed. PTS:1DIF:Cognitive Level: Comprehension REF: Page 353-354, 355-357 Skill 14-7 OBJ: 12 TOP: Vacuum-assisted device KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. Which are the phases of wound healing? (Select all that apply.) a. Reconstruction
b. Hemostasis c. Inflammation d. Granulation e. Maturation ANS: A, B, C, E The steps in wound healing are hemostasis, inflammation,reconstruction, and maturation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 334-335 OBJ:1TOP:Wound healing KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 34. Which solution(s) can be used on a wet-to-dry dressing? (Select all that apply.) a. Normal saline b. Lactated Ringer c. Acetic acid d. Dakin e. Lysol ANS: A, B, C, D Normal saline, sterile water, lactated Ringer, acetic acid, or Dakin solution are all acceptable for use on wet-to-dry dressings. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 341 OBJ:7TOP:Wet-to-dry dressings KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 35. What are the advantages of a transparent dressing? (Select all that apply.) a. Adheres to undamaged skin b. Contains the exudate c. Reduces wound contamination d. Serves as a barrier to external bacteria e. Slows epithelial growth ANS: A, B, C, D Transparent dressings have the advantages of adhering to undamaged skin,
containing the exudate, reducing wound contamination, serving as a barrier to external bacteria, and speeding epithelial growth. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 341-342 OBJ:7TOP:Transparent dressings KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity COMPLETION 36. The nurse assures a patient that the purple, raised, immature scar of a surgical wound is normal and caused by formation. ANS: collagen Collagen forms as an immature scar over a new surgical wound. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 334 OBJ:1TOP:Immature scarring KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 37. The nurse encourages a patient recovering from a hysterectomy to drink at least mL of fluid a day. ANS: 2000 two thousand A recovering surgical patient should drink between 2000 and 2400 mL of fluid daily. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 335 OBJ: 2 TOP: Fluid intake KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 38. When preparing to remove a dressing, the nurse should don gloves. ANS: clean To remove a dressing, clean gloves are appropriate. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 337 OBJ:7TOP:Removal of a dressing KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment
Chapter 15: Specimen Collection and Diagnostic Testing My Nursing Test Banks Chapter 15: Specimen Collection and Diagnostic Testing Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. New physician orders are transcribed for a patient to receive a colonoscopy. What must be completed before the colonoscopy to indicate the patient has been given full knowledge about what will be done along with its risks and complications? a. Patients rights b. Advance directive c. Informed consent d. Patient protection ANS: C Informed consent states that the patient must fully understand and be aware of the risks and complications of what is to be done. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 366, 373 Table 151 OBJ:1TOProper preparation KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 2. The nurse is preparing a patient for a diagnostic examination. What can the nurse implement to assist with reducing anxiety? a. Explain the costs of the examination b. Demonstrate use of equipment c. Answer questions for clarification d. Fill out required paperwork ANS: C The nurse must be prepared to answer questions that the patient may have to reduce anxiety and give valid information. PTS: 1 DIF: Cognitive Level: Application REF: Page 366 OBJ:2TOProper preparation KEY:Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity 3.A patient is required to provide a sample of body excretions per physician order. What action can the nurse take when providing proper instructions to lessen the patients embarrassment? a. Instruct patient to provide the specimen behind a screen. b. Instruct patient to obtain his or her own specimen. c. Instruct patient to return later when he or she is more comfortable. d. Instruct patient to use a CNA for assistance to obtain the specimen. ANS: B With proper instruction, many patients may obtain their own specimen. PTS: 1 DIF: Cognitive Level: Application REF: Page 383 OBJ:3TOP:Specimen collection KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 4. What health care professional has the responsibility for notifying the physician when laboratory and diagnostic studies deviate from the norm? a. Laboratory technician b. Cooperating physician c. Nurse d. Supervisor ANS: C It is the nurses responsibility to notify the physician when laboratory and diagnostic studies deviate from the norm. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 383 OBJ:4TOPiagnostic studies KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 5. What is the term for the cleanest part of a voided urine specimen that is collected after voiding is initiated and before it is finished? a. Sterile specimen b. Caught specimen c. Midstream specimen d. Patient-collected specimen
ANS: C A midstream urine specimen is collected after voiding is initiated and before it is completed. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 385 OBJ: 5 | 6 TOP: Specimen KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 6. The patient is to be catheterized for residual urine. The nurse must perform this catheterization within how many minutes following voiding? a. 40 minutes b. 30 minutes c. 20 minutes d. 10 minutes ANS: D Catheterization is performed within 10 minutes of the patient voiding to check for residual urine. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 385 OBJ: 8 TOP: Specimen KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 7. The process for collecting a blood specimen for measuring blood glucose levels begins by asking the patient to hold the selected arm at his or her side for 30 seconds. From what anatomic location is the specimen obtained? a. Tip of the finger b. Cubital fossa c. Side of the finger d. Center of the thumb ANS: C The specimen should be collected from the side of the selected finger to avoid painful fingertip sticks. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 389, Skill 15-5 OBJ: 9 TOP: Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. What type of stool specimen must be sent to the laboratory immediately? a. Occult blood
b. Ova and parasites c. Infection d. Fats ANS: B A stool specimen for the presence of ova or parasites must be taken to the laboratory immediately. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 391, Skill 15-6 OBJ: 10 TOP: Specimen KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 9. What is the probable source of bright red blood in the stool? a. Stomach b. Small intestine c. Lower gastrointestinal tract d. Higher intestinal tract ANS: C When blood in the stool is bright red, the site of bleeding is most likely from the lower gastrointestinal tract. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 390 OBJ: 4 | 10 TOP: Specimen KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10.A sputum specimen is ordered on a patient diagnosed with pneumonia. When is the best time for the nurse to the attempt to collect this specimen? a. At bedtime b. After lunch c. In the early morning d. After breakfast ANS: C Early morning before a meal is the best time to collect a sputum specimen. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 390 OBJ: 11 TOP: Specimen KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 11.A patient is unable to obtain a sputum specimen by coughing and expectorating. What is the best way for the nurse to collect this specimen?
a. Ask the patient to spit b. Direct the patient to turn, cough, and breathe deeply c. Perform tracheal suctioning d. Perform a bronchoscopy ANS: C Some patients cannot expectorate and must have the trachea suctioned to obtain a specimen. PTS: 1 DIF: Cognitive Level: Application REF: Page 390 OBJ: 11 TOP: Specimen KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 12. The nurse is collecting a specimen for a wound culture. What should be avoided when collecting this specimen? a. A dressing b. Deep in the wound c. The outer edge of the wound d. Old drainage ANS: D The nurse should not collect a wound culture from old drainage. PTS: 1 DIF: Cognitive Level: Application REF: Page 395 OBJ: 5 TOP: Specimen KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 13. Anaerobic organisms tend to grow within body cavities. What will the nurse use to collect an anaerobic specimen? a. Sterile cotton applicator b. Sterile culture tube c. Sterile syringe tip d. Sterile glass rod ANS: C To collect an anaerobic specimen deep in a body cavity, the nurse uses a sterile syringe tip. PTS: 1 DIF: Cognitive Level: Application REF: Page 395 OBJ: 5 TOP: Specimen KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment
14. The nurse is obtaining a throat culture. What area will the nurse swab with
a cotton-tipped applicator? a. Larynx b. Oral mucosa c. Pharynx d. Trachea ANS: C The nurse should swab the tonsillar area (pharynx) with a sterile cottontipped applicator to obtain a specimen for a throat culture. PTS: 1 DIF: Cognitive Level: Application REF: Page 398, Skill 15-11 OBJ: 4 TOP: Specimen KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 15. The nurse explains that electrocardiograms are graphic representations of electrical impulses generated by the heart. What type of abnormalities can an electrocardiogram identify? a. Those that produce a cardiac cycle b. Those that interfere with electrical conduction c. Those that result from an interrupted blood flow d. Those that interfere with heart contraction ANS: B Electrocardiograms identify abnormalities that interfere with electrical conduction. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 402 OBJ:13TOP:Electrocardiogram KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 16. What is the rationale for the nurse to assess a patients knowledge of an ordered procedure? a. To determine difficulties the patient may encounter b. To determine the nurses role in the procedure c. To determine health teaching required d. To determine anxiety the patient has ANS: C
The nurse will need to assess the patients knowledge of the procedure to determine the level of health care teaching needed. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 368, Box 15-1 OBJ:2TOP:Teaching needs KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 17. What should the nurse assess the patient for before administration of contrast media? a. Has been NPO b. Is allergic to iodine c. Has emptied the bladder d. Has taken medication ANS: B The patient should always be assessed for allergies to iodine before administration of contrast media. PTS: 1 DIF: Cognitive Level: Application REF: Page 368, Box 15-2 OBJ:2TOPiagnostic examination KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 18. The nurse should administer Telepaque in preparation for a cholecystogram. How frequently will the nurse administer one tablet of Telepaque before this procedure? a. Every 5 minutes b. Every 10 minutes c. Every 15 minutes d. Every 20 minutes ANS: C Telepaque should be taken one at a time, waiting 15 minutes after each tablet. PTS: 1 DIF: Cognitive Level: Application REF: Page 376, Table 15-1 OBJ:2TOPiagnostic examination KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 19. Following a liver biopsy, the nurse should observe for hemorrhage and
ensure that the patient is kept on bed rest for 24 hours. How should the nurse keep the patient for the first 1 to 2 hours? a. On his or her left side b. On his or her back c. On his or her right side d. In high Fowler position ANS: C The nurse should keep the patient on his or her right side for 1 to 2 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 378, Table 15-1 OBJ:1 | 2TOPiagnostic examination KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 20. The patient has undergone a lumbar puncture. What position will the nurse place the patient in for up to 12 hours to avoid discomfort from postpuncture spinal headache? a. Supine b. Lateral c. Sims d. Prone ANS: D The nurse should place the patient in the prone position and keep in reclining position for 12 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 478, Table 15-1 OBJ:1 | 2TOPiagnostic examination KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 21. The procedure for collecting a sterile urine specimen via a catheter port includes clamping the Foley catheter tubing below the catheter port. How long will the clamp remain in place? a. 5 minutes b. 10 minutes c. 20 minutes d. 30 minutes
ANS: D Clamp just below the catheter port for 30 minutes. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 487, Skill 15-3 OBJ: 1 TOP: Specimen KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 22. The nurse is caring for a patient following a bronchoscopy and maintains NPO status for 2 hours. What additional assessment will indicate to the nurse that this patients risk for aspiration has decreased? a. Patient is fully awake b. Patient asks for a drink c. Gag reflex has returned d. Preoperative medication has worn off ANS: C The nurse should not allow the patient to eat or drink after a bronchoscopy until the gag reflex has returned. PTS: 1 DIF: Cognitive Level: Application REF: Page 372, Table 15-1 OBJ:1TOPiagnostic examination KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 23. The nurse has an order to perform occult blood testing on a patients emesis. What color will the sample turn to indicate that the test is positive for occult blood? a. Red b. Blue c. Green d. Yellow ANS: B If the sample turns blue, the test is positive for occult blood; if it turns green, it is negative for occult blood. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 393, Skill 15-8 OBJ:1TOP:Occult blood testing KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
24. What should the nurse do when preparing the patient for an abdominal
scan? a. Assess laboratory results only for liver function b. Assess patient for allergies to dye or shellfish c. Instruct patient to limit fluid intake immediately following procedure d. Instruct patient to be NPO for 1 hour before scan if contrast medium ANS: B The patient should be assessed for allergies to dye or shellfish. When a patient has an abdominal scan, laboratory results should be assessed for kidney function. The patient should be instructed to be NPO for 4 hours before the examination if contrast medium is to be used. The patient should be encouraged to consume fluids after the examination. PTS: 1 DIF: Cognitive Level: Application REF: Page 369, Table 15-1 OBJ:1 | 2TOPiagnostic examination KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. What should the nurse do when preparing the patient for an arteriography? a. Verify if the patient has been taking anticoagulants b. Keep the patient NPO for 24 hours before the procedure c. Instruct the patient to have a full bladder for the procedure d. Inform the patient that a coldness may be felt when dye is injected ANS: A When a patient has an arteriography, the nurse should assess if the patient has been taking anticoagulants. The patient is kept NPO for 2 to 8 hours before the procedure. The nurse informs the patient that a warm flush may be felt when dye is injected. The patient is instructed to void before the arteriography. PTS: 1 DIF: Cognitive Level: Application REF: Page 369, Table 15-1 OBJ:1 | 2TOPiagnostic examination KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. The nurse is preparing a patient for a barium enema. What color will the nurse inform the patient his stools will be following this procedure?
a. Blue b. White c. Green d. Brown ANS: B Immediately following a barium enema, a patients stools are white until all of the barium is expelled. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 370, Table 15-1 OBJ:2 | 3TOPiagnostic examination KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. What should the nurse do when preparing the patient for an amniocentesis? a. Restrict food intake b. Restrict fluid intake c. Monitor fetal heart tones d. Inform patient results will be available immediately ANS: C When a patient has an amniocentesis, fetal heart tones should be monitored. There are no fluid or food restrictions, and the patient should be told to contact her physician to obtain results, which are usually available after 2 weeks. PTS: 1 DIF: Cognitive Level: Application REF: Page 369, Table 15-1 OBJ:2TOPiagnostic examination KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. What should the nurse do when preparing the patient for a bone scan? a. Sedate the patient b. Restrict food intake c. Restrict fluid intake d. Encourage water intake ANS: D Before a bone scan, the patient is encouraged to drink several glasses of
water. No fasting or sedation is required before a bone scan. PTS: 1 DIF: Cognitive Level: Application REF: Page 371, Table 15-1 OBJ:2TOPiagnostic examination KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. What should the nurse do when preparing the patient for a brain scan? a. Allow the patient to wear a wig during the scan b. Allow the patient to wear a partial denture plate during the scan c. Inform the patient that a clicking noise will be heard during the scan d. Keep the patient NPO for 12 hours before scan if contrast dye is use ANS: C Before a brain scan, the patient is kept NPO for 4 hours if contrast dye is to be used, the patient is instructed not to wear a wig, hairpins, clips, or partial denture plates, and the nurse informs the patient that a clicking noise is made as the scanner moves. PTS: 1 DIF: Cognitive Level: Application REF: Page 371, Table 15-1 OBJ:2TOPiagnostic examination KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. What should the nurse do when preparing the patient for a bronchoscopy? a. Instruct the patient to hold his or her breath during the procedure b. Instruct the patient to remain NPO 24 hours before the procedure c. Obtain informed consent after premedicating the patient d. Reassure the patient that he or she will be able to breathe during the p ANS: D The nurse should reassure a patient before a bronchoscopy that they will be able to breathe during the procedure. The patient is instructed to remain NPO after midnight (4 to 8 hours) before the procedure. Informed consent must be obtained before the patient is premedicated. PTS: 1 DIF: Cognitive Level: Application REF: Page 372, Table 15-1 OBJ:2TOPiagnostic examination KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
31. What should the nurse encourage the patient to consume when preparing
for an electroencephalogram (EEG)? a. Tea b. Food c. Cola d. Coffee ANS: B Food intake should be encouraged, but coffee, tea, and colas should be eliminated before an EEG. PTS: 1 DIF: Cognitive Level: Application REF: Page 374, Table 15-1 OBJ:2TOPiagnostic examination KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 32. What intervention should the nurse implement when preparing the patient for a glucose tolerance test (GTT)? a. Restrict water intake before the test b. Encourage water intake before the test c. Keep patient NPO 4 hours before the test d. Instruct patient to have a full bladder for the test ANS: B A patient having a glucose tolerance test should be kept NPO for 12 hours before the test except for water consumption so that they can provide urine samples. The patient should empty their bladder before the examination. PTS: 1 DIF: Cognitive Level: Application REF: Page 376, Table 15-1 OBJ:2TOPiagnostic examination KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. What should the nurse do when preparing the patient for an exercise tolerance test (treadmill)? a. Withhold all foods and fluids before the test b. Withhold all heart medications before the test c. Allow the patient to drink water before the test d. Allow the patient to consume food before the test
ANS: C A patient having an exercise tolerance test is kept NPO, except for water, for 4 hours until after the test. The nurse should never withhold the patients heart medications before this test. PTS: 1 DIF: Cognitive Level: Application REF: Page 375, Table 15-1 OBJ:2TOPiagnostic examination KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 34.A patient has just had a liver biopsy. What should the nurse do immediately following this procedure? a. Assist the patient up to a chair b. Keep the patient on his or her left side c. Assist the patient with ambulation d. Tell the patient to avoid coughing ANS: D The nurse should tell the patient to avoid coughing or straining, which may cause increased intra-abdominal pressure. Immediately following a liver biopsy, the patient is kept on bed rest for 24 hours. The patient should lie on his or her right side for about 1 to 2 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 378, Table 15-1 OBJ:1TOPiagnostic examination KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 35. The nurse is preparing to collect a urine specimen. What will this nurse include when labeling this specimen? (Select all that apply.) a. Date and time of collection b. Identification of last name only c. Room number d. Medical record number e. Insurance information ANS: A, C, D When labeling a specimen date and time of collection, room number and
medical record number should be included. Patient should be identified by full name. Insurance information is not necessarily included. PTS: 1 DIF: Cognitive Level: Application REF: Page 390, Box 15-5 OBJ:7TOP:Labeling specimens KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment COMPLETION 36. After a bone scan, the nurse assesses a hematoma at the injection site of the dye. The nurse should apply soaks or compresses. ANS: warm Heat will speed absorption of collected blood. PTS: 1 DIF: Cognitive Level: Application REF: Page 371, Table 15-1 OBJ:1TOP:Hematoma at injection site KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 37. When initiating a 24-hour urine collection, the nurse asks the patient to void. The nurse then the specimen. ANS: discards The first voided specimen of a 24-hour collection is discarded. PTS: 1 DIF: Cognitive Level: Application REF: Page 388, Skill 15-4 OBJ:4 | 8TOP:24-hour urine specimen KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 38. Following an intravenous pyelogram, the nurse should watch the patient closely for a delayed reaction to the dye, usually occurring within to hours following the procedure. ANS: 2, 6 two, six Delayed reactions to iodine may not be obvious until 2 to 6 hours postprocedure. PTS: 1 DIF: Cognitive Level: Application REF: Page 368, Box 15-2
OBJ:1TOP:Iodine allergy KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 39. When collecting a stool specimen for a guaiac (occult blood in stool), the nurse should take a specimen from different parts of the stool. ANS: 2 two The selection of different parts of the stool gives a broader testing range of the specimen. PTS: 1 DIF: Cognitive Level: Application REF: Page 392, Skill 15-7 OBJ:10TOP:Occult blood specimen KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 40. When performing a venipuncture, the tourniquet should be left on no more than to minutes. ANS: 1, 2 one, two Occluding the vein for longer than 1 or 2 minutes may cause damage to the vein or cause it to rupture. PTS: 1 DIF: Cognitive Level: Application REF: Page 405, Skill 15-13 OBJ:12TOP:Venipuncture KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment Chapter 16: Care of Patients Experiencing Urgent Alterations in Health My Nursing Test Banks Chapter 16: Care of Patients Experiencing Urgent Alterations in Health Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. When administering first aid in emergency situations, the nurse must first survey victims for severity of injuries. What term correctly describes this process?
a. The Good Samaritan law b. An emergency interview c. Triage d. Taking vital signs ANS: C This process of patient classification is called triage. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 414
OBJ: 1 TOP: First aid KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The Good Samaritan law will protect all people who offer assistance. What is necessary for this protection? a. A license b. The person acts prudently c. Licensed supervision d. The patient improves ANS: B The Good Samaritan law will protect any person who follows a prudent course of action. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 415 OBJ: 2 TOP: Good Samaritan law KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 3.A nurse is assessing victims in an emergency situation. What will the nurse assess for first? a. Hemorrhage b. Fractures c. Mobility d. Abnormal breathing ANS: D A life-threatening situation of the highest priority is arrested or abnormal breathing. PTS: 1 DIF: Cognitive Level: Application REF: Page 415 OBJ:1TOP:ABC of assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. CPR has been initiated at an accident site. When can CPR be terminated? a. Victim is clinically dead b. Victim is brain dead c. Paramedics arrive d. Rescuer perceives CPR is futile ANS: C
There is a moral obligation to continue CPR once it has been initiated unless the rescuer is exhausted and cannot continue, trained medical personnel take over CPR, or a licensed physician pronounces the victim dead. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 416 OBJ:4TOP:Cardiopulmonary resuscitation (CPR) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse determines clinical death and initiates CPR immediately. How long is resuscitation considered possible? a. If cardiopulmonary arrest has existed for no more 2 minutes b. If cardiopulmonary arrest has existed for no more 3 minutes c. If cardiopulmonary arrest has existed for no more 4 minutes d. If cardiopulmonary arrest has existed for no more 5 minutes ANS: C CPR can reverse clinical death if initiated before 4 minutes. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 416 OBJ:3TOP:Cardiopulmonary resuscitation (CPR) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. When assessing the adult victim for pulselessness, the CPR rescuer should palpate the most reliable and accessible pulse. Which pulse will be palpated? a. Radial b. Brachial c. Carotid d. Femoral ANS: C When assessing the adult victim for pulselessness, the most reliable and accessible pulse is the carotid. PTS: 1 DIF: Cognitive Level: Application REF: Page 417 OBJ:4TOP:Cardiopulmonary resuscitation (CPR) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. When a patient suddenly experiences respiratory difficulty in the cafeteria,
the nurse begins assessment for foreign body airway obstruction. What is the most appropriate question to ask the victim? a. What did you swallow? b. Are you choking? c. Are you OK? d. Can I help you? ANS: B With complete airway obstruction, the victim cannot speak. Ask, Are you choking? With this question the nurse pinpoints the problem and can perform the Heimlich maneuver with no wasted time. PTS: 1 DIF: Cognitive Level: Application REF: Page 421 OBJ:1TOP:Heimlich maneuver KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The patient arrived at the emergency department in pain and bleeding profusely with the following vital signs: BP 80/54, P 102, RR 22. What does the nurse recognize that these symptoms indicate? a. Inadequate perfusion b. Circulatory shock c. Massive vasodilation d. Heart failure ANS: B Shock results from failure of the circulatory system to provide sufficient blood circulation. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 423 OBJ: 7 TOP: Shock KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. CPR has been initiated on an adult patient. How will the nurse confirm the effectiveness of CPR? a. Assessing an EKG pattern with each compression b. Assessing a palpable carotid pulse during each compression c. Assuring a compression depth of to 2 inches d. Observing pupils that change from pinpoint to dilated
ANS: B During effective CPR, a carotid pulse is palpable during each compression. PTS: 1 DIF: Cognitive Level: Application REF: Pages 417-418 OBJ:4TOP:Cardiopulmonary resuscitation (CPR) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10.A patient with multiple serious injuries sustained in a motorcycle accident is lying beside his wrecked motorcycle unconscious and bleeding when the rescuer arrives at the scene. What will be the rescuers priority action? a. Assessing blood loss b. Assessing respiratory status c. Obtaining vital signs d. Organizing laypeople at the scene ANS: B Priority intervention is to assess respiratory status. PTS: 1 DIF: Cognitive Level: Application REF: Pages 415-416 OBJ: 4 TOP: First aid KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. The worried mother of an accident victim asks the nurse how much circulating blood an average adult male is supposed to have.What will the nurse reply? a. 8 pints b. 10 pints c. 12 pints d. 14 pints ANS: C An average adult male has 12 pints of blood. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 425 OBJ:8TOP:Circulating blood volume KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse is assessing a patient who is severely bleeding and at risk for hypovolemic shock. What can the nurse anticipate?
a. Slow, labored breathing b. Hot, flushed skin c. Edematous extremities d. Weak, thready pulse ANS: D The pulse becomes weak and thready with hypovolemic shock. PTS: 1 DIF: Cognitive Level: Application REF: Page 424 OBJ:7TOP:Symptoms of shock KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13.A nurse assesses an accident victim who has bright red blood spurting from a laceration on his right forearm. Where will the nurse apply pressure after applying direct pressure and elevating the limb? a. Right subclavian artery b. Right radial artery c. Right ulnar artery d. Right brachial artery ANS: D Arterial bleeding is characterized by the spurting of bright red blood and can be controlled by direct pressure, elevation, and indirect pressure on the appropriate pressure point. The brachial artery is the closest pressure point to the injury. PTS: 1 DIF: Cognitive Level: Application REF: Page 425 OBJ:10TOPressure points KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse is attempting to control bleeding in a patient with a profusely bleeding scalp wound. What is the most effective initial treatment of this bleeding? a. Elevate the head b. Apply direct pressure c. Apply an ice pack d. Apply indirect pressure
ANS: B The most effective general treatment of bleeding is to apply direct pressure. PTS: 1 DIF: Cognitive Level: Application REF: Page 425 OBJ:10TOP:Control of bleeding KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. When other methods have failed to stop the bleeding and the victims life is in danger, the rescuer at the scene applies a tourniquet to a young womans leg above the knee. What is another step that is essential for the rescuer to follow? a. Never release the tourniquet b. Wrap the tourniquet around the limb twice c. Mark the patient with a T d. Leave the limb elevated ANS: A A tourniquet must never be released once it is in place. All other options are enhancements to the procedure of the tourniquet application, but not essential. PTS: 1 DIF: Cognitive Level: Application REF: Page 427, Skill 16-1 OBJ: 8 TOP: Tourniquet KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is teaching a patient with epistaxis about the best way to control bleeding. What information will the nurse relay to this patient? a. Place ice on the nose and pinch the nostrils b. Maintain a flat position c. Pack nostrils with cotton d. Lean backward ANS: A Apply steady pressure to both nostrils while applying ice to the nose is the best way to attempt to control the bleeding of epistaxis. PTS: 1 DIF: Cognitive Level: Application REF: Page 426 OBJ: 8 TOP: Epistaxis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
17.A farm worker who has been kicked in the stomach by a mule passes a foul, black, tarry stool. What is this called? a. Loose stool b. Melena c. Hematuria d. Hemoptysis ANS: B When internal bleeding occurs, the patient may demonstrate hemoptysis (bloody sputum), hematemesis (bloody vomit), melena (foul black tarry stool), or hematuria (bloody urine). PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 426 OBJ: 2 TOP: Melena KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18.A machinist visits the industrial nurses clinic with a deep laceration of the thigh. What should be the nurses first action? a. Splint the thigh and apply tape to approximate the edges b. Apply ice and a pressure dressing to the thigh c. Give a tetanus booster injection d. Wash the laceration with an antiseptic ANS: D Lacerations should be cleaned thoroughly and bandaged to approximate the edges. PTS: 1 DIF: Cognitive Level: Application REF: Page 429 OBJ: 9 TOP: Wounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The patients lower chest has been punctured with a knife that is still in place. What should the nurses first action be? a. Remove the knife b. Apply an airtight dressing over the wound c. Place the patient in a modified Trendelenburg position d. Immobilize the knife with dressings and tape ANS: D When the patients lower chest has been punctured with the weapon still in
place, the nurse should immobilize the weapon with dressings and tape. PTS: 1 DIF: Cognitive Level: Application REF: Page 428 OBJ: 9 TOP: Wounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20.A patient arrives in the emergency department with a sucking wound to the left chest. What is the first action the nurse should take? a. Place several layers of gauze dressing over the wound b. Place the patient in a supine position c. Cover the wound with an airtight dressing taped on three sides d. Turn the patient to the left side ANS: C Sucking chest wounds should be dressed with a flutter dressing so that air can escape the pleural space, but no more air can be sucked in. PTS: 1 DIF: Cognitive Level: Application REF: Page 429 OBJ:9TOP:Sucking chest wounds KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse is assisting a victim of an accident who requires bandaging of the right lower extremity. What should the nurse do when applying the bandage? a. Use sterile material b. Leave the toes exposed c. Bandage the extremity tightly d. Bend the knee after bandaging ANS: B The tips of the toes should remain exposed to assess circulation. PTS: 1 DIF: Cognitive Level: Application REF: Page 429 OBJ: 1 TOP: Bandaging KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22.A patient who had taken a poisonous substance is brought to the emergency department. What is the first action the nurse should take? a. Give syrup of ipecac b. Contact the poison control center
c. Give milk to coat the stomach d. Observe for symptoms ANS: B The nurse should immediately call the poison control center. PTS: 1 DIF: Cognitive Level: Application REF: Page 431 OBJ: 11 TOP: Poison KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23.A patient has been stung by a bee and is brought to the emergency department. The nurse observes the sting site and identifies that the stinger is still in the skin. What action should the nurse take? a. Remove it with sterile tweezers b. Soak the area with a cold compress c. Scrape the stinger with the side of a knife d. Squeeze the surrounding tissue to expel the stinger ANS: C The stinger should be removed with the side of a knife by scraping to avoid forcing more venom into the skin. PTS: 1 DIF: Cognitive Level: Application REF: Page 432 OBJ: 1 TOP: Wounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. The patient with heat stroke has been undressed and treated with cold packs and a fan. The patients temperature is now down to 101.2 F. The patient starts to shiver. What action should the emergency department nurse take? a. Raise the head of the bed b. Offer warm liquids c. Remove cold packs and fan d. Continue with cooling interventions ANS: C The cooling techniques have caused the patient to shiver, which will increase the patients temperature. PTS: 1 DIF: Cognitive Level: Application REF: Page 435 OBJ: 12 TOP: Heat stroke KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 25. The patient is admitted to the emergency department, having suffered frostbite to the hands, which are grayish-white in color. What action should the nurse implement when attempting to warm the hands? a. Have the patient rub the hands together briskly b. Wipe the hands vigorously with a warm towel c. Run tepid water over the hands to warm slowly d. Wrap the hands in hot, moist towels ANS: D Warming the hands in moist towels will warm the hands slowly. Friction of frozen body parts should be avoided. PTS: 1 DIF: Cognitive Level: Application REF: Page 436 OBJ: 12 TOP: Frostbite KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26.A visitor in the hospital slips and falls. The patients arm appears dislocated and the visitor is unable to move it. What is the first action the nurse should implement? a. Apply cold packs b. Check range of motion c. Splint the arm d. Apply an Ace bandage ANS: C The nurse should splint the arm where it lies and not attempt to move or rearrange the limb. PTS: 1 DIF: Cognitive Level: Application REF: Pages 436-437 OBJ: 13 TOP: Fracture KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The patient is brought to the emergency department after having fractured an arm 12 hours ago. The arm is very edematous from the fingers to the elbow, and the patient cannot move it. What should be the initial action of the nurse? a. Test range of motion b. Take the vital signs
c. Place ice packs on the arm d. Check fingers for capillary refill ANS: D Swelling from the fracture can impede circulation. PTS: 1 DIF: Cognitive Level: Application REF: Page 436 OBJ: 13 TOP: Injuries KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. When assessing a patient who has suffered a burn injury, the nurse classifies the burn as a deep partial-thickness burn. What is this observation most likely based upon? a. Painful reddened skin b. Charred skin with milky-white areas c. Erythema and blisters d. Erythema, pain, and swelling ANS: C With deep partial-thickness burns, blister formation may be seen with erythema. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 439 OBJ: 12 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. The nurse arrives on the scene of a fire. What is the first thing the nurse will do for a burn victim? a. Apply dressings b. Cover with a blanket c. Cool the burn immediately d. Apply topical ointment ANS: C The burn should be cooled immediately to stop the burning process. PTS: 1 DIF: Cognitive Level: Application REF: Page 438 OBJ: 12 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30.A patient is admitted to the hospital after receiving a blow to the head. The patient begins to show signs of shock. How should the patient be positioned?
a. With the head lower than the body b. Flat with the legs elevated c. Flat on the back d. In a side-lying position ANS: C If head injuries are suspected, the victim must be kept flat. PTS: 1 DIF: Cognitive Level: Application REF: Page 424 OBJ: 1 TOP: Shock KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 31. While on break in the hospital cafeteria a nurse witnesses her pregnant coworker start to choke. The co-worker is conscious, but unable to breathe. Where should the nurse administer thrusts? a. Below the navel b. The chest c. At the xiphoid process d. The upper back ANS: B If the victim is pregnant or obese, chest thrusts are acceptable instead of abdominal thrusts. To provide chest thrusts, the nurse should place his or her hands in the same position that is used for chest compressions during CPR. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 422 OBJ: 5 TOP: Choking KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 32. When treating an infant choking on a foreign body, the nurse should use a combination of and chest thrusts. ANS: back blows If the nurse is assisting a child who has aspirated a foreign body, the nurse may treat the child in a manner similar to the adult with performance of abdominal thrusts. However, there is a potential for injury if the nurse uses this maneuver in the infant. The nurse should use a combination of back blows and chest thrusts with an infant.
PTS: 1 DIF: Cognitive Level: Application REF: Pages 422-423 OBJ: 6 TOP: Choking KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. If a spinal injury is suspected, before the rescuer starts CPR, the trachea should be opened with a maneuver. ANS: jaw thrust The jaw thrust maneuver does not hyperextend the neck. PTS: 1 DIF: Cognitive Level: Application REF: Page 418 OBJ:14TOP:Cardiopulmonary resuscitation (CPR) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 34. When two nurses perform two-person CPR, there should be slow breaths for every compressions. ANS: 2, 30 two, thirty Two slow breaths are given after every 30 compressions. PTS: 1 DIF: Cognitive Level: Application REF: Page 420 OBJ:4TOP:Two-person CPR KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 35. The acronym RICE directs the nurse in the care of a sprain. The C in the acronym stands for . ANS: compression The acronym stands for Rest, Ice, Compression, and Elevation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 437 OBJ: 13 TOP: Sprain KEY: Nursing Process Step: Application MSC: NCLEX: Physiological Integrity 36.A burn patient is brought into the emergency department with the following burns: half of the front torso, entire left arm, and front of left leg. The nurse should record that the patient has a % burn. ANS:
27 twenty-seven Half of the front torso = 9, entire left arm = 9, front of the left leg = 9 PTS: 1 DIF: Cognitive Level: Analysis REF: Page 438, Figure 16-17 OBJ:12TOP:Rule of nines KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 37.When performing CPR on an infant, the breastbone is depressed approximately to inch(es). ANS: 0.5 to 1 one-half to one The breastbone is depressed 0.5 to 1 inch when doing CPR on an infant. PTS: 1 DIF: Cognitive Level: Application REF: Page 420 OBJ:4TOP:Cardiopulmonary resuscitation (CPR) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity Chapter 17: Complementary and Alternative Therapies My Nursing Test Banks Chapter 17: Complementary and Alternative Therapies Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient recovering from a hip replacement and is providing education regarding exercises in physical therapy. What type of therapy should the nurse call these exercises? a. Alternative therapies b. Complementary therapies c. Comfort therapies d. Body therapies ANS: B Complementary therapies are used in addition to conventional therapies. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 444 OBJ:1TOP:Complementary therapies
KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. An older adult patient tells the home health nurse, My doctor hasnt helped my arthritis at all. I am using the chiropractor now. What change has the patient made? a. Western medicine to complementary therapy b. Complementary therapy to alternative therapy c. Alternative therapy to allopathic medicine d. Allopathic medicine to alternative therapy ANS: D Alternative therapies may become the primary treatment modality; for instance, the patient switching from traditional (allopathic) medicine to chiropractic (alternative). PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 444 OBJ: 1 TOP: Therapies KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. What is the responsibility of the National Center for Complementary and Alternative Medicine (NCCAM)? a. To certify alternative medical practitioners b. To evaluate effectiveness of alternative medical treatments c. To set standards for the practice of alternative medicine d. To train alternative medical practitioners ANS: B The National Center for Complementary and Alternative Medicine was established to facilitate the evaluation of alternative medical treatment. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 445 OBJ:1TOP:National Center for CAM KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 4. What is the importance of the nurse asking about the patients use of alternative therapies when obtaining a health history? a. Alternative therapies can be covered by insurance. b. Alternative therapies have unfortunate interactions with traditional th
c. Alternative therapies can be substituted for allopathic medicine. d. Alternative therapies have curative and healing power. ANS: B Some alternative therapies may have serious side effects. As a rule, complementary and alternative (CAM) therapies are not curative or healing as is allopathic medicine. Some complementary therapies are covered by insurance, but alternative remedies are not. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 447, Patient Teaching OBJ: 3 TOP: Complementary and alternative (CAM) therapies KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The nurse is obtaining health history information on a new patient at a physicians office and he or she records a barbiturate medication on the current list. What herb should the nurse ask if the patient is taking? a. St. Johns wort b. Aloe vera c. Valerian d. Ginkgo ANS: C Valerian enhances the effect of barbiturates. PTS: 1 DIF: Cognitive Level: Application REF: Page 449, Table 17-1 OBJ: 3 | 5 TOP: Valerian KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. What should the nurse instruct a patient who takes tincture of rosemary to do several times a day? a. Assess pulse frequently b. Avoid constipation c. Watch for hypoglycemia d. Wear sunscreen ANS: D Rosemary can cause photosensitivity. PTS: 1 DIF: Cognitive Level: Application REF: Page 451, Table 17-2
OBJ: 2 | 5 TOP: Rosemary KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. What is true regarding manufacturers of herbal remedy products? a. They do extensive field testing on the products. b. They must show dosage equivalents. c. They must adhere to standards of strength. d. They do not have to demonstrate their safety. ANS: D Herbal remedy manufacturers are not required by law to demonstrate the safety of their products. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 446 OBJ:4TOP:Herbal remedies KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 8. Herbs have not been approved for use as drugs. How are herbs allowed to be sold? a. For pain relief b. To improve body strength c. To prolong life d. As diet supplements ANS: D Herbs are sold as food supplements. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 446 OBJ: 4 TOP: Herbal remedies KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 9. What is the goal of herbal therapy? a. Treat symptoms b. Restore balance c. Treat disease d. Improve nutrition ANS: B The goal of herbal therapy is to restore balance. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 446
OBJ: 4 TOP: Herbal therapy KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 10. Confusion and misinformation relative to herbal medicine can make patients reluctant to disclose their herbal use to health care providers. What should be the nurses approach? a. Instructive b. Nonjudgmental c. Inquisitive d. Determined ANS: B A nonjudgmental open attitude will encourage the patient to share information about the use of CAM (complementary and alternative medicine). PTS: 1 DIF: Cognitive Level: Application REF: Pages 444-445 OBJ:2TOP:Health interview KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 11. What will placing an herb in alcohol or vinegar make? a. A suspension b. An emulsion c. An infusion d. A tincture ANS: D Tinctures are made by placing the herb in alcohol or vinegar. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 450 OBJ:5TOP:Making herbal remedies KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. During a follow-up visit with a patient recently started on Coumadin, the home health nurse is concerned after seeing an herbal remedy that enhances the effect of anticoagulants by the patients bedside. What is this herbal remedy? a. Cayenne
b. Aloe vera c. Asian ginseng d. Kava ANS: C Asian ginseng may enhance the effect of Coumadin. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 447, Table 17-1 OBJ: 5 TOP: Ginseng KEY: Nursing Process Step: Assessment MSC:NCLEX: Safe, Effective Care Environment 13. Acupuncture is a complementary therapy that uses fine needles placed in acupoints. What is the believed purpose of these acupoints? a. Close the gate for pain transmission b. Align the internal organs c. Open meridians to release qi d. Stimulate the centering of qi ANS: C Acupuncture therapy uses needles placed in acupoints to open meridians to release qi (life force). PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 450 OBJ: 7 TOP: Acupuncture KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 14. The nurse is educating a patient with phlebitis of the left leg. What alternative therapy should this patient avoid until the condition is resolved? a. Acupuncture b. Therapeutic massage c. Yoga d. Acupressure ANS: B Therapeutic massage is contraindicated in conditions such as thrombosis, phlebitis, and infective skin diseases. PTS: 1 DIF: Cognitive Level: Application REF: Page 453 OBJ:9TOP:Therapeutic massage KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment
15. What type of alternative therapy is the nurse practicing when using
essential oils to provide inhalation treatments? a. Magnet therapy b. Respiratory therapy c. Herbal therapy d. Aromatherapy ANS: D Aromatherapy uses pure essential oils to provide health benefits. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 453 OBJ:10TOP:Aromatherapy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is educating a patient regarding reflexology. Information includes that reflexology is a therapy based on the theory that the entire body can be reached by applying pressure to specific areas. Where is pressure mainly applied? a. Hands b. Head c. Back d. Feet ANS: D In reflexology it is thought that the entire body can be reached by applying pressure to specific areas on the feet. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 454 OBJ: 2 | 11 TOP: Reflexology KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychological Integrity 17. What type of therapy is thought to increase circulation to the affected area, promote healing, and stimulate acupuncture points? a. Relaxation therapy b. Magnetic therapy c. Yoga therapy d. Imagery therapy ANS: B
Magnets are thought to increase circulation to affected areas, promote healing, and stimulate acupuncture points. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 455 OBJ: 12 TOP: Magnetic therapy KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 18. Which term describes using the conscious mind to create situations that evoke physical changes in the body? a. Imagination b. Self-hypnosis c. Imagery d. Visualization ANS: C Imagery uses the conscious mind to create images that evoke physical changes in the body. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 455 OBJ: 1 TOP: Imagery KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The nurse describes a therapy that can produce a state of decreased cognitive, physiological, and/or behavioral arousal. To what alternative therapy is the nurse referring? a. Subconscious b. Imagery c. Sleep d. Relaxation ANS: D Relaxation is the state of general decreased cognitive, physiological, and/or behavior arousal. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 455 OBJ: 1 | 2 TOP: Relaxation KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 20. What is a therapeutic treatment that joins the mind and body and increases muscle tone and flexibility? a. Acupressure
b. Spiritual enrichment c. Yoga therapy d. Therapeutic massage ANS: C Yoga therapy is the joining of the mind, body, and spirit to enrich the quality of ones life. Yoga also increases muscle tone and flexibility. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 457 OBJ: 14 TOP: Yoga KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. What training system may help prevent osteoporosis? a. Acupressure b. Yoga c. Therapeutic massage d. Tai chi ANS: D Tai chi, although a martial arts skill, increases balance and timing and may prevent osteoporosis. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 458 OBJ: 15 TOP: Tai chi KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22.A patient wants to use aromatherapy to treat pneumonia, but the hospital policy will not allow burning of eucalyptus-scented candles. What should the nurse suggest the patient use instead? a. Another essential oil b. Prescribed medications c. A topical eucalyptus product d. Massage therapy ANS: C Eucalyptus oils can be used for inhalation or may be applied topically. PTS: 1 DIF: Cognitive Level: Application REF: Pages 453-454 OBJ:10TOP:Aromatherapy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
23.A patient admitted with lower back pain is not sure that the prescribed treatment is helping and asks what alternative therapies might help. What should the nurse suggest? a. Herbal therapy b. Chiropractic therapy c. Acupressure d. Reflexology ANS: B Chiropractic therapy is currently viewed as an acceptable treatment for certain disorders, including back pain. PTS: 1 DIF: Cognitive Level: Application REF: Page 450 OBJ: 6 TOP: Chiropractic KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 24. Herbal remedies vary from pharmaceutical remedies in what way(s)? (Select all that apply.) a. Herbal remedies use the whole plant. b. Herbal remedies have no quality control. c. Herbal remedies have no standard dose. d. Herbal remedies are sold as food supplements. e. Herbal remedies are always safe and effective. ANS: A, B, C, D Herbal remedies are not always safe and effective. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 446 OBJ:1TOP:Herbal remedies KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. Founded in 1992, the National Center for Complementary and Alternative Medicine (NCCAM) has the responsibility for what actions? (Select all that apply.) a. Evaluating alternative treatments b. Distributing information to the public c. Coordinating and conducting research
d. Removing defective products from the market e. Regulating third-party reimbursement ANS: A, B, C The National Center for Complementary and Alternative Medicine has the responsibility to evaluate treatments, distribute information, and conduct research. It has no power to remove defective products from the market or deal with insurance payments. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 445 OBJ: 1 TOP: National Center for CAM KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 26. The nurse recommends that a patient have animal-assisted therapy sessions (AAT) because this therapy has been found to have what effect(s)? (Select all that apply.) a. Improvement in mood b. Decrease in blood pressure c. Decrease in blood sugar d. Reduction of allergies e. Increase in socialization skills ANS: A, B, E Animal-assisted therapy (AAT) has been found to improve mood, decrease blood pressure, and increase socialization skills. AAT has not been found to decrease blood sugar or reduce allergies. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 457 OBJ:13TOP:Animal-assisted therapy (AAT) KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 27. Why do people often choose complementary and alternative medicine (CAM)? (Select all that apply.) a. CAM is less invasive. b. CAM is more holistic. c. CAM is focused on treatment of disease. d. CAM is dedicated to health maintenance. e. CAM is within the control of the patient.
ANS: A, B, D, E CAM is less invasive, more holistic, dedicated to health maintenance, and within control of the patient. CAM is focused on prevention, not treatment. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 444-445 OBJ: 1 TOP: CAM KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION 28. The nurse reassures a patient that almost % of all health care consumers in the United States take some form of herbal or natural supplement alone or in combination with conventional medicines but rarely report this practice to their health care providers. ANS: 50 fifty It is estimated that almost half of all health care consumers in the United States take some form of herbal or natural product supplement alone or in combination with conventional medicines but rarely report this practice to their health care providers. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 444 OBJ:3TOP:Herbal supplements KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. People with fractures, rheumatoid arthritis, and osteoporosis are not candidates for therapy. ANS: chiropractic Contraindications for chiropractic therapy include acute myelopathy, fractures, dislocations, rheumatoid arthritis, and osteoporosis. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 450 OBJ: 6 TOP: Chiropractic KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 30. is a noninvasive method an individual can employ to learn control of the body to manage certain conditions. Monitoring equipment is used to measure vital signs and muscle tension. The messages
are sent back to the individual. ANS: Biofeedback Biofeedback is a noninvasive method an individual can employ to learn control of the body to manage certain conditions. It may be considered when other therapies have not been successful or in conjunction with other treatments. Health concerns such as anxiety, stress, irritable bowel syndrome, and asthma may be managed using biofeedback. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 458 OBJ: 16 TOP: Biofeedback KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 18: Pain Management, Comfort, Rest, and Sleep My Nursing Test Banks Chapter 18: Pain Management, Comfort, Rest, and Sleep Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1.A patient reports to the nurse that he is experiencing a moderate amount of back pain rated 6 out of 10 on the pain scale. What should the nurse recognize about this assessment? a. Pain is objective for the nurse. b. Pain is easy to recognize. c. Pain is subjective for the patient. d. Pain is easily relieved if found early. ANS: C Pain is subjective. Pain is exactly what the patient says it is. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 464 OBJ: 3 | 5 TOP: Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2.A patient has pain in the left arm secondary to coronary insufficiency. This is an example of what type of pain? a. Acute pain b. Chronic pain c. Referred pain
d. Subacute pain ANS: C An example of referred pain is coronary insufficiency manifested by pain in the left arm, which is a distant location from the real source of discomfort. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 465 OBJ: 1 | 2 TOP: Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse reassures a patient that most acute pain is intense and of short duration. How long does can acute pain usually last? a. 1 week b. Less than 6 months c. At least 9 months d. More than 1 year ANS: B Acute pain lasts less than 6 months. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 465 OBJ: 1 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. What is the defining term for continuous or intermittent pain that does not serve as a warning of tissue damage? a. Acute b. Unrelieved c. Chronic d. Subacute ANS: C Chronic pain can be continuous or intermittent and may not be indicative of tissue damage. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 465 OBJ: 1 | 2 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is planning interventions for a patient experiencing pain. For what type of synergistic relationship should the nurse assess? a. Inflammatory process
b. Circulatory disorder c. Food allergy d. Fatigue ANS: D Fatigue, sleep disturbance, and depression act in a synergistic relationship. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 465 OBJ: 2 | 7 TOP: Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse is giving a backrub to a patient to relieve pain. What pain theory is the nurse using? a. Synergism b. Gate control c. Distraction d. Guided imagery ANS: B The pressure of a backrub will close the gate, according to the gate control theory of pain. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 465 OBJ: 4 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7.A young athlete asks the nurse why he felt little pain when he broke his leg during a game. What does the nurse describe as having an effect on this patients perception of pain? a. Hormones b. Enzymes c. Adrenaline d. Endorphins ANS: D Endorphins found in the pituitary gland and other areas of the central nervous system create the same effect as morphine, producing an analgesic effect. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 465 OBJ: 1 | 2 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
8. Where does the nurse recognize that many institutions are now including
pain assessment in implementing patient care? a. The initial assessment b. Discharge planning c. Assessing vital signs d. Care planning ANS: C Making pain a vital sign would ensure that pain is monitored on a regular basis. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 466 OBJ: 6 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. Why should a nurse promptly administer a prescribed analgesic after a pain assessment? a. The physician has ordered it b. It is an efficient use of time c. Unrelieved pain can cause setbacks d. It meets the goals of the nursing care plan ANS: C Appropriate pain management can bring about quicker recoveries, shorter hospital stays, fewer readmissions, and can improve the quality of life. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 467 OBJ: 10 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse obtains information from a patient about the site, severity, and duration of the pain. What type of data is this considered? a. Patient data b. Objective data c. Focused data d. Subjective data ANS: D Information from the patient concerning site, severity, and duration of the pain is subjective data that only the patient knows.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 473 OBJ: 5 TOP: Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. The nurse is assessing pain reported by a Latino male patient. What is important for the nurse take into consideration when observing objective data? a. Latino men are suspicious of female caregivers. b. Latino men have a cultural bias against use of narcotics. c. Latino men believe pain is necessary for cure. d. Latino men feel it is unmanly to admit to pain. ANS: D Many Latino men feel that to admit to being in pain is unmanly. PTS:1DIF:Cognitive Level: Application REF: Page 476, Cultural Considerations OBJ: 10 TOP: Latino culture KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 12. To share assessment findings and pain relief interventions, which documentation sample is the most helpful? a. 1600: Patient reports chest pain. Medicated with morphine sulfate. b. 1600: Patient reports sharp chest pain. Morphine sulfate given IM. 1600: Patient reports sharp pain in left chest radiating to neck. Morphi c. administered IM in right deltoid. 1600: Patient requested medication for pain in left chest. Morphine su d. given. ANS: C The nurse should record subjective information relative to the pain, as well as the intervention and administration route. PTS: 1 DIF: Cognitive Level: Application REF: Page 473 OBJ:10TOPain medication documentation KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 13. The nurse teaches noninvasive pain relief techniques, such as guided imagery, biofeedback, and relaxation. What is the primary advantage of these techniques?
a. Can be done any time b. Does not require a nurse c. Gives the patient some control d. Is most effective ANS: C The greatest advantage of noninvasive pain relief techniques is that they give the patient some control. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 467, 476 OBJ:11TOP:Noninvasive pain control KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 14. The nurse explains that transcutaneous electrical nerve stimulation (TENS) provides a continuous mild electrical current to the skin. How does the TENS unit act to reduce pain? a. Distracts the patient b. Blocks endorphin production c. Warms the skin d. Blocks pain impulses ANS: D TENS works by blocking pain impulses. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 468, Table 18-1 OBJ: 11 TOP: TENS KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. An American Indian patient requests that an egg yolk be placed in a saucer and put under his bed to absorb the pain. What should the nurse do? a. Explain that medication will relieve the pain better b. Place the egg in a saucer under the bed c. Ask the physician for permission d. Warn that housekeeping staff will remove the egg ANS: B The nurse should use methods of pain control that the patient believes will work. PTS: 1 DIF: Cognitive Level: Application REF: Pages 466-467, 482
OBJ:10TOP:Cultural considerations KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 16. The home health nurse is caring for a patient with an implanted pacemaker. What type of pain management would be contraindicated? a. Peripheral analgesics b. A TENS unit c. Opioid analgesics d. Adjuvant analgesics ANS: B A TENS unit may interfere with the function of the pacemaker. PTS: 1 DIF: Cognitive Level: Application REF: Page 468 OBJ: 10 TOP: Pain control KEY: Nursing Process Step: Analysis MSC: NCLEX: Physiological Integrity 17. The nurse is trying to reassure a patient who is concerned about receiving addictive drugs. What percentage of patients become addicted to analgesics? a. Less than 0.1% b. Less than 1% c. Less than 5% d. Less than 6% ANS: B Research findings suggest that less than 1% of patients receiving analgesics become addicted. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 469 OBJ: 10 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 18. The nurse is caring for a patient using patient-controlled analgesia (PCA). What is a major advantage to this method? a. Less expensive b. More effective c. Less addictive d. Quicker ANS: D
The use of the PCA gives quicker relief as there is no delay in waiting for the nurse to respond to the request for analgesia. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 471-472 OBJ:10TOPatient-controlled analgesia (PCA) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19.A patient tearfully declares the use of relaxation techniques does not work for her. What is the best action for the nurse to implement? a. Give up on the idea b. Encourage the patient to try again c. Assure the patient that not everyone is successful d. Give the patient a sedative ANS: B Some alternative approaches to pain control require practice. Encouragement to try again is appropriate. PTS: 1 DIF: Cognitive Level: Application REF: Pages 473, 482 OBJ:11TOP:Alternate methods of pain control KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20.A patient is receiving an opioid narcotic. What common side effect should the nurse be aware of when assessing this patient? a. Addiction b. Vomiting c. Constipation d. Diarrhea ANS: C Constipation is the most common opioid narcotic side effect for which patients do not develop a tolerance. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 469 OBJ: 10 TOP: Constipation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21.A male patient reports to the home health nurse that he does not feel rested although he has slept 8 hours. For what should the nurse assess?
a. Having vivid dreams b. Eating a heavy meal before going to bed c. Consuming an excessive amount of alcohol d. Taking an anxiolytic medication ANS: D Anxiolytic (antianxiety) medications interfere with REM sleep, which is when people achieve full rest. PTS: 1 DIF: Cognitive Level: Application REF: Page 479, Box 18-4 OBJ: 14 | 15 TOP: Sleep KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22. Although denying pain, a patient is irritable, responds slowly, and exhibits periods of tachycardia. What should the nurse assess for in this patient? a. Electrolyte imbalance b. Allergic response c. Sleep deprivation d. Constipation ANS: C With sleep deprivation, patients may experience a variety of physiologic and psychological symptoms. PTS: 1 DIF: Cognitive Level: Application REF: Pages 480-481 OBJ:16TOP:Sleep deprivation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 23. When preparing a patient for sleep, diming the lights and decreasing the noise levels are examples of nursing interventions. What are these interventions designed to do? a. Mimic usual sleep patterns b. Decrease environmental stimuli c. Prepare the patient for sleep d. Provide for more rest ANS: B Environmental stimuli should be decreased when preparing the patient for sleep.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 481 OBJ: 13 TOP: Sleep KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. What is the best approach for a nurse to use when planning pain relief measures? a. Use a variety of pain relief methods b. Use only nonopioid analgesics c. Use at least three alternating methods d. Use only one method at a time ANS: A A variety of methods applied simultaneously have an additive effect on pain control. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 477 OBJ: 10 TOP: Pain control KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. The nurse is trying to establish an effective relationship with a patient in pain. What is the best statement for the nurse to make when beginning the assessment? a. Ill check to see if you can have anything. b. Let me give you a backrub and see if it helps. c. I believe you are in pain. d. When was your last medication for pain? ANS: C A nursing intervention to establish an effective relationship is to believe the patient. Al-though the other options are not wrong, they do not help establish an effective relationship. PTS: 1 DIF: Cognitive Level: Application REF: Pages 473, 482 OBJ: 10 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 26. What action should the nurse take when evaluating the effectiveness of new or revised therapies for pain relief? a. Observe the patient performing activities of daily living b. Observe the patients facial expressions
c. Frequently assess subjective data d. Perform evaluation of outcome goals ANS: D Continuous evaluation allows the nurse to determine if new or revised therapies are required. PTS: 1 DIF: Cognitive Level: Application REF: Pages 482-483 OBJ: 10 TOP: Pain KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 27. The home health nurse is instructing the family of an older adult patient with arthritis about sleep promotion. What intervention can best promote sleep for the older adult patient? a. Giving nonsteroidal anti-inflammatory drugs (NSAIDs) in the morni b. Administering diuretics in the mornings c. Encouraging daytime sleeping d. Avoiding the stimulation of backrubs or warm drinks before bedtime ANS: B Older adults sleep lightly. Give NSAIDs before bedtime for comfort. Diuretics should be given in the mornings to reduce having to wake up to go to the bathroom during the night. Daytime sleeping may negatively affect nighttime sleep. Nonpharmacologic interventions are helpful to induce sleep. PTS:1DIF:Cognitive Level: Comprehension REF: Page 478, Life Span Considerations OBJ: 13 TOP: Sleep promotion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. The nurse is using a pain scale of 0 to 10 to assess pain in a postoperative patient. What is considered the maximum pain level at which a patient can usually function effectively? a.2 b.3 c.4 d.5 ANS: C Most patients do not function effectively if the pain level exceeds 4 on a scale
of 10. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 474, 476 OBJ: 8 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29.A patient is receiving epidural analgesics. What should the nurse monitor closely in this patient? a. Temperature elevation to 99.2 F from 98 F b. Increase in pulse rate from 88 to 99 c. Decrease in respirations from 16 to 14 d. Decrease in blood pressure from 120/80 to 110/68 ANS: C Administering epidural analgesics requires close monitoring for respiratory depression. None of the other options is indicative of opiate toxicity. PTS: 1 DIF: Cognitive Level: Application REF: Page 468 OBJ:10TOP:Opiate toxicity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. When should a nurse administer prescribed analgesic medication when treating a postoperative patient? a. Before activity b. Only when requested by the physician c. Only when requested by the family d. Only when requested by the patient ANS: A To control pain early, an analgesic should be given 30 to 40 minutes before a patient must walk or perform an activity. PRN medications should be given around the clock to effectively control moderately severe to severe pain. Waiting for the patient or family to request analgesics results in delays in administration and inadequate pain control. PTS: 1 DIF: Cognitive Level: Application REF: Page 477 OBJ: 10 TOP: Pain control KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 31. What action should the nurse implement when assisting a postoperative
patient with pain control and comfort? a. Pull the patient up in bed b. Lift the patient up in bed c. Tighten constricting bandages d. Restrict fluid and dietary intake ANS: B Pain control and comfort measures include loosening constricting bandages, lifting, not pulling the patient up in bed, and preventing constipation by encouraging appropriate fluid and dietary intake. PTS: 1 DIF: Cognitive Level: Application REF: Page 477 OBJ: 10 TOP: Pain control KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 32.A nurse is caring for a patient who requires long-term management for severe pain. What should be the drug of choice for this patient? a. Aspirin b. Morphine c. Oxycodone d. Acetaminophen ANS: B Morphine and hydromorphone are the opioids of choice for long-term management of severe pain. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 473, Box 18-2 OBJ: 9 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 33. The nurse should administer an analgesic to an unconscious patient after observing which signs? (Select all that apply.) a. Increased heart rate from 82 to 94 b. Decreased systolic blood pressure c. Increased muscle tension d. Perspiration on upper lip e. Facial grimacing ANS: A, C, D, E
Pain indicators in the unconscious patient might include increased heart rate, blood pressure, and muscle tension; diaphoresis; and grimacing. PTS: 1 DIF: Cognitive Level: Application REF: Pages 476-477 OBJ:10TOP:Assessing pain in the unconscious patient KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 34.A patient tells the nurse he is reluctant to report his pain because he does not want to be a bother. What problems is the nurse aware that unrelieved pain can cause? (Select all that apply.) a. Decreased oxygen demand b. Depression c. Respiratory dysfunction d. Decreased GI motility e. Irritability ANS: B, C, D, E Pain, which is unrelieved, can cause many physical and psychological symptoms including depression, respiratory dysfunction, decreased GI motility, and irritability. Pain causes increased oxygen demand. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 467 OBJ:10TOP:Unrelieved pain KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 35. The pain relief intervention that stimulates large cutaneous nerve fibers to close the gate is the unit. ANS: TENS: transcutaneous electrical nerve stimulator TENS stimulates cutaneous nerve fibers with electrical impulses, which follow the same spinal pathway as do pain impulses. The cutaneous nerves close the gate to the pain impulses. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 467 OBJ: 4 | 11 TOP: TENS KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 36. The nurse clarifies that the term peripheral analgesics describes the group
of drugs also referred to as . ANS: NSAIDs Peripheral analgesics are also the group of drugs referred to as NSAIDs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 468-469 OBJ: 10 TOP: Nonsteroidal anti-inflammatory drugs (NSAIDs) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 37. The nurse is aware that the state at which a person is mentally relaxed, free from worry, and is physically calm is . ANS: rest When a person is mentally relaxed, free from worry and is physically calm, he or she is at rest. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 478 OBJ: 12 TOP: Rest KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity Chapter 19: Nutritional Concepts and Related Therapies My Nursing Test Banks Chapter 19: Nutritional Concepts and Related Therapies Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse makes nutrition a focus in the care plan. Where does nutrition play the most important role? a. Weight control b. Sustained appetite c. Building strong bones d. Health maintenance ANS: D Nutrition is the total of all processes involved in taking in and using food substances for proper growth, functioning, and maintenance of health. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 485 OBJ: 1 TOP: Nutrition KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance 2. The nurse is explaining the activity recommendations from the USDAs new MyPlate plan. What is the minimum amount of moderate weekly exercise needed to balance nutritional intake? a. 15 minutes b. 1 hour and 15 minutes c. 2 hours and 30 minutes d. 60 minutes ANS: C MyPlate recommends a minimum of 2 hours and 30 minutes of moderate aerobic physical activity a week to balance nutritional intake and 1 hour and 15 minutes of vigorous physical activity a week. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 487, Skill 19-1 OBJ: 2 TOP: MyPlate KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. What are elements that are found in food and necessary for good health but that the body cannot make? a. Important nutrients b. Life-saving nutrients c. Essential nutrients d. Necessary nutrients ANS: C Elements found in food that our bodies cannot make are essential nutrients. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 487 OBJ: 3 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion 4. To demonstrate the energy-producing potential of different foods, the nurse explains that 3 g of lean meat produces 12 kcal/g. How many kcal/g does 3 g of fish oil produce? a. 6 kcal/g b. 15 kcal/g c. 21 kcal/g d.
27 kcal/g
ANS: D Fat provides 9 kcal/g. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 487 OBJ: 3 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. What has replaced the USDAs Recommended Dietary Allowance (RDA)? a. Nutrition Recommended Allowance (NRA) b. National Bionutritional Allowance (NBA) c. Dietary Reference Intake (DRI) d. Dietary Guidelines for Americans (DGA) ANS: C The Dietary Reference Intake (DRI) has replaced the Recommended Dietary Allowance (RDA). PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 487 OBJ: 2 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. How many kcal/g does 1 g of alcohol provide? a. 4 kcal/g b. 5 kcal/g c. 6 kcal/g d. 7 kcal/g ANS: D Alcohol provides 7 kcal/g of energy. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 487 OBJ: 3 TOP: Alcohol KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. The nurse is educating a group of high school students regarding nutrition. How should the nurse respond when the students ask what occurs when protein, mineral, iron, and fat combine? a. Body processes are regulated b. Energy is provided c. Tissue is built and repaired d.
Body function is restored
ANS: C Many nutrients are necessary to build and repair tissue, including protein, minerals, iron, and fat. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 487 OBJ: 4 TOP: Nutrition KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance 8. When reviewing a patients dietary intake, the nurse recommends that sugar consumption be reduced to the recommended daily level. What is this level? a. No more than 24% of total daily kilocalories b. No more than16% of total daily kilocalories c. No more than 8% of total daily kilocalories d. No more than 4% of total daily kilocalories ANS: C DRIs relating to carbohydrates indicate that 45% to 65% of an adults total calorie intake should be in the form of carbohydrates and that added sugars should be limited to no more than 8% (approximately 40 g) of the total number of calories consumed daily PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 489 OBJ: 3 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. What is the bodys storage form of carbohydrates, usually found in the liver with some storage in the muscles? a. Sugar b. Glucose c. Lipids d. Glycogen ANS: D Glycogen is not generally consumed in the diet but is the bodys storage form of carbohydrate. It is found mainly in the liver, with some storage in the muscles. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 489 OBJ: 4 TOP: Glycogen KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
10. What is the term for stored fat that insulates the body and serves as a
cushion to protect organs? a. Subcutaneous tissue b. Adipose tissue c. Cohesive tissue d. Lipid tissue ANS: B Fat is stored in the body as adipose tissue. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 490 OBJ:4TOP:Adipose tissue KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 11. The nurse is providing information about high cholesterol levels. What is the rationale for avoiding saturated fats? a. They block absorption of nutrients b. They interfere with metabolism c. They increase blood cholesterol d. They must be hydrogenated ANS: C Saturated fats tend to increase blood cholesterol. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 491 OBJ:6TOP:Saturated fats KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. When discussing the digestion and metabolism of fat, the nurse tells the patient who has a history of cholecystitis and who is on a low-fat diet that fat must be emulsified to be digested. What is the substance necessary for emulsification? a. Sugar b. Cholesterol c. Bile d. Protein ANS: C
Bile is necessary to emulsify fat. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 491 OBJ:6TOP:Function of bile KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 13. The body uses 22 common amino acids, but 9 of them must be obtained from protein in the diet. What are these proteins considered? a. Essential b. Basic c. Fundamental d. Primary ANS: A Essential amino acids must be consumed in the diet, because the body cannot make them. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 492 OBJ: 4 TOP: Essential amino acids KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 14. The nurse is educating a patient on a vegan diet. What supplement will the nurse encourage this patient to take to avoid a deficiency? a. b. c. d. ANS: B
B6 B12 K D
B12 is almost exclusively found in animal products, but it can be supplemented with fortified cereals or vitamins. PTS: 1 DIF: Cognitive Level: Application REF: Page 497 OBJ: 7 TOP: B12 deficit KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 15.A fit, young woman was at zero nitrogen balance. The nurse discovers that
this patient is now pregnant with her first child. For what is this patient at risk? a. Embolism b. Anabolism c. Catabolism d. Metabolism ANS: B When more nitrogen is consumed than is excreted, anabolism occurs. This is also called a positive nitrogen balance. PTS: 1 DIF: Cognitive Level: Application REF: Page 493 OBJ:8TOP:Nitrogen balance KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 16. The nurse explains that a patient with a heart problem should follow a decreased sodium diet. What will this diet help reduce the risk for or prevent? a. Stroke b. Fluid excretion c. Heart attacks d. Obesity ANS: C Sodium attracts water and causes fluid retention. Hypervolemia increases the hearts workload, which can lead to a heart attack. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 499, Table 19-6; 500 OBJ:2TOP:Fluid retention KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 17. The patient complains to the nurse that he feels terrible since he has been taking several different kinds of vitamin preparations. What should the nurse assess for indications of vitamin toxicity? a. Edema b. Hypertension c. Fatigue
d. Diarrhea ANS: C Toxicity usually occurs from the use of large supplemental doses of vitamins and minerals and presents as fatigue, nausea, vomiting, and headache. PTS: 1 DIF: Cognitive Level: Application REF: Pages 494-497 OBJ:7TOP:Vitamin toxicity KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 18. The nurse cautions a patient with a pancreatic disorder that will interfere with the digestion of fats and may lead to a clotting disorder. What is the cause of these potential problems? a. Inability to use vitamin B b. Inability to use vitamin C c. Inability to use vitamin D d. Inability to use vitamin K ANS: D Vitamins A, D, E, and K are fat-soluble. Difficulty with fat metabolism will result in the inability to use fat-soluble vitamins. Vitamin K plays a role in blood clotting. It is important in maintaining four of the eleven clotting factors found in the blood. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 520 OBJ:7TOP:Fat-soluble vitamins KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 19. The home health nurse is caring for a patient that has undergone removal of a part of the stomach. For what should the nurse carefully assess this patient? a. A stomach ulcer b. Digestive problems c. Pernicious anemia d. Malabsorption ANS: C Pernicious anemia results when the intrinsic factor is missing due to surgery
on the stomach. PTS: 1 DIF: Cognitive Level: Application REF: Page 497 OBJ:17TOPernicious anemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 20.A patient taking a diuretic is assessed by the nurse as having an erratic pulse and muscle weakness. What should the nurse suspect is deficient? a. Sodium b. Potassium c. Chloride d. Iron ANS: B Diuretics can deplete potassium through urine excretion and lead to muscle weakness and cardiac arrhythmias. PTS: 1 DIF: Cognitive Level: Application REF: Page 521 OBJ:9TOPotassium depletion KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 21.A patient who has hypertension is complaining about the lack of taste with the low- sodium diet that has been prescribed. What should the nurse emphasize that sodium may do? a. Contribute to hypertension b. Interfere with blood clotting c. Produce stomach ulcers d. Decrease calcium in the bones ANS: A Sodium may contribute to hypertension. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 520-521 OBJ:1TOP:Sodium-induced hypertension KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 22. The young woman who is breastfeeding will need an increase of calories and protein. What foods should the nurse suggest as sources of protein?
a. Green, leafy vegetables b. Citrus fruits c. Asparagus d. Nuts ANS: D Nuts are a safe source of protein for lactating women. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 503, Table 19-8, 505 OBJ:4TOProtein source KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 23. At approximately 4 to 6 months of age, solid food is introduced to a baby. What foods with high iron content should be recommended by the nurse? a. Pureed fruit b. Fortified cereals c. Fruit juice d. Rice ANS: B At approximately 4 to 6 months, iron-rich foods, such as fortified cereal and pureed meat, are introduced to a baby. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 505 OBJ:8TOP:Iron-rich foods KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 24.A school nurse is teaching a group of adolescents about adequate nutrition. What increased intake should the nurse encourage? a. Potassium and sodium b. Chloride and magnesium c. Iron and calcium d. Vitamins and minerals ANS: C Dietary inadequacies in adolescence include iron and calcium. PTS: 1 DIF: Cognitive Level: Application REF: Page 506
OBJ:8TOP:Adolescent nutrition KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 25.A nurse caring for a patient who is prescribed a full-liquid diet recognizes that this diet lacks some nutrients. What nutrients are lacking? a. Fat-soluble vitamins b. Potassium c. Iron and fiber d. Water-soluble vitamins ANS: C A full-liquid diet is deficient in iron and fiber. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 508-509 OBJ:10TOP:Full-liquid diets KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 26. The nurse has assessed a patients body mass index (BMI) to be 19.6. This assessment of weight versus height indicates that this patients weight category is in which category? a. Low health risk b. Overweight c. Obese d. Morbidly obese ANS: A A BMI between 18.5 and 24.9 is associated with the lowest health risk. Those with BMIs between 25 and 29.9 are considered overweight, and those with BMIs of 30 or greater are considered obese. A BMI of less than 18.5 is considered underweight and is also associated with health risks. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 510 OBJ:12TOP:Body mass index (BMI) KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 27. What eating disorder is characterized by body image distortion, excessive exercise, and vicarious enjoyment of food?
a. Self-fasting b. Anorexia nervosa c. Bulimia nervosa d. Binge eating ANS: B Anorexia nervosa is an eating disorder characterized by self-imposed starvation, excessive exercise, and body image distortion. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 513, 514 Table 19-11 OBJ:13TOP:Anorexia nervosa KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 28. The nurse is counseling a patient about the difference between type 1 and type 2 diabetes. What should the nurse stress that patients with type 2 diabetes are required to receive on a daily basis? a. Regular carbohydrate-controlled meals b. Oral hyperglycemic agents c. Insulin injections d. Stringent low-calorie diets ANS: A People with type 2 diabetes must take daily regulated meals with controlled carbohydrate content. Type 1 diabetics must have insulin injections. PTS:1DIF:Cognitive Level: Comprehension REF: Pages 515-516, 523 Table 19-15 OBJ: 1 TOP: Nutrition in type 2 diabetes KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 29. Careful attention to carbohydrate consumption can improve metabolic control of diabetes. The nurse teaches a meal planning approach that focuses on the total amount of carbohydrates eaten at a meal. What is this meal planning approach called? a. Carbohydrate splitting b. Reduced caloric intake c. Carbohydrate counting
d. Carbohydrate balancing ANS: C Carbohydrate counting is a meal planning approach that focuses on the total amount of carbohydrates eaten. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 516-517 OBJ:13TOP:Carbohydrate counting KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 30. The patient who had a gastrostomy complains to the nurse about frequent episodes of dumping syndrome. What can the nurse recommend to this patient to decrease this problem? a. Eat small, frequent meals b. Include more fiber in meals c. Increase seasoning on food d. Limit intake to semi-liquids ANS: A The symptoms of dumping syndrome can be reduced by consuming small frequent meals of mildly seasoned food; extra fiber is not essential. PTS: 1 DIF: Cognitive Level: Application REF: Page 518 OBJ:2TOPumping syndrome KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 31. The nurse reminds the male patient with lactose intolerance that he can avoid the unpleasant symptoms of nausea, bloating, flatulence, and diarrhea, if he will avoid certain foods. What product should the patient be instructed to avoid? a. Soy beans b. Rice c. Milk d. High fiber ANS: C Lactose intolerance occurs as a result of a lack of lactase that makes it impossible to break down milk sugar.
PTS: 1 DIF: Cognitive Level: Application REF: Page 518 OBJ:2TOP:Lactose intolerance KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 32.A patient diagnosed with renal failure is unable to excrete protein waste products and develops a condition that requires a protein-restricted diet. The nurse instructs the patient that azotemia can be diminished by substituting other food groups for protein. What is an example of a food that this patient can substitute for protein? a. Potatoes b. Beans c. Cheese d. Soy products ANS: A The foods that a patient with renal disease can substitute for energy are in the carbohydrate group. Potatoes are the only carbohydrate listed. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 520 OBJ: 11 TOP: Azotemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 33. What is a nursing intervention to decrease the thirst of a patient who is on a fluid restriction? a. Rinsing the mouth with warm water b. Sipping carbonated drinks c. Sucking on occasional ice chips d. Limiting tooth brushing to once per day ANS: C Sucking on occasional ice chips is a way to decrease thirst without adding a large amount of fluid. Rinsing the mouth with cool water and frequent tooth brushing are helpful also. Carbonated drinks contain sodium and will enhance fluid retention. PTS: 1 DIF: Cognitive Level: Application REF: Page 522 OBJ:16TOP:Fluid restrictions KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and
Maintenance 34. The nurse recognizes that when a patient is unable to consume adequate nutrition by mouth, an alternative route such as a feeding ostomy may be used. What is the proper term for feeding a patient by this method? a. Total parenteral nutrition (TPN) b. Nasogastric c. Enteral d. Parenteral ANS: C The administration of nutritionally balanced liquid foods through a feeding ostomy is called enteral nutrition. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 522 OBJ:2TOP:Enteral feedings KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 35. The nurse teaches a patient who has a nonfunctioning or dysfunctional GI tract that total parenteral nutrition (TPN) will be infused. Where will the infusion occur? a. Through the carotid artery b. Through the superior vena cava c. Through the femoral vein d. Through the inferior vena cava ANS: B TPN solution is usually infused through the superior vena cava. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 525 OBJ:2TOP:Total parenteral nutrition KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 36. Which are the energy-providing food groups? (Select all that apply.) a. Carbohydrates b. Fats c. Proteins
d. Vitamins e. Minerals ANS: A, B, C The food groups that provide energy are carbohydrates, fats, and proteins. PTS: 1 DIF: Cognitive Level: Application REF: Page 487 OBJ:3TOP:Energy-producing food groups KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 37. To simplify food values, the measurement of energy obtained by food is defined as the . ANS: kilocalorie The kilocalorie is the energy value by which foods are measured for their energy-producing potential. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 487 OBJ: 3 TOP: Kilocalorie KEY: Nursing Process Step: Intervention MSC: NCLEX: Health Promotion and Maintenance 38. The body mass index (BMI) of a man 6 feet tall weighing 250 pounds is . ANS: 33.9 The BMI is calculated by dividing the pounds expressed as kilograms by the height in meters squared. 6 feet = 72 inches 39.37 = 1.83 meters 250 pounds 2.2 = 113.6 kg 113.6 (1.83 1.83) = 33.9 PTS: 1 DIF: Cognitive Level: Analysis REF: Page 510 OBJ:12TOP:Calculating body mass index (BMI) KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 39. softens stools, speeds transit of foods through the digestive tract, and reduces pressure in the colon. ANS:
Insoluble fiber Insoluble fiber softens stools, speeds transit of foods through the digestive tract, and reduces pressure in the colon. Thus it may help relieve constipation and reduce the risk of certain gastrointestinal (GI) disorders, such as diverticulosis or hemorrhoids. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 489 OBJ: 5 TOP: Fiber KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance
Chapter 20: Fluids and Electrolytes My Nursing Test Banks Chapter 20: Fluids and Electrolytes Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What percentage of an adults body weight consists of water? a. 10% to 20% b. 30% to 40% c. 50% to 60% d. 70% to 80% ANS: C The percentage of water declines to 50% to 60% in adults. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 536 OBJ: 1 TOP: Fluids KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. When administering intravenous (IV) fluids, the nurse ensures that the IV fluids are infusing as ordered to prevent dehydration in an adult. When could dehydration become lethal? a. If the patient loses 5% of body fluid b. If the patient loses 10% of body fluid c. If the patient loses 15% of body fluid d. If the patient loses 20% of body fluid ANS: D A loss of 20% of body fluid in an adult is fatal. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 537 OBJ: 1 TOP: Fluids KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse uses a diagram to show that fluids in the interstitial and intravascular compartments are combined. What do they combine to form? a. Intercellular compartment b. Circulating compartment c. Vertical compartment d. Extracellular compartment ANS: D
The fluids in the interstitial and intravascular compartments are combined to form the extracellular compartment. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 537 OBJ:1TOP:Fluid compartments KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse encourages a patient who has been vomiting to drink fluids because the body fluid lost daily must match the amount of fluid taken in to maintain homeostasis. What is the recommended daily amount of fluid for an adult? a. 1000 mL b. 1500 mL c. 2050 mL d. 2500 mL ANS: D Daily fluid intake and output is about 2200-2700 mL/day, and urinary output is about 1000-2000 mL/day. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 538 OBJ: 1 TOP: Fluids KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The nurse must keep an accurate intake and output record to assess kidney efficiency. In order for the kidneys to remove waste, what is the least amount of hourly urine output the kidneys must produce to remove waste? a. 10 mL b. 20 mL c. 30 mL d. 40 mL ANS: C The kidneys must excrete a minimum of 30 mL/hour to eliminate waste products. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 538 OBJ: 6 TOP: Fluids KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. The nurse weighs a patient at the same time of day with the same scale and
same clothing. What is this a simple and accurate method of determining? a. An accurate weight b. Water balance c. Adequate nutrition d. Urinary output ANS: B A simple and accurate method of determining water balance is to weigh the patient under the same conditions each day. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 539 OBJ: 8 TOP: Fluids KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. When a patient takes substances into the body, they first enter the extracellular compartment. What must the substances enter to carry out their function? a. Horizontal compartment b. Intracellular compartment c. Compartmental d. Vertical compartment ANS: B To carry out their function, substances must enter the cell. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 539 OBJ: 2 TOP: Fluids KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 8. What is the method by which inhaled oxygen is moved into the intravascular compartment called? a. Active transport b. Oxygenation c. Passive transport d. Mass movement ANS: C Passive transport occurs when the patient inhales oxygen into the lungs, with the oxygen passing by diffusion into the intravascular compartment.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 539 OBJ:4TOP:Transport process KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 9. The nurse explains to a patient that the drug Lasix reduces edema by drawing water from the interstitial space into the intravascular space. What is this process called? a. Diffusion b. Filtration c. Osmosis d. Homeostasis ANS: C Osmosis is the movement of water from an area of lower concentration to an area of higher concentration. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 540 OBJ:2TOP:Transport process KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 10. What does actively transporting electrolytes from an area of higher concentration to an area of lower concentration require? a. Hydrostatic pressure b. Osmotic pressure c. Blood pressure d. Pulse pressure ANS: A Electrolytes are moved by hydrostatic pressure, which is a form of active transport. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 541 OBJ:4TOP:Transport process KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. Electrolytes are not measured by weight; their chemical activity is expressed in milliequivalents. What does 1 milliequivalent of potassium have
the same combining power as? a. 1 mEq of nitrogen b. 1 mEq of oxygen c. 1 mEq of hydrogen d. 1 mEq of magnesium ANS: C Electrolytes are measured in milliequivalents: 1 mEq of any electrolyte is equal to 1 mEq of hydrogen. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 542 OBJ: 5 TOP: Electrolytes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. Sodium is the most abundant electrolyte in the body. The location of electrolytes is important for maintaining homeostasis. Sodium is the major electrolyte in which fluid compartment? a. Intracellular b. Intravascular c. Extracellular d. Interstitial ANS: C Sodium is the major extracellular electrolyte. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 542 OBJ: 5 TOP: Electrolytes KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 13. The lactating mother is counseled by the nurse to eat adequate amounts of meat and legumes. What level will this help to increase? a. Potassium b. Chloride c. Magnesium d. Phosphorus ANS: D Phosphorus should be increased during pregnancy and lactation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 547 OBJ: 5 TOP: Electrolytes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 14.A nurse assesses an edematous cardiac patient. The nurse is aware that this condition is a result of retained fluid. What is the patient considered to be? a. Hyponatremic b. Hypokalemic c. Hypernatremic d. Hypercalcemic ANS: C Hypernatremia is a greater-than-normal concentration of sodium, which leads to retained fluids and edema. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 542-543 OBJ: 5 TOP: Electrolytes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. What is the nurse closely assessing for in a patient with hypokalemia? a. Systemic edema b. Cardiac complications c. Muscle cramping d. Impaired kidney function ANS: B Hypokalemia can affect cardiac function. PTS: 1 DIF: Cognitive Level: Application REF: Pages 543-544, Box 20-4 OBJ: 5 TOP: Electrolytes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse modifies the care plan for the immobilized patient after assessing a calcium level of 6.2 mEq/L. What nursing assessment should the nurse include when modifying this care plan? a. Osteoporosis b. Tooth loss c. Renal calculi d. Contractures ANS: C Hypercalcemia occurs when calcium levels exceed 5.8 mEq/L. It may occur
when calcium stored in the bone enters the circulation, for example, in patients who are immobilized. Renal calculi may develop because of high levels of calcium. PTS: 1 DIF: Cognitive Level: Application REF: Pages 546 OBJ: 5 TOP: Electrolytes KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 17. Homeostasis of the hydrogen ion concentration in body fluids depends on the ratio of carbonic acid to bicarbonate in the extracellular fluid. What is this ratio? a. 1:5 b. 1:10 c. 1:15 d. 1:20 ANS: D The ratio needed for homeostasis is 1 part carbonic acid to 20 parts bicarbonate. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 548 OBJ: 3 TOP: Electrolytes KEY: Nursing Process Step: N/A MSC:NCLEX: N/A
18. When reading the laboratory report of a patient with excessive diarrhea, the nurse notes that the pH is 7.10, and the PaCO2 and the PaO2 are normal. What should the nurse recognize as this patients state from this information alone? a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis ANS: B The profile of a patient in metabolic acidosis is that the blood pH will be below 7.35 and the oxygen readings are within normal limits. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 551-552
OBJ: 7 TOP: Electrolytes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. What should the nurse expect when assessing a patient with respiratory alkalosis? a. Slow respirations b. Muscle weakness c. Strong, even heart rate d. Flushed face ANS: B Tetany and muscle weakness, tachypnea, and cardiac arrhythmias are symptomatic of respiratory alkalosis. PTS: 1 DIF: Cognitive Level: Application REF: Page 552, Box 20-11 OBJ: 7 TOP: Electrolytes KEY: Nursing Process Step: Analysis MSC: NCLEX: Physiological Integrity 20. Three body systems work at different speeds to keep the pH in the narrow range of normal. What is the order of effectiveness for these three systems? a. Blood buffers, kidneys, and lungs b. Kidneys, lungs, and blood buffers c. Blood buffers, lungs, and kidneys d. Lungs, kidneys, and blood buffers ANS: C The three systems are blood buffers, lungs, and kidneys. The blood buffers speed is a fraction of a second, the lungs take minutes, and the kidneys take hours to days. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 550 OBJ:6TOP:Acid-base balance KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21.A patient admitted in a state of extreme anxiety has vital signs of: T 98.6 F, P 81, BP 130/86, R 32. What will result if this hyperventilation continues? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis
d. ANS: D
Respiratory alkalosis
Respiratory alkalosis is caused by hyperventilation as the lungs blow off large amounts of CO2. PTS: 1 DIF: Cognitive Level: Application REF: Pages 550-551 OBJ:7TOP:Acid-base balance KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22.A patient began vomiting and continued to do so for several hours. What is the result of this loss of stomach contents? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: B The most common cause of metabolic alkalosis is vomiting gastric contents. PTS: 1 DIF: Cognitive Level: Application REF: Pages 552-553 OBJ:7TOP:Acid-base balance KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 23. What should the nurse focus on when creating a nursing care plan for a patient with metabolic acidosis? a. Frequent periods of ambulation b. Increasing fluid intake c. Decreasing fluid intake d. Deep-breathing exercises ANS: D
Deep breathing will cause the patient to blow off CO2 and assist in increasing the pH and reduce the acidity. PTS: 1 DIF: Cognitive Level: Application REF: Page 552-553 OBJ:8TOP:Acid-base balance
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 24.The nurse is educating a patient regarding the need to avoid foods high in potassium. What food choices led the nurse to conclude that teaching was not effective? a. Apples and green beans b. Kiwis and onions c. Apricots and asparagus d. Grapes and lima beans ANS: C Apricots and asparagus are potassium-rich. PTS: 1 DIF: Cognitive Level: Application REF: Page 543, Box 20-3 OBJ:8TOP:Nursing process KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 25. What are the three types of passive transport? (Select all that apply.) a. Diffusion b. Titration c. Osmosis d. Distillation e. Filtration ANS: A, C, E The three types of passive transport are diffusion, osmosis, and filtration. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 539 OBJ:4TOPassive transport KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 26. What are the three buffer systems of the body? (Select all that apply.) a. Bicarbonate/carbonic acid system b. Respiratory system c. Renal system d. GI system e. Integumentary system ANS: A, B, C
The bicarbonate/carbonic acid system, the respiratory system, and the renal system are the buffer systems of the body. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 550 OBJ:6TOP:Buffer systems KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 27. The nurse expects an adult with normal kidney function to void a minimum of mL of urine in 4 hours. ANS: 120 one hundred twenty The norm is to excrete at least 30 mL/hour. In 4 hours, the urine output is expected to be 120 mL. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 538 OBJ:8TOP:Kidney output KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28.A child has been having an asthma attack for the last 8 hours. Because of the childs inability to exhale effectively, the nurse assesses for respiratory . ANS: acidosis
Retained CO2 will lead to respiratory acidosis. PTS: 1 DIF: Cognitive Level: Application REF: Pages 550-551 OBJ:7TOP:Respiratory acidosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29.The nurse explains that a normal adult will lose approximately mL of water through respiration in the course of a day. ANS: 350 three hundred fifty Adults lose about 350 mL of water daily through respiration.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 538, Table 20-3 OBJ:8TOP:Insensible loss KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance Chapter 21: Mathematics and Medication Administration My Nursing Test Banks Chapter 21: Mathematics and Medication Administration Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1.What is the correct conversion for the improper fraction ? a.7 b.8 c. 7.79 d. 79.7 ANS: B Divide the numerator by the denominator. The correct conversion for the improper fraction is 8 . PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 561 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 2. What is the fraction 80/100 when reduced to lowest terms? a. b. c. d. ANS: C Find a number that will evenly divide into the numerator and the denominator. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 561 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 3. Which of the following fractions is the largest? a. 1/2
b. 1/3 c. 1/4 d. 1/5 ANS: A The smaller the denominator, the larger the fraction. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 561-562 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 4. Which of the following fractions is the smallest? a. 3/12 b. 2/3 c. 5/6 d. 3/4 ANS: A The larger the denominator, the smaller the fraction. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 561-562 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 5. What is the sum of and ? a. b. c. d. ANS: D Find the common denominator and add. will equal . Add + = . Reduce to lowest terms = 1 . PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 562 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 6. What is the product of ? a. b. c.
d. ANS: A Multiply the numerators. Multiply the denominators. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 563 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 7. What is divided by ? a. b. c. d. ANS: B Write the problem down correctly, invert the second number, and multiply. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 563 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 8.What is 2.34 + 0.77? a. 0.01 b. 90.4 c. 2.417 d. 3.11 ANS: D Align the decimal point of each decimal fraction in a column and add. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 564 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 9. What is 6.147 rounded to the nearest tenth? a. 6.2 b. 6.15 c. 6.14 d. 6.1 ANS: D A subsequent number that is 5 or larger can increase the previous number by
one whole number. A subsequent number that is less than 5 will leave the number unchanged. PTS: 1 DIF: Cognitive Level: Application REF: Page 564 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 10. What is 2.5 2? a. 1.25 b. 5 c. 50 d. 22.5 ANS: B When multiplying, decimal points do not have to be aligned. The decimal point in the answer is determined by the number of decimal points found to the right of the decimal point in the numbers multiplied. PTS: 1 DIF: Cognitive Level: Application REF: Page 564 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 11. What is 4.5 divided by 3? a. 0.75 b. 1.5 c. 5 d. 0.66 ANS: B In the divisor, move the decimal point all the way to the right and move the decimal point in the dividend the same number of places as moved in the divisor. PTS: 1 DIF: Cognitive Level: Application REF: Pages 564-565 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 12. What is 0.9% expressed as a decimal? a. 9 b. 0.9 c. 0.09
d. 0.009 ANS: D Remove the % and move the decimal point two places to the left. PTS: 1 DIF: Cognitive Level: Application REF: Page 565 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 13.What is expressed as a percent? a. 50% b. 20% c. 10% d. 5% ANS: B Change a fraction to a percent by dividing the numerator by the denominator and multiplying by 100. PTS: 1 DIF: Cognitive Level: Application REF: Page 565 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 14. Which is the same ratio as 2:100? a. 1:50 b. 5:300 c. 1:20 d. 4:25 ANS: A The value of a ratio is not changed if both sides are multiplied or divided by the same number. PTS: 1 DIF: Cognitive Level: Application REF: Page 566 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 15. The medication order reads Ibuprofen 600 mg PO tid. The bottle is labeled Ibuprofen 200 mg/tab. How many tablets should the nurse administer? a. One b. Two c. Three
d. Six ANS: C Desired dose over available dose times the unit. The unit is what the available dose is contained in. PTS: 1 DIF: Cognitive Level: Application REF: Pages 566-567 OBJ: 3 TOP: Math KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 16. The physician has ordered furosemide 20 mg stat. The ampule is labeled 40 mg/mL. What dose should the nurse administer? a. 0.8 mL b. 0.5 mL c. 2.0 mL d. 8.0 mL ANS: B Desired dosage over the available dosage times the unit. The unit is what the available dosage is contained in. PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 566-567 OBJ: 3 TOP: Math KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 17.6 mg is equal to how many grams? a. 6.0 g b. 0.6 g c. 0.06 g d. 0.006 g ANS: D Small to big, move decimal point three places to the left. PTS: 1 DIF: Cognitive Level: Application REF: Page 560 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 18.0.5 liter is equal to how many mL? a. 0.0005 mL b. 0.05 mL c.
50 mL
d. 500 mL ANS: D Big to small, move decimal point three places to the right. PTS: 1 DIF: Cognitive Level: Application REF: Page 560 OBJ: 3 TOP: Math KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 19. The average adult dose of Phenergan is 50 mg. Using the Young rule for a 10-year-old, what is the correct dosage for the child? a. 23 mg b. 25 mg c. 30 mg d. 35 mg ANS: A [Age of the child over age of the child + 12] the average adult dose = childs dose. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 568 OBJ: 4 TOP: Math KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 20.A 35-lb child is to receive an IM medication. The average adult dose is 75 mg. Using the Clark rule, what dosage should the nurse administer? a. 30.5 mg b. 25.5 mg c. 20.5 mg d. 17.5 mg ANS: D [Weight of child in pounds 150] average adult dose = childs dose. PTS: 1 DIF: Cognitive Level: Application REF: Page 568 OBJ: 4 TOP: Math KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 21. Tylenol gr V is ordered. The available tablet is 0.3 g. What dosage should the nurse administer? a. 1 tablet b. 1.5 tablets
c. tablet d. 2 tablets ANS: A Gram to grain, multiply by 15. (0.3 15 = 4.5 grains) PTS: 1 DIF: Cognitive Level: Application REF: Page 567 OBJ: 2 TOP: Math KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 22. Lanoxin 0.125 mg is to be given. The nurse converts the dose to how many grams? a. 1.250 g b. 1250 g c. 0.000125 g d. 0.00125 g ANS: C Small, arrow to big, move the decimal point three places in the direction the arrow points; move decimal three places to the left. PTS: 1 DIF: Cognitive Level: Application REF: Page 560 OBJ: 1 TOP: Math KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 23. Atropine 0.4 mg is to be given. Ampule is labeled gr 1/150/mL. What dose should the nurse administer? a. 1.5 mL b. 0.25 mL c. 0.5 mL d. 1 mL ANS: D To convert mg to gr, divide by 60. PTS: 1 DIF: Cognitive Level: Application REF: Pages 566-567 OBJ: 2 TOP: Math KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 24.A 150-lb man is to receive a medication based on milligrams/kilograms. He is to receive 1 mg/kg. What dosage should the nurse administer? a. 50 mg
b. 68 mg c. 75 mg d. 80 mg ANS: B 2.2 lb equals 1 kg. PTS: 1 DIF: Cognitive Level: Application REF: Page 567 OBJ: 1 TOP: Math KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 25.0.5 g of medication is ordered. The label reads 125 mg/mL. What is the correct dose to be administered? a. 1 mL b. 2 mL c. 3 mL d. 4 mL ANS: D Desired dose over available dose the unit. Unit is what the available dose is contained in. PTS: 1 DIF: Cognitive Level: Application REF: Pages 566-567 OBJ: 3 TOP: Math KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 26. What is the main organ that inactivates and metabolizes drugs? a. Spleen b. Liver c. Lungs d. Pancreas ANS: B The liver is the main organ that inactivates and metabolizes drugs. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 569 OBJ:8TOPharmacology KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 27. When giving a subcutaneous injection to a very thin patient, how does the nurse alter the injection technique?
a. Using a 23-G needle b. Spreading the skin before injection c. Pinching up the skin and inserting the needle at a 90-degree angle d. Injecting the medicine quickly to reduce pain ANS: C The subcutaneous technique changes when injecting a thin patient. The selection of needles is the same (-inch needle of 27 or 28 G), the site selection is the same, but the technique changes to pinch up the skin and inject at a 90-degree angle. PTS: 1 DIF: Cognitive Level: Application REF: Page 605, Skill 21-17 OBJ:11TOP:Subcutaneous injections KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 28. The nurse cautions a patient taking an anticoagulant that he should avoid taking aspirin because one drug may increase the action of the other drug. What is the correct term for this effect? a. Compatibility b. Antagonism c. Synergism d. Cooperation ANS: C When one drug increases the action of another drug, it is called synergism. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 570 OBJ:7TOPharmacology KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 29. When a patient comes into the emergency department with a narcotic overdose, the nurse anticipates that the patient will be treated with Narcan. What drug classification is Narcan? a. Enhancer b. Substitute c. Control d. Antagonist
ANS: D An antagonist is a drug that will block the action of another drug, such as Narcan with Demerol. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 570 OBJ:7TOPharmacology KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 30.The nurse administered a sedative to an older adult who was having difficulty sleeping. Later, the patient was walking the halls and becoming agitated. What is this drug response known as? a. Expected b. Untoward c. Idiosyncratic d. Hypersensitive ANS: C An unexpected response to a medication is termed idiosyncratic. PTS: 1 DIF: Cognitive Level: Application REF: Page 570 OBJ:8TOPharmacology KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31. In some health care facilities, the LPN/LVN is allowed to take telephone orders from a physician. What is one precaution the nurse must take when receiving a verbal order? a. Write quickly b. Repeat the order to the physician c. Have another nurse listen on an extension d. Sign and initial the physicians name on the order ANS: B The nurse should always repeat the order to the physician. The nurse should write slowly to avoid making a mistake. It is not necessary to have another nurse listen to the verbal order. The nurse should not sign the physicians name to the order. PTS: 1 DIF: Cognitive Level: Application REF: Page 574 OBJ:13TOPharmacology
KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 32. The nurse who was going off shift had prepared the medications for the nurse who was going to relieve her to save the oncoming nurse time. What would be the correct action of the oncoming nurse? a. Give the medications when ordered b. Recheck the medications c. Never give medications another person has prepared d. Identify each medication as it is given ANS: C The nurse should never give a medication that has been prepared by another person. PTS: 1 DIF: Cognitive Level: Application REF: Page 575 OBJ:9TOPharmacology KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment 33. What important principle should be taken to prevent medication errors? a. Placing an unlabeled syringe on the medication cart b. Following the six rights of medication administration c. Leaving a medication with the patient only when family is there d. Always charting medications before the end of the shift ANS: B Following the six rights ensures excellent drug administration practice. Unlabeled syringes should never be left on a medication cart. Medications should never be left in a patients room. Medications should be charted immediately after they are administered. PTS: 1 DIF: Cognitive Level: Application REF: Pages 574-575 OBJ: 10 TOP: Pharmacology KEY: Nursing Process Step: N/A MSC:NCLEX: Safe, Effective Care Environment 34. When the patient complains about his IV lines and asks if he can have the medication by mouth, what is the most appropriate response by the nurse? a. Pills are difficult for many patients to swallow. b. Medication by mouth is absorbed more slowly than by any other rout
c. It takes more time for the nurse to prepare and administer oral medic d. It leads to more errors to give pills, because the pills all look alike. ANS: B Medications that enter the GI tract are absorbed more slowly than by any other route. It is not known whether or not this particular patient has difficulty swallowing. The decision to give IV medications does not depend on the time of administration. It is not true that all pills look alike. PTS: 1 DIF: Cognitive Level: Application REF: Page 580 OBJ:11TOPharmacology KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 35. What landmarks are used for the administration of an intramuscular injection into the gluteal site? a. The tip of the coccyx and the greater trochanter b. Between the center of the gluteus and the iliac spine c. Between the posterior iliac crest and the greater trochanter d. On an imaginary line between the center of the gluteus and the greate ANS: C The gluteal site is marked by the greater trochanter and the posterior iliac crest. PTS: 1 DIF: Cognitive Level: Application REF: Page 601 OBJ:16TOPharmacology KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 36. What screening test is accomplished by performing an intradermal injection? a. Diabetes b. Tuberculosis c. Hepatitis d. Meningitis ANS: B Intradermal injection absorption is slow, which makes it the best route for tuberculosis screening.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 603 OBJ:11TOPharmacology KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 37. Using the illustration below, select the proper angle for the nurse to use in administering a subcutaneous injection for the average adult. a. 90 b. 45 c. 15 d. Any of the above ANS: B Subcutaneous injections are given at a 45-degree angle for the average adult. This angle is used to ensure that the medication is injected into the subcutaneous tissue rather than into the muscle. PTS: 1 DIF: Cognitive Level: Application REF: Page 604 OBJ:9TOP:Subcutaneous injections KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment MULTIPLE RESPONSE 38. What should the nurse do with an injection of 2 mL of Demerol that the patient has refused? (Select all that apply.) a. Independently waste the drug in a secure place. b. Record in the narcotic log that the drug was wasted. c. Chart in the patients record the reason the medication was refused. d. Get any staff member to sign the narcotic log as witness to the drug b e. Confirm the count is correct on the narcotic log. ANS: B, C, E When a controlled substance is wasted, the actual wasting must be witnessed by a licensed person, the narcotic log must be signed by both the nurse wasting the drug and the witness, and the narcotic count is confirmed by both people. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 574 OBJ:9TOP:Wasting a controlled drug
KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment COMPLETION 39. To help relax the anal sphincter during the insertion of a suppository, the nurse should ask the patient to . ANS: exhale Exhaling will help relax the anal sphincter. PTS: 1 DIF: Cognitive Level: Application REF: Page 585, Skill 21-4 OBJ:8TOP:Rectal suppository KEY: Nursing Process Step: Intervention MSC: NCLEX: Safe, Effective Care Environment 40. When giving a tubal medication, the nurse should flush the tubing with to mL of water. ANS: 30, 50 thirty, fifty The water will enhance the absorption of the drug and also clear the tubing. PTS: 1 DIF: Cognitive Level: Application REF: Page 584, Skill 21-3 OBJ:8TOP:Tubal administration KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 41. The following information is included in a physicians order: Jane Doe September 23 Amoxicillin 250 mg PO every 6 hours for 10 days Dr. John Smith The essential component missing is the . ANS: time The physicians order should include the patients name, date, time, medication, dose, route, frequency, and physicians signature. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 573 OBJ: 13 TOP: Physicians order KEY: Nursing Process Step: N/A
MSC:NCLEX: N/A 42. The order is for 100 mL to run over 8 hours as a piggyback. The drop factor of the secondary unit is 15. The nurse should set the drop control to deliver gtts/min. ANS: 3 three 100 ml divided by 8 = 12.5 mL/hr PTS: 1 DIF: Cognitive Level: Application REF: Page 608 OBJ:3TOPharmacology KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment Chapter 22: Care of Patients with Alterations in Health My Nursing Test Banks Chapter 22: Care of Patients with Alterations in Health Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. Why should the nurse instill eye irrigation from the inner to the outer canthus? a. To avoid harming the sclera b. To include the conjunctiva in the irrigation c. To keep the pupil constricted d. To protect the nasolacrimal ducts ANS: D The irrigation flow is directed to the outer canthus to protect the nasolacrimal ducts from contaminants. PTS: 1 DIF: Cognitive Level: Application REF: Page 615 OBJ:1TOP:Eye irrigation KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. When an order for eye irrigation is received, to whom can the nurse delegate the procedure to? a. The patient
b. Another nurse c. A nursing assistant d. A family member ANS: B Performing eye irrigation requires the skills of a licensed nurse. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 615 OBJ: 1 TOP: Delegation KEY: Nursing Process Step: Planning MSC:NCLEX: Safe, Effective Care Environment 3. To what temperature should water for eye compress be heated? a. 95 F b. 110 F c. 115 F d. 120 F ANS: D Water for an eye compress may be heated to no more than 120 F. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 618, Skill 22-2 OBJ:2TOP:Eye compress KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 4. When a patient complains of progressive hearing loss, crackling and ringing noises in his ear, and progressive ear pain, what should the nurse assess for? a. A dead battery in the patients hearing aid b. Cerumen impaction c. Sinus congestion d. A middle ear infection ANS: B Symptoms of cerumen impaction are progressive hearing loss, bothersome noises in the ear, and progressive ear pain. PTS: 1 DIF: Cognitive Level: Application REF: Page 617 OBJ:1TOP:Cerumen impaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. When a patient asks if he can keep the heating pack on his leg all the time,
the nurse reminds him of which of the following complication of long-term heat application? a. The heat can cause extreme vasoconstriction. b. The heat can increase the possibility of infection. c. The heat can cause the blood pressure to increase. d. The heat can damage epithelial cells. ANS: D Prolonged contact with heat can cause damage to the epithelial cells. PTS: 1 DIF: Cognitive Level: Application REF: Page 622 OBJ:2TOP:Heat applications KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 6. How does an Aquathermia pad differ from a traditional heating pad? a. The Aquathermia pad can be folded to fit the anatomic location snug b. The Aquathermia pad can be placed under the patient. c. The Aquathermia pad has circulating water for temperature control. d. The Aquathermia pad can be left on for as long as 2 hours. ANS: C The Aquathermia pad should not be folded or placed under the patient, nor should it be left on for longer than 20 minutes. The Aquathermia pad has water that circulates and stays warm for the entire time of the treatment with no need to reheat the compress. PTS: 1 DIF: Cognitive Level: Application REF: Page 626 OBJ:2TOP:Aquathermia pad KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. What gauge needle should be selected by the nurse when preparing to administer blood? a. 25 b. 22 c. 21 d. 18
ANS: D A large-bore needle will allow blood flow without clogging. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 632 OBJ:6TOP:Blood administration KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 8. What is the nurses first priority when a patient receiving IV fluid therapy shows an increase in blood pressure and has bilateral crackles? a. Raise the head of the bed b. Slow the infusion c. Turn the patient to the left side d. Notify the charge nurse ANS: B When signs of circulatory overload are observed, the infusion is slowed down initially, then the nurse should notify the charge nurse. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 636 OBJ:4TOP:Fluid overload KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 9. The nurse notes an edematous area around the insertion site of an IV that is cool to the touch and the skin of which appears blanched. Based on these assessment findings, what is the first priority of the nurse? a. Apply warm compresses to the area b. Notify the charge nurse c. Stop the infusion d. Reposition the arm to improve the fluid flow ANS: C The infusion should be stopped and restarted in another location. Warm compresses are contraindicated. Repositioning the arm will not remedy the infiltration. The charge nurse can be notified after the fact. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 636 OBJ: 4 TOP: Infiltration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
10. While teaching a patient about the signs of IV therapyassociated phlebitis,
how does the nurse describe an area with phlebitis? a. Warm, edematous, and red b. Painful and cyanotic c. Painless and numb d. Edematous and cool ANS: A Areas of phlebitis are warm, edematous, and red. PTS: 1 DIF: Cognitive Level: Application REF: Page 636 OBJ: 4 TOP: Phlebitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. When an older adult patient with chronic emphysema comes to the emergency department in respiratory distress, at what rate should the nurse begin oxygen per nasal cannula? a. 2 L/min b. 3 L/min c. 4 L/min d. 5 L/min ANS: A
Administering O2 at more than 2 L/min to a person with chronic pulmonary disease may cause respiratory failure. PTS: 1 DIF: Cognitive Level: Application REF: Page 648 OBJ:7TOP:O2 administration KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
12. The nurse instructs a patient receiving home O2 therapy to drink plenty of fluids to help keep bronchial secretions liquefied. What is the recommended fluid? a.
Milk
b. Water c. Tea with artificial sweetener d. Coffee ANS: B Water is the best option. Drinks with caffeine, sugar, or dairy products are not helpful to liquefy secretions. PTS: 1 DIF: Cognitive Level: Application REF: Page 648 OBJ: 7 TOP: Fluids KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. The wife of a patient with a cuffed tracheostomy asks why the cuff is inflated intermittently. What is the purpose of the inflated cuff? a. Prevent regurgitation after meals b. Hold the trachea open until it is completely healed c. Dilate the tracheal opening for passage of secretions d. Prevent aspiration when eating ANS: D The cuff is inflated to prevent aspiration while eating or when cleaning the tracheostomy tube. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 656 OBJ:9TOP:Cuffed tracheostomy tubes KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 14. After a Foley catheter has been removed, the nurse should assess the patient for: a. hemorrhage. b. constipation. c. urinary retention. d. bladder spasm. ANS: C While an indwelling urinary catheter is in place, the bladder loses tone and can retain urine after the removal of the catheter. PTS: 1 DIF: Cognitive Level: Application REF: Pages 674, 675, Skill 22-16 OBJ:11TOP:Catheter removal
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. What would be the correct explanation of catheter care? a. Cleansing the first 2 inches of the catheter with soap and water every b. Disinfecting the entire catheter with alcohol every shift c. Lubricating the catheter with antiseptic lotion every 24 hours d. Cleansing the meatal-catheter junction every 24 hours ANS: A The first 2 inches of the catheter should be cleaned with soap and water every shift or more often if the patient is incontinent. Alcohol and lotions are contraindicated. Catheter care should be done every shift. PTS: 1 DIF: Cognitive Level: Application REF: Page 669, Skill 22-14 OBJ:11TOP:Catheter care KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 16. Which of the following is an appropriate nursing measure when performing tracheostomy care? a. Wear clean gloves b. Insert the catheter without suction c. Suction for 1 minute before removing the catheter d. Place the used catheter in a plastic shield for later use ANS: B Insertion of the suction catheter without suction reduces the probability of tissue injury. Sterile gloves should be used for tracheostomy care. Suctioning should be done for a maximum of 10 seconds at a time. A used catheter should be disposed of appropriately. PTS: 1 DIF: Cognitive Level: Application REF: Pages 659-661, Skill 22-12 OBJ:9TOP:Tracheal suction KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. During insertion of a Foley catheter, the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse? a. Withdraw the catheter
b. Ask the patient to bear down c. Continue to inflate the balloon d. Advance the catheter into the bladder ANS: D Grimacing is a sign of pain indicating that the balloon might be in the urethra instead of the bladder. The catheter should be advanced before inflation. PTS: 1 DIF: Cognitive Level: Application REF: Pages 665-668, Skill 22-12 OBJ:11TOP:Catheterization KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18. When explaining the difference between a colostomy and an ileostomy, the nurse explains which of the following about an ileostomy? a. It is always permanent b. It drains semi-liquid stool c. It has a much larger stoma d. It does not need a pouch ANS: B The ileostomy is higher in the GI tract and drains semi-liquid stool. The ileostomy is very similar in appearance to the colostomy, may not be permanent, and needs a pouch. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 685 OBJ: 17 TOP: Ileostomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. Before inserting a nasogastric tube, what measurement should the nurse take? a. Tip of the nose to the earlobe to the xiphoid process b. Bridge of the nose to the xiphoid process c. Nose to the top of the ear to the stomach d. Clavicular notch to the stomach ANS: A The measurement is from the tip of the nose to the ear lobe to the xiphoid process. PTS: 1 DIF: Cognitive Level: Application REF: Page 679, Skill 22-18
OBJ:13TOP:Nasogastric (NG) tube KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 20. When irrigating an ear, the nurse should perform which intervention(s)? (Select all that apply.) a. Heat the water to 115 F b. Pull the auricle back firmly and hold it c. Place the tip of the syringe loosely in the ear canal d. Introduce fluid with a slow, gentle irrigation e. Use a stronger flow if a foreign body is present ANS: C, D The water is heated to body temperature, the auricle is pulled gently back, the tip is placed loosely in the ear canal, and the flow is gently introduced. Irrigation is contraindicated if a foreign body is in the canal. PTS: 1 DIF: Cognitive Level: Application REF: Pages 619-620, Skill 22-3 OBJ:1TOP:Ear irrigation KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. Hot moist compresses have which positive effect(s)? (Select all that apply.) a. Improvement of circulation b. Relief of edema c. Consolidation of exudates d. Enhancement of scabbing e. Relief of pain ANS: A, B, C Hot moist compresses improve circulation, relieve edema, and consolidate exudate. Compresses may delay scabbing and increase pain. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 623-624 OBJ:2TOP:Hot moist compresses KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
COMPLETION 22. The appliance that connects to an IV drip and delivers a continuous irrigation to the eye is known as a . ANS: Morgan therapeutic lens A Morgan therapeutic lens attaches to an IV drip and can deliver continuous eye irrigation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 617 OBJ: 1 TOP: Morgan cup KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 23. The nurse is alert for a serious condition called that results from pathogens being introduced into the blood stream. ANS: septicemia Septicemia is a condition that results when pathogens are introduced into the blood stream. PTS: 1 DIF: Cognitive Level: Application REF: Page 637 OBJ: 5 TOP: Septicemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity OTHER 24. If a patient has a transfusion reaction, the nurse should perform the following interventions in which priority order? Put a comma and space between each answer choice (A, B, C, D, etc.). a. Take and record vital signs b. Notify physician and blood bank c. Stop the transfusion d. Monitor urine output e. Return blood and tubing to the blood bank ANS: C, A, B, E, D The correct sequence of interventions is to stop the transfusion, take and record vital signs, notify physician and blood bank of the reaction, return the blood and tubing to the blood bank, and monitor urine output. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 645
OBJ:6TOP:Transfusion reaction KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity Chapter 23: Life Span Development My Nursing Test Banks Chapter 23: Life Span Development Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse tells a mother that the blueprint for all inherited traits, such as height, is found in which of the following? a. Sperm b. Ovary c. Chromosomes d. Nucleus of the cell ANS: C The blueprint for all inherited traits is found in the chromosomes. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 699 OBJ: 4 TOP: Growth KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. The nurse discovers during the intake assessment of a 5-year-old child that the child lives with his biologic parents and siblings. How would the nurse categorize this family type? a. Extended family b. Blended family c. Social family d. Nuclear family ANS: D The nuclear family is considered the traditional family pattern. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 700 OBJ: 4 TOP: Family KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 3.A newborn baby weighs 7 lb at birth. What does the nurse anticipate the babys weight will be at 1 year of age? a. 14 lb
b. 17 lb c. 21 lb d. 25 lb ANS: C By 1 year, birth weight is expected to triple. Thus, the weight at 1 year would be 7 lb times three, which would equal 21 lb. PTS: 1 DIF: Cognitive Level: Application REF: Page 706 OBJ: 4 TOP: Growth KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 4. The mother of a 5-month-old child is concerned because the child cannot sit by himself. The nurse explains that sitting alone is not expected until the baby reaches what age? a. 6 months b. 7 months c. 8 months d. 9 months ANS: B By the end of the seventh month, most babies can sit up without support. PTS: 1 DIF: Cognitive Level: Application REF: Page 707 OBJ:4TOPevelopment KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 5.A young mother asks the nurse how long she should wait before introducing solid food to her infant. The nurse explains that breast milk will provide all the nutrition her infant needs for how many months? a. 2 to 3 months b. 4 to 6 months c. 7 to 9 months d. 10 to 12 months ANS: B Breast milk or formula is the only nutrition needed for the first 4 to 6 months of an infants life. PTS: 1 DIF: Cognitive Level: Application REF: Page 708
OBJ: 4 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. When a mother asks the nurse about introducing solid foods into the childs diet, which of the following would be the best answer? a. Introduce meat first. b. Introduce one solid food at a time several days apart. c. Introduce solid foods by mixing two or three foods together. d. Introduce solid foods by adding strained food to the infants bottle. ANS: B The best advice is to introduce one solid at a time, allowing several days between. Cereals should be introduced first, followed by fruits and vegetables. Meats should be introduced last. Avoid mixing foods to allow the infant to develop an interest in different tastes. Strained foods should not be added to a bottle. PTS: 1 DIF: Cognitive Level: Application REF: Page 709 OBJ: 4 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7.A babys muscular development progresses in what type of pattern? a. Regressive b. Erratic c. Cephalocaudal d. Unpredictable ANS: C Muscular development proceeds from head to foot (cephalocaudal). PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 699 OBJ: 4 TOP: Growth KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8. At what age does a child typically possess the physiological, neuromuscular, and psychological maturity necessary to master toilet training? a. 6 to 10 months b. 10 to 14 months c. 14 to 18 months
d. 18 to 24 months ANS: D Children reach psychological and physiological maturity for toilet training by 18 to 24 months. PTS: 1 DIF: Cognitive Level: Application REF: Page 711 OBJ:5TOP:Toilet training KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. How can a family best assist a toddler who is attempting to feed himself? a. Encourage the child to use a fork b. Feed the child themselves using a fork c. Encourage large portions for easier handling d. Offer the child finger foods ANS: D Toddlers need to develop autonomy and do things for themselves in a trialand-error method. Finger foods allow the child a feeling of independence. PTS: 1 DIF: Cognitive Level: Application REF: Page 712 OBJ:5TOPevelopment KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 10. In response to a mothers concern about the development of a food allergy in her 5-month-old, the nurse should suggest the delay of which foods? a. Oat cereals b. Potatoes c. Citrus fruits d. Green vegetables ANS: C The general guideline for foods to avoid until the baby is 6 months old are egg whites, citrus fruits, and wheat flour. Cereals and vegetables are the first foods that should be introduced. PTS: 1 DIF: Cognitive Level: Application REF: Page 709 OBJ: 4 TOP: Allergy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
11.A 5-year-old who has an imaginary friend with whom he converses frequently is displaying characteristics consistent with which of Piagets stages of cognitive development? a. Operational stage b. Preoperational stage c. Formal operations stage d. Concrete operations stage ANS: B Piagets preoperational stage describes the preschooler as imaginative and egocentric, believing in magical thinking. PTS: 1 DIF: Cognitive Level: Application REF: Page 714 OBJ:3TOPevelopment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 12.A 14-year-old male patient has undergone a leg amputation. What should be the primary focus of the patients care plan? a. Nutritional status b. Academic progress c. Body image d. Socialization needs ANS: C Body image is a major developmental task of the adolescent. Nutritional status, academic progress, and socialization should be addressed, but they would not be the primary focus. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 720 OBJ: 10 TOP: Adolescent KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 13. According to Piaget, what is the cognitive developmental level of the adolescent? a. Concrete operational stage b. Sensorimotor stage c. Preoperational stage d. Formal operational stage
ANS: D The formal operational stage is the cognitive developmental level of adolescence. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 720 OBJ: 3 TOP: Cognitive development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 14. The nurse performing a routine physical assessment on a 25-year-old understands that the patient is most likely experiencing which of the following? a. A gradual decline in physical capabilities b. Optimal level of functioning c. Slight diminishing of visual acuity d. Minimal hearing loss ANS: B During early adult years, the body is at an optimal level of functioning. The gradual decline in physical capabilities, diminishing of visual acuity, and hearing loss will not occur until later in adulthood. PTS: 1 DIF: Cognitive Level: Application REF: Page 722 OBJ:6TOP:Early adulthood KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 15. Erikson identifies intimacy as a developmental task of adulthood. What will occur if intimacy is not established? a. Inferiority b. Isolation c. Mistrust d. Guilt ANS: B Intimacy versus isolation is a developmental task of adulthood. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 723 OBJ: 8 TOP: Erikson KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 16.What is the leading cause of death in young adults?
a. Diabetes b. Accidents c. Hypertension d. Testicular cancer ANS: B The leading cause of death in young adults is accidents. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 724 OBJ: 11 TOP: Accidents KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 17.A 53-year-old woman complains of night sweats and mood swings. The nurse recognizes that these symptoms most likely relate to which condition? a. Menopause b. Weight problems c. Dietary problems d. Thyroid problems ANS: A Signs and symptoms of menopause may include sweats and mood swings. PTS: 1 DIF: Cognitive Level: Application REF: Page 724 OBJ: 6 TOP: Menopause KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18.A 58-year-old male is concerned about some hearing loss he is experiencing. The nurse recognizes that this might be due to a sensory change of this age group known as which of the following? a. Presbycusis b. Otitis externa c. Presbyopia d. Otitis media ANS: A Presbycusis is a normal age-related loss of hearing. Otitis externa and otitis media are infections of the ear. Presbyopia is a condition in which it becomes difficult to focus on objects nearby. PTS: 1 DIF: Cognitive Level: Application REF: Page 724 OBJ: 6 TOP: Middle age KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 19. What is the correct term for prejudice against older adults? a. Socialism b. Sexism c. Racism d. Ageism ANS: D Ageism is a form of discrimination and prejudice against the older adult. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 727 OBJ: 13 TOP: Late adulthood KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 20. What theory claims that there is a hereditary basis for aging? a. Activity theory b. Physiological theory c. Disengagement theory d. Biologic programming theory ANS: D Biologic programming theory suggests a hereditary basis for aging. PTS: 1 DIF: Cognitive Level: Application REF: Page 728 OBJ: 14 TOP: Aging KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 21. The nurse reminds an older adult patient that the task for the older adult is to achieve ego integrity. Failure to achieve this task results in which of the following? a. Failure b. Despair c. Reminiscing d. Accomplishment ANS: B The challenge of late adulthood is integrity versus despair. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 729 OBJ: 8 TOP: Older adult KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
22. When assessing the home for fall risks and increased safety for an 85-
year-old, what should be a suggestion of the home health nurse? a. Bright lights be kept on at all times b. Sponge baths be taken rather than showers c. Excess furniture be removed d. Loose, comfortable shoes be worn ANS: C Clearing the home of excess furniture and scatter rugs, the use of night-lights, and wearing supportive shoes reduce the risk of falls in older adults. It is not necessary to keep bright lights on at all times. It is not necessary to avoid showers. PTS: 1 DIF: Cognitive Level: Application REF: Page 732 OBJ: 7 TOP: Older adult KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 23. The home health nurse assesses an older adults respiratory function carefully because age-related changes in the respiratory system could result in which of the following? a. Vital capacity b. Susceptibility to respiratory infections c. Expiratory capacity due to increased chest size d. Oxygen and carbon dioxide exchange ANS: B Older adults are more susceptible to respiratory infections. PTS: 1 DIF: Cognitive Level: Application REF: Page 730, Table 23-4 OBJ: 6 TOP: Older adult KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 24. What is the family pattern in which the relationships are unequal and the parents attempt to control the children with strict, rigid rules and expectations? a. Autocratic family pattern b. Patriarchal family pattern c. Matriarchal family pattern d. Democratic family pattern
ANS: A In the autocratic family pattern the relationships are unequal. The parents attempt to control the children with strict, rigid rules and expectations. This family pattern is least open to outside influence. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 701-702 OBJ: 1 TOP: Family patterns KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 25. Which family pattern is least open to outside influence? a. Autocratic family pattern b. Patriarchal family pattern c. Matriarchal family pattern d. Democratic family pattern ANS: A In the autocratic family pattern the relationships are unequal. The parents attempt to control the children with strict, rigid rules and expectations. This family pattern is least open to outside influence. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 701-702 OBJ: 1 TOP: Family patterns KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 26. What is the family pattern in which the male usually assumes the dominant role and functions in the work role, controls the finances, and makes most of the decisions? a. Autocratic family pattern b. Patriarchal family pattern c. Matriarchal family pattern d. Democratic family pattern ANS: B In the patriarchal family pattern, the male usually assumes the dominant role. The male member functions in the work role, is responsible for control of finances, and makes most decisions. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 702 OBJ: 1 TOP: Family patterns KEY: Nursing Process Step: N/A MSC:NCLEX: N/A
27. What is the family pattern in which the female assumes primary
dominance in the areas of child care and homemaking, as well as financial decision making? a. Autocratic family pattern b. Patriarchal family pattern c. Matriarchal family pattern d. Democratic family pattern ANS: C In the matriarchal family pattern, the female assumes primary dominance in areas of child care and homemaking, as well as financial decision making. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 702 OBJ: 1 TOP: Family patterns KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 28. What is the family pattern in which the adult members function as equals? a. Autocratic family pattern b. Patriarchal family pattern c. Matriarchal family pattern d. Democratic family pattern ANS: D In the democratic family pattern, the adult members function as equals. Children are treated with respect and recognized as individuals. This style encourages joint decision making, and it recognizes and supports the uniqueness of each individual member. This family pattern favors negotiation, compromise, and growth. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 702 OBJ: 1 TOP: Family patterns KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 29. What is the stage of family development that begins when the couple acknowledges that they are considering marriage? a. Expectant stage b. Parenthood stage c. Establishment stage d. Engagement/commitment stage
ANS: D The engagement/commitment stage begins when the couple acknowledges to themselves and others that they are considering marriage. At this time, opposition or support will be evident from friends and parents. Wedding plans must be arranged. Housing, work, and furnishings are some of the items discussed and explored. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 702 OBJ: 1 TOP: Family development KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 30. What is the stage of family development that extends from the wedding until the birth of the first child? a. Expectant stage b. Parenthood stage c. Establishment stage d. Engagement/commitment stage ANS: C The establishment stage extends from the wedding until the birth of the first child. During this phase, one of the important tasks is the adjustment from the single independent to the married, interdependent state. The challenges facing the newly married couple include learning to live with another person, decision making, conflict resolution, and communication. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 702 OBJ: 1 TOP: Family development KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 31. What is the stage of family development that begins when conception begins and continues through the pregnancy? a. Expectant stage b. Parenthood stage c. Establishment stage d. Engagement/commitment stage ANS: A The expectant stage begins when conception occurs and continues through the pregnancy.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 702 OBJ: 1 TOP: Family development KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 32. What is the stage of family development that begins at the birth or adoption of the first child? a. Expectant stage b. Parenthood stage c. Establishment stage d. Engagement/commitment stage ANS: B The parenthood stage begins at the birth or adoption of the first child. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 703 OBJ: 1 TOP: Family development KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 33. What stage of family development involves the grown children departing from home? a. Expectant stage b. Senescence stage c. Establishment stage d. Disengagement stage ANS: D The disengagement stage of parenthood is the period of family life when the grown children depart from the home. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 703 OBJ: 1 TOP: Family development KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 34. What is known as the last stage in the life cycle? a. Expectant stage b. Senescence stage c. Establishment stage d. Disengagement stage ANS: B The senescence stage is the last stage of the life cycle, which requires the
individual to cope with a large range of changes. For the older adult the family unit continues to be a major source of satisfaction and pleasure. Most older adults prefer to live independently. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 703 OBJ: 1 TOP: Family development KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 35. The nurse recognizes that during the first 5 months of life, an infant is expected to gain approximately how many pounds per month? a. 0.5 b. 1 c. 1.5 d. 2 ANS: C The infant is expected to gain about 1.5 lb per month until 5 months. PTS: 1 DIF: Cognitive Level: Application REF: Page 706 OBJ: 4 TOP: Growth and development KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 36.A nurse is caring for a neonate who weighs 7 lb 3 oz at birth. What should the infants weight be at 1 year? a. 10 lb 3 oz b. 14 lb 6 oz c. 21 lb 9 oz d. 28 lb 12 oz ANS: C By the time the baby is 1 year of age, the birth weight should have tripled. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 706 OBJ: 4 TOP: Growth and development KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 37.A nurse is caring for a neonate who is 22 inches in height. What will the childs expected height be at 1 year? a. 29 inches b. 33 inches c.
44 inches
d. 56 inches ANS: B Height increases by about 1 inch per month for the first 6 months. By 12 months of age, the infants birth length has increased about 50%. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 707 OBJ: 4 TOP: Growth and development KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 38. What is the average apical heart rate for a 2-month-old infant? a. 80 bpm b. 100 bpm c. 120 bpm d. 150 bpm ANS: C At 2 months of age, the average apical rate is about 120 bpm. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 707 OBJ: 4 TOP: Growth and development KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 39. What is the average resting respiratory rate for a 12-month-old child? a. 15 breaths/min b. 20 breaths/min c. 30 breaths/min d. 50 breaths/min ANS: C Average resting respiratory rate for the 12-month-old is about 30 breaths/min. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 707 OBJ: 4 TOP: Growth and development KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 40.A nurse assessing a 2-month-old infant would expect the infant to do which of the following? a. Crawl on the floor b. Creep on the floor c.
Sit up steadily without support
d. Hold its head up while in the prone position ANS: D At 2 months the infant is able to hold the head up while in the prone position. Infants may crawl at 7 months and creep at about 9 months. By the end of the seventh month, infants can sit up steadily without support. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 707 OBJ:4TOP:Growth and development KEY:Nursing Process Step: AssessmentMSC:NCLEX: N/A 41.A nurse assessing a 4-month-old infant would expect the infant to do which of the following? a. Crawl up the stairs b. Creep on the floor at least 30 feet c. Walk upright with a waddling gait d. Hold head at a 90-degree angle while prone ANS: D At 4 months the infant is able to hold the head up steadily to a 90-degree angle while in the prone position. Infants may crawl at 7 months and creep at about 9 months. Standing with support and walking occur at about 8 months to 15 months. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 707 OBJ:4TOP:Growth and development KEY:Nursing Process Step: AssessmentMSC:NCLEX: N/A 42.A nurse teaching the mother about infant oral hygiene instructs the mother to offer the infant sips of: a. cola. b. milk. c. juice. d. water. ANS: D Oral hygiene for the young infant consists of offering sips of clear water and wiping and massaging the infants gums. Cola, milk, and juice should not be introduced at this young age. PTS: 1 DIF: Cognitive Level: Application REF: Page 707
OBJ: 4 TOP: Dentition KEY: Nursing Process Step: Implementation MSC:NCLEX: N/A 43.A mother asks the nurse when she should introduce solid foods into her infants diet. What would be the most correct response? a. Introduce fruits and vegetables first. b. Mix foods to allow the infant variety. c. Introduce only one new food at a time. d. Introduce new foods at 24-hour intervals. ANS: C Only one new food should be introduced at a time, followed by several days between new foods. Cereals should be introduced first, followed by fruits and vegetables, and last meats. Food should not be mixed to allow the infant to develop interest in different foods and tastes. PTS: 1 DIF: Cognitive Level: Application REF: Page 709 OBJ: 4 TOP: Diet KEY: Nursing Process Step: Implementation MSC:NCLEX: N/A 44. What is the leading cause of injury and death among infants and young children? a. Accidents b. Child abuse c. Drug abuse d. Adolescent parents ANS: A Accidents are the leading cause of injury and death of infants and young children. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 710 OBJ: 11 TOP: Prevention KEY: Nursing Process Step: Implementation MSC:NCLEX: N/A 45.A nurse assessing a toddler should consider which finding abnormal? a. Lumbar lordosis b. Cyanotic nail beds c. A protruding abdomen d. A convex lumbar curve
ANS: B Normal assessment findings in a toddler include lumbar lordosis (convex lumbar curve) and a protruding abdomen. Cyanotic nail beds are an abnormal finding. PTS: 1 DIF: Cognitive Level: Application REF: Page 710 OBJ: 4 TOP: Abnormal findings KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 46. Which theory of aging suggests that the body becomes less able to tolerate the self? a. Free radical theory
b. Autoimmunity theory c. Wear-and-tear theory d. Biologic programming theory ANS: B The autoimmunity theory holds that with aging, the body becomes less able to recognize or tolerate the self. As a result the immune system produces antibodies that act against the self. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 728 OBJ: 14 TOP: Theories of aging KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 47. Which theory of aging suggests that there should be a natural withdrawal between the individual and society? a. Free radical theory b. Autoimmunity theory c. Wear-and-tear theory d. Disengagement theory ANS: D According to supporters of the disengagement theory of aging, there should be a natural withdrawal, or disengagement, between the individual and society. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 728 OBJ: 14 TOP: Theories of aging KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 48. Which theory of aging suggests that the older person who is more socially active is more likely to adjust well to aging? a. Activity theory b. Autoimmunity theory c. Wear-and-tear theory d. Disengagement theory ANS: A According to the activity theory, the older person who is more active socially is more likely to adjust well to aging. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 728
OBJ: 14 TOP: Theories of aging KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 49. Which theory of aging suggests that previously developed coping abilities and the ability to maintain previous roles and activities are critical to adjustment to old age? a. Continuity theory b. Autoimmunity theory c. Wear-and-tear theory d. Disengagement theory ANS: A Supporters of the continuity theory suggest that the critical factors in adjustment to old age are previously developed coping abilities and the ability to maintain previous roles and activities. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 728 OBJ: 14 TOP: Theories of aging KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 50. Which of the following measures would be included in a teaching plan to instruct new parents on reducing the incidence of sudden infant death syndrome? a. Bottle-feed an infant at night b. Place infants on their stomach to sleep c. Keep an infants room well ventilated d. Place soft bedding and pillows in an infants crib ANS: C Steps to reduce the incidence of sudden infant death syndrome include placing infants on their back to sleep, avoiding exposure to cigarette smoke, avoiding using soft bedding or pillows, keeping rooms well ventilated, breastfeeding if possible, and maintaining regular medical checkups for infants. PTS: 1 DIF: Cognitive Level: Application REF: Page 709 OBJ: 4 TOP: Safety KEY: Nursing Process Step: Implementation MSC:NCLEX: N/A 51.A nurse instructing a group of parents about safety rules for infants and
young children should include which of the following measures in the teaching plan? a. Remove plants from the childs reach b. Provide the infant with a pillow at night c. Use a plastic covering on the infants mattress d. Keep the crib sides up and set the mattress at the highest setting ANS: A Safety rules for infants and young children include keeping the crib sides up and the mattress set at the lowest setting, never using plastic bags or coverings on mattresses or near the infants playthings, avoiding the use of pillows with small infants, and removing plants from the childs reach. PTS: 1 DIF: Cognitive Level: Application REF: Page 711 OBJ: 4 TOP: Safety KEY: Nursing Process Step: Implementation MSC:NCLEX: N/A 52.A child who uses senses and motor abilities to understand the world is displaying characteristics consistent with which stage of Piaget cognitivedevelopment? a. Sensorimotor stage of cognitive development b. Preoperational stage of cognitive development c. Formal operational stage of cognitive development d. Concrete operational stage of cognitive development ANS: A The Piaget sensorimotor stage of cognitive development uses senses and motor abilities to understand the world; this period begins with reflexes and coordinates sensorimotor skills. PTS: 1 DIF: Cognitive Level: Application REF: Page 705, Box 23-6 OBJ: 3 TOP: Piaget KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 53.A child who has just begun to demonstrate object permanence is in which of the Piaget stages of cognitive development? a. Sensorimotor b. Preoperational thought c. Formal operational thought
d. Concrete operational thought ANS: A The Piaget sensorimotor stage of cognitive development uses senses and motor abilities to understand the world; this period begins with reflexes and coordinates sensorimotor skills. While in this stage, a child learns that an object still exists when it is out of sight (object permanence). PTS: 1 DIF: Cognitive Level: Application REF: Page 705, Box 23-6 OBJ: 3 TOP: Piaget KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 54.A child who has just begun to demonstrate egocentric thinking is in which of the Piaget stages of cognitive development? a. Sensorimotor b. Preoperational thought c. Formal operational thought d. Concrete operational thought ANS: B The Piaget preoperational stage of cognitive development includes the development of egocentric thinking (understanding the world from only one perspective, that of the self). PTS: 1 DIF: Cognitive Level: Application REF: Page 705, Box 23-6 OBJ: 3 TOP: Piaget KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 55.A child who has just begun to demonstrate the ability to understand and apply logical operations to help interpret specific experiences or perceptions is in which of the Piaget stages of cognitive development? a. Sensorimotor b. Preoperational thought c. Formal operational thought d. Concrete operational thought ANS: D The Piaget concrete operational stage of cognitive development includes the ability to understand and apply logical operations or principles to help interpret specific experiences or perceptions.
PTS: 1 DIF: Cognitive Level: Application REF: Page 705, Box 23-6 OBJ: 3 TOP: Piaget KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 56.A child who is able to use a systematic, scientific problem-solving approach is in which of the Piaget stages of cognitive development? a. Sensorimotor b. Preoperational thought c. Formal operational thought d. Concrete operational thought ANS: C The Piaget formal operational stage of cognitive development includes the ability to use a systematic, scientific problem-solving approach. PTS: 1 DIF: Cognitive Level: Application REF: Page 705, Box 23-6 OBJ: 3 TOP: Piaget KEY: Nursing Process Step: Assessment MSC:NCLEX: N/A 57. According to Erikson, an infant who was abandoned by his or her primary caregiver is at risk for developing which of the following? a. Guilt b. Mistrust c. Isolation d. Confusion ANS: B During infancy a childs developmental task is basic trust versus mistrust. PTS: 1 DIF: Cognitive Level: Application REF: Page 703, Box 23-2 OBJ: 8 TOP: Erikson KEY: Nursing Process Step: N/A MSC:NCLEX: N/A MULTIPLE RESPONSE 58. Separation anxiety includes which stage(s)? (Select all that apply.) a. Detachment b. Protest c. Anger d. Despair e. Withdrawal
ANS: A, B, D The phases of separation anxiety are protest, despair, and detachment. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 708 OBJ:9TOP:Separation anxiety KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 59. The nurse informs a group of college students that young adults will face which challenges in this particular time of life? (Select all that apply.) a. Starting a family b. Selecting housing c. Job security d. Relations with extended family e. Establishing intimacy ANS: A, B, C, D, E All options are developmental tasks of the young adult of today. PTS: 1 DIF: Cognitive Level: Application REF: Page 722, Box 23-19, 723 OBJ: 11 TOP: Young adult KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 60. The process that refers to gradual change and differentiation is . ANS: development Development is the process of gradual change and differentiation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 699 OBJ: 4 TOP: Development KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 61. Any substance such as a drug, alcohol, or virus that interferes with fetal development is called a(n) . ANS: teratogen A teratogen is any substance that interferes with fetal development, such as a drug, alcohol, or a virus. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 699
OBJ: 4 TOP: Teratogen KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 62. Growth and development that proceeds from the head toward the feet is known as . ANS: cephalocaudal Cephalocaudal is defined as growth and development that proceeds from the head toward the feet. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 699 OBJ: 4 TOP: Development KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 63. Growth and development that moves from the center toward the outside is known as . ANS: proximodistal Proximodistal refers to growth and development that moves from the center toward the outside. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 699 OBJ: 4 TOP: Development KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 24: Loss, Grief, Dying, and Death My Nursing Test Banks Chapter 24: Loss, Grief, Dying, and Death Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What is the final stage of human growth and development? a. Integrity b. Death c. Despair d. Resolution ANS: B Death is the final stage of growth and development. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 735-736 OBJ: 3 TOP: Death KEY: Nursing Process Step: N/A
MSC:NCLEX: N/A 2.A young nurse caring for a dying patient hastens through the care and leaves the room as quickly as possible. What common reaction to the care of the dying is the nurse exhibiting? a. Efficiency b. Anger c. Withdrawal d. Anxiety ANS: C Withdrawal is a common reaction to the care of the dying. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 744 OBJ: 5 TOP: Withdrawal KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 3. Changes in health care reimbursement measures have resulted in which of the following changes regarding care of the terminally ill? a. Patients spend more time in hospitals b. Nurses provide more care in hospitals c. More patients die at home d. Patients spend more time in rehab facilities ANS: C Due to changes in reimbursement measures, more patients are dying at home. PTS: 1 DIF: Cognitive Level: Application REF: Page 736 OBJ: 2 TOP: Death KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 4. How does a perceived loss differ from an actual loss? a. A perceived loss is more quickly resolved. b. A perceived loss is situational. c. A perceived loss is easily overlooked. d. A perceived loss has a superficial response. ANS: C Perceived losses are easily overlooked. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 736 OBJ: 1 TOP: Loss KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity 5. Upon being told of her fathers death, the daughter cries out, No! Oh, God, no! What stage of grief is the daughter in? a. Anger b. Bargaining c. Denial d. Prayer ANS: C The daughter is exhibiting signs of denial, which is commonly one of the first stages of grief. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 740, Box 24-3 OBJ: 4 TOP: Grief KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 6. What should the nurse do before approaching a grieving family member? a. Offer sympathy b. Assess level of resolution c. Give assurance that the pain will pass d. Encourage the family member to return to normal activities ANS: B The nurse should assess each aspect of grieving to fully understand where family members are in their grief in order to offer the most effective assistance. PTS: 1 DIF: Cognitive Level: Application REF: Page 745 OBJ: 6 TOP: Grief KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 7.A dying patient uses the call light frequently to ask the nurse to do simple tasks. The nurse recognizes this as a fear of: a. increased pain. b. failure. c. abandonment. d. isolation. ANS: C A major fear of the dying patient is fear of abandonment.
PTS: 1 DIF: Cognitive Level: Application REF: Page 754 OBJ: 10 TOP: Death KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 8. What is the first thing the nurse should do before involving the family in the care of a dying patient? a. Ask the patient if he or she wants family care b. Ask family members if they want to assist with care c. Check the hospital policy on the family giving care d. Set a caring example ANS: B Ascertaining whether the family wants to assist in the patients daily care will clarify what the family members are comfortable doing. PTS: 1 DIF: Cognitive Level: Application REF: Page 744 OBJ: 13 TOP: Death KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 9. Which of the following would lead the home health nurse to make a nursing diagnosis of unresolved grief for a patient who was widowed 5 months ago? a. Seeing that the patient keeps a picture of the husband by her bed b. The patient said tearfully, I cant believe he is gone. c. Assessing that the patient eats out frequently rather than cooking at h d. The patient says that she attends church three times a week. ANS: B Unresolved grief results when a grieving person does not move past some stage of the grief process. The widow is still in denial. It would be expected for the widow to keep pictures of her husband in the home. Eating out frequently and attending church would not lead to a diagnosis of unresolved grief, but instead would be encouraged. PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 741, 742, Table 24-1 OBJ:4TOP:Unresolved grief KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 10. When the nurse is developing a care plan for a terminally ill patient, what
might be a realistic goal? a. The patient will remain pain-free. b. The patient will function optimally. c. The patient will spend time out of bed. d. The patient will demonstrate improved nutritional status. ANS: B The goal of the care plan for a terminally ill patient is to assist the patient to function optimally. The other options are not realistic. PTS: 1 DIF: Cognitive Level: Application REF: Page 747 OBJ: 10 TOP: Care plan KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 11. Following the death of a day-old infant, the nurse brings the baby to the parents. What is the rationale for the parents visit with the deceased baby? a. Bond with the family b. Reinforce the individuality of the baby c. Generate preparation for another child d. Make the death a reality ANS: D When possible, the parents should see, touch, and hold the infant to cope better with the reality of the death. PTS: 1 DIF: Cognitive Level: Application REF: Page 748 OBJ: 6 TOP: Death KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 12. The nurse spends a great deal of time in the room of a dying 12-year-old because the nurse knows that most children are aware of their condition and want the nurse to do which of the following? a. Keep them clean b. Help them eat c. Care about them d. Keep them comfortable ANS: C Children, like adults, fear abandonment as death approaches and gain comfort from the presence of the nurse.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 748 OBJ:6TOP:Childhood death KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 13. After a physician in the emergency department has pronounced a 2-yearold dead following a swimming pool accident, the mother tearfully says to the father, I am so sorry. I am so sorry. What is the mother expressing? a. Fear b. Guilt c. Hostility d. Grief ANS: B Parents often harbor extreme guilt in an out of sequence death. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 738 OBJ:4TOP:Out of sequence death KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 14. What is the termination of tube feedings to a dying patient considered? a. Active euthanasia b. Holistic care c. Passive euthanasia d. Terminal care ANS: C Permitting the death of a patient by withholding treatments is referred to as passive euthanasia. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 750 OBJ:7TOPassive euthanasia KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 15. How is a durable power of attorney helpful to an incapacitated patient? a. It directs treatment in accordance with the patients wishes. b. It directs an agent to make health care decisions. c. It gives power to an agent to make decisions regarding health, propert
d. It can only be executed by an attorney. ANS: B The durable power of attorney gives an agent the power to make health care decisions. It can be executed by anyone and does not extend beyond health care issues. A living will directs treatment according to the patients wishes. PTS: 1 DIF: Cognitive Level: Application REF: Page 751 OBJ:7TOPurable power of attorney KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 16. When a nurse informs a patients spouse that the patient has died, the spouse states, You must be mistaken. Which of Kbler-Rosss stages of dying is the spouse demonstrating? a. Anger b. Denial c. Depression d. Bargaining ANS: B When experiencing denial, the individual acts as though nothing has happened and may refuse to believe or understand that loss has occurred. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 740, Box 24-3 OBJ:3TOP:Stages of dying KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 17.A patient whose spouse died 1 year earlier complains of feeling overwhelmingly lonely and has withdrawn from interpersonal interactions. The patient is demonstrating what stage of dying according to Kbler-Rosss stages of dying theory? a. Anger b. Denial c. Depression d. Bargaining ANS: C When experiencing depression, the individual feels overwhelmingly lonely
and withdraws from interpersonal interaction. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 740, Box 24-3 OBJ:3TOP:Stages of dying KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 18.A nurse is caring for the dying mother of a 7-year-old child. What is important for the nurse to understand regarding the child? a. The child associates death with aggression. b. The child believes his or her own death cannot be avoided. c. The child lacks understanding of the concept of death. d. The child understands death as the inevitable end of life. ANS: A A child from 5 to 9 years old understands that death is final, believes ones own death can be avoided, associates death with aggression or violence, and believes wishes or unrelated actions can be responsible for death. A child between the ages of 9 to 12 years understands that death is the inevitable end of life. PTS: 1 DIF: Cognitive Level: Application REF: Page 740, Table 24-1 OBJ:4TOP:Understanding of death KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 19. The home health nurse assesses that the goal of grief resolution has been accomplished when the nurse observes that a widow has performed which activities? (Select all that apply.) a. Adjusted to an environment without the spouse b. Put financial affairs in order c. Made plans for a lengthy trip d. Sought new relationships e. Acquired a job ANS: A, D Environmental adjustment and seeking new relationships are clear evidence of grief resolution. A trip, arranging financial affairs, or finding employment
may be a form of denial or activities that may be dictated by the situation and is not necessarily resolution of grief. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 759 OBJ:13TOP:Grief resolution KEY: Nursing Process Step: Evaluation MSC: NCLEX: Psychosocial Integrity 20. Which of the five aspects of human functioning must a nurse address when dealing with a grieving person? (Select all that apply.) a. Physical b. Emotional c. Intellectual d. Financial e. Spiritual ANS: A, B, C, E The five areas of human function are physical, emotional, intellectual, sociocultural, and spiritual. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 741 OBJ: 5 TOP: Aspects of human function KEY: Nursing Process Step: N/A MSC:NCLEX: N/A COMPLETION 21. The nurse explains to a grieving husband that the process of the resolution of the hurt and the reestablishment of his life is called the . ANS: grief process grieving process The grief process includes the resolution of the hurt and the reestablishment of life activities following bereavement. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 735 OBJ:13TOP:Grief process KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity Chapter 25: Health Promotion and Pregnancy My Nursing Test Banks
Chapter 25: Health Promotion and Pregnancy Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. Where does implantation of the fertilized ovum usually occur? a. Lower uterine wall b. Side of the uterus c. Fundus of the uterus d. Body of the uterus ANS: C Implantation usually occurs in the fundus of the uterus. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 763 OBJ: 1 TOP: Implantation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2.A patient has been diagnosed with a tubal pregnancy. What is the typical outcome of a tubal pregnancy? a. The patient will carry the pregnancy to term and have a cesarean deli b. The patient will have to remain in bed for the remainder of the pregn c. The patient will spontaneously abort this ectopic pregnancy. d. The patient will require surgery to remove the zygote. ANS: D Any pregnancy where implantation occurs outside the uterine cavity is called ectopic. Tubal pregnancies usually must be resolved by surgical removal of the zygote. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 763 OBJ: 1 TOP: Pregnancy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. How long does the embryonic stage of pregnancy typically last? a. 3 weeks b. 4 weeks c. 6 weeks d. 8 weeks ANS: D The embryonic stage encompasses the first 8 weeks.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 764 OBJ: 1 TOP: Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 4. Why is the nurse concerned about a patient in her first trimester of pregnancy being exposed to German measles? a. The disease is capable of causing a spontaneous abortion. b. The disease is capable of causing birth defects. c. The disease is capable of causing high fever and convulsions. d. The disease is capable of interfering with placental implantation. ANS: B Rubella is a known teratogen, which can cause birth defects. PTS: 1 DIF: Cognitive Level: Application REF: Page 764 OBJ: 1 TOP: Teratogen KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. Which hormone is secreted by the placenta? a. Follicle-stimulating hormone (FSH) b. Alpha-fetoprotein (AFP) c. Human chorionic gonadotropin (HCG) d. Luteinizing hormone (LH) ANS: C The placenta functions as an endocrine gland, secreting estrogen, progesterone, and HCG. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 764 OBJ:2TOPlacenta function KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6.What protects the fetus from most bacterial infections? a. The yolk sac b. The placental barrier c. The cotyledons d. The chorionic villa ANS: B The placental barrier protects the embryo/fetus from most bacteria, but not
from viruses or drugs. The cotyledons are sections that make up the placenta. The chorionic villa are tiny vascular projections on the chorionic surface that help form the placenta. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 764 OBJ:2TOPlacental barrier KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. What period of the maternity cycle does the intrapartal period cover? a. Beginning of pregnancy to midterm b. Conception to third trimester c. Onset of labor to delivery of the baby d. Onset of labor to delivery of the placenta ANS: D The intrapartal period of the maternity cycle covers the onset of labor to delivery of the placenta. The antepartal period begins at conception and continues until the onset of labor. The postpartal period begins after the delivery of the placenta and continues for approximately 6 weeks, until the reproductive organs return to their prepregnancy state. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 778 OBJ:3TOP:Intrapartal period KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8.A woman who has just discovered she is pregnant states that the first day of her last menstrual period was July 10. What will be her expected date of birth (EDB)? a. April 10 b. April 17 c. May 10 d. October 17 ANS: B To determine the EDB (estimated date of birth), the woman should count from the first day of her last menstrual period. Count back 3 months and forward 7 days.
PTS: 1 DIF: Cognitive Level: Application REF: Page 780 OBJ:4TOP:Estimated date of birth (EDB) KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 9. Which is a positive sign of pregnancy? a. Positive pregnancy test b. Positive Chadwick sign c. Ultrasonic tracing of the fetus d. Positive Goodell sign ANS: C A positive sign of pregnancy is an ultrasonic tracing of the fetus. A positive pregnancy test, positive Chadwick sign, and positive Goodell sign are all probable signs of pregnancy. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 780 OBJ:4TOPositive signs of pregnancy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. What is the cause of frequent urination in early pregnancy? a. Increased fluid intake b. The fetuss kidneys functioning c. Retention of fluid d. Increased circulating volume ANS: D Early in pregnancy, the increase in circulating volume and the enlarging uterus placing pressure on the bladder cause urinary frequency. PTS: 1 DIF: Cognitive Level: Application REF: Page 786 OBJ:7TOP:Frequency of urination KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11.A woman asks the nurse about the safety of sexual intercourse during her pregnancy. Which response by the nurse is the most correct? a. Sexual activity should be avoided after the first trimester. b. Sexual activity should be ceased in the case of vaginal bleeding.
c. Sexual activity should be avoided in the second trimester. d. Sexual activity should be limited to activity that does not include inte ANS: B Sexual intercourse can be enjoyed throughout pregnancy unless it is contraindicated by other conditions. In the case of vaginal bleeding, sexual activity should cease until the cause of the bleeding is determined by the doctor. PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 787, 788 OBJ:5TOP:Sexual activity during pregnancy KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 12.A woman tells the nurse that this is her third pregnancy. She has had twin girls at full term and one miscarriage. How does the nurse record the information? a. G2, T2, L3 b. G4, T3, A1, L1 c. G3, T3, A2, L1 d. G3, T1, A1, L2 ANS: D Standard obstetrical terminology is: G = gravida, T = term birth, P = preterm birth, A = abortion, L = living children. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 780-781, Box 256 OBJ:3TOP:Terminology KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 13. During which gestational week can a primigravida expect to first feel fetal movement? a.8 b. 10 c. 16 d. 20 ANS: C
At about 16 to 18 weeks, the sensation of the first movement is felt. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 779 OBJ: 4 TOP: Quickening KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 14. At what week of fetal development can the nurse expect to first hear fetal heart tones with an amplified stethoscope? a. 10 b. 12 c. 14 d. 16 ANS: D During week 16, the fetal heart can be heard with an amplified stethoscope. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 780, Box 25-5 OBJ: 4 TOP: Fetal age KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 15. The nurse assures an anxious primigravida that during fetal development from week 34 and beyond, maternal antibodies are transferred to the baby. How long will these antibodies provide the baby with immunity? a. 1 month b. 3 months c. 4 months d. 6 months ANS: D The maternal antibodies that are transferred to the baby provide immunity for 6 months. PTS: 1 DIF: Cognitive Level: Application REF: Page 771, Table 25-1 OBJ: 2 TOP: Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 16. Early in the first trimester, a woman complains of morning sickness. What does the nurse suggest to aid with the discomfort? a. Eating something with a high-fat content b. Eating dry crackers before getting up c. Eating three well-balanced meals
d.
Getting rest and taking antiemetics
ANS: B A remedy for morning sickness is to eat a few dry crackers before getting up. PTS: 1 DIF: Cognitive Level: Application REF: Page 783 OBJ:7TOP:Morning sickness KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. What does the increase in circulating blood volume during pregnancy cause in the mother? a. Shortness of breath b. Frontal headaches c. Decreased white blood cell count d. Decreased hemoglobin ANS: D Maternal circulating volume increases 30% to 40%, causing a virtual decrease in hemoglobin. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 786, Table 25-5 OBJ:2TOPecreased Hgb KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18.A woman entering the 22nd week of pregnancy complains that she has become unsightly because of chloasma. What should the nurse recommend to reduce the appearance of the chloasma? a. Use heavy makeup b. Take extra doses of vitamin A c. Avoid exposure to the sun d. Reduce caffeine intake ANS: C At week 22, skin pigment changes called chloasma are found. Avoiding exposure to the sun will reduce the pigmentation. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 784 OBJ: 7 TOP: Chloasma KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
19. During the final weeks of pregnancy, urinary frequency may return due to
the enlarged uterus, compressing the bladder against the pelvic bones. What does the nurse suggest to aid in relieving the urinary frequency? a. Decrease fluid intake b. Use the knee-chest position c. Sleep on her side d. Avoid fluid intake in evening ANS: C The patient should decrease pressure on the bladder at night by sleeping on her side. Fluids should not be decreased unless directed by a physician. PTS: 1 DIF: Cognitive Level: Application REF: Page 787 OBJ: 7 TOP: Frequency KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20.A pregnant teenager presents with the following complaints. Which complaint could be an indicator of a serious complication? a. Painful hemorrhoids b. Linea nigra c. Visual disturbances d. Low back pain ANS: C Visual disturbances may be an indicator of increased blood pressure and retained fluids. These are indicators of eclampsia. Hemorrhoids, linea nigra, and back pain are common discomforts of pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 783, Box 25-10 OBJ:5TOPanger signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. During the last trimester of pregnancy, the nurse recommends that the woman wear low-heeled shoes. What is the nurse trying to prevent with this recommendation? a. Lower back pain b. Leg cramps c. Leg swelling
d. Joint pain ANS: A A remedy for backache is to wear low-heeled shoes. PTS: 1 DIF: Cognitive Level: Application REF: Page 786 OBJ:7TOP:Low back pain KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The newly diagnosed primigravida who is 6 weeks pregnant states, I dont feel like I have a real baby inside me. To reassure the mother, the nurse provides reassurance that which of the following is functioning in the 6week-old embryo? a. Brain b. Lungs c. Hands d. Heart ANS: D At 6 weeks, the fetus has a pumping heart. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 765, Table 25-1 OBJ:1TOP:Fetal development KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 23.Smoking by the mother can have what effect in the fetus? a. Hearing deficits b. Neuromuscular deformities c. Cerebral palsy d. Low birth weight ANS: D Smoking has been proven to cause slow intrauterine growth and low birth weight. PTS: 1 DIF: Cognitive Level: Application REF: Page 782 OBJ: 5 TOP: Smoking KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 24. When can the sex of the fetus be confirmed?
a. Conception b. 2 weeks c. 6 weeks d. 9 weeks ANS: D At 9 weeks the genitalia are well defined. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 766, Table 25-1 OBJ:1TOP:Fetal sex determination KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 25. The physician decides to send the mother for a test to determine the fetal lung maturity. What is the name of this fetal well-being test? a. Biophysical profile b. Alpha-fetoprotein c. Amniocentesis d. Ultrasound ANS: C Amniocentesis helps determine the maturity of the fetal lungs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 773, Table 25-2 OBJ: 3 TOP: Amniocentesis KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 26. When the young primigravida asks about how to adjust her diet for her pregnancy, what should the nurse suggest the mother add to her diet? a. Leafy green vegetables and fruit b. Beef and poultry c. Foods high in sodium and potassium d. Bread and grains ANS: A A pregnant woman should eat foods containing roughage, such as raw fruits, vegetables, and cereals with bran. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 770, Table 25-1 OBJ: 6 TOP: Diet KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
27. Which of the following discomforts of a pregnant woman should be
reported to the physician at the first occurrence? a. Leg cramps b. Pelvic discomfort c. Vaginal bleeding d. Urinary frequency ANS: C Vaginal bleeding at any time during pregnancy should be reported to the physician. Leg cramps, pelvic discomfort, and urinary frequency are common discomforts of pregnancy and not a cause for immediate concern. PTS: 1 DIF: Cognitive Level: Application REF: Page 788 OBJ:5TOPanger indicators KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. What do the arteries in the umbilical cord carry? a. Nutrients to the fetus from the placenta b. Oxygenated blood to perfuse the placenta c. Antibodies from the fetus to the mother d. Deoxygenated blood back to the placenta ANS: D The arteries of the umbilical cord are unique in that they carry deoxygenated blood back to the placenta. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 772 OBJ:2TOP:Umbilical arteries KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 29. What should a nurse instruct the patient to do before assessing fundal height? a. Press her lower back against the examination table b. Empty her bladder c. Take a deep breath and hold it d. Bear down ANS: B
The bladder should be emptied before the measurement of the fundal height. PTS: 1 DIF: Cognitive Level: Application REF: Page 773 OBJ:3TOP:Fundal height KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 30. The nurse concludes that the prenatal patient has no need for further instruction when she correctly states that amniocentesis can determine which of the babys characteristics? (Select all that apply.) a. Sex b. Maturity c. Approximate weight d. Health e. Genetic defects ANS: A, B, D, E The amniocentesis can reveal the sex, maturity, health, and some genetic defects. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 776 OBJ:3TOP:Amniocentesis KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance 31. Which of the following demonstrate culturally competent care of the pregnant patient? (Select all that apply.) a. Discuss beliefs with the patient and incorporate them in the plan of c b. Prohibit visits from anyone other than immediate family members. c. Require the patients participation in every aspect of the health care sy d. Maintain the patients modesty at all times. e. Strive to maintain a harmonious environment for the patient. ANS: A, D, E The nurse should discuss the patients cultural beliefs and incorporate as many as possible into the plan of care. Modesty is important in almost all cultures, and the nurse should take measures to ensure the patients modesty. Absence of a stressful environment is important for a positive outcome for both
mother and baby, and the nurse should strive to alleviate stress and maintain a harmonious environment. Many cultures will foster relationships, and visits from extended family members may be important. The patient may not participate in all aspects of the health care system due to cultural issues. PTS: 1 DIF: Cognitive Level: Application REF: Page 791 OBJ:8TOP:Cultural considerations KEY: Nursing Process Step: Intervention MSC: NCLEX: Health Promotion and Maintenance COMPLETION 32. The nurse instructor reminds the nursing student that the Shiny Schultz is a name given to the side of the placenta. ANS: fetal The fetal side of the placenta is called the Shiny Schultz and the maternal side is called the Dirty Duncan. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 764 OBJ:1TOPlacental sides KEY: Nursing Process Step: Intervention MSC: NCLEX: Health Promotion and Maintenance 33. The chorion and the amnion are the two components of the . ANS: fetal membrane The fetal membrane is composed of the chorion and the amnion. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 764 OBJ: 1 TOP: Fetal membrane KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 34. During the 30th week of gestation, the nurse would anticipate that the fundal height would be centimeters above the symphysis. ANS: 30 thirty The fundal height is equal to the weeks of gestation. PTS: 1 DIF: Cognitive Level: Application REF: Page 773
OBJ:3TOP:Fundal height KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 35. The nurse assesses a reactive result to a nonstress test when the fetal heart rate increases beats per minute. ANS: 15 fifteen The reactive criterion is that the fetal heart rate will increase 15 beats per minute when stimulated in the nonstress test. PTS: 1 DIF: Cognitive Level: Application REF: Page 776 OBJ:3TOP:Nonstress test KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance Chapter 26: Labor and Delivery My Nursing Test Banks Chapter 26: Labor and Delivery Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1.A woman who is 38 weeks pregnant tells the nurse that the baby has dropped and she is having urinary frequency again. What do these symptoms describe? a. Lightening b. Braxton-Hicks contractions c. Initiation of labor d. Engagement ANS: A The symptoms of lightening are a return of urinary frequency, and the patient is able to breathe more normally. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 798 OBJ: 3 TOP: Lightening KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. How do Braxton-Hicks contractions, which may begin in the first trimester and become increasingly stronger during the pregnancy, differ from labor
contractions? a. Last several minutes b. Are always regular c. Do not dilate the cervix d. Are only mild ANS: C Braxton-Hicks contractions do not dilate the cervix. Braxton-Hicks contractions remain irregular, can range from mild to moderate in severity, and increase in duration as the pregnancy progresses. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 799 OBJ: 4 TOP: Braxton-Hicks contractions KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 3. When trying to differentiate false labor from true labor, the nurse realizes which of the following statements regarding true labor is correct? a. Discomfort of the contraction is in the fundus. b. Contractions do not follow a pattern. c. Contractions get stronger with ambulation. d. Contractions may stop with ambulation. ANS: C Contractions get stronger with ambulation in true labor. True labor is also marked by the onset of regular, rhythmic contractions. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 800, Table 26-1 OBJ: 4 TOP: True labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 4. Why is the size and shape of the true pelvis more important than that of the false pelvis? a. The fetal head must be able to pass through the true pelvis. b. The true pelvis are the mothers measurements. c. The size of the false pelvis can change. d. The size of the true pelvis needs to be larger. ANS: A The size and shape of the true pelvis is more important than the false pelvis because the fetal head must be able to pass through for vaginal delivery to
occur. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 800 OBJ: 5 TOP: True pelvis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. What method is used to visualize soft tissue and to determine adequacy of the pelvis with no detrimental effects to the fetus? a. Pelvimetry b. Palpation c. Ultrasonography d. X-ray ANS: C In more than 20 years of use, ultrasonography has had no detrimental effects on the fetus. Pelvimetry and x-ray uses radiation to visualize bony prominences. Pelvimetry is not used in the pregnant patient due to detrimental effects to the fetus. Palpation does not allow for visualization of soft tissue. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 801 OBJ: 5 TOP: Ultrasound KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. What area of the uterus provides the force during a contraction? a. Lower portion b. Middle portion c. Upper portion d. Cervical portion ANS: C The upper portion of the uterus provides the force during contractions. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 805 OBJ: 7 TOP: Passageway KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 7. What is the largest diameter of the fetal skull? a. Temporal b. Biparietal c. Lateral
d. Frontal-occipital ANS: B The largest transverse diameter of the fetal skull is the biparietal measurement. If this is too large, the skull may not be able to enter the mothers pelvis. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 802 OBJ: 6 TOP: Passageway KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8.A nurse is teaching a group of primigravidas that during delivery, pressure on the fetal skull may produce changes in the shape of the skull. What is thereshaping of the skull called? a. Pressure response b. Overlapping c. Molding d. Spacing ANS: C The reshaping of the skull bones in response to pressure is called molding. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 801 OBJ: 5 TOP: Molding KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. What is the ideal attitude for the fetal body during labor? a. Extension b. Lateral c. Flexion d. Transverse ANS: C The ideal attitude for the fetal body is flexion. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 802 OBJ: 5 TOP: Attitude KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 10. Using Leopold maneuvers to assess fetal position, the nurse finds a soft rounded prominence at the level of the fundus, a hard round prominence just above the symphysis pubis, and nodulations on the left side of the uterus.
How should the nurse document the fetal position? a. Right occiput anterior (ROA), vertex b. Left occiput anterior (LOA), vertex c. Right occiput transverse (ROT), breech d. Left occiput anterior (LOA), breech ANS: A Fetal position can be determined by the Leopold maneuver, which defines the relationship of the presenting part to the maternal pelvis quadrant. A soft rounded prominence at the level of the fundus, a hard round prominence just above the symphysis pubis, and nodulations on the left side of the uterus indicate a right occiput anterior (ROA), vertex positioning. PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 803, 804, Figure 26-5 OBJ:5TOP:Fetal position KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 11. During the second stage of labor, how often should the nurse should monitor the fetal heart rate? a. Every 5 minutes b. Every 15 minutes c. Every 30 minutes d. Every hour ANS: A Fetal heart rate should be assessed every 5 minutes during the second stage of labor. PTS: 1 DIF: Cognitive Level: Application REF: Page 815 OBJ:10TOP:Fetal heart rate KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. Which type of monitor will assesses the intensity of contractions? a. External monitor b. Fetal monitor c. Maternal monitor d. Internal monitor
ANS: D Internal monitoring is used to monitor the intensity of contractions, the frequency and duration of contractions, and the resting tone of uterine contractions. An external monitor is used to monitor the fetal heart rate and uterine activity. PTS: 1 DIF: Cognitive Level: Application REF: Page 815 OBJ:13TOP:Fetal monitoring KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 13. When observing the fetal heart monitor, the nurse recognizes the fetal heart rate (FHR) decreases to 120 bpm at the beginning of a contraction and returns to a baseline of 155 bpm at the end of the contraction. What should this indicate to the nurse? a. Early deceleration due to head compression b. That the fetus is in acute distress c. Variable decelerations due to cord compression d. That these are late decelerations ANS: A This indicates early decelerations because of head compression. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 815, Box 26-2 OBJ:10TOP:Fetal monitoring KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 14. The first-time mother has been told by the nurse that the first stage of labor is the longest. What would be an appropriate nursing intervention for comfort during this time? a. Cool fluids to drink b. A backrub in the sacral area c. Assisting to lie in a supine position d. Decreasing illumination in the room ANS: B Backache in the sacral area is a common complaint during the first stage of labor. The keyword is comfort in the question. Providing a backrub is
providing comfort to the laboring patient. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 829, Box 26-7 OBJ:12TOP:First stage of labor KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 15.A woman is admitted in active labor, and the nurse assesses the fetal heart rate (FHR) at 124 bpm. What action should the nurse take based on the assessment? a. Position patient on her left side b. Start oxygen per nasal cannula c. Reassure the mother the rate is normal d. Notify the physician at once ANS: C The normal FHR is 120 to 160 bpm. No interventions are required. PTS: 1 DIF: Cognitive Level: Application REF: Page 815 OBJ:10TOP:Fetal heart rate (FHR) KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 16. The patients membranes have just ruptured. What is the first priority of the nurse? a. Turn the patient on the left side b. Perform a Nitrazine test c. Check the fetal heart rate (FHR) d. Perform a vaginal examination ANS: C The FHR should be assessed immediately after rupture of the membranes to determine the well-being of the baby. PTS: 1 DIF: Cognitive Level: Application REF: Page 815 OBJ:10TOP:Ruptured membranes KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 17.A patient arrives at the hospital having contractions. How should the nurse determine that the patient is in true labor?
a. There is no dilation b. The contractions are in the fundus c. The cervix has softened and effaced d. The contractions are irregular ANS: C One sign of true labor is when the cervix has softened and effaced. True labor contractions are regular and rhythmic. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 799 OBJ: 4 TOP: Effacement KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 18. The nurse is alarmed as she assesses a protruding umbilical cord from the vagina. What immediate action should the nurse take? a. Monitor intensity of contractions b. Place the patient in the knee-chest position c. Notify the charge nurse d. Ask the patient to perform a Valsalva maneuver ANS: B The knee-chest position reduces the pressure on the prolapsed cord. The charge nurse will need to be notified, and the contractions will need to be monitored. However, the priority is reducing the pressure on the prolapsed cord. PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 803, 804, Figure 26-7 OBJ:12TOP:Cord prolapse KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 19.A nurse is assessing the printout from the fetal monitor. What is the legal responsibility of the nurse? a. Correctly identifying abnormal FHR patterns and prescribing medicat b. Correctly identifying abnormal FHR patterns and notifying the health c. The nurse is not legally responsible for fetal monitoring d. Providing technical assessment to the monitor technicians ANS: B Nurses are responsible for the timely notification of the primary caregiver in
the event of an abnormal fetal heart rate (FHR) pattern. The nurse cannot write a medication order. PTS: 1 DIF: Cognitive Level: Application REF: Page 819 OBJ:10TOP:Fetal monitoring KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 20.A mother is in early labor and asks the nurse how long the labor will last. The nurse explains that the first stage of labor lasts from the beginning of regular contractions until when? a. The cervix is completely effaced b. The baby is in position c. The cervix is fully dilated d. The woman begins pushing ANS: C The first stage of labor begins with regular contractions and ends with complete dilation of the cervix. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 808 OBJ:9TOP:Labor and delivery KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 21. The nurse is admitting a patient to the labor and delivery unit. While performing the initial assessment, which assessment is the priority? a. The number of previous pregnancies b. When the baby is due c. When the patient last ate d. The timing of contractions ANS: D Assessment begins with timing the contractions on admission to form a database. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 827 OBJ:10TOP:Admission of labor patient KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
22. During labor, the patient screams at her husband to get out of her sight.
What would be the most appropriate action for the nurse? a. Ask the husband to leave the room b. Assure the husband that such behavior is normal c. Remind the patient that the husband wants to help d. Change the patients position ANS: B During labor the patient frequently becomes angry and outspoken. It is a normal occurrence, but the husband needs to be reassured that such behavior is normal. PTS: 1 DIF: Cognitive Level: Application REF: Page 823 OBJ:12TOP:Care during labor KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 23.A primigravida patient is admitted to the labor and delivery unit. During initial assessment, the baby is found to be engaged. Which statement is true? a. The narrowest diameter of the presenting part has reached the pelvic b. The descending part is being initiated through the midpelvis. c. The widest diameter of the presenting part crosses the pelvic inlet. d. The narrowest diameter of the presenting part is at the ischial spines. ANS: C Engagement occurs when the biparietal diameter, which is the widest part of the fetal head, crosses the pelvic inlet. PTS: 1 DIF: Cognitive Level: Application | Cognitive Level: Analysis REFage 80BJ:8TOP:Engagement KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 24. The physician has decided to induce labor with prostaglandin gel and an amniotomy. When should the nurse expect that labor will start? a. 1 hour b. 4 hours c. 8 hours d. 12 hours
ANS: A Medically approved methods of inducing labor include prostaglandin gel application that usually induces labor in 1 hour or less. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 829 OBJ: 13 TOP: Induction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 25.A mother has entered the second stage of labor. When does the second stage of labor end? a. When the mother begins to push b. When the babys head crowns c. With delivery of the baby d. With delivery of the placenta ANS: C The second stage of labor begins with complete dilation and ends with the birth of the baby. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 809 OBJ:9TOP:Second stage of labor KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 26.Why is oxytocin administered in the third stage of labor? a. To stimulate lactation b. To relieve postpartum pain c. To stimulate uterine contractions d. To sedate the mother so she can rest ANS: C Oxytocin makes the uterus contract and reduces postpartum hemorrhage. PTS: 1 DIF: Cognitive Level: Application REF: Page 812 OBJ:13TOP:Third stage of labor KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 27. After the delivery of a newborn, what is the priority action of the nurse? a. Place the newborn on the right side b. Cover the cord stump
c. Dry the infant immediately d. Suction nose and mouth ANS: D To prevent aspiration of amniotic fluid, the baby should be suctioned, then quickly dried to prevent hypothermia. PTS: 1 DIF: Cognitive Level: Application REF: Page 820, Box 26-4 OBJ:12TOP:Newborn care KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 28. An infant presents 5 minutes after delivery with a heart rate of 105, is crying, has some flexion in the arms, sneezes, and has a pink body and blue limbs. What Apgar score should be assigned to this infant? a.5 b.7 c.8 d. 10 ANS: C The Apgar scoring is: fetal heart rate (FHR) over 100 = 2; crying = 2; flexed arms = 1; sneeze = 2; pink body, blue limbs = 1 PTS: 1 DIF: Cognitive Level: Application | Cognitive Level: Analysis REF: Page 819, Table 26-5 OBJ: 10 TOP: Apgar scoring KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 29. For the first hour following delivery, how often should the nurse assess the mother? a. Every 5 minutes b. Every 10 minutes c. Every 15 minutes d. Every 30 minutes ANS: C During the first hour, assessments are done every 15 minutes. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 812 OBJ:10TOPostdelivery assessment
KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 30. When the nurse performs the Nitrazine test on vaginal secretions of a patient who thinks her membranes have ruptured, the paper turns yellow. What does this finding indicate? a. Acidic discharge, membranes intact b. Acidic discharge, membranes have ruptured c. Neutral, not enough discharge to measure d. Alkaline, membranes have ruptured ANS: A When the Nitrazine paper turns yellow it is indicative of acidic discharge, meaning the membranes are intact. Amniotic fluid is alkaline and turns the paper blue. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 799, Box 26-1 OBJ:4TOP:Nitrazine test KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 31. In the illustration below, which item depicts the LOT position? a.1 b.2 c.3 d.4 e.5 f.6 ANS: E The LOT position is left occiput transverse. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 803, Figure 26-5 OBJ:7TOP:Fetal position KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 32. Which assessment findings suggest probable fetal distress? (Select all that apply.)
a. Fetal heart rate (FHR) of 120 b. Meconium-stained amniotic fluid c. Decreased FHR during contractions d. Strong contractions 10 seconds apart e. Slow return of FHR to baseline ANS: B, E Meconium-stained amniotic fluid and the slow return of the FHR to the baseline are indicative of fetal distress. All other options are normal. PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 817, 819 OBJ:10TOP:Fetal distress KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 33.A pregnant woman is discussing her desire to have her baby in a birthing center. Which factors could exclude the patient from delivering in a birthing center? (Select all that apply.) a. The patient is a primigravida. b. The patient will be having a planned cesarean delivery. c. The mother has preeclampsia. d. The baby is a boy. e. The mother has no support system. ANS: B, C Birthing centers are ideal only for women who are considered low risk. Cesarean deliveries would not be done in a birthing center. The mother with preeclampsia would be considered high risk and would probably be excluded from delivering in the birthing center. The number of previous pregnancies, sex of the baby, and mothers support system would not be factors considered when determining risk for delivering in a birthing center. PTS: 1 DIF: Cognitive Level: Application REF: Page 799 OBJ:9TOP:Ruptured membranes KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 34.The nurse explains to the patient whose membranes ruptured an hour ago
that delivery is usually accomplished in to hours postrupture. ANS: 18, 24 eighteen, twenty-four After the rupture of membranes, labor is usually accomplished in 18 to 24 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 801, Table 26-2 OBJ:6TOP:Android pelvis KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 35.A primigravida has a pelvis of the android type, which usually means the delivery will be a . ANS: cesarean The narrow outlet of the android-type pelvis usually requires a cesarean delivery. PTS: 1 DIF: Cognitive Level: Application REF: Page 802 OBJ: 7 TOP: Fetal lie KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 36.A nurse shows the patient an x-ray of the fetal spine in parallel alignment with the mothers to demonstrate a lie. ANS: longitudinal A longitudinal lie is when the fetal spine and the maternal spine are parallel to each other. PTS: 1 DIF: Cognitive Level: Application REF: Page 798 OBJ:2TOP:Birth settings KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance Chapter 27: Care of the Mother and Newborn My Nursing Test Banks Chapter 27: Care of the Mother and Newborn Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE
1. When assessing a mother 12 hours following the delivery of a baby, where
should the nurse expect to palpate the fundus? a. 2 cm below the umbilicus b. At the umbilicus c. 1 cm below the umbilicus d. Halfway between the umbilicus and the symphysis pubis ANS: B Within 12 hours, the fundus rises to the level of the umbilicus. The fundus should be firm. Immediately following delivery, the fundus will be felt halfway between the umbilicus and the symphysis. PTS: 1 DIF: Cognitive Level: Application REF: Page 835 OBJ: 1 TOP: Postpartum KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. What is the name of the vaginal discharge that occurs immediately following delivery? a. Lochia serosa b. Lochia rubra c. Lochia palatine d. Lochia alba ANS: B The vaginal discharge that occurs immediately following discharge is known as lochia rubra and is made up mostly of blood. As the placenta heals, the draining turns pink to dark brown in color and is known as lochia serosa. After about 7 days, the discharge turns slight yellow to white and is called lochia alba. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 835 OBJ: 1 TOP: Lochia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. What is the first secretion produced by the breast? a. Prolactin b. Colostrum c. False milk d. Whey
ANS: B The first secretion to be produced by the breast is colostrum. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 837 OBJ: 2 TOP: Lactation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. What should be included in a teaching plan regarding breast engorgement? a. It typically occurs on the first postpartum day b. It is usually first observed in the axillary region c. It occurs only in women who are not breastfeeding d. It occurs near the nipple on the third postpartum day ANS: B Filling of the breast with milk (engorgement) usually begins in the axillary region on the third postpartum day when the milk comes in. It occurs regardless of whether the mother is breastfeeding or bottle-feeding. PTS: 1 DIF: Cognitive Level: Application REF: Page 851 OBJ:2TOP:Engorgement KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. When is breast engorgement most likely to occur? a. When the infants mouth surrounds the areola when feeding b. When the breast tissue becomes congested c. When the breast is emptied completely at each feeding d. When the infants mouth grasps the nipple firmly ANS: B Engorgement is the result of venous and lymphatic stasis (congestion). Emptying the breast at each feeding, the infant grasping the nipple firmly, and the infants mouth surrounding the areola when feeding are all measures that will aid in decreasing engorgement. PTS: 1 DIF: Cognitive Level: Application REF: Page 851 OBJ:2TOP:Engorgement KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. Which statement would be a correct description of colostrum?
a. Slightly yellow and low in protein b. Slightly yellow and provides antibodies c. Creamy and high in fat and protein d. Colorless and high in fat and carbohydrates ANS: B Colostrum is slightly yellow in color and is rich in antibodies. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 866 OBJ: 13 TOP: Colostrum KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The new mother has decided not to breastfeed the baby. How should the nurse correctly instruct the mother to suppress her milk supply? a. Pump the breasts to remove milk b. Apply warm, moist compresses c. Restrict oral fluids d. Apply a firm bra and ice packs ANS: D If a patient is not breastfeeding, compress the breasts with a firm bra and wrapped ice packs to suppress the milk supply. Pumping the breasts and applying warm, moist compresses are instructions for the breastfeeding mother to deal with the painful symptoms of engorgement. PTS: 1 DIF: Cognitive Level: Application REF: Page 851 OBJ:3TOP:Engorgement KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. During the immediate postpartum period, the mother has a temperature of 100.2 F, pulse 52, respirations 18, BP 138/84. What should the nurse do? a. Report the temperature as abnormal b. Continue to monitor every 15 minutes c. Report the pulse as abnormal d. Nothing as the vital signs are normal ANS: D The vital signs are normal for a new postpartum patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 846, Table 27-2
OBJ: 1 TOP: Postpartum KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. Within the first hour following a vaginal delivery, the nurse assesses the mother and finds the fundus is firm and there is a trickle of bright red blood. What should be the nurses reaction to the assessment? a. This is a normal occurrence. b. This is abnormal and should be reported. c. The patient should be administered a blood thinner. d. The patient should be restricted to bed rest. ANS: A A bright red drainage is normal immediately after delivery. The patient should be monitored at regular intervals. Bed rest is not indicated. A blood thinner would not be given. PTS: 1 DIF: Cognitive Level: Application REF: Page 835 OBJ: 1 TOP: Postpartum KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. What is the appropriate way to assess the fundus of the postpartum patient? a. Using the side of one hand moving down from the umbilicus b. Using one hand over the lower segment of the uterus c. Using one hand pushing upward from the lower uterus Using one hand on the lower uterine segment while the other hand loc d. the uterus ANS: D The proper way to assess the fundus of a mother who has just given birth is by placing one hand on the lower uterine segment while the other hand locates the fundus of the uterus. PTS: 1 DIF: Cognitive Level: Application REF: Page 835, Figure 27-1 OBJ:1TOP:Fundal assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. The postpartum mother with a third degree laceration tells the nurse she is afraid to have a bowel movement because of her painful episiotomy. What should the nurse do?
a. Offer a suppository or enema b. Encourage ambulation c. Offer stool softeners as prescribed d. Offer pain medication before defecating ANS: C Stool softeners are available to ease the pain of defecation caused by hemorrhoids and birth trauma. Suppositories or enemas are contraindicated in mothers with third or fourth degree lacerations. Pain medications can often cause constipation. Ambulation may aid in defecation, but will not soften the stool. PTS: 1 DIF: Cognitive Level: Application REF: Page 837 OBJ:3TOPostpartum elimination KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12.A new mother had spinal anesthesia during a cesarean delivery. She now has a desire to void and can wiggle her toes. What should be the nurses response when the mother asks to go the bathroom? a. Assess her blood pressure b. Obtain a wheelchair c. Palpate her bladder d. Put slippers on her feet ANS: D The nurse should check that the mother is wearing slippers to ensure better footing. If the mother has a desire to void and can move her toes, there is no need for her to remain bedridden. PTS: 1 DIF: Cognitive Level: Application REF: Page 847 OBJ:3TOPostspinal anesthesia KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 13.A mother delivered her baby at midnight and it is now 9 AM. She wants to sleep and asks the nurse to take care of the baby. What is this considered? a. Fatigue from labor b. Normal taking in response
c. Abnormal taking in response d. Risk for altered maternal-infant bonding ANS: B Her primary focus will be on her own needs such as sleep (taking in stage). PTS: 1 DIF: Cognitive Level: Analysis REF: Page 851, Box 27-9, 854 OBJ:5TOP:Taking in response KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 14. Which of the following would be considered a normal assessment finding in a 1-day postpartum patient? a. Pinkish to brown lochia b. Voiding frequently 50 mL to 75 mL of urine c. Complaining of after pains d. Fundus 1 cm above the umbilicus ANS: C The common discomfort of after pains is a normal assessment finding at 1day postpartum. The normal discharge 1-day postpartum would be lochia rubra, which is made up of mostly blood. The fundus would be palpated at the level of the umbilicus. Frequent voiding would be considered abnormal. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 854 OBJ: 2 TOP: Postpartum KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15.A new Native American mother tells the nurse that when she goes home, her mother-in-law will be caring for the baby while she rests. The nurse has concerns. What should the nurse do? a. Explain the importance of ambulating to recover b. Explain the importance of maternal-infant bonding c. Explore ways to blend this with safe health teaching d. Encourage this cultural behavior ANS: C Follow principles that facilitate nursing practice within transcultural situations. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 857
OBJ:5TOP:Ethnic considerations KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity 16.Before initially feeding an infant, what reflex should the nurse assess? a. Moro reflex b. Rooting reflex c. Babinski reflex d. Swallow reflex ANS: D The nurse should verify that the infant is able to swallow normally before feeding. PTS: 1 DIF: Cognitive Level: Application REF: Page 861, Table 27-5 OBJ: 9 TOP: Postpartum KEY: Nursing Process Step: Assessment MSC:NCLEX: Safe, Effective Care Environment 17. Following delivery of the newborn, which nursing intervention should be carried out immediately? a. Weigh the infant b. Warm the infant c. Bathe the infant d. Inoculate the infant ANS: B Maintenance of body temperature is the primary concern when caring for the newborn. The infant will also be weighed, bathed, and inoculated, but those measures are not the primary concern. PTS: 1 DIF: Cognitive Level: Application REF: Page 867 OBJ:8TOP:Newborn care KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 18.Where would acrocyanosis be assessed on a newborn? a. Circumoral area b. Brow c. Feet d. Mucous membrane ANS: C
Acrocyanosis is the slightly blue appearance of the hands and feet that is caused by poor circulation. It can last for 7 to 10 days in the newborn. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 859 OBJ:7TOP:Newborn assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. The nurse identifies that the newborn is jaundiced within the first 24 hours of birth, with jaundice occurring over bony prominences of the face and the mucous membrane. What type of jaundice does this represent? a. Physiological b. Normal c. Pathologic d. Transitory ANS: C Jaundice that appears within the first 48 hours of life is termed pathologic jaundice and is abnormal. Pathologic jaundice indicates excessive red blood cell destruction and it should be reported. Jaundice that appears after the first 48 hours of life is known as physiological jaundice and is considered normal. PTS: 1 DIF: Cognitive Level: Application REF: Page 860 OBJ:9TOP:Newborn assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. What is the term for the cream cheeselike substance that protects the infants skin from amniotic fluid? a. Lanugo b. Meconium c. Desquamation d. Vernix caseosa ANS: D At birth, the skin is covered with a yellowish-white cream cheeselike substance called vernix caseosa. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 860 OBJ:8TOP:Newborn assessment
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. Which tests are performed to detect inborn errors of metabolism in the newborn? a. Blood glucose b. Phenylketonuria (PKU) c. Blood urea nitrogen (BUN) d. Prothrombin time (PT) ANS: B State law requires certain diagnostic tests be performed on the newborn, including PKU, which detects an inborn error of metabolism. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 866 OBJ:7TOP:Newborn care KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 22. Which newborn assessment finding can suggest a chromosomal disorder? a. Epstein pearls b. Gynecomastia c. Babinski reflex d. Simian crease ANS: D A simian crease may indicate a chromosomal disorder. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 865 OBJ:9TOP:Newborn assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 23. Why is vitamin K given by injection to the newborn? a. Most mothers have a vitamin K deficiency that develops during preg b. Bacteria that synthesize vitamin K are not present in newborns. c. Vitamin K prevents the synthesis of prothrombin. d. The newborn does not store vitamin K. ANS: B Newborns are not able to synthesize vitamin K in the colon until they have
adequate intestinal flora, therefore, the vitamin K injection is given as a prevention measure against hemorrhage. PTS: 1 DIF: Cognitive Level: Application REF: Page 866 OBJ:8TOP:Care of newborn KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 24. What should be included when discussing the care of a circumcised infant after discharge from the hospital? a. Gently remove the yellow exudate from the foreskin. b. Apply sterile petroleum gauze after each diaper change. c. Wipe the circumcision with alcohol each day. d. Avoid the use of cloth diapers until the foreskin has healed. ANS: B Wash the penis at diaper change and apply sterile petroleum gauze. The yellow exudate should not be removed as it is part of the normal healing process. The circumcised area should be cleansed gently, not with alcohol. Cloth diapers are sometimes recommended to promote healing. PTS: 1 DIF: Cognitive Level: Application REF: Page 868 OBJ:11TOP:Circumcision KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. The nurse is caring for a newborn who was circumcised earlier in the day. What should be included in the plan of care? a. Administration of a topical anesthetic to the site b. Application of ice to stop bleeding c. Retraction of any remaining foreskin d. Observation for bleeding for the first 12 hours ANS: D The nurse should assess for bleeding for the first 12 hours following the circumcision. Gentle pressure should be applied to control bleeding. The administration of topical anesthetic and the retraction of the remaining foreskin are not included in the plan of care. PTS: 1 DIF: Cognitive Level: Application REF: Page 868
OBJ:11TOP:Circumcision KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. Which finding should the nurse suspect as abnormal in the newborn during the initial assessment? a. Eyes crossed at times b. Persistent high-pitched cry c. Arms and legs flexed d. Slight bluish tinge of the extremities ANS: B A high-pitched cry may indicate neurologic problems. Occasional crossing of the eyes, flexing of the arms and legs, and a bluish tinge of the extremities are all considered normal assessment findings in the newborn. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 870 OBJ:9TOP:Newborn assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 27. What is characteristic of a normal breastfed infants stool? a. Green and loose b. Dark green and sticky c. Pale yellow and frequent d. Light brown and pasty ANS: C Breastfed infants tend to pass stools frequently and they are pale yellow to golden in color and pasty in consistency. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 869 OBJ:8TOP:Breastfed stool KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. The new mother calls the nurse to her room to show how her baby is jerking around when she changes his position. The nurse understands that the baby is exhibiting which normal reflex? a. Traction reflex
b. Babinski reflex c. Tonic neck reflex d. Moro reflex ANS: D The Moro reflex (startle reflex) causes the baby to abduct the extremities and fan the fingers with the thumb and index fingers making a C shape followed by flexion and adduction of the extremities. PTS: 1 DIF: Cognitive Level: Application REF: Page 863, Table 27-5 OBJ: 10 TOP: Reflexes KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 29. The nurse is giving a bath demonstration for a group of new mothers. What should be included in the demonstration? a. Apply baby powder generously to keep baby dry. b. Cleanse perineum from front to back. c. Use scented soap to make baby smell good. d. Partially submerge head in water when shampooing. ANS: B The perineum should be cleansed by wiping from the anterior to the posterior. Excessive use of powders and scented soaps can irritate the skin. The head should not be submerged in water. PTS: 1 DIF: Cognitive Level: Application REF: Page 869 OBJ:4TOP:Newborn bath KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 30. Which of the following measures could help prevent infant abduction? (Select all that apply.) a. Only transport infants by carrying them b. Require staff members to wear appropriate identification badges c. Respond immediately when an alarm sounds d. Never leave infants unattended at any time e. Take all the infants to their mothers at the same time ANS: B, C, D
Staff members should always wear appropriate ID badges and should respond immediately when an alarm sounds. Infants should never be left unattended. Infants should always be transported in their cribs, never by carrying them. The nurse should transport only one infant at a time. PTS: 1 DIF: Cognitive Level: Application REF: Page 857 OBJ:6TOP:Infant abduction KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 31. The nurse is observing a new mother interact with her infant. Which observation would indicate that bonding is occurring? (Select all that apply.) a.
The mother is making eye contact with the infant. b. c. d.
The mother is sending the infant to feedings. The mother is cuddling with the inf The mother is requesting that the m all diapers. The mother states that her favorite t baby is to breastfeed.
e. ANS: A, C, E Eye contact, cuddling, and enjoying infant feeding are all signs of positive parent-infant attachment (bonding). Sending the infant to the nursery for feedings and having someone else change all diapers could indicate difficulty with bonding. PTS: 1 DIF: Cognitive Level: Application REF: Page 870 OBJ: 12 TOP: Bonding KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 32.A new mother asks for advice on how to quiet her fussy newborn. Which responses would be appropriate to suggest to the mother? (Select all that apply.) a. Prewarm the crib sheets with a hot water bottle b. Swaddle the newborn tightly in a receiving blanket c. Place the baby in a larger crib or infant bed d. Offer a pacifier or allow the infant to suckle at the breast e. Take the infant for a ride in the car ANS: A, B, D, E Oftentimes, infants are comforted by warm sheets. Infants tend to like to be swaddled snugly. Many infants find comfort sucking a pacifier; breastfed infants can suckle at the breast. Car rides are often soothing for infants. A large sleeping space is not soothing for infants. The opposite is true. A small sleeping space, such as a bassinette, tends to comfort a fussy baby. PTS: 1 DIF: Cognitive Level: Application REF: Page 870 OBJ:14TOP:Infant quieting techniques KEY:Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance COMPLETION 33. After delivery of a 9-lb baby, the nurse assesses a perineal laceration extending through the muscles of the perineum. The nurse records this as a -degree laceration. ANS: second A second-degree laceration extends through the superficial tissues into the muscles of the perineum. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 836 OBJ:3TOP:Second-degree lacerations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 34. The nurse describes the return of the postpartum patients uterus to a pregravid state as . ANS: involution Involution is the decrease in size of the uterus to a prepregnant state. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 835 OBJ: 2 TOP: Involution KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 35. The new mother tells the home health nurse that she is concerned about her 5-day-old infants hard, dried umbilical stump. What time frame should the nurse give the mother for the umbilical stump to fall off? days ANS: 10 to 14 ten to fourteen The umbilical stump will turn brownish black and fall off within 10 to 14 days after birth. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 861 OBJ:4TOP:Mummification KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
Chapter 28: Care of the High-Risk Mother, Newborn, and Family with Special Needs My Nursing Test Banks Chapter 28: Care of the High-Risk Mother, Newborn, and Family with Special Needs Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1.A patient is admitted to the hospital with hyperemesis gravidarum. The patient is malnourished and severely dehydrated. The care plan should be altered to include which interventions? a. Hyperalimentation b. IV fluids and electrolyte replacement c. Hormone replacement therapy d. Vitamin supplements ANS: B Medical treatment is aimed at meeting fluid and electrolyte replacement. PTS: 1 DIF: Cognitive Level: Application REF: Page 878 OBJ:1TOP:Hyperemesis gravidarum KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 2.A patient with hyperemesis gravidarum asks the nurse what would have happened if she had not come to the hospital. What result is the best response by the nurse? a. A large for gestational age infant b. Anorexia nervosa c. Preterm delivery d. Maternal or fetal death ANS: D If untreated, hyperemesis gravidarum can result in maternal or fetal death. PTS: 1 DIF: Cognitive Level: Application REF: Page 879 OBJ:1TOP:Hyperemesis gravidarum KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. How should twins who share a placenta and come from one fertilized ovum be identified?
a. Dizygotic b. Trizygotic c. Genetically different d. Monozygotic ANS: D Monozygotic twins, also known as identical twins, originate from one fertilized ovum and share a placenta. Monozygotic twins carry the same genetic code. Dizygotic twins are the result of two separate ova being fertilized at the same time. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 879 OBJ:1TOP:Multifetal pregnancy KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. What complication of delivery should the nurse expect with the birth of multiple fetuses? a. An ectopic tendency b. Difficulty with breastfeeding c. A vaginal delivery d. Loss of uterine tone ANS: D Delivery of multiple fetuses is often complicated by loss of uterine tone. Oftentimes multiple fetuses are delivered by cesarean. An ectopic tendency would present before delivery. While it can be difficult to breastfeed multiple infants, this does not relate to the delivery. PTS: 1 DIF: Cognitive Level: Application REF: Page 879 OBJ:1TOP:High-risk pregnancy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5.A patient is admitted to the hospital with signs of an ectopic pregnancy. What should the plan of care include for the patient? a. Long-term bed rest b. Episodes of extreme hypertension c. Surgery to remove the embryo/fetus
d. Treatment for dehydration ANS: C An ectopic implantation occurs somewhere outside the uterus and either resolves itself in a spontaneous abortion or requires surgical intervention. PTS: 1 DIF: Cognitive Level: Application REF: Page 881 OBJ:1TOP:Ectopic pregnancy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 6.What percent of first-trimester pregnancies spontaneously abort? a. 5% to 10% b. 10% to15% c. 20% to 25% d. 40% to 50% ANS: B It is estimated that 10% to 15% of first-trimester pregnancies end in spontaneous abortion. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 882 OBJ: 1 TOP: Abortions KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 7. What symptom, no matter what stage of pregnancy, should be reported immediately? a. Backache b. Urinary frequency c. Vaginal bleeding d. Uterine tightening ANS: C Women should be instructed to contact their physician if any bleeding occurs during pregnancy. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 884 OBJ:2TOP:Vaginal bleeding KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8.A patient in her second trimester of pregnancy arrives at the hospital complaining of bright red, painless vaginal bleeding. What condition should
the nurse immediately suspect? a. Abruptio placentae b. Hemorrhage c. Placenta previa d. Placentitis ANS: C Placenta previa is a serious condition that consists of bright red painless vaginal bleeding occurring after 20 weeks of pregnancy. The major symptoms of abruptio placentae are severe abdominal pain and uterine rigidity. PTS: 1 DIF: Cognitive Level: Application REF: Page 884 OBJ:2TOPlacenta previa KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9.A pregnant woman comes to the hospital 3 weeks before her estimated date of birth (EDB) complaining of severe pain and a rigid abdomen. What should the nurse immediately suspect as the cause of the pain? a. Placenta previa b. Appendicitis c. Ectopic pregnancy d. Abruptio placentae ANS: D The major symptoms of abruptio placentae are severe pain and a rigid abdomen. Placenta previa consists of painless bleeding. Appendicitis is not usually accompanied by a rigid abdomen. Symptoms of an ectopic pregnancy would usually occur in the first trimester. PTS: 1 DIF: Cognitive Level: Application REF: Page 885 OBJ:2TOP:Abruptio placentae KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10.A patient presents with symptoms of abruptio placentae. To facilitate uterine-placental perfusion, in what position would the nurse place the patient?
a. Prone position b. Trendelenburg position c. Supine position d. Modified side-lying position ANS: D A modified side-lying position facilitates uterine-placental perfusion. PTS: 1 DIF: Cognitive Level: Application REF: Page 886 OBJ:2TOP:Abruptio placentae KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11.A pregnant woman visits a clinic visit during her 21st week of pregnancy. The nurse identifies edema, hypertension, and proteinuria. What condition does the nurse suspect? a. Allergy b. Protein deficiency c. Circulatory problem d. Gestational hypertension ANS: D Gestational hypertension (GH), formerly referred to as pregnancy-induced hypertension (PIH), is a disease encountered during pregnancy or early in the puerperium, characterized by increasing hypertension, proteinuria, and generalized edema. These signs generally appear after the 20th week of pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 889 OBJ:4TOPregnancy-induced hypertension (PIH) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. What is the cause of gestational hypertension? a. Too much salt b. A toxin c. Unknown d. Diabetes ANS: C
The cause of gestational hypertension is unknown. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 889 OBJ:4TOPregnancy-induced hypertension (PIH) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. What should the nurse hope to identify by keeping a record of a patients blood pressure during prenatal visits? a. Ketoacidosis b. Placenta previa c. Gestational diabetes d. Gestational hypertension ANS: D Blood pressure should be assessed routinely during pregnancy, because symptoms of gestational hypertension include hypertension. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 889 OBJ:4TOPregnancy-induced hypertension (PIH) KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 14. The nurse is assessing a kick count for a patient with gestational hypertension. What result should be a cause for concern? a. Less than three kicks per hour b. Less than five kicks per hour c. Less than seven kicks per hour d. Less than nine kicks per hour ANS: A A kick count of fewer than three per hour is considered serious and a cause for concern. PTS: 1 DIF: Cognitive Level: Application REF: Page 891 OBJ:3TOPregnancy-induced hypertension (PIH) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. When discussing toxoplasmosis infection during pregnancy, what should the nurse caution the patient to avoid?
a. Contact with an infected person b. Emptying cat litter boxes bare-handed c. Having unprotected sex d. Eating excessive amounts of shellfish ANS: B A pregnant woman should wear gloves whenever having contact with cat feces as this is a possible source of toxoplasmosis infection. PTS: 1 DIF: Cognitive Level: Application REF: Page 895, Box 28-5 OBJ: 6 TOP: Infections KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 16. What is a major complication of gestational diabetes that affects the infant? a. Lack of nutrition b. Dehydration c. Hypoglycemia d. Hyperglycemia ANS: C A result of gestational diabetes is neonatal hypoglycemia. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 898 OBJ: 1 TOP: Diabetes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17.A pregnant patient who has type 2 diabetes (NIDDM) may require insulin. Why is the insulin necessary? a. The growing baby will require more glucose. b. Oral hypoglycemic agents may be teratogenic. c. Increased hormone levels raise blood glucose. d. Oral hypoglycemics do not reach the fetus. ANS: B Oral hypoglycemics are discontinued because of teratogenic effects. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 898 OBJ: 5 TOP: Diabetes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. Why is the fetus dependent on the mother for glucose control?
a. The insulin requirements are higher. b. Insulin is destroyed by the placenta. c. Insulin does not cross the placenta. d. Insulin is absorbed by the fetus. ANS: C Insulin will not cross the placenta, but high glucose levels do. Therefore, it is imperative that the mother control glucose levels. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 901 OBJ: 5 TOP: Diabetes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19.A patient with a history of rheumatic heart disease is being admitted to the labor and delivery unit. To prevent further stress on the heart, what should the nurse anticipate to be ordered? a. Oxygen administration b. Administering large amount of IV fluids c. Positioning the patient on her back d. Encouraging activity between contractions ANS: A Oxygen is administered to increase blood oxygen saturation and decrease the stress on the heart. IV fluid administration is kept to a minimum to prevent fluid overload. The patient would be positioned in a semi-Fowler position to improve circulation. The patient should be encouraged to rest between contractions to conserve energy. PTS: 1 DIF: Cognitive Level: Application REF: Page 902 OBJ:12TOP:Cardiovascular defects KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 20.A 14-year-old pregnant adolescent arrives at the hospital in early labor. The nurse should recognize that the adolescent is at a greater risk for which problem? a. Calcium deficit b. Cephalopelvic disproportion c. Bleeding tendency
d. Low hemoglobin levels ANS: B There are several physiological concerns for pregnant adolescents, including cephalopelvic disproportion. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 903 OBJ:7TOP:Adolescent pregnancy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. When should the gestational age of the infant be determined? a. Within 5 to 10 minutes of delivery b. Within 1 to 2 hours of delivery c. Within 2 to 8 hours of delivery d. Within 12 to 24 hours of delivery ANS: C The gestational age tests are done within 2 to 8 hours of delivery. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 908 OBJ:9TOP:Gestational age KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 22. The newborn infant has oxygenation problems and a lack of subcutaneous fat. What should the nurse determine as the gestational age of this infant? a. 20 to 37 completed weeks of pregnancy b. 38 to 41 completed weeks of pregnancy c. 14 to 36 completed weeks of pregnancy d. 42 or more completed weeks of pregnancy ANS: A The lungs of preterm infants have not fully developed; therefore, they have problems with oxygenation. Preterm infants also lack subcutaneous fat. The gestational age of the preterm is classified as 20 to 37 complete weeks of pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 908 OBJ: 9 TOP: Preterm KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
23. Compared to older infants of comparable weight, how much higher is the
morbidity and mortality rate for preterm infants? a. 1 to 2 times b. 2 to 3 times c. 3 to 4 times d. 4 to 5 times ANS: C The morbidity and mortality rate for preterm infants is higher by 3 to 4 times that of an older infant of similar weight. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 908 OBJ: 9 TOP: Preterm KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 24.A neonate is born with weak muscle tone, froglike extremities, and ears that fold easily. From these observations, what gestational age should the nurse give this infant? a. Full term b. Small for gestational age c. Preterm d. Post-term ANS: C Preterm infant posture is froglike, the muscle tone is weak, and the ears are easily folded. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 909 OBJ: 9 TOP: Preterm KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. An infant born to a diabetic mother should be closely monitored for the presence of what condition? a. Hyperglycemia b. Hypercalcemia c. Hypoglycemia d. Cardiac abnormalities ANS: C The infant of a diabetic mother will frequently exhibit hypoglycemia,
hypocalcemia, perinatal asphyxia, congenital abnormalities, and respiratory difficulties. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 912 OBJ: 11 TOP: Diabetes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26.A primigravida is Rh negative and her husband is Rh positive. She is concerned about the health of the fetus. The nurse explains that there is little danger to the fetus if it is Rh positive; however, the mother would become sensitized during delivery. If this were the case, the mother would produce what in subsequent pregnancies? a. Rh-negative blood cells b. Rh-positive blood cells c. Rh-negative antibodies d. Rh-positive antibodies ANS: D If the mother is exposed to the Rh antigen, Rh-positive antibodies will be produced after delivery of an Rh-positive baby. If the baby is Rh negative, no antibodies will be produced. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 912 OBJ:10TOP:Hemolytic disease KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The nurse assures a patient who has become sensitized to the Rh antigen that she can be protected for future pregnancies by receiving what injection? a. Iron b. Vitamin B12 c. RhoGAM d. Type O blood ANS: C RhoGAM prevents the development of naturally occurring maternal antibodies. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 913 OBJ:10TOP:Hemolytic disease
KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 28. The nurse is assessing the newborn and discovers a yellowing of the skin. What is true for jaundice that appears at birth? a. Within normal limits b. Pathologic c. A result of iron deficiency d. Indicating possible hepatitis ANS: B Jaundice observed at birth is considered an indicator of a pathologic condition, erythroblastosis fetalis. It is considered abnormal. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 912 OBJ:10TOP:Hemolytic disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. What test is used to identify the maternal level of Rh antibodies in the mothers blood? a. Indirect Coombs test b. Hemolytic test c. Rh antibody test d. Direct Coombs test ANS: A The indirect Coombs test measures the maternal level of antibodies. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 912 OBJ:3TOP:Hemolytic disease KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 30.A nursery nurse is implementing phototherapy for a jaundiced infant. What is the purpose of the phototherapy? a. It is initiated when the bilirubin level reaches 5 mg/dL. b. It converts bilirubin to a water-soluble form to be excreted in the uri c. It changes bilirubin to a bile salt to be excreted through the bowel. d. It requires eye patches to remain in place 24 hours a day.
ANS: B Phototherapy converts the bilirubin into a water-soluble form to be excreted by the kidneys. It is initiated when the bilirubin level reaches 12 to 15 mg/dL. The eye patches are worn during therapy, but removed for feeding, bathing, and socialization. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 913 OBJ:10TOP:Hemolytic disease KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 31. Why do alcohol and illegal drugs endanger the fetus? a. Both are absorbed into the bloodstream. b. Both affect the mother. c. Both cross the placental barrier. d. Both increase the heart rate of the fetus. ANS: C Alcohol and illicit drugs cross the placental barrier and affect the fetus. PTS: 1 DIF: Cognitive Level: Application REF: Page 914 OBJ:8TOP:Fetal risk from drugs KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 32. Cognitive impairment, facial abnormalities, and growth retardation are characteristics of which abnormality in a fetus? a. Fetal dependency b. Fetal immaturity c. Malnutrition dependency d. Fetal alcohol syndrome ANS: D Use of alcohol may result in multiple anomalies called fetal alcohol syndrome. The fetus may also be born with alcohol dependency and immaturity, but the characteristics noted are specific for fetal alcohol syndrome. PTS: 1 DIF: Cognitive Level: Application REF: Page 915, Table 28-4 OBJ: 8 TOP: Fetal risk KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance 33. What should be specifically monitored in a patient who is hospitalized with gestational hypertension? a. Blood sugar b. Temperature c. Level of consciousness d. Deep tendon reflexes ANS: D If the patient is hospitalized for gestational hypertension, deep tendon reflexes are monitored. The blood sugar, temperature, and LOC will also be monitored, but they are not the priority in the hypertensive patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 890 OBJ: 4 TOP: Eclampsia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 34. What is the antidote for magnesium sulfate toxicity? a. Vitamin K b. Calcium gluconate c. Potassium sulfate d. Calcium carbonate ANS: B The antidote for magnesium sulfate toxicity is calcium gluconate. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 892, Box 28-4 OBJ:11TOP:Maternal risk KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 35. What is a prominent feature of postpartum depression? a. Failure to thrive b. Rejection of the infant c. Inability to care for the baby d. Problems with the babys father ANS: B A prominent feature of PPD is rejection of the infant. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 916
OBJ:1TOPostpartum depression (PPD) KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 36. What is the usual treatment for severe postpartum depression? a. Improved nutrition b. Vitamin therapy c. Pharmacologic interventions d. Support group therapy ANS: C Support therapy is not enough for major PPD. Pharmacologic interventions are needed in most instances. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 916 OBJ:1TOPostpartum depression (PPD) KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 37.A pregnant patient with tuberculosis asks the nurse how the disease will affect her pregnancy and her newborn. What statements by the nurse are most appropriate? (Select all that apply.) a. You have nothing to worry about. You will be disease free before you b. The tuberculosis can be transmitted to the fetus in rare occurrences. c. Your newborn will be tested for tuberculosis after delivery. d. There is no approved treatment for the infant if she tests positive for th You will not be able to hold your newborn until you have been cleared e. health department guidelines. ANS: B, C, E TB can be transmitted to a fetus in the womb. Newborns of infected mothers are skin tested for TB after birth and treated if the skin test is positive. Mothers who have TB are not allowed to have exposure to their newborn until they have been cleared according to the health department standards. PTS: 1 DIF: Cognitive Level: Application REF: Page 897 OBJ:13TOPulmonary tuberculosis KEY:Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance COMPLETION 38. Following an abruptio placentae, the patient suddenly becomes dyspneic, complains of chest pain, and begins to ooze blood from her IV insertion site. The nurse assesses these as indicators of . ANS: disseminated intravascular coagulation (DIC) disseminated intravascular coagulation DIC DIC is characterized by dyspnea, chest pain, and uncontrolled bleeding. PTS: 1 DIF: Cognitive Level: Application REF: Page 887 OBJ: 2 TOP: Disseminated intravascular coagulation (DIC) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 39. The nurse reports to the charge nurse that the 3-hour postpartum patient is bleeding excessively as she has saturated one peripad in less than minutes. ANS: 15 fifteen The saturation of one peripad within 15 minutes is considered to be excessive bleeding. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 888 OBJ:3TOPostpartum hemorrhage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 40. The nurse explains that severe preeclampsia needs to be controlled because it can develop into another syndrome called . ANS: HELLP (Hypertension, Elevated Liver enzymes, and Low Platelets) HELLP Hypertension, Elevated Liver enzymes, and Low Platelets Progressive preeclampsia can develop into HELLP syndrome.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 893 OBJ: 4 TOP: Hypertension, Elevated Liver enzymes, and Low Platelets (HELLP) KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 41. The patient who has taken the ovulation stimulant clomiphene (Clomid), and who has been determined to be pregnant, calls the clinic nurse to report that she is bleeding and has passed a small grapelike object. From this information the nurse suspects a . ANS: hydatidiform mole Hydatidiform moles occur frequently in people who have taken Clomid. The physical changes are similar to a real pregnancy until bleeding occurs and some grapelike clusters are passed. PTS: 1 DIF: Cognitive Level: Application REF: Page 880 OBJ:3TOP:Hydatidiform mole KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 42.A woman who is 14 weeks pregnant calls the clinic nurse to report that after a brief bleeding episode a week ago, her uterus seems to have gotten smaller, but her periods have not begun. The nurse assesses the indicators for a abortion. ANS: missed A missed abortion is initiated by a bleeding episode in which the fetus is not expelled. The uterus begins to shrink, but periods do not resume. PTS: 1 DIF: Cognitive Level: Application REF: Page 882 OBJ:3TOP:Missed abortion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity Chapter 29: Health Promotion for the Infant, Child, and Adolescent My Nursing Test Banks Chapter 29: Health Promotion for the Infant, Child, and Adolescent
Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse stresses that regular physical activity has been identified as a leading health indicator. Regular physical activity has which positive effect on children? a. Improves social skills b. Reduces fluid retention c. Increases bone and muscle strength d. Increases attention span ANS: C In children, regular physical activity increases bone and muscle strength. PTS: 1 DIF: Cognitive Level: Application REF: Page 920 OBJ:2TOPhysical activity KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. What is the single most preventable cause of death and disease in the United States today? a. Drug use b. Alcohol addiction c. Cigarette smoking d. Malnutrition ANS: C Cigarette smoking continues to be the single most preventable cause of death. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 921 OBJ: 1 TOP: Tobacco use KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. Smoking contributes to an increased risk of heart and lung disease in children by which methods? a. Air pollution b. Allergens in the environment c. Environmental smoke d. Lack of oxygen in the air ANS: C
Environmental smoke may result in an increased risk of heart and lung disease, particularly asthma and bronchitis in children. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 922 OBJ: 1 TOP: Tobacco use KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. Which factor is mostly associated with problems such as domestic violence, sexually transmitted infections (STIs), school failure, and motor vehicle accidents (MVAs)? a. Lack of supervision b. Psychological problems c. Substance abuse d. Physiological problems ANS: C Substance abuse is associated with many social problems such as domestic violence, STIs, school failure, and MVAs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 922 OBJ: 1 TOP: Substance abuse KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 5. Approximately half of all new HIV cases are among people under what age? a. 50 years b. 40 years c. 30 years d. 25 years ANS: D Approximately half of all new HIV cases are among people younger than 25. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 923 OBJ:1TOP:Sexual behavior KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. Which children must be secured in the back seat in a rear-facing safety seat? a. Children weighing up to 20 lb
b. Children weighing between 20 and 30 lb c. Children weighing between 30 and 40 lb d. Children weighing more than 40 lb ANS: A The law states that a child from birth to 20 lb must be situated in a rear-facing safety seat that is secured in the back seat when riding in an automobile. PTS: 1 DIF: Cognitive Level: Application REF: Page 923 OBJ: 7 TOP: Injury KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. The pediatric nurse reminds the parents of a 2-year-old that by this age the child should be protected against how many vaccine-preventable childhood diseases? a.4 b.6 c.8 d. 10 ANS: D Children who follow the immunization schedule are protected against 10 vaccine-preventable childhood diseases by age 2. PTS: 1 DIF: Cognitive Level: Application REF: Page 924 OBJ:3TOP:Immunizations KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8.A major dental problem among very young children is bottle mouth caries. What is a preventative measure the nurse should suggest? a. Juice at bedtime b. Milk at bedtime c. A sugar-coated pacifier d. Water at bedtime ANS: D Specific interventions can prevent bottle mouth caries, such as offering water in the bedtime bottle. PTS: 1 DIF: Cognitive Level: Application REF: Page 926
OBJ:4TOPental health KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. What practice should be used by a pediatric nurse to remind parents of their responsibility in reducing the number of accidents involving children? a. Child awareness b. Good manners c. Anticipatory guidance d. Strict discipline ANS: C Anticipatory guidance has been the most widely used approach to educating parents in accident prevention. PTS: 1 DIF: Cognitive Level: Application REF: Page 926 OBJ:9TOP:Injury prevention KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 10. To prevent accidental poisoning of a child, where should medications be placed in the home? a. In a dresser drawer b. In the medicine cabinet c. In a locked cupboard d. On a high shelf ANS: C Medications should be kept in a locked cupboard. PTS: 1 DIF: Cognitive Level: Application REF: Page 928 OBJ: 5 TOP: Poisoning KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 11. What is the leading cause of fatal injury in children younger than 1 year old? a. Burns b. Poisons c. Asphyxiation d. Motor vehicle accidents
ANS: C In children younger than 1 year, the leading cause of fatal injury is asphyxiation by aspiration of foreign material into the respiratory tract. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 928 OBJ:6TOP:Asphyxiation KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. What is the third leading cause of accidental death in children 1 to 4 years of age? a. Falls b. Asphyxiation c. Poisons d. Burns ANS: D Burns are the third leading cause of accidental death in children 1 to 4 years of age. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 928 OBJ: 9 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 13. The school nurse recognizes that lack of physical activity and increased consumption of fast food by children are causative factors contributing to which of the following problems? a. Nutritional disorders b. Weight gain c. Type I diabetes d. Dental caries ANS: B Many factors have contributed to the excess weight carried by children, including lack of physical activity and increased consumption of fast food. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 920 OBJ: 1 TOP: Obesity KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 14. The nurse sets up a sample physical activities schedule to fit the FDAs
Dietary Guidelines for Americans that recommends that children get at least how many minutes of physical activity per day? a. 15 b. 30 c. 45 d. 60 ANS: D The Dietary Guidelines for Americans recommend that children get at least 60 minutes of physical activity per day. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 921 OBJ:2TOPhysical activity KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 15. What age group is experiencing the largest increase in drug use? a. 7- to 9-year-olds b. 10- to 12-year-olds c. 12- to 13-year-olds d. 15- to 17-year-olds ANS: C Research shows an increase in children aged 12 to 13 years who are experimenting with drugs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 922 OBJ:1TOP:Substance abuse KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 16. Because the water in the infants residential area is not fluoridated, when should the nurse suggest that the infant receive supplemental fluoride? a. 2 months old b. 4 months old c. 5 months old d. 6 months old ANS: D Fluoride supplementation should be initiated at 6 months of age if the water
in the infants residential area is not fluoridated. PTS: 1 DIF: Cognitive Level: Application REF: Page 926 OBJ: 4 TOP: Dental care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 17. What are reasons that a pediatric nurse should stress that health promotion activities must be ongoing? (Select all that apply.) a. To identify health risks b. To encourage healthy behavior c. To strengthen family bonds d. To improve nutrition e. To prevent accidents ANS: A, B, D, E Health promotion activities must be ongoing to identify health risks, to encourage healthy behavior, to improve nutrition, and to prevent accidents. There is no link between health promotion activities and strengthening family bonds. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 919 OBJ:1TOP:Health promotion KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 18. The school nurse collaborates with the physical education instructor to increase the amount of physical activity during the school day. What are major benefits of physical activity? (Select all that apply.) a. Reduced death rates as adults b. Reduced risk of cardiovascular disease c. Reduced risk of hypertension d. Reduced risk of diabetes e. Reduced self-esteem ANS: A, B, C, D Physical activity reduces death rates as adults, reduces the risk of cardiovascular disease, and reduces the risk of diabetes and hypertension. Physical activity increases self-esteem.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 920 OBJ:2TOP:Benefits of physical exercise KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 19. Which are physical risks associated with excess weight? (Select all that apply.) a. Poor eyesight b. Heart disease c. Arthritis d. Stroke e. Appendicitis ANS: B, C, D Heart disease, arthritis, and stroke are physical risks that are associated with excess weight. Poor eyesight and appendicitis are not associated with weight gain. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 920 OBJ: 10 TOP: Obesity KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 20. Which of the following interventions should be included when teaching a healthy behaviors class for parents of adolescents? (Select all that apply.) a. Always monitor the childs telephone conversations b. Insist on seatbelt use at all times c. Encourage tanning bed use versus exposure to the sun d. Maintain recommended immunization schedule e. Encourage good dental care ANS: B, D, E Adolescents should always wear seatbelts. Immunizations should be obtained according to the recommended schedule. Good dental care is important. Parents should give the child privacy in their telephone conversations. Tanning bed exposure is as detrimental to skin as exposure to the sun and both should be avoided. PTS: 1 DIF: Cognitive Level: Application REF: Page 921 OBJ:10TOP:Healthy behaviors
KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 21.A nurse emphasizes a study that focused on the amount of time children spend using various media, such as TV, video games, and computers and stated that by cutting this time by %, it would have a significant impact on increasing physical activity. ANS: 50 fifty If sedentary time were cut in half, this would have a significant effect on the increase in physical activity. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 920 OBJ:2TOP:Sedentary lifestyle KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 22.The nurse recognizes that preventive programs in schools must be stepped up in order to prevent violence, especially . ANS: shootings Premeditated intentional shootings are occurring more frequently among adolescents. PTS: 1 DIF: Cognitive Level: Application REF: Page 923 OBJ: 10 TOP: Shootings KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance Chapter 30: Basic Pediatric Nursing Care My Nursing Test Banks Chapter 30: Basic Pediatric Nursing Care Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What was one of the major strides in pediatric care made by Dr. Abraham Jacobi? a. Pediatric wards in hospitals b. Free inoculations against smallpox
c. Milk stations in the city of New York d. Serving nutritious foods in orphanages ANS: C Dr. Abraham Jacobi, referred to as the father of pediatrics, initiated the establishment of milk stations in New York demonstrating how to sanitize milk for children. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 932 OBJ: 2 TOP: Abraham Jacobi KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 2. What was founded by Lillian Wald? a. National Commission on Children b. Henry Street Settlement c. White House Conference d. U.S. Childrens Bureau ANS: B Lillian Wald, regarded as the founder of public health, founded Henry Street Settlement, which provided nursing services and social assistance. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 932 OBJ: 2 TOP: Lillian Wald KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 3. When the pediatric nurse is attempting to establish a trusting relationship with a child, what is the most important and lasting thing to do? a. Convey respect b. Talk with the child c. Be honest d. Talk with family ANS: C To establish a trusting relationship, the most important thing is to be honest. PTS: 1 DIF: Cognitive Level: Application REF: Page 933 OBJ:4TOPediatric nurse KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 4. What is the special category that encompasses children who have
congenital abnormalities, malignancies, gastrointestinal (GI) diseases, or central nervous system (CNS) anomalies? a. Very dependent children b. Children requiring special education c. Children with special needs d. Children requiring long-term care ANS: C The definition of children with special needs includes congenital abnormalities, malignancies, GI diseases, and CNS anomalies. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 934 OBJ: 6 TOP: Children KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. The mother of a child with diabetes asks the nurse in charge of the familycentered pediatric unit if she might see her childs laboratory reports. What response by the nurse is the most appropriate? a. Although the actual reports are not shared, I can tell you the blood su b. Ill write them down for you and bring them to your room. c. Come to the conference room where we can have privacy while you l d. Ill notify the physician that you wish to see the reports. ANS: C With a family-centered care approach, hospitals welcome parents, and parents have access to information 24 hours a day. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 934 OBJ:5TOP:Family-centered care KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. What should be the focus of a practice where the pediatric nurse uses a developmental approach? a. Stimulation of the child to reach expected norms b. Age-centered care plans c. Strengths and abilities of the child d. Characteristics for the particular age ANS: C
A developmental approach emphasizes the childs strengths and abilities and considers individuality. It builds on what the child can do instead of focusing on what the child cannot do. PTS: 1 DIF: Cognitive Level: Application REF: Page 936 OBJ:6TOPevelopmental approach KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. When using anticipatory guidance to prepare a 5-year-old for an IM injection, what statement by the nurse would be most appropriate? a. Ethan, Im going to give you a shot. b. Ethan, the doctor wants you to have some medicine, and it will hurt. c. Ethan, some medicine can only be given with a needle. d. Ethan, I am going to give you some medicine that will sting, but only ANS: D Anticipatory guidance is the psychological preparation of a patient for a stressful event by explaining what will happen and the probable outcome. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 937 OBJ:14TOP:Anticipatory guidance KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 8. When measuring the head circumference of an infant, where should the nurse place the tape measure? a. Across the eyebrows and around the occipital lobe b. Over the zygomatic arches and around the parietal areas c. Around forehead and around the crown of the head d. Above the eyebrows and pinnas, and around the occipital lobe ANS: D Head circumference is measured in children up to 36 months above the eyebrows and pinnas, and around the occipital lobe. PTS: 1 DIF: Cognitive Level: Application REF: Page 937 OBJ:14TOP:Head circumference KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
9. What activity by an infant would cause a false elevation of the tympanic
temperature? a. Having a bowel movement b. Crying vigorously c. Having just eaten d. Having been in a cold room ANS: B Crying increases the temperature; eating and bowel movements do not. A cold room would lower the temperature. PTS: 1 DIF: Cognitive Level: Application REF: Page 939 OBJ: 7 TOP: Vital signs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. What is the correct order for assessing vital signs in an infant to ensure the accuracy of measurements? a. Respiration, temperature, pulse b. Pulse, respiration, temperature c. Temperature, pulse, respiration d. Respiration, pulse, temperature ANS: D The respiration is taken first on an infant before the child is disturbed, pulses are assessed next, and last the temperature is obtained. PTS: 1 DIF: Cognitive Level: Application REF: Page 939 OBJ: 7 TOP: Vital signs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. Why does obtaining the respirations of an infant require a modified approach from that of an adult? a. Infants breathe through their noses b. Infants have very rapid respirations c. Infants respirations are thoracic in nature d. Infants respiratory movements are abdominal ANS: D In children under 6 or 7 years of age, respiratory movements are abdominal or diaphragmatic. Abdominal movements must be observed when counting
respirations. PTS: 1 DIF: Cognitive Level: Application REF: Page 940 OBJ: 7 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. An 8-year-old child asks how a blood pressure is taken. What would be the most appropriate response? a. This small machine will measure your systolic and diastolic pressure. The armband will hug your arm and tell me how well your blood is go b. arm. The armband will cut off your circulation for a while and then we can c. back. d. When you are ill we need to know if your blood is still moving in you ANS: B Because children are upset by unfamiliar procedures, it is best to explain each step in simple terms. It is best not to mention anything that may increase anxiety. PTS: 1 DIF: Cognitive Level: Application REF: Page 941 OBJ: 9 TOP: Vital signs KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 13. What is the correct way to assess for the presence of jaundice in an African American child? a. Examine the sclera b. Press the edge of the pinna c. Apply pressure to the gum d. Compare the color on the soles of the feet ANS: C The gums in individuals with dark complexions can be used to assess jaundice by pressing the gums about the teeth. PTS: 1 DIF: Cognitive Level: Application REF: Page 941 OBJ: 7 TOP: Jaundice KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. When discussing growth and development with the parents of a child, the nurse explains that nutrition is the single most important influence on: a. cognitive development.
b. secondary sexual characteristics. c. the production of blood cells. d. the growth of bones and muscle. ANS: D Nutrition is probably the single most important influence on growth. PTS: 1 DIF: Cognitive Level: Application REF: Page 945 OBJ: 8 TOP: Nutrition KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 15. The mother of a 3-year-old expresses concern about her daughters slowed growth rate. What would be the most informative response by the nurse? Three-year-olds have typically finished a growth spurt, and you may n a. rate in your daughters growth. b. Childrens growth is hereditary. She may be of small stature like you. c. The growth of a 3-year-old is associated with their nutrition. How is s d. Your daughter is healthy and happy. Dont worry about her growth rig ANS: A Three-year-olds slow down in their growth in a natural cycle. PTS: 1 DIF: Cognitive Level: Application REF: Page 936 OBJ: 7 TOP: Growth KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 16. What should be included in the teaching plan for the parents of a 3-yearold child who has been prescribed an opioid analgesic? a. The opioid is likely to cause significant respiratory depression. b. The medicine is prescribed with the knowledge that addiction may o c. The opioid is very effective as a pain control method. d. The opioid is only to be given in cases of severe pain. ANS: C It is an effective type of analgesia. When administered to children, opioid analgesics do not have any greater respiratory depression than when given to an adult, and the risk of addiction is virtually nonexistent in children. PTS: 1 DIF: Cognitive Level: Application REF: Page 953 OBJ:12TOP:Opioid analgesia KEY:Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 17. The parents ask about preparation of their toddler for hospital admission. When does the nurse suggest that the parents tell their toddler of the admission? a. A week prior b. 2 weeks prior c. The day of admission d. Only two or three days before ANS: D The nurse should suggest the toddler be told only days before. School-age children can be given more time to prepare. Adolescents should be told as far in advance as possible. PTS: 1 DIF: Cognitive Level: Application REF: Page 951 OBJ:11TOP:Hospitalization KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 18. When the newly admitted 2-year-old who was potty-trained before admission begins to wet the bed, the mother is frightened. What statement by the nurse will be most helpful to the mother? a. Dont be concerned. Accidents happen. b. Lets put a diaper on your child until this gets better. c. The stress of hospitalization makes children regress a little. d. Your child will relearn potty-training if you are patient. ANS: C It is not unusual for children to regress when hospitalized. Explaining that regression is normal during hospitalization will help allay the mothers anxiety. PTS: 1 DIF: Cognitive Level: Application REF: Pages 952-953 OBJ:13TOP:Hospitalization regression KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 19. When attempting to provide information to the parents of a child undergoing surgery, the nurse notes that the parents appear confused and do
not seem to remember what they are being told. What is the most probable cause of the parents forgetfulness? a. Noisy environment b. Serious nature of surgery c. Increased level of parents anxiety d. Developmental age of the child ANS: C Anxiety of the parents may result in confusion and forgetfulness. It is not known if the environment is noisy, if the surgery is serious in nature, or what is the developmental age of the child. PTS: 1 DIF: Cognitive Level: Application REF: Page 956 OBJ:13TOP:Hospitalization KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 20.What is the best time to bathe an infant? a. At bedtime b. Early in the morning c. After a feeding d. Before a feeding ANS: D Bathing is usually done before a feeding to reduce the possibility of vomiting, regurgitation, or stimulation. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 957 OBJ: 11 TOP: Feeding KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 21. How should an infant be positioned after a feeding? a. On the stomach b. On the right side c. On the left side d. On the back ANS: B After feeding, the infant is positioned on the right side to direct the food into the stomach.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 958 OBJ: 11 TOP: Feeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. When a safety reminder device (SRD) is used to protect a child, what is a responsibility of the nurse? a. Apply it loosely b. Remove it every 2 hours c. Place it over clothing d. Apply only one type ANS: B Any SRD should be removed every 2 hours. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 960 OBJ: 11 TOP: Safety KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 23. What should be done before initiating a gavage feeding? a. Hold the feeding tube under water to check for bubbling b. Check for gastric distention c. Aspirate stomach contents d. Ensure the sterility of feeding equipment ANS: C Aspirating stomach contents and aspirating a small amount of air while listening for stomach gurgling are the best ways to ensure correct tube placement. Holding the feeding tube under water to check for bubbling is not an effective method to check tube placement. Gastric distention would be important following the feeding. A gavage feeding is not a sterile procedure. PTS: 1 DIF: Cognitive Level: Application REF: Page 959 OBJ:14TOP:Tube feedings KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 24.What is the purpose of a mist tent? a. To provide a constant oxygen supply b. To liquefy respiratory secretions c. To aid in lowering temperature
d. To improve the infants hydration ANS: B The purpose of the mist tent is to liquefy respiratory secretions. A constant oxygen supply can be given by methods other than a mist tent. A mist tent does not lower temperature or improve hydration. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 963 OBJ: 14 TOP: Mist tent KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. What is the maximum amount of time that a nurse should suction an artificial airway? a. 1 second b. 5 seconds c. 30 seconds d. 1 minute ANS: B The nurse should limit suctioning to no more than 5 seconds. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 964 OBJ:14TOP:Tracheal suction KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. What is a disadvantage of using a mist tent with a toddler? a. The nurse must remove the restless child. b. The wet bedding and clothing must be changed frequently. c. The mist tent must be opened at least once every hour. d. All objects must be kept outside of the tent. ANS: B Frequent linen and clothing changes will be necessary because of the heavy humidity in the tent. The nurse can open the tent to soothe the restless child instead of removing the child. The tent does not have to be opened every hour. Toys can be placed inside the tent. PTS: 1 DIF: Cognitive Level: Application REF: Page 964 OBJ: 14 TOP: Mist tent KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
27. What is one way to enhance the nutrition of the hospitalized toddler?
a. Reward with sweets for eating meals b. Discourage participation in noneating activities c. Offer nutritious fluids frequently d. Leave nutritious finger foods out for the child to eat ANS: C Using nutritious liquids may satisfy the nutritional needs when a toddler is too busy to eat. Toddlers should not be left to eat unsupervised because of the danger of aspiration. Junk food should not be used as rewards. Activities are important and should not be discouraged. PTS: 1 DIF: Cognitive Level: Application REF: Page 964 OBJ: 11 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. Why must the pediatric nurse be cautious about medicating infants and young children? a. They are less susceptible to medication effects than adults. b. They are more susceptible to medication effects than adults. c. They are equally susceptible to medication effects as adults. d. They are more susceptible to drug interactions than adults. ANS: B Newborns and young children are more susceptible to the toxic effects of certain medications than adults. PTS: 1 DIF: Cognitive Level: Application REF: Page 965 OBJ: 15 TOP: Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. What is the preferred IM injection site for a 2-year-old? a. Deltoid muscle b. Upper thigh c. Vastus lateralis d. Gluteus ANS: C The preferred site for an IM injection for a 2-year-old is the vastus lateralis. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 966, Table 30-10
OBJ:15TOP:IM medication KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 30. Where is the typical IV insertion site in an infant younger than 9 months of age? a. Radial vein b. Scalp vein c. Femoral vein d. Brachial vein ANS: B A superficial scalp vein is the injection site for administering IV medication to infants younger than 9 months of age. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 967 OBJ:15TOP:IV medication KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 31. Following a lumbar puncture of a 2-year-old, what should the nurse do? a. Keep the child flat for several hours b. Allow the child to play quietly at will c. Hold the child in a flexed position for 5 minutes d. Stand the child upright immediately ANS: B Children younger than 3 years of age are usually not affected by postlumbar headache. These children are allowed to play at will following a lumbar puncture. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 962 OBJ:14TOP:Lumbar puncture KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 32. What should the nurse do to minimize an unpleasant-tasting drug? a. Pour the drug over ice b. Squirt the drug in the mouth with a syringe c. Administer the drug through a straw
d. Enlist the parents assistance ANS: C Administering the drug through a straw will diminish an unpleasant taste. Having the child hold the nose is helpful, as bad taste is associated with the smell of the drug. Pouring the drug over ice may result in the child not getting the entire amount of the drug. Squirting the drug into the mouth with a syringe will still allow the child to taste the medication. The parents assistance should be enlisted, but will not minimize the taste of the drug. PTS: 1 DIF: Cognitive Level: Application REF: Page 966 OBJ: 15 TOP: Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33.A disfiguring facial wound would have the most significant developmental impact on which child? a. 4-year-old b. 6-year-old c. 10-year-old d. 14-year-old ANS: D The adolescent fears a change in body image associated with surgery. PTS: 1 DIF: Cognitive Level: Application REF: Page 955, Table 30-8 OBJ: 6 TOP: Surgery KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 34. When the nurse is inserting a feeding tube in an 8-month-old, what safety reminder device (SRD) should the nurse most likely use? a. Mummy b. Clove hitch c. Jacket device d. Elbow device ANS: A The mummy restraint controls the arms and the body of the infant. PTS: 1 DIF: Cognitive Level: Application REF: Page 960 OBJ:14TOP:Safety reminder devices (SRDs) KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care
Environment 35. The nurse clarifies that child abuse and neglect are complicated and preventable problems falling under which broader term? a. Child abandonment b. Child mismanagement c. Child maltreatment d. Child torment ANS: C Child maltreatment is a broad term used to describe neglect and abuse of children. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 947 OBJ: 10 TOP: Child abuse KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 36. What observation in an emergency department should lead a nurse to suspect child abuse in a child with a fractured arm? a. Lack of parental concern for the severity of the injury b. The child not answering questions concerning the injury c. Parents not asking about the childs condition d. Inconsistency between the injury and the parents explanation of it ANS: D Special attention must be paid to injuries that are inconsistent with the parents explanation. PTS: 1 DIF: Cognitive Level: Application REF: Page 948 OBJ: 10 TOP: Child abuse KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 37. When communicating with parents suspected of child abuse, what should the nurse be sure to do? a. Tell them the law requires reporting of the incident b. Be sympathetic to their needs c. Interact with them in a nonjudgmental manner d. Suggest psychiatric counseling ANS: C The nurse should maintain a nonjudgmental attitude toward the parents. The
nurse does not have to tell the parents that she is reporting them. The nurse does not have to be sympathetic, she only has to be professional at all times. It is not the place of the nurse to suggest counseling. PTS: 1 DIF: Cognitive Level: Application REF: Page 949 OBJ: 10 TOP: Child abuse KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 38. After observing parental behavior that leads the nurse to suspect child abuse, when should the nurse report the abuse? a. If the parent confesses to child abuse b. If the child admits to being abused c. Whenever maltreatment of a child is suspected d. When the type of abuse can be determined ANS: C Mandatory reporting of child abuse is required when the health care provider has reason to suspect the child has been abused. PTS: 1 DIF: Cognitive Level: Application REF: Page 948 OBJ: 10 TOP: Child abuse KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 39. The nurse welcomes the presence of the family in a pediatric unit because it reduces the stressors of hospitalization. Which are common stressors for the hospitalized child? (Select all that apply.) a. Separation b. Lack of love c. Fear of pain d. Unfamiliar food e. Loss of control ANS: A, C, E Parents lend stability and comfort for the child and restore his or her sense of control. PTS: 1 DIF: Cognitive Level: Application REF: Page 934 OBJ:5TOParents on the pediatric unit KEY:Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance 40. The nurse clarifies that the family-centered care approach terminates which policies? (Select all that apply.) a. Rigid visiting hours b. Freedom to choose which medications to take c. Exclusion of family during procedures d. Discouraging family to stay overnight e. Restricting parents from reading the chart ANS: A, C, D, E Family-centered care terminates all the restrictive policies of traditional hospitals. Medication orders should still be followed. PTS: 1 DIF: Cognitive Level: Application REF: Page 934 OBJ:5TOP:Family-centered care KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 41. The pediatric nurse, along with the primary caregiver(s), has a special duty to the child and the family. ANS: teach The pediatric nurse is in a position to assess, instruct, and support children and their families about developmental progress, nutrition, and possible undiagnosed anomalies. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 935 OBJ: 4 TOP: Teaching KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 42. The nurse is aware that visual acuity evaluation in a child is best assessed after the age of years. ANS: 6 six A childs refraction does not reach 20/20 until about the age of 6. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 942 OBJ:7TOP:Visual acuity
KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance Chapter 31: Care of the Child with a Physical and Mental or Cognitive Disorder My Nursing Test Banks Chapter 31: Care of the Child with a Physical and Mental or Cognitive Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse uses a diagram to show that the tetralogy of Fallot involves a combination of four congenital defects. What are the defects? a. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular h Pulmonary stenosis, ventricular septal defect, overriding aorta, right v b. hypertrophy c. Aortic stenosis, atrial septal defect, overriding aorta, right ventricular Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left d. hypertrophy ANS: B Tetralogy of Fallot involves a combination of four congenital defects: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 982 OBJ: 1 TOP: Heart defect KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. What is the most common clinical manifestation of coarctation of the aorta? a. Clubbing of the digits b. Upper extremity hypertension c. Pedal edema and portal congestion d. Loud systolic ejection murmur ANS: B Coarctation of the aorta results in hypertension in the upper extremities. The pressure in the arms is typically 20 mm Hg higher than in the legs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 983 OBJ: 1 TOP: Heart defect KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 3. Parents of a 6-month-old child, who has just been diagnosed with iron deficiency anemia, ask why it was not diagnosed earlier. What would be the best response by the nurse? a. Are you sure your child has iron deficiency anemia? b. This happens when the maternal stores of iron are depleted at about 6 c. This anemia is caused by blood loss. d. The child may not have had it for a long time. ANS: B Iron deficiency anemia becomes apparent at about 6 months of age in a fullterm infant, when maternal stores of iron are depleted. PTS: 1 DIF: Cognitive Level: Application REF: Page 983 OBJ: 2 TOP: Anemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. What should the therapeutic management of iron deficiency anemia include? a. Multivitamins b. Calcium c. Ferrous sulfate d. Iodine ANS: C Therapeutic management of iron deficiency anemia is iron (ferrous sulfate) supplementation, nutritional counseling, and treatment of any underlying condition. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 984 OBJ: 2 TOP: Anemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The parents of a child who has been diagnosed with sickle cell anemia ask why their child experiences pain. What is the most likely cause of the pain? a. Inflammation of the vessels b. Obstructed blood flow c. Overhydration d. Stress-related headaches
ANS: B The signs and symptoms of sickle cell anemia include the sickle-shaped cells clumping and obstructing blood flow, which causes severe tissue hypoxia and necrosis leading to pain. PTS: 1 DIF: Cognitive Level: Application REF: Page 985 OBJ:2TOP:Blood disorders KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The parents of a child recently diagnosed with sickle cell anemia ask what can be done to avoid a sickle cell crisis. What should be included in the medical management of sickle cell crisis? a. Information for the parents including home care b. Provisions for adequate hydration and pain management c. Pain management and administration of iron supplements d. Adequate oxygenation and factor VIII ANS: B Medical management of sickle cell crisis includes palliative analgesics, hydration, and oxygen. PTS: 1 DIF: Cognitive Level: Application REF: Page 986 OBJ:2TOP:Blood disorders KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. Which laboratory results should the nurse anticipate to be abnormal in a child with hemophilia? a. Prothrombin time b. Bleeding time c. Platelet count d. Partial thromboplastin time ANS: D Expected laboratory findings for a child with hemophilia include a prolonged partial thromboplastin time. The prothrombin time, bleeding time, and platelet count are typically normal. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 987
OBJ:3TOP:Blood disorders KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. The parents of a child with acute lymphoblastic leukemia ask about the best approach for maintaining remission of the disease. What would be the most effective therapy? a. Surgery to remove enlarged lymph nodes b. Long-term chemotherapy c. Nutritional supplements to enhance blood cell production d. Blood transfusions to replace ineffective red cells ANS: B The treatment of choice is methotrexate, a chemotherapeutic agent, to produce remission. PTS: 1 DIF: Cognitive Level: Application REF: Page 989 OBJ:4TOP:Blood disorders KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. What most influences the severity of respiratory distress syndrome (RDS)? a. Poor cough and gag reflex b. The gestational age at birth c. Administering high concentrations of oxygen d. The sex of the infant ANS: B RDS is caused by a deficiency of surfactant and it occurs almost exclusively in preterm, low-birth-weight infants. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 994 OBJ:7TOP:Respiratory distress syndrome (RDS) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10.A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the oxygen tent. The oxygen level in the tent is 25%, and blood gases are normal. What would be the correct action by the nurse? a. Restrain the child in the tent and notify the physician
b. Increase the oxygen concentration in the tent c. Take the child out of the tent and into the playroom d. Ask the mother for help in comforting the child ANS: B The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is caused by poor oxygenation. The child should not be taken out of the oxygenated tent. While the mother could be asked to help comfort the child, and the physician may be notified, the priority is to set the oxygen at the correct level. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 999 OBJ:7TOP:Laryngotracheobronchitis (LTB) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The mother of a child with acute laryngotracheobronchitis (LTB) asks why her child must be kept NPO. Which responses would be the most correct? a. The epinephrine given causes nausea and vomiting b. The child is being hydrated with IV fluids c. The child is not hungry d. The childs rapid respirations pose a risk for aspiration ANS: D Rapid respirations predispose to aspiration. The child is kept hydrated with IV fluids, but this is not the reason that the child must be kept NPO. PTS: 1 DIF: Cognitive Level: Application REF: Page 999 OBJ:7TOP:Laryngotracheobronchitis (LTB) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. What could suddenly occur in a child with acute epiglottitis? a. Increased carbon dioxide levels b. Airway obstruction c. Inability to swallow d. Bronchial collapse ANS: B
In acute epiglottitis, the infected epiglottis becomes inflamed and causes total airway obstruction. Immediate treatment of acute epiglottitis includes an artificial airway. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 999 OBJ: 7 TOP: Epiglottitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. When conducting a class for parents about sudden infant death syndrome (SIDS), the nurse instructs the class that the infant should be placed in which position to sleep? a. Right side-lying b. Left side-lying c. Prone d. Supine ANS: D The American Academy of Pediatrics recommends placing the infant on its back, or supine, to sleep. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 997 OBJ:7TOP:Sudden infant death syndrome (SIDS) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. When interacting with the parents of a SIDS infant, the nurse should attempt to assist the parents with: a. encouraging the parents to have another baby. b. encouraging the parents to remain stoic. c. allaying feelings of guilt and blame. d. learning how the event could have been prevented. ANS: C As parents try to cope, they have feelings of guilt and blame. PTS: 1 DIF: Cognitive Level: Application REF: Page 997 OBJ:7TOP:Sudden infant death syndrome (SIDS) KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 15. The nurse educates the family of a newly admitted child with cystic
fibrosis that the treatment will be centered on what therapy? a. Chest physiotherapy b. Mucus-drying agents c. Prevention of diarrhea d. Insulin therapy ANS: A Chest physiotherapy and aerosol medications are the center of treatment for cystic fibrosis. PTS: 1 DIF: Cognitive Level: Application REF: Page 1002 OBJ:7TOP:Cystic fibrosis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What is the main characteristic of cystic fibrosis? a. Multiple upper respiratory infections b. An underproduction of exocrine glands c. Excessive, thick mucus d. An overproduction of thin mucus ANS: C The pathophysiology of cystic fibrosis includes excessive, thick mucus. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1002 OBJ:7TOP:Cystic fibrosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. What is the best time to administer pancreatic enzyme replacement? a. Before meals and snacks b. Before bedtime c. Early in the morning d. After meals and snacks ANS: A Pancreatic enzymes are administered before meals and snacks to digest carbohydrates, fats, and proteins. PTS: 1 DIF: Cognitive Level: Application REF: Page 1003 OBJ:7TOP:Cystic fibrosis
KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. Following surgical repair of a cleft palate, what should be used to prevent injury to the suture line? a. Straw b. Spoon c. Syringe d. Cup ANS: D When feeding a child with a repaired cleft palate, the nurse should avoid utensils, straws, droppers, and syringes. PTS: 1 DIF: Cognitive Level: Application REF: Page 1007 OBJ:8TOP:Cleft lip and palate KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 19. What is the priority nursing diagnosis for the parents of a newborn born with cleft lip and palate? a. Parental role conflict b. Risk for delayed growth and development c. Risk for impaired attachment d. Anticipatory grieving ANS: C Parents of a child with cleft lip and palate may have difficulty bonding with their child due to the appearance of the child. The priority nursing diagnosis is risk for impaired attachment. A goal is to promote bonding between parents and infant. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1007 OBJ:8TOP:Cleft lip and palate KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 20. Which is a long-term complication of cleft lip and palate? a. Cognitive impairment b. Altered growth and development
c. Faulty dentition d. Physical abilities ANS: C The older child with cleft lip and palate may experience psychological difficulties because of the cosmetic appearance of the defect, problems with impaired speech, and faulty dentition. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1006 OBJ:8TOP:Cleft lip and palate KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. How should the nurse measure urinary output for an infant with dehydration? a. Attaching a urine collecting bag b. Wringing out the diaper c. Weighing the diaper d. Inserting a catheter ANS: C Wet diapers are weighed to assess the amount of output. PTS: 1 DIF: Cognitive Level: Application REF: Page 1008 OBJ: 8 TOP: Dehydration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. Following a bout of diarrhea, which foods should be offered to the schoolage child? a. Apricots and peaches b. Chocolate milk c. Applesauce and milk d. Bananas and rice ANS: D When rehydration has been completed, foods that are nonirritating to the bowel should be offered to the child. Bananas and rice would be the least irritating to the bowel, as fruits and milk could cause GI irritation. PTS: 1 DIF: Cognitive Level: Application REF: Page 1009 OBJ: 8 TOP: Nutrition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 23. How is the infant with gastroesophageal reflux (GER) typically treated? a. By making the infant NPO b. By thickening the formula or breast milk with cereal c. By placing the infant to sleep on the side d. By switching the infant to cows milk ANS: B GER is treated with small feedings thickened with cereal. The infant should not be made NPO or switched to cows milk. Infants should only be placed on the back to sleep due to the risk of SIDS. PTS: 1 DIF: Cognitive Level: Application REF: Page 1011 OBJ: 8 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. What should the nurse assess in an infant who has been diagnosed with hypertrophic pyloric stenosis? a. A history of diarrhea following each feeding b. Gastric pain evidenced by vigorous crying c. Poor appetite due to a poor sucking reflex d. An olive-shaped mass right of the midline ANS: D Examination of the abdomen may assist in the diagnosis and reveal key signs of hypertrophic pyloric stenosis. Visible peristaltic waves that move from left to right across the epigastric region may be evident, and palpation may reveal an olive-shaped mass in this area to the right of the midline. PTS: 1 DIF: Cognitive Level: Application REF: Page 1012 OBJ:8TOPyloric stenosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. What is the hallmark sign of intussusception? a. Mucus-like stools b. Currant jellylike stools c. Tarry, black stools d. Green, soft stools
ANS: B The hallmark sign of intussusception is currant jelly stools. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1013 OBJ:8TOP:Gastrointestinal disorders KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. Which is a causative factor of Hirschsprung disease? a. Frequent evacuation of solids, liquid, and gases b. Excessive peristaltic movement c. The absence of parasympathetic ganglion cells in a portion of the col d. One portion of the bowel telescoping into another ANS: C The causative factor in Hirschsprung disease is the absence of parasympathetic ganglion cells in a portion of the colon. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1014 OBJ:8TOP:Gastrointestinal disorders KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. What should the nurse caring for a 6-year-old child with acute glomerulonephritis anticipate as the most difficult part of the care to implement? a. Forced fluids b. Increased feedings c. Bed rest d. Frequent position changes ANS: C During the acute phase of glomerulonephritis, bed rest is usually recommended. A diet of restricted fluid, sodium, potassium, and phosphate is initially required. Bed rest can be very hard to implement with an active 6year-old child. PTS: 1 DIF: Cognitive Level: Application REF: Page 1018 OBJ:10TOP:Genitourinary disorders KEY:Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 28. When selecting nursing diagnoses for the 4-year-old child with nephrosis, what should be a priority for the nurse? a. Impaired body image b. Skin impairment c. Nutritional deficit d. Injury ANS: B Nephrosis is a clinical state characterized by gross edema, which makes skin care a priority. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1017 OBJ:10TOP:Genitourinary disorders KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. When caring for a 7-week-old infant with hypothyroidism, the nurse explains that the prevention of what complication is dependent on the administration of oral thyroid replacement therapy and is critical for the child? a. Excessive growth b. Cognitive impairment c. Damage to the nervous system
d. Damage to the urinary system ANS: B The treatment of choice for congenital and acquired hypothyroidism is oral thyroid hormone replacement therapy. Prompt treatment is especially critical in the infant with congenital hypothyroidism to avoid permanent cognitive impairment. PTS: 1 DIF: Cognitive Level: Application REF: Page 1021 OBJ:11TOP:Hypothyroidism KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. The nurse explains to the parents of a child with developmental hip dysplasia that the application of a Pavlik harness is necessary. In what position will the harness hold the childs femurs? a. Abduction b. Adduction c. Flexion d. Extension ANS: A The use of the Pavlik harness maintains the hips in abduction for 4 to 6 months. PTS: 1 DIF: Cognitive Level: Application REF: Page 1026 OBJ:12TOPavlik harness KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 31.A teenage girl has been placed in a brace for the treatment of scoliosis, the most common skeletal deformity of adolescence. The family asks what they can do to be more supportive. What suggestion of the nurse is the most appropriate? a. Enrolling her in a health club b. Taking her to the mall in a wheelchair c. Purchasing clothes to disguise the cast d. Spending a majority of their time with her ANS: C
The adolescent is trying to fit in with peers and has concerns about body image. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1027 OBJ: 12 TOP: Scoliosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 32.A newborn has talipes and is wearing casts. How often should the casts be changed? a. Daily b. Weekly c. Bi-weekly d. Monthly ANS: B Treatment of talipes consists of manipulation and the application of a series of short leg casts. The foot is gently manipulated into a more normal position and then placed in a cast to maintain the correction. Casts are changed weekly to allow for further manipulation and to accommodate the rapidly growing infant. PTS: 1 DIF: Cognitive Level: Application REF: Page 1028 OBJ: 12 TOP: Club foot KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33.A child with Duchenne muscular dystrophy rises from the floor by walking up the thighs with the hands. How should the nurse record this observation? a. Hand assistance b. Leg crawling c. Gowers sign d. Bright sign ANS: C Using the hands to walk up the thighs is known as the Gowers sign. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1029 OBJ:12TOPuchenne muscular dystrophy (DMD) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
34. Which signs/symptoms would be considered classical signs of meningeal
irritation? a. Positive Kernig sign, diarrhea, and headache b. Negative Brudzinski sign, positive Kernig sign, and irritability c. Positive Brudzinski sign, positive Kernig sign, and photophobia d. Negative Kernig sign, vomiting, and fever ANS: C Classical manifestations of meningitis include positive Kernig and Brudzinski signs. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1031 OBJ: 13 TOP: Meningitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 35. The physician is treating a child with meningitis with a course of antibiotic therapy. When should the nurse expect the child to be out of isolation? a. When the course of antibiotics is complete b. When a negative CNS culture is obtained c. When the antibiotics have been initiated for 24 hours d. When the child has no symptoms of the disease ANS: C The child with bacterial meningitis is isolated for at least 24 hours until antibiotic therapy has been administered. PTS: 1 DIF: Cognitive Level: Application REF: Page 1031 OBJ: 13 TOP: Meningitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 36. What are priority nursing interventions designed to do for a 4-year-old child with cerebral palsy? a. Assist with referral to specialized education b. Support the child with independent toileting c. Assist the child to develop effective communication d. Encourage the child to ambulate independently ANS: D A child with cerebral palsy is usually in need of support with communication,
locomotion, and self-help. PTS: 1 DIF: Cognitive Level: Application REF: Page 1035 OBJ:13TOP:Cerebral palsy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 37.The nurse is caring for a newborn with a myelomeningocele. Before surgery, what should the nursing interventions include? a. Leaving the lesion uncovered and placing the infant supine b. Covering the lesion with a sterile, saline-soaked gauze c. Applying lotion to the lesion to keep it moist d. Covering the lesion with a dry, sterile gauze ANS: B Nursing interventions for an infant with myelomeningocele include covering the lesion with a sterile, saline-soaked gauze. PTS: 1 DIF: Cognitive Level: Application REF: Page 1039, Box 31-10 OBJ: 13 TOP: Spina bifida KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 38. Which additional congenital malformation is expected in 80% of infants with a myelomeningocele? a. Cerebral palsy b. Hydrocephalus c. Meningitis d. Neuroblastoma ANS: B Hydrocephalus is present in 80% of infants affected by a myelomeningocele. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1037 OBJ: 13 TOP: Spina bifida KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 39. When speaking to young parents, the nurse states that lead poisoning is one of the most common preventable health problems affecting children. What condition occurs when the level of lead ingested exceeds the amount that can be absorbed by the bone? a. Malnutrition b. Anemia
c. Bone pain d. Diarrhea ANS: B When the amount of lead ingested exceeds the amount that can be absorbed by the bone, it leads to anemia. PTS: 1 DIF: Cognitive Level: Application REF: Page 1040 OBJ:14TOP:Lead poisoning KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 40. An infant has been diagnosed with cradle cap. What is the correct intervention to treat the scalp? a. Alcohol b. Mineral oil c. Calamine d. A&D ointment ANS: B Crusty patches can be removed with the application of mineral oil. PTS: 1 DIF: Cognitive Level: Application REF: Page 1044 OBJ:15TOP:Skin disorders KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 41. An adolescent female asks the nurse about taking retinoic acid (Accutane). What guidance should be provided by the nurse? a. The medication should be used only for 10 weeks b. The medication requires that sexually active females use contracepti c. The medication lowers hemoglobin very quickly d. The medication has few side effects ANS: B Accutane has many side effects and can produce birth defects. Effective contraception is necessary during treatment and for 1 month after the 20 weeks it is to be taken. PTS: 1 DIF: Cognitive Level: Application REF: Page 1046 OBJ: 15 TOP: Acne KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 42.A new mother asks the clinic nurse if she must continue giving her baby nystatin for thrush since the white lesions on his tongue have disappeared. What response by the nurse is most appropriate? a. No. When the lesions have gone you may stop the nystatin. b. Yes. You should continue it for the full 7 days. c. No. Thrush is a self-limiting disorder and nystatin is given for comfo d. Yes. The medication should be refilled for a second week of therapy. ANS: B Nystatin should be given for the full 7 days even if the lesions are no longer present. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1048 OBJ:15TOP:Skin disorders KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 43.What are early signs of varicella disease? a. High fever over 101 F b. General malaise c. Increased appetite d. Crusty sores ANS: B Early signs of varicella will develop during the prodromal period and are mainly low-grade fever, malaise, and anorexia. Lesions do not appear until later. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1051, Table 31-7 OBJ:15TOP:Skin disorders KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 44. The mother of a child who has been diagnosed with varicella asks the nurse when the child can return to school. When is the child no longer contagious? a. When the fever dissipates b. After the incubation period
c. When the lesions have healed d. When the lesions are crusted over ANS: D Varicella is no longer contagious when the lesions are dry. PTS: 1 DIF: Cognitive Level: Application REF: Page 1051, Table 31-7 OBJ:15TOP:Skin disorders KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 45.A child has developed a diaper rash, and the parents are using zinc oxide to treat it. What does the nurse suggest to aid in the removal of the zinc oxide? a. Mild soap and water b. A cotton ball c. Mineral oil d. Alcohol swabs ANS: C To completely remove ointment, especially zinc oxide, mineral oil should be used. PTS: 1 DIF: Cognitive Level: Application REF: Page 1043, Box 31-12 OBJ: 15 TOP: Diaper rash KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 46. The nurse instructs the parents of a child who has had a myringotomy to place the child in which position? a. Supine b. On the affected side c. On the unaffected side d. In a Trendelenburg position ANS: B Lying on the affected side facilitates ear drainage following a myringotomy. PTS: 1 DIF: Cognitive Level: Application REF: Page 1054 OBJ:16TOP:Myringotomy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
47. What are the clinical manifestations of otitis media?
a. Earache, wheezing, vomiting b. Coughing, rhinorrhea, headache c. Fever, irritability, pulling on ear d. Wheezing, cough, drainage in ear canal ANS: C Clinical manifestations of otitis media include fever, irritability, and pulling on the ear. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1053 OBJ: 16 TOP: Otitis media KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 48. The nurse instructs the mother of a child with a ventricular septal defect that she can expect the child to become cyanotic when the child does what? a. Experiences an elevation in temperature b. Sleeps on the left side c. Cries vigorously d. Eats ANS: C Crying vigorously will increase the pressure in the right ventricle, which will allow unoxygenated blood to enter the circulating volume. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 981 OBJ:1TOP:Septal defects KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 49. Parents of a 5-year-old child diagnosed as cognitively impaired have come to the nurse to discuss different approaches to the ongoing care of their child. The nurse should suggest focusing on what activity? a. Acquiring job skills b. Making decisions c. Performing self-care activities d. Reading and doing simple math ANS: C The cognitively impaired young child should be encouraged to learn simple
skills for doing self-care. PTS: 1 DIF: Cognitive Level: Application REF: Page 1056 OBJ:19TOP:Cognitive impairment KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 50. The nurse explains that cognitive impairment is categorized by four levels that depend on the intelligence quotient (IQ). How is a child with an IQ of 45 classified? a. Within the normal low range b. Educable c. Trainable d. Severe ANS: C The category of trainable is identified on the basis of an IQ of 35 to 55. PTS: 1 DIF: Cognitive Level: Application REF: Page 1056 OBJ:17TOP:Cognitive impairment KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 51. What is the major criterion for diagnosing a child as cognitively impaired? a. An IQ of 75 or less b. Subaverage functioning c. An IQ of 70 or less d. Onset before 18 ANS: C Cognitive impairment is based upon IQs from 20 to 70. PTS: 1 DIF: Cognitive Level: Application REF: Page 1056 OBJ:17TOP:Cognitive impairment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 52. Which is a priority nursing intervention for the cognitively impaired child? a. The family will provide good nutrition. b. The family will provide loving interactions.
c. Stimulation will improve. d. There will be contact with peers. ANS: B Nursing interventions focus on promoting optimal development and loving interactions with family. PTS: 1 DIF: Cognitive Level: Application REF: Page 1056 OBJ:19TOP:Cognitive impairment KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 53. Which statement correctly explains the etiology of Down syndrome? a. There is an extra chromosome on the 21st pair. b. There is a missing chromosome on the 21st pair. c. There are two pairs of the 21st chromosome. d. The chromosomes 21st pair is missing. ANS: A Down syndrome is attributed to an extra chromosome on the 21st pair. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1056 OBJ:18TOP:Cognitive impairment KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance 54. What other congenital defects are common in children with Down syndrome? a. Hypospadias b. Pyloric stenosis c. Heart defects d. Hip dysplasia ANS: C Many children with Down syndrome have congenital heart defects. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 1056-1057 OBJ:18TOP:Congenital impairment KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 55. What assessment findings should lead the nurse to suspect Down
syndrome in a newborn? a. Hypertonia and dark skin b. Low-set ears and a simian crease c. Inner epicanthal folds and a high, domed forehead d. Long, thin fingers and excessive hair ANS: B Manifestations of the Down syndrome infant include low-set ears, simian crease, protruding tongue, and hypotonic extremities. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1056 OBJ:18TOP:Congenital impairment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 56. Parents of a school-age child ask the nurse for suggestions in helping the child who is demonstrating school avoidance. What is an appropriate suggestion by the nurse? a. Take the child to the physician for testing. b. Be firm and insist the child go to school. c. Allow the child to stay home and rest. d. Consult with the teacher at school. ANS: B Parents should be firm and insist the child go to school. PTS: 1 DIF: Cognitive Level: Application REF: Page 1060 OBJ:20TOP:Nursing interventions KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 57. The nurse is caring for a child who has been diagnosed as having an attention deficit hyperactivity disorder (ADHD). What is the most important intervention for the nurse? a. Have the child enrolled in a special education class. b. Allay any feelings of guilt the parents may have. c. Counsel the parents that the medications are lifelong. d. Teach the parents to set limits. ANS: B
It is most important to allay any feelings of guilt the parents may have. PTS: 1 DIF: Cognitive Level: Application REF: Page 1061 OBJ: 21 TOP: Attention deficit hyperactivity disorder (ADHD) KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 58. Since children with attention deficit hyperactivity disorder (ADHD) take medication for long periods of time, side effects must be considered. How often should children be assessed for side effects of the drug therapy? a. Every 2 months b. Every 4 months c. Every 6 months d. Every 8 months ANS: C Children should be checked for medication side effects every 6 months. PTS: 1 DIF: Cognitive Level: Application REF: Page 1061 OBJ: 21 TOP: Attention deficit hyperactivity disorder (ADHD) KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 59. The parents of a child suffering from depression ask the nurse what causes depression in children. Which answer is an appropriate response by the nurse? a. The causes of major depression are unknown. b. Major affective disorders in parents increase depression in children. c. Boys are more likely than girls to be depressed. d. The prevalence rate is higher in prepubescent children. ANS: A The causes of depression have not been established. However, many studies have shown that children have a three times greater rate of suffering from depression if their parents have a major affective disorder. PTS: 1 DIF: Cognitive Level: Application REF: Page 1061 OBJ: 22 TOP: Depression KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 60. When the nurse performs the initial assessment of an adolescent with
depression, what is the most important question to ask? a. What is making you depressed? b. Have you ever thought about suicide? c. What could we do to make you happy? d. Would you like your friends to visit? ANS: B Ask direct questions about suicidal thoughts. The discovery of whether the person has an actual plan is an indicator of the seriousness of the situation. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1063 OBJ: 23 TOP: Suicide KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 61. What is the most common method of attempted suicide? a. Hanging b. Medication ingestion c. Gunshot d. Slashing the wrists ANS: B Ingesting medication is the most common method of attempted suicide. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1062 OBJ: 23 TOP: Suicide KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 62. Recurrent abdominal pain (RAP) is most often seen in school-age or adolescent children. The nurse should assess closely for what potential problems? a. Physical problems b. Relational problems c. Eating disorders d. Emotional problems ANS: D RAP is often related to emotional factors in the child. PTS: 1 DIF: Cognitive Level: Application REF: Page 1063 OBJ:22TOP:Recurrent abdominal pain (RAP) KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial
Integrity 63. When performing an assessment of a child with recurrent abdominal pain (RAP), the nurse recognizes the child will most likely experience what symptom? a. Increased temperature b. Constipation c. Right quadrant pain d. Exercise-associated pain ANS: B The child may be constipated with periumbilical pain unrelated to eating, defecation, or exercise. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1063 OBJ:22TOP:Recurrent abdominal pain (RAP) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 64. The nurse is recording a history for a child who has been diagnosed with recurrent abdominal pain (RAP). What is a finding that is characteristic of this disorder? a. Morning headaches b. Pain for 3 consecutive months c. Febrile episodes in the late afternoon d. Diaphoresis when attacks occur ANS: B Recurrent abdominal pain occurring consecutively for 3 months supports a diagnosis of RAP once other causes have been ruled out. PTS: 1 DIF: Cognitive Level: Application REF: Page 1063 OBJ:22TOP:Recurrent abdominal pain (RAP) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 65. When assessing the laboratory values of a child with nephrosis, the nurse anticipates which results? (Select all that apply.) a. High levels of protein in the urine
b. High serum lipid levels c. Low serum protein levels d. Low hemoglobin e. High white blood cell count ANS: A, B, C A patient with nephrotic syndrome has high levels of serum lipids, low serum protein, and albumin in urine that is dark and frothy with a high specific gravity. The hemoglobin and WBC are usually normal. PTS: 1 DIF: Cognitive Level: Application REF: Page 1017 OBJ: 10 TOP: Nephrosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 66. The nurse explains that which diagnostic studies are needed for the diagnosis of cognitive impairment? (Select all that apply.) a. Denver Developmental Screening Test b. Stanford-Binet Intelligence Scale c. Wechsler Intelligence Scale d. Millers Analogies e. Strong Personality Assessment ANS: A, B, C The Denver, Stanford-Binet, and Wechsler are standard intelligence tests that aid in the diagnosis of a cognitively impaired child. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1056 OBJ:17TOP:Intelligence tests KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 67. When the mother of a child with gastroesophageal reflux calls the clinic nurse to report that her baby is vomiting small amounts of blood, the nurse explains that the esophagus has been irritated by . ANS: gastric acid Gastric acid that has repeatedly come in contact with the esophageal mucosa will erode the mucosa, and bleeding will result.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1011 OBJ:8TOP:Gastroesophageal reflux (GER) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 68. The nurse reassures the anxious mother of a child with pyloric stenosis who is to have surgery that the surgical procedure, called a , is quickly done and the child recovers almost immediately. ANS: pyloromyotomy When the muscle is cut, the obstruction is immediately relieved and the child who is hungry will begin to eat and keep food down. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1013 OBJ:8TOPyloromyotomy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 69. The nurse anticipates that the cerebrospinal fluid (CSF) taken from a child with bacterial meningitis would have a low level. ANS: glucose The glucose level in the CSF of a child with bacterial meningitis is low because the bacteria in the fluid have digested the glucose. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1031 OBJ:13TOP:Cerebrospinal fluid (CSF) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 70. The nurse reminds a family that people with autism are also referred to as . ANS: savants Autistic people are referred to as savants. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1058 OBJ: 19 TOP: Autism KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
Chapter 32: Health Promotion and Care of the Older Adult My Nursing Test Banks Chapter 32: Health Promotion and Care of the Older Adult Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. When discussing aging, to whom does the term older adulthood apply? a. Age 55 and above b. Age 65 and above c. Age 70 and above d. Age 75 and above ANS: B Older adulthood begins at about age 65. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1068 OBJ: 1 TOP: Aging KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. When the nurse discusses prevention of cardiac disease, falls, and depression with a group of older adults, the benefits of what are important to stress? a. Nutrition b. Medications c. Exercise d. Sleep ANS: C Primary prevention stresses exercise for the prevention of cardiac disease, falls, and depression. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1069 OBJ:1TOP:Health promotion KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. When was the Social Security Act, which was the first major legislation providing financial security for older adults, passed? a. 1930 b. 1935 c. 1940
d. 1945 ANS: B The first major legislation to provide financial security for older adults was the Social Security Act of 1935. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1073 OBJ: 1 TOP: Legislation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 4. When assessing the skin of an older adult patient who is complaining of pruritus, what should the nurse advise the patient to avoid to reduce further drying of her skin? a. Perfumed soap b. Hard-milled soap c. Antibacterial soap d. Lotion soap ANS: C Antibacterial soap is very drying. PTS: 1 DIF: Cognitive Level: Application REF: Page 1075 OBJ:8TOP:Integumentary alterations KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. Because thin skin and lack of subcutaneous fat predisposes the older adult to pressure ulcers, the nurse alters the care plan to include turning the bedfast patient how often? a. Once every shift b. Every 4 hours c. Each evening d. Every 2 hours ANS: D Pressure ulcers can be avoided by repositioning the patient every 2 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 1076 OBJ:8TOP:Integumentary alterations KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
6. At mealtime, the older adult seems to be eating less food than would be
adequate. Compared to the younger adult, what is a requirement for the older adult? a. More fluids b. Less calcium c. Fewer calories d. More vitamins ANS: C The older adult requires 30 calories per kilogram of body weight, whereas the younger adult requires 40 calories. PTS: 1 DIF: Cognitive Level: Application REF: Page 1077 OBJ:5TOP:Gastrointestinal alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 7. The older patient informs the nurse that food has no taste and therefore the patient has no appetite. What is this most likely caused by? a. Tasteless food b. Overuse of salt c. Lack of variety d. Loss of taste buds ANS: D Older adults may experience a loss of appetite. Change in taste as a result of decreased saliva production and a decreased number of taste buds may make food unappealing. PTS: 1 DIF: Cognitive Level: Application REF: Page 1078 OBJ:5TOP:Gastrointestinal alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. An older adult is having difficulty swallowing. What position should the nurse recommend to aid in swallowing? a. Chin parallel b. Chin upward c. Chin down
d. Chin to the side ANS: C The upright position, leaning slightly forward with the chin down, improves swallowing with the assistance of gravity. PTS: 1 DIF: Cognitive Level: Application REF: Page 1079 OBJ:8TOP:Gastrointestinal alterations KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The patient complains to the nurse about a newly developed intolerance to milk. What should the nurse suggest to fulfill calcium needs? a. Rye bread b. Yogurt c. Apples d. Raisins ANS: B Lactose, primarily found in milk, is a common source of food intolerance. Dairy products are an important source of calcium, which is needed to prevent osteoporosis. Lactose-intolerant individuals need to replace milk with cheese and yogurt, which are processed and digested more easily. PTS: 1 DIF: Cognitive Level: Application REF: Page 1079 OBJ:8TOP:Gastrointestinal alterations KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The older adult patient complains to the nurse about nocturia. This problem is most likely related to: a. loss of bladder tone. b. decrease in testosterone. c. decrease in bladder capacity. d. intake of caffeine. ANS: C At least 50% of older men and 70% of older women must get up two or more times during the night to empty their bladders, a condition known as nocturia (excessive urination at night). The most significant age-related change is the
decrease in bladder capacity. PTS: 1 DIF: Cognitive Level: Application REF: Page 1081 OBJ: 5 TOP: Incontinence KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. The older adult female patient is concerned about incontinence when she sneezes. What is the correct terminology for this type of incontinence? a. Urge incontinence b. Stress incontinence c. Overflow incontinence d. Functional incontinence ANS: B Stress incontinence results from increased abdominal pressure, which occurs with coughing or sneezing. Urge incontinence occurs after a sudden urge to void and is associated with cystitis, tumors, stones, and CNS disorders. Overflow incontinence is associated with diabetic neuropathy and spinal cord injuries. Functional incontinence results from unwillingness or inability to get to the toilet. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1081 OBJ: 5 TOP: Incontinence KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12.A change of aging related to the circulatory system includes decreased blood vessel elasticity. For what should the nurse assess? a. Confusion b. Tachycardia c. Hypertension d. Retained secretions ANS: C The blood vessels become less elastic because of aging and may lead to increased blood pressure. PTS: 1 DIF: Cognitive Level: Application REF: Page 1083 OBJ:5TOP:Circulatory alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
13. What should be suggested to a patient to aid with the pain of claudication?
a. Rest b. Exercise c. Cross legs d. Stand ANS: A A nursing intervention to relieve pain is to recommend the patient rest periodically until the pain subsides. Exercise and standing for long periods of time can exacerbate the pain. Crossing the legs can limit blood flow to the extremities and increase pain. PTS: 1 DIF: Cognitive Level: Application REF: Page 1084 OBJ:8TOP:Circulatory alterations KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse recommends a breathing technique to help a patient with chronic obstructive pulmonary disease (COPD) to empty the lungs of used air and to promote inhalation of adequate oxygen. What is this method of breathing called? a. Pursed-lip breathing b. Increased inspiration c. Vital capacity d. Decreased expiration ANS: A Pursed-lip breathing can help empty the lungs of used air and promote inhalation of additional oxygen. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1086 OBJ: 8 TOP: Chronic obstructive pulmonary disease (COPD) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse reminds the 80-year-old patient that her respiratory system has decreased resistance to respiratory infections. For what is this patient at increased risk? a. COPD
b. Bronchitis c. Pneumonia d. Atelectasis ANS: C Decreased resistance to respiratory infections places older adults at higher risk for pneumonia. PTS: 1 DIF: Cognitive Level: Application REF: Page 1086 OBJ:5TOP:Respiratory alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse recognizes that an older adult patient with COPD has a higher incidence of developing which age-related skeletal change that will alter the ability to exchange air effectively? a. Osteoporosis b. Arthritis c. Kyphosis d. Osteomyelitis ANS: C Kyphosis, usually caused by osteoporosis, is a curvature of the spine that alters respiration and air exchange. PTS: 1 DIF: Cognitive Level: Application REF: Page 1089 OBJ:5TOP:Musculoskeletal alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. What is a major difference between rheumatoid arthritis and osteoarthritis? a. Rheumatoid arthritis is degenerative. b. Rheumatoid arthritis only affects patients over 40 years of age. c. Rheumatoid arthritis is inflammatory. d. Rheumatoid arthritis is curable. ANS: C Rheumatoid arthritis is an inflammatory disease; osteoarthritis is degenerative. Rheumatoid arthritis can affect patients at any age. Neither type
of arthritis is curable. PTS: 1 DIF: Cognitive Level: Application REF: Pages 1087-1088 OBJ: 5 TOP: Arthritis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. For what is the older adult patient at increased risk because of age-related changes in the musculoskeletal system? a. Fractures due to poor uptake of calcium b. Heart attacks due to increased effort to ambulate c. Respiratory failure due to kyphosis d. Falls related to posture changes ANS: D Falls are the leading cause of accidental death in individuals over 65, in part because of posture changes brought on by aging. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1087, Table 32-8 OBJ:7TOP:Musculoskeletal alterations KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 19. The nurse is assisting an older adult patient out of bed when suddenly the patient begins to fall. What is the likely cause of the fall? a. Fever b. Orthostatic hypotension c. Dehydration d. A decrease in venous return ANS: B Orthostatic hypotension occurs when the patient changes position. In the older adult, the loss of elasticity in the vessels slows the vascular accommodation to sudden postural changes to a standing position. PTS: 1 DIF: Cognitive Level: Application REF: Page 1101 OBJ:10TOP:Musculoskeletal alterations KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. To help prevent falls related to muscle weakness, what type of exercises should be selected for the aging patient?
a. Daily b. Running c. Weight-bearing d. Aerobic ANS: C Appropriate interventions to increase muscle strength begin with weightbearing exercises. They do not have to be done daily to be effective. Running and aerobic exercise would not be appropriate or effective for the aging patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 1101 OBJ:8TOP:Musculoskeletal alterations KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. What is the best test to identify the risk of osteoporosis in postmenopausal women? a. Skeletal x-ray b. Bone density scan c. Calcium blood level d. CAT scan ANS: B Bone density testing can identify women at risk for fractures. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1089 OBJ:5TOP:Osteoporosis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. When an older female patient complains of painful sexual intercourse, what should the nurse recognize as the probable cause? a. Urinary incontinence b. Arthritic joints c. Kyphosis d. Mucosal drying ANS: D Sexual intercourse may be uncomfortable because of drying of the mucosa of
the vagina. PTS: 1 DIF: Cognitive Level: Application REF: Page 1092 OBJ:5TOP:Reproductive alterations KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. What is age-related vision change caused by the loss of elasticity of the lens called? a. Nearsightedness b. Cataracts c. Presbyopia d. Blepharitis ANS: C Age-related changes include presbyopia and farsightedness resulting from a loss of elasticity of the lens. Cataracts are due to opacity of the lens. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1093 OBJ:5TOP:Sensory alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. When communicating with an older adult patient who has difficulty hearing, how should the nurse change her speech? a. Speak very loudly b. Speak rapidly c. Lower the tone of the voice d. Raise the tone of the voice ANS: C To communicate with a patient with a hearing loss, the nurse should lower the tone of the voice. PTS: 1 DIF: Cognitive Level: Application REF: Page 1095 OBJ:8TOP:Sensory alterations KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. Which symptom of diabetes distorts tactile sensation? a. Proprioception
b. Loss of visual acuity c. Progressive paresis d. Peripheral neuropathy ANS: D Peripheral neuropathy is the presence of abnormal sensation and it distorts tactile sensation. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1091 OBJ: 4 TOP: Diabetes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. What is the result of a slowing of the impulse transmission in the nervous system? a. Hypertension b. Hearing deficit c. Decrease in tactile sensations d. Longer reaction time ANS: D When nerve impulses in the nervous system of an older adult slow down, the result is a longer reaction time. PTS: 1 DIF: Cognitive Level: Application REF: Page 1095 OBJ:5TOP:Neurologic alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 27. What is the most common cause of dementia? a. Multi-infarct b. Medications c. Alzheimer disease d. Parkinson disease ANS: C Alzheimer disease is the most common cause of dementia. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1098 OBJ: 9 TOP: Dementia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 28. What is one positive aspect of Parkinson disease?
a. The disease does not alter ability to communicate b. Anti-Parkinson drugs have few side effects c. Intellectual function is not impaired d. Involuntary movements can be controlled ANS: C Parkinson disease does not impair the intellect. The disease does alter the ability to communicate. Anti-Parkinson drugs have many side effects. The involuntary movements associated with the disease cannot be controlled. PTS: 1 DIF: Cognitive Level: Application REF: Page 1099 OBJ:4TOParkinson disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. When should family members of a stroke victim expect to see some of the neurologic involvement disappear? a. Within 2 to 3 weeks b. Within 1 to 2 months c. Within 3 to 6 months d. Within 6 to 9 months ANS: C Some of the initial neurologic deficits of a Cerebrovascular Accident may disappear in 3 to 6 months. PTS: 1 DIF: Cognitive Level: Application REF: Page 1100 OBJ: 4 TOP: Stroke KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. When communicating with an older adult patient, the nurse becomes aware of the fact that the patient is well satisfied with his accomplishments over a lifetime and has no regrets concerning aging. Which of Eriksons developmental stages has the patient achieved? a. Acceptance b. Withdrawal c. Ego integrity d. Interaction ANS: C
The last stage of life is acceptance of life and it results in ego integrity. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1072, Box 32-4 OBJ: 3 TOP: Aging KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 31. Which areas are affected only minimally by age? a. Physical activity b. Productivity c. Cognition d. Sexuality ANS: C Aging has little influence on cognition. Only through disease processes is cognition altered. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1096 OBJ: 5 TOP: Aging KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 32. How often does a 76-year-old need a screening for preventative health? a. Every 2 years b. Every 6 months c. Every 3 years d. Every year ANS: D A complete physical is recommended annually after 75. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1070, Table 32-1 OBJ:6TOP:Health promotion KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 33. When assessing the older adult, the nurse considers which aspect of the patients routine as a possible contributor to constipation? a. Intake of antacids several times a day b. Taking a laxative once a week c. Excessive exercise routine d. Eating two apples a day ANS: A
Intake of antacids is constipating. All other options decrease the risk of constipation. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1080 OBJ: 8 TOP: Constipation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 34. What should the nurse do to help the dysphagic patient? (Select all that apply.) a. Sit the patient upright b. Reduce distraction during mealtime c. Offer fluid from a straw d. Thicken liquids e. Cue the patient to swallow ANS: A, B, D, E Offering fluids using a straw increases the possibility of choking or aspiration. All other options would be beneficial to the dysphagic patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 1079 OBJ:8TOP:Gastrointestinal alterations KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 35. Which statements are myths that have been disproved concerning aging? (Select all that apply.) a. All older adults are senile. b. Most older adults live in their own homes. c. Older adults are poor. d. Older adults have frequent contact with family members. e. Older adults are disabled. ANS: A, C, E All older adults are not senile; this is a myth. Mental decline is not inevitable. Older adults are not all poor; this is a myth. Older adults have a lower poverty rate than younger adults. Older adults are not all disabled; this is a myth. Most are able to manage their own care. Most older adults do live in their own homes and have frequent contact with family members.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1072, Box 32-3 OBJ:2TOP:Aging Myths KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 36. Which approaches should be included when teaching medication safety to an older, homebound adult? (Select all that apply.) Always dispose of expired medications in the toilet or the sink; never a. trash can. b. Never share medications with others. c. If a medication is not finished as prescribed, save it for future use. d. Keep medications in their original containers. e. Always request child-proof containers, even if the patient has trouble ANS: A, B, D Expired medications should always be disposed of in the toilet or sink; they should never be thrown in the trash where they could be retrieved by others. Medications should never be shared with anyone else. Medications should always be stored in their original containers. A prescription should always be taken as prescribed by the physician. Medications should never be saved for future use. If an older adult has trouble opening child-proof medication containers, he should request non-childproof lids. PTS: 1 DIF: Cognitive Level: Application REF: Pages 1101-1103 OBJ:8TOP:Medication practices KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 37. When bathing an 80-year-old woman who lives on a farm, the nurse assesses brown macules on the patients hands and forearms. The nurse recognizes these as . ANS: lentigo Lentigo is a term that refers to brown-pigmented lesions on the skin of the older person who has spent a great deal of time in the sun. These macules are also called age spots. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1075
OBJ:5TOP:Integumentary alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 38. The nurse initiates the application of a draw sheet on every bedfast patient on her unit to facilitate lifting and to prevent forces. ANS: shearing Shearing forces cause skin damage by friction; for instance, when a patient is dragged across bed linens during a position change. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1076 OBJ:8TOP:Integumentary alterations KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 39.The nurse recognizes that a term referring to mechanical difficulty of swallowing is . ANS: dysphagia Dysphagia is a term that refers to mechanical difficulties in swallowing. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1079 OBJ:5TOP:Gastrointestinal alterations KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity Chapter 33: Concepts of Mental Health My Nursing Test Banks Chapter 33: Concepts of Mental Health Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What is the mental health nurse referring to when using the term behavior? a. An isolated incident b. The manner in which a person performs c. A product of a coping strategy d. Failure to adapt ANS: B Behavior may be defined as the manner in which a person performs any or all of the activities of daily living.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1110 OBJ:1TOP:Mental health KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 2. What definition should the nurse use to clarify the concept of mental health? a. A wellness of attitude b. A persons response to disease and dysfunction c. The ability to cope and adjust to everyday stresses d. How the person performs activities of daily living ANS: C Mental health can be defined as a persons ability to cope and adjust to everyday stresses. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1110 OBJ:1TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 3. How should the nurse document the behavior of a patient with mental illness? a. Very disruptive to a person in society b. Differing from socially acceptable behavior c. Causing the person to be involved in problems d. Resulting from an inability to exercise control ANS: B Mental illness can cause behavior that deviates from socially and culturally acceptable behavior. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1111 OBJ:2TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 4. How many people in the United States will develop a mental disorder during their lifetime? a. One in two
b. One in five c. One in eight d. One in ten ANS: A It is estimated that 50% of people in the United States will develop a mental disorder during their lifetime. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1111 OBJ:2TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 5. During the 19th and 18th centuries, care of patients with mental illness often was cruel. What type of care was used by Dr. Philippe Pinel to bring about change? a. Personal care b. Individual care c. Behavior care d. Humane care ANS: D Dr. Philippe Pinel advocated humane care. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1112 OBJ: 1 TOP: Mental health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 6. When was psychiatric training for nurses initially offered? a. 1852 b. 1882 c. 1902 d. 1922 ANS: B In 1882, McLean Hospital in Waverly, Massachusetts, provided the first psychiatric training school for nurses. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1112 OBJ: 1 TOP: Mental health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A
7. Using the mental health continuum as a guide, the nurse observes behavior
that usually places an individual on the illness end of the continuum. What is true of this behavior? a. It causes extreme concern about health. b. It results in inability to function in society. c. It demonstrates that the person is out of touch with reality. d. It results in inability to interact with people. ANS: C On the illness end of the mental health continuum, the person is rarely in touch with reality. PTS: 1 DIF: Cognitive Level: Application REF: Page 1113 OBJ:1TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 8. The majority of people function in a relatively healthy manner. What can diminish their functional capacity? a. Lack of a support system b. Periods of crisis c. Nutritional deficits d. A physical disease process ANS: B Periods of crisis can decrease functional capacity, moving a person toward the illness end of the continuum. PTS: 1 DIF: Cognitive Level: Application REF: Page 1113 OBJ: 1 TOP: Mental health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 9. What is the basis for classifying a person as having a mental illness? a. Behavior exhibited and the context b. Response of society to the behavior c. Ability of the patient to conform d. Patients history and previous behavior ANS: A A person is deemed to be mentally ill by the behavior exhibited and the
context in which that behavior occurs. PTS: 1 DIF: Cognitive Level: Application REF: Page 1114 OBJ: 2 TOP: Mental health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 10. Using Freuds personality theory, what action by a patient identifies the influence of the superego? a. Eating an entire chocolate pie b. Becoming anxious about having no visitors c. Monopolizing the attention of the physician d. Returning a $5 bill that another patient left on the table ANS: D The superego is the mediator between right and wrong (the conscience). PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1114, Box 33-2 OBJ:3TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 11. Using Freuds personality theory, what action by a patient indicates a strong ego? a. Laughs at himself for being foolish b. Continually boasts of his accomplishments c. Apologizes continually d. Insists that the TV channel stay tuned to CNN ANS: A Ego is the reality tester. Laughing at oneself shows that the patient can compare his own foolish behavior to the norm. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1114, Box 33-2 OBJ:3TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 12. Which theorist believed that personality development was based on task mastery? a. Sigmund Freud b. Erik Erikson
c. Jean Piaget d. Friedrich Nietzsche ANS: B Erik Erikson provided a framework for understanding personality development in terms of task mastery. Sigmund Freud described personality development as having three parts: id, ego, and superego. Jean Piaget theorized that development was based on how humans acquire and utilize knowledge. Friedrich Nietzsches theories had more to do with morality than personality development. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1114 OBJ: 2 TOP: Mental health KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 13. Which role is an example of an ascribed role? a. Sex b. Occupation c. Manner of dealing with stress d. Attitude toward homosexuality ANS: A Ascribed roles are those that a person takes on, but had no personal choice in the matter. Ethnicity, sex, and nationality are examples of ascribed roles. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1115 OBJ:3TOP:Mental health KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 14. The nurse is assessing a young woman who is a teacher, happily married, raising two children, taking care of her disabled mother, and going to school to get a masters degree. How should the behavior of the young woman be classified? a. Ego-centered b. Role integrated c. High-level wellness d. Unbounded energy ANS: B
Role integration is performing several ascribed roles at the same time. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1115 OBJ:3TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 15. What action consistently done by a patient should indicate to a nurse that the patient has a poor self-concept? a. Wears bright-colored clothing b. Demands the attention of staff c. Apologizes to others repeatedly d. Becomes angry when frustrated ANS: C Apologizing repeatedly is indicative of self-effacement. Anger, demanding attention, and wearing attention-getting clothing are not characteristics of a poor self-concept. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1115 OBJ:2TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 16. What does any event that requires change stimulate? a. Anger b. Depression c. Stress d. Anxiety ANS: C Any event that requires change leads to stress, which is the nonspecific response of the body to any demand. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1115 OBJ:7TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 17.A nurse tearfully confides to the head nurse that being assigned to care for eight patients is stressful and overwhelming. What demonstrates the use of a
healthy coping mechanism? a. Writing down long lists of needed interventions before starting the da b. Delegating appropriate care assignments to nursing assistants c. Asking a co-worker to take one of her patients d. Asking for the day off ANS: B The use of delegation is an effective coping mechanism. The other options are not healthy as they either delay or avoid dealing with the stress. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1116 OBJ:2TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 18.A perceived threat to self causes what emotion? a. Fear b. Anger c. Depression d. Anxiety ANS: D Anxiety can be defined as a vague feeling of apprehension resulting from a perceived threat to self. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1115 OBJ:7TOP:Mental health KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 19. What action by a student before taking a test should indicate to a nursing instructor that the student is demonstrating signs of moderate anxiety? a. Studies for 6 hours b. Sleeps 6 hours because of fatigue c. Vomits d. Argues about the scheduling of the test ANS: C Symptoms of anxiety include the following: vocal changes, rapid speech, increased pulse, respirations, and blood pressure, tremors, restlessness,
increased perspiration, nausea, decreased appetite, diarrhea, frequent urination, and vomiting. PTS: 1 DIF: Cognitive Level: Application REF: Page 1115 OBJ:7TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 20. What coping mechanism demonstrated by a patient should indicate to the nurse that the patient is seeking ways to deal with and resolve stress? a. Projection b. Adaptation c. Reaction formation d. Compensation ANS: B An individual who develops ways to deal with stress and resolve it has adapted. PTS: 1 DIF: Cognitive Level: Application REF: Page 1116 OBJ:9TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 21.A 40-year-old patient cries and has a tantrum when the physician refuses to give her a prescription for diet pills. The nurse realizes that this is the use of which defense mechanism? a. Compensation b. Denial c. Regression d. Repression ANS: C Regression is a behavior that reflects the return to an earlier form of coping. PTS: 1 DIF: Cognitive Level: Application REF: Page 1117, Table 33-1 OBJ:6TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 22. When the patient who overeats insists that weight gain is related to
retained fluids, the nurse recognizes the patient is using which defense mechanism? a. Compensation b. Rationalization c. Sublimation d. Regression ANS: B Defense mechanisms are unconscious reactions that offer protection to the self from stressful situations. Rationalization offers a reasonable explanation for an event rather than facing reality. PTS: 1 DIF: Cognitive Level: Application REF: Page 1117, Table 33-1 OBJ:6TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 23. After finding the patient with diabetes eating candy, the nurse reminds the patient that the candy will elevate blood sugar levels. The patients response is: Its only a little bit, and it wont do anything. Which defense mechanism is the patient using? a. Conversion b. Denial c. Repression d. Regression ANS: B The patient is using denial as a defense mechanism. Reality is denied. PTS: 1 DIF: Cognitive Level: Application REF: Page 1117, Table 33-1 OBJ:6TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 24. The patient complains to the nurse that the physician does not like him and wants him to fail at following the diet prescribed. The nurse recognizes that the patient is using which defense mechanism? a. Conversion b. Projection
c. Introjection d. Repression ANS: B Projection is attributing to others characteristics that the person does not want to acknowledge. PTS: 1 DIF: Cognitive Level: Application REF: Page 1117, Table 33-1 OBJ:6TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 25. The nurse is sensitive to the fact that patients lose control over their lives when admitted to the hospital. In what does this loss of control frequently result? a. Anger b. Depression c. Fear d. Anxiety ANS: D Loss of control may result in feelings of apprehension and uncertainty. PTS: 1 DIF: Cognitive Level: Application REF: Page 1118 OBJ:5TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 26. The patient admitted to the hospital may adjust to illness by assuming a role in which everyday responsibilities are avoided. What is this role called? a. Patient role b. Illness role c. Sick role d. Dependent role ANS: C The sick role allows the patient to be excused from everyday responsibilities. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1118 OBJ:8TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial
Integrity 27. Why is it important for the nurse to be observant of patient behavior? a. Behavior is preformed b. Behavior is important c. Behavior is learned d. Behavior is repeated ANS: C Behavior is learned and has meaning. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1119 OBJ:9TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 28. What is a nursing intervention that helps to build trust, encourages the patient to have faith in the care being received, and meets psychosocial needs? a. Developing a care plan b. Implementing nurse orders c. Patient education d. Meeting patient goals ANS: C One of the steps to meet the psychosocial needs of the patient is patient education. PTS: 1 DIF: Cognitive Level: Application REF: Page 1118 OBJ:10TOP:Mental health KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 29.A family is informed that the brain damage to their daughter is irreversible. The father is later overheard making vacation plans and discussing what the family will do when his daughter leaves the hospital. The nurse recognizes the father is in which crisis stage? a. High anxiety b. Denial c. Reconciliation
d. Adaptation ANS: B The father is exhibiting signs of denial. Once the reality of the situation becomes evident, anger and confusion follow. PTS: 1 DIF: Cognitive Level: Application REF: Page 1119 OBJ:9TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 30. When developing a care plan for a mentally ill patient, what should the nurse assess first? a. Coping strategies b. Emotional status c. Medications taken d. Nutritional status ANS: B The nurses first priority would be to assess the emotional status of the mentally ill patient. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1120 OBJ:9TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 31. When the patient is told that his insurance will no longer pay for his physical therapy, the nurse is aware that this obstruction to his goal may result in which concept? a. Conflict b. Adaptation c. Frustration d. Anxiety ANS: C Frustration refers to anything that interferes with goal-directed activity. PTS: 1 DIF: Cognitive Level: Application REF: Page 1116 OBJ:9TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial
Integrity 32. What is the most likely result when an attempt at adaptation fails? a. Depression b. Anger c. Frustration d. Anxiety ANS: D When adaptive behavior fails, anxiety increases. PTS: 1 DIF: Cognitive Level: Application REF: Page 1115 OBJ:5TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 33. The nurse is assessing a nervous 18-year-old patient who has vital signs of P 120, R 30, and BP 160/90. The patient states that he feels something bad is about to happen. Based on this data alone, how should the nurse identify the patients level of anxiety? a. Mild b. Moderate c. Severe d. Panic ANS: C Severe anxiety may be manifested by elevated blood pressure, pulse, and respiratory rate, a feeling of impending danger, and feelings of fatigue. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1116, Box 33-3 OBJ:9TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 34. When assisting the older adult who is despondent about the need to leave his home, what technique should the nurse use? a. Ask him if he has a drinking problem b. Explore the option of his moving in with someone c. Reminisce with the patient and review his life d. Assess for hopelessness and helplessness
ANS: C Reminiscence and life review are effective techniques to help older adults deal with changing life circumstances. PTS: 1 DIF: Cognitive Level: Application REF: Page 1118 OBJ:10TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 35.A patient admitted to the hospital after a motorcycle crash that has left him paralyzed from the waist down tells the nurse he has feelings of helplessness and hopelessness. What other feelings may the patient have that should be recognized? a. Isolation b. Suicidal ideation c. Fear d. Anger ANS: B Hopelessness and helplessness can lead to possible thoughts of suicide. PTS: 1 DIF: Cognitive Level: Application REF: Page 1118 OBJ:9TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 36. The nurse uses a diagram to show how the four parts of self fit together. What are the four parts? (Select all that apply.) a. Body image b. Ego c. Self-esteem d. Role e. Identity ANS: A, C, D, E The four parts of the self are body image, self-esteem, role, and identity. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1114 OBJ:3TOP:Mental health
KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 37.A variety of factors influence the level of anxiety experienced by the patient faced by a stressful situation. Which would the nurse outline? (Select all that apply.) a. How others perceive the event b. The number of stressors present at one time c. Degree of change the stressors require d. Present role assumption e. Previous experience with a similar situation ANS: B, C, D, E The number of stressors present at one time, the degree of change the stressors require, present role assumption, and previous experience with a similar situation are all factors that can influence the level of anxiety experienced when faced with a stressful situation. The level of anxiety experienced is also influenced by how the event is perceived by the individual, not how the event is perceived by others. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1115 OBJ:7TOP:Mental health KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity COMPLETION 38. The situation in which a parent must choose between attending a daughters ballet recital or a sons baseball game is an example of a . ANS: conflict Conflict occurs when there is a presence of simultaneous goals, only one of which can be met. PTS: 1 DIF: Cognitive Level: Application REF: Page 1116 OBJ:7TOP:Mental health KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 39. In the movie Gone with the Wind, Scarlett OHara says, Ill think about that
tomorrow. Tomorrow is another day. The nurse recognizes the defense mechanism of . ANS: repression Repression is an unconscious barring of anxiety-producing thoughts. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1117, Table 33-1 OBJ:6TOP:Mental health KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity OTHER 40. Place the events in the mental health care movement in chronologic order. Put a comma and space between each answer choice (A, B, C, D, etc.). a. Establishment of Pennsylvania Hospital b. Deinstitutionalization movement c. Formation of Committee for Mental Health d. Passage of Omnibus Budget Reconciliation Act (OBRA) e. Dorothea Dix awakens public awareness of plight of mentally ill ANS: A, E, C, B, D Pennsylvania Hospital1731, Dorothea Dix1882, Committee for Mental Health1909, deinstitutionalization movement1960, OBRA1981. PTS: 1 DIF: Cognitive Level: Application REF: Pages 1111-1112 OBJ: 1 TOP: Mental health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 34: Care of the Patient with a Psychiatric Disorder My Nursing Test Banks Chapter 34: Care of the Patient with a Psychiatric Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is discussing the differences between a patient with a neurosis and one with a psychosis. What is true of the patient experiencing a neurosis? a. The patient experiences a flight from reality. b. The patient usually needs hospitalization.
c. The patient has insight that there is an emotional problem. d. The patient has severe personality deterioration. ANS: C An individual with a neurosis has insight that he has an emotional problem. A person with psychosis is out of touch with reality and has severe personality deterioration. Treatment for neurosis is usually completed in the outpatient setting, while treatment for psychosis often requires hospitalization. PTS: 1 DIF: Cognitive Level: Application REF: Page 1123 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 2. When the patient with a psychosis is thought to be a danger to self or others, by what method should the patient be admitted to the hospital? a. Probating b. Nurses request c. Physicians order d. Family request ANS: A Probating can be done if the individual is thought to be a danger to self or others. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1123 OBJ:4TOP:Mental illness KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 3. The Diagnostic and Statistical Manual of Psychiatric Disorders, V (DSMV), is used by most hospitals and is the current tool used to examine mental health and illness. What approach does the DSM-V use to classify mental disorders? a. Holistic system b. Hierarchical system c. Multiaxial system d. Evaluation system ANS: C
The DSM-V is a multiaxial system. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1123 OBJ: 1 TOP: Mental illness KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 4. When all five axes of the Diagnostic and Statistical Manual of Psychiatric Disorders, V, are used, it provides what type of assessment approach to comprehensive care? a. Personalized b. Individualized c. Holistic d. Organic ANS: C Using all five axes of the DSM-V provides a holistic assessment. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1124 OBJ:1TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 5.A young man with malaria spikes a temperature of 105 F and begins to hallucinate. How should the nurse assess this? a. Delirium b. Psychotic break c. Possible stroke d. Anxiety disorder ANS: A Delirium is an organic mental disorder that is frequently brought on by a severe physical illness, such as fever. PTS: 1 DIF: Cognitive Level: Application REF: Page 1124 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 6.A patient admitted for delirium demonstrates increased disorientation and agitation only during the evening and nighttime. What is the term applied to this type of delirium?
a. Disordered thinking b. Schizophrenia c. Dementia d. Sundowning syndrome ANS: D A patient with sundowning syndrome displays increased disorientation and agitation only during evening and nighttime. Disordered thinking occurs when an individual is not able to interpret information being received in the brain. Disordered thinking is one characteristic of schizophrenia, which is a large group of psychotic disorders that includes nonreality-based thinking. Dementia is an altered mental state secondary to cerebral disease. PTS: 1 DIF: Cognitive Level: Application REF: Page 1124 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 7. Dementia is an organic mental disease secondary to what problem? a. Chemical imbalance b. Emotional problems c. Circulatory impairment d. Cerebral disease ANS: D Dementia describes an altered mental state secondary to cerebral disease. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1124 OBJ:2TOP:Mental illness KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 8.A profound, disabling mental illness is characterized by bizarre, nonreality thinking. What is the illness? a. Manic depressive b. Schizophrenia c. Paranoia d. Bipolar ANS: B
Schizophrenia, a thought process disorder, is one of the most profoundly disabling mental illnesses. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1124 OBJ:2TOP:Mental illness KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 9.A patient believes himself to be the president of the United States and that terrorists are trying to kidnap him. The nurse records these observations as which type of behavior? a. Absent behavior b. Positive behavior c. Negative behavior d. False behavior ANS: B The behaviors of schizophrenic individuals can be categorized as positive (or excessive) or negative (or absent). Examples of positive behaviors include hallucinations, delusions, and disordered thinking. Examples of negative behaviors include apathy, social withdrawal, and flat affect. PTS: 1 DIF: Cognitive Level: Application REF: Page 1128 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 10. The patient talks with his dead brother and arranges furniture so that his brother will have a place to sit. How should the nurse document this behavior? a. Disordered thinking b. Anhedonia c. Hallucination d. Alogia ANS: C A hallucination is a sensory experience without a stimulus trigger. Disordered thinking occurs when the individual is not able to interpret information being received in the brain. Anhedonia describes lack of expressed feelings. Alogia
is reduced content of speech. PTS: 1 DIF: Cognitive Level: Application REF: Page 1128 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 11. What is the prognosis for a schizophrenic patient who is exhibiting positive behaviors? a. Guarded b. Poor c. Good d. Repeatable ANS: C Prognosis for schizophrenic patients who are exhibiting positive behavior patterns is good. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1128 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 12. The nurse cautions a patient to watch his step. What response indicates concrete thinking? a. The patient fixedly begins to watch his feet. b. The patient immediately examines his watch. c. The patient begins to watch the nurses feet. d. The patient stands rigidly in one place without moving. ANS: A Concreteness is an indication of disordered thinking. The patient is unable to translate any words except by a very concrete definition. PTS: 1 DIF: Cognitive Level: Application REF: Page 1128 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 13. The nurse asks a patient with schizophrenia if he had any visitors on Sunday. Which response indicates loose association?
a. No. b. Yes! I had 90 visitors who came from every state in the union. c. Sunday is the Sabbath. Do we have visitors on the Sabbath? d. We visited Yellowstone Park last summer. ANS: D Loose association is a type of disordered thinking that occurs when the individual cannot interpret information and the conversation does not flow. PTS: 1 DIF: Cognitive Level: Application REF: Page 1128 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 14. The nurse is caring for a patient with a diagnosis of catatonic schizophrenia. What behavior is consistent with this diagnosis? a. Talks excitedly about going home b. Suspiciously watches the staff c. Stands on one foot for 15 minutes d. States he has a cat under his bed that talks to him ANS: C Maintaining a rigid pose for long periods of time is an example of behavior expected with catatonic schizophrenia. PTS: 1 DIF: Cognitive Level: Application REF: Page 1129 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 15. What is the term used for the beginning stage of schizophrenia, characterized by a lack of energy and complaints of multiple physical problems? a. Prepsychotic b. Residual c. Acute d. Prodromal ANS: D The prodromal phase is the beginning stage of schizophrenia. Hallucinations
and delusions sometimes occur in the prepsychotic stage. In the acute phase, individuals often lose touch with reality. The residual phase follows the acute phase and the symptoms of that phase are similar to those of the prodromal stage. PTS: 1 DIF: Cognitive Level: Application REF: Page 1129 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 16. For the past 3 weeks, the nurse has observed a patient interacting with staff and other patients, helping decorate the dining room for a party, and leading the singing in the activity room. Today, the patient tearfully refuses to dress or get out of bed. The nurse recognizes these behaviors as evidence of which psychiatric disorder? a. Unipolar depression b. Dysthymic disorder c. Hypomanic episode d. Bipolar disorder ANS: D Bipolar disorder can cause the patient to experience a sudden shift in emotion from one extreme to the other. PTS: 1 DIF: Cognitive Level: Application REF: Page 1130 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 17. The nurse recognizes that researchers have identified that hereditary factors account for what percentage of mood disorders? a. 10% to 15% b. 20% to 30% c. 35% to 50% d. 60% to 80% ANS: D Research indicates that hereditary factors account for 60% to 80% of mood disorders.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1129 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 18.A home health nurse has a patient who is taking lithium. What should be included in the teaching plan? a. Examine her skin closely for eruptions b. Take her blood pressure twice a day to check for hypertension c. Have her drug blood level checked every month d. Avoid aged cheese and red wine ANS: C Lithium has a very narrow therapeutic window. The drug blood levels should be closely monitored. PTS: 1 DIF: Cognitive Level: Application REF: Page 1139, Table 34-3 OBJ:6TOP:Mental illness KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The nurse alters the care plan for a patient with depression to include what type of activity? a. Domino game with three other patients b. Ping-Pong game with one other patient c. Group outing to view wildflowers d. Magazine to read alone ANS: C The quiet, noncompetitive trip to view wildflowers would be the best option. Depressed people should not be put in situations where they must concentrate or compete. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1132, Care Plan 34-1 OBJ:5TOP:Mental illness KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity 20.The nurse is assessing a female patient who has become rapidly and exceedingly anxious because her fingernail polish is chipped. What type of anxiety should the nurse conclude that the patient is exhibiting?
a. b.
Signal anxiety General anxiety
c. Anxiety traits d. Panic disorder ANS: C An individual with anxiety traits has anxious reactions to relatively nonstressful events. Signal anxiety is a learned response to an event such as test taking. An individual with general anxiety worries over many things. A panic attack occurs suddenly and typically peaks within 10 minutes. PTS: 1 DIF: Cognitive Level: Application REF: Page 1131 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 21. The home health nurse assesses a patient who creates elaborate excuses for not leaving home. Further questioning reveals the patient had not left home for 6 months. How should this be documented? a. Mania b. Depression c. Agoraphobia d. Anxiety ANS: C Agoraphobia is a high level of anxiety in which an anxiety attack could occur in individuals who avoid other people, places, or events. PTS: 1 DIF: Cognitive Level: Application REF: Page 1131 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 22. When a patient demonstrates accelerated heart rate, trembling, choking, and chest pain along with acute, intense, and overwhelming anxiety, the nurse should recognize that the patient is most likely experiencing what condition? a. Terror b. Fright c. Fear d. Panic
ANS: D Panic can be defined as an attack of acute, intense, and overwhelming anxiety. PTS: 1 DIF: Cognitive Level: Application REF: Page 1131 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 23. When a patient is experiencing a panic attack, how should the nurse best assist the patient? a. Assist with reality orientation b. Aid in decision making c. Assist with rational thought d. Coach in deep breathing ANS: D Coaching in relaxation techniques such as deep breathing is an effective intervention for a patient who is experiencing a panic attack. PTS: 1 DIF: Cognitive Level: Application REF: Page 1126, Table 34-1 OBJ:5TOP:Mental illness KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 24.A patient is frequently late for appointments because he goes back to his room numerous times to assure himself that none of his belongings have been stolen. What does this behavior represent? a. Senseless behavior b. Controlled repetition c. Obsessive-compulsive d. Anxiety tension ANS: C Obsessive-compulsive disorders have two features: thoughts that are recurrent, intrusive, and senseless; and behaviors that are performed repeatedly and ritualistically. PTS: 1 DIF: Cognitive Level: Application REF: Page 1133 OBJ:2TOP:Mental illness
KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 25.A 14-year-old survivor of a school shooting screams and dives under a table when firecrackers go off. What does this behavior represent? a. Phobia b. Post-traumatic stress disorder c. Obsessive-compulsive disorder d. Disordered thinking ANS: B Post-traumatic stress disorder describes a response to an intense traumatic experience that is beyond the usual range of human experience. PTS: 1 DIF: Cognitive Level: Application REF: Page 1133 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 26. What should the nurse preparing a patient for a scheduled appointment for electroconvulsive therapy (ECT) remind the patient to do? a. Drink plenty of fluids before ECT to ensure adequate hydration. b. Bring a change of clothes in case of incontinence. c. Be prepared for visual disturbances after the treatment. d. Arrange for transportation to and from the appointment. ANS: D If the patient has not arranged for adequate transportation to and from the appointment, the treatment will be canceled because driving after ECT is dangerous. The patient is typically NPO before the procedure. Incontinence and visual disturbances are not common following the procedure. PTS: 1 DIF: Cognitive Level: Application REF: Page 1138 OBJ:5TOP:Mental illness KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The nurse is told that a patient believes he was born into the wrong body. What is the correct terminology for the desire to have the body of the opposite sex?
a. Homosexuality b. Transsexualism c. Heterosexuality d. Bisexuality ANS: B Transsexualism is a persistent desire to be the opposite sex and to have the body of the opposite sex. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1135 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 28. The patient complains of recurrent, multiple physical ailments for which there is no organic cause. How should the nurse assess this? a. Obsessive-compulsive disorder b. Phobia anxiety disorder c. Somatoform disorder d. Delusional disorder ANS: C Somatoform disorder is characterized by recurrent, multiple physical complaints for which there is no organic cause. PTS: 1 DIF: Cognitive Level: Application REF: Page 1135 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 29. What disorder is a severe form of self-starvation that can lead to death? a. Bulimia nervosa b. Anorexia nervosa c. Teenage nervosa d. Obesity nervosa ANS: B Anorexia nervosa is a severe form of self-starvation that can lead to death. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1135 OBJ:2TOP:Mental illness
KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 30. The patient is concerned about confidentiality and asks the nurse not to tell anyone what is said. What is the best response by the nurse? a. I am required to report any intent to hurt yourself or others. b. Conversations between patient and nurse are confidential. c. What we say can be secret. What I write in the chart is available to th d. I cant help you unless you trust me. ANS: A No secrets are allowed to be kept by a member of the health care team. PTS: 1 DIF: Cognitive Level: Application REF: Page 1137 OBJ:5TOP:Mental illness KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 31. What is the term for a long-term and intense form of psychotherapy developed by Sigmund Freud that allows a patients unconscious thoughts to be brought to the surface? a. Adjunctive b. Behavior c. Psychoanalysis d. Cognitive ANS: C Psychoanalysis technique was developed by Sigmund Freud and is a longterm and intense therapy. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1136 OBJ: 5 TOP: Psychotherapy KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 32. What is the typical schedule for electroconvulsive therapy (ECT)? a. 3 treatments over 2 weeks b. 6 treatments over 2 months c. 8 treatments over several weeks d. 10 treatments over several weeks ANS: D
ECT is done as a treatment for depression, mania, and schizoaffective disorders that have not responded to other treatments. The usual protocol is 10 treatments over several weeks. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1137 OBJ:5TOP:Mental illness KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 33.A patient who is taking a monoamine oxidase inhibitor (MAOI) asks the nurse about the addition of St. Johns wort to help with his depression. What would be the best response of the nurse? a. That is a great idea. Alternative therapies can be very helpful. b. You will feel better sooner if you include phenylalanine. c. Did you know that St. Johns wort can raise your blood pressure dram d. You will need to drink lots of water. ANS: C St. Johns wort can raise blood pressure dramatically in people who are also taking MAOIs. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1141 OBJ:6TOPsychopharmacology KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 34. Adjunctive therapies are used for which reasons? (Select all that apply.) a. To increase self-esteem b. To promote positive interaction c. To enhance reality orientation d. To stimulate communication e. To increase energy ANS: A, B, C The purpose of adjunctive therapies is to increase self-esteem, promote positive interaction, and enhance reality orientation. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1136 OBJ:6TOP:Mental illness
KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 35. What are considered warning signs of suicide? (Select all that apply.) a. Talking about suicide b. Increased interactions with friends and family c. Drug or alcohol abuse d. Difficulty concentrating on work or school e. Personality changes ANS: A, C, D, E Warning signs of suicide include talking about suicide, decreased interactions with friends and family, drug/alcohol abuse, difficulty concentrating on work or school, and personality changes. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1130, Box 34-1 OBJ: 3 TOP: Suicide KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity COMPLETION 36. The nurse recognizes that a woman who has experienced physical abuse and has inadequate income to care for herself and her family would be categorized under Axis . ANS: 4 four Axis 4 queries the environmental and psychosocial information of a patient. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1124 OBJ:1TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 37. The nurse instructs a patient who has just been prescribed a protocol of fluoxetine HCl (Prozac) that the drug takes to weeks to take effect. ANS: 2, 4 two, four Antidepressants of this type take 2 to 4 weeks before any effect is felt by the
patient. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1130 OBJ:5TOP:Mental illness KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 38. The nurse explains that an alternative therapy that uses essential oils and scented candles to help a patient relax and focuses on the atmosphere of the moment is . ANS: aromatherapy Aromatherapy uses essential oils and scented candles to soothe the senses and make people aware of the here and now of the pleasant environment. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1142 OBJ:6TOP:Mental illness KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 39. The nurse recognizes that stress can cause an ulcer, which is classified as a illness. ANS: psychophysical Psychophysical illness addresses the stress-related problems that can result in physical signs and symptoms. Psychophysiological disorders are thought to have an emotional basis, manifested as a physical illness. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1135 OBJ:2TOP:Mental illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity Chapter 35: Care of the Patient with an Addictive Personality My Nursing Test Banks Chapter 35: Care of the Patient with an Addictive Personality Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1.A 60-year-old man was admitted for cholecystitis that resulted in a
cholecystectomy. On his third day of hospitalization, he begins to sweat profusely, tremble, and has a blood pressure of 160/100. Based on these findings, what focused assessment should the nurse complete? a. Cardiac problems b. Respiratory problems c. Withdrawal problems d. Circulatory problems ANS: C Diaphoresis, tremors, and hypertension are all symptoms of withdrawal from alcohol consumption. The nurse, concerned about the patients medical condition, may not consider substance abuse until withdrawal symptoms appear. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1148 OBJ: 4 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. What age of onset of alcohol consumption is most predictive of alcohol addiction? a. 8 or younger b. 10 or younger c. 12 or younger d. 14 or younger ANS: D Forty-four percent of those who start drinking at the age of 14 or younger will develop alcoholism. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1145 OBJ: 4 TOP: Alcoholism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Alcohol is involved in motor vehicle accidents, suicides, and homicides. Approximately how many deaths each year are related to alcohol consumption? a. 50,000 b. 70,000 c. 80,000
d. 100,000 ANS: D About 100,000 deaths each year are related to alcohol consumption. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1146 OBJ: 4 TOP: Alcoholism KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 4. What stage of dependence is described by a patient when he tells the nurse that he has tried to stop his drug habit, but he does not feel normal without it? a. Early b. Prodromal c. Middle d. Late ANS: C In the middle stage, the user shows signs of withdrawal with abstinence and must use the drug to feel normal. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1147 OBJ: 2 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 5. What must a patient in the late stages of dependence do in order to recover? a. Gain insight into the addiction b. Receive treatment for substance abuse c. Pledge to lead a completely different lifestyle d. Seek a nondrug-oriented support system ANS: B Very few people in the late stage of dependence will recover without treatment. The other options may aid in the recovery, but it is the treatment that is essential for recovery. PTS: 1 DIF: Cognitive Level: Application REF: Page 1147 OBJ: 2 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 6. What is the best response by a nurse when a patient inquires how alcohol acts so quickly on his system? a. Alcohol is digested quickly.
b. Alcohol is converted to glycogen immediately. c. Alcohol is metabolized into ethanol rapidly. d. Alcohol is excreted in urine slowly. ANS: C Alcohol is not digested or converted into glycogen, but it is metabolized quickly by the liver to ethanol. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1148 OBJ: 4 TOP: Alcoholism KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The nurse reminds a group of high school students that most states have laws limiting blood alcohol levels of drivers. What is the legal blood alcohol serum level in most states? a. 0.08% b. 0.20% c. 0.40% d. 0.50% ANS: A Most states designate blood alcohol serum levels of 0.08% as the legal limit for driving a motor vehicle. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1148 OBJ: 3 TOP: Alcoholism KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8.A pregnant adolescent tells the nurse that she only drinks a little. How many drinks per day can cause an adverse effect in an infant? a. One drink a day b. Two drinks a day c. Three drinks a day d. Four drinks a day ANS: B As few as two drinks per day may cause adverse effects in an infant. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1148 OBJ: 4 TOP: Alcoholism KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
9. The nurse assesses an alcoholic patient carefully for signs of withdrawal.
How soon after cessation of alcohol intake do withdrawal symptoms usually appear? a. 3 hours b. 4 hours c. 5 hours d. 6 hours ANS: D Withdrawal signs can occur as early as 6 hours after cessation of alcohol intake and sometimes last for 3 to 5 days. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1148 OBJ: 4 TOP: Alcoholism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. The nurse is performing an initial assessment on an alcoholic patient. Which of the following actions by the nurse would best ensure honest answers? a. Not asking personal questions b. Having a nonjudgmental attitude c. Including the family d. Promising the patient not to tell anyone ANS: B Maintaining a nonjudgmental attitude may reassure the patient and allow him to be more honest in his responses to the admission assessment. PTS: 1 DIF: Cognitive Level: Application REF: Page 1149 OBJ: 5 TOP: Alcoholism KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 11. During the detoxification period, what does the nurse aim to achieve when designing interventions? a. Enroll the patient in Alcoholics Anonymous (AA) b. Keep the patient safe from aspiration and seizure c. Help the patient interact in nonaddictive activities d. Help the patient gain insight into the addiction ANS: B
Care for the addicted patient starts with detoxification and is focused on keeping the patient safe from the symptoms of withdrawal. Enrolling the patient in AA, helping the patient interact in nonaddictive activities, and helping the patient gain insight into the addiction would be part of the rehabilitation process. PTS: 1 DIF: Cognitive Level: Application REF: Page 1150 OBJ: 5 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. What should the entire health team focus on during the rehabilitation phase? a. Establishing a support system b. Seeking and maintaining employment c. Abstaining from drug use d. Addressing the problems related to addiction ANS: C The focus of rehabilitation is for the patient to abstain from drug use. PTS: 1 DIF: Cognitive Level: Application REF: Page 1151 OBJ: 5 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 13. What should the nurse do to decrease the patients disorientation at night during the detoxification period? a. Place the patient in a room with another recovering patient b. Instruct the patient to orient himself to his surroundings at bedtime c. Wake the patient up every 4 hours to eat a small snack d. Use nightlights and remove extra furniture from the room ANS: D Use of nightlights and removing extra furniture that could be misidentified will reduce disorientation. The patient should not be woken up to eat, but if he is awake, small snacks can be offered. The nurse should orient the patient to his surroundings. PTS: 1 DIF: Cognitive Level: Application REF: Page 1150 OBJ: 5 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
14. The nurse explains that Alcoholics Anonymous (AA) consists of abstinent
alcoholics who help other alcoholics become and stay sober. What is the foundation of AA? a. Psychotherapy b. A 12-step program c. Treatment center d. Individual counseling ANS: B The foundation of AA is a 12-step program. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1152 OBJ: 5 TOP: Alcoholism KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 15. What severe side effect will occur if an alcoholic patient consumes alcohol while taking disulfiram (Antabuse)? a. Nausea b. Blackouts c. Headaches d. Hypertension ANS: A When a person who is taking Antabuse consumes alcohol, severe nausea, tachycardia, shortness of breath, confusion, and dizziness are experienced. The drug is used as a form of aversion therapy. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1151 OBJ: 5 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. If the patient tells the nurse, Im not an alcoholic. I can stop whenever I want to, what should be the nurses most therapeutic response? a. Well, why dont you? b. Hasnt alcohol use interfered with your employment? c. A positive attitude like that is a good start. d. What would you call alcoholism? ANS: B When the addicted person presents in denial, the nurse should use techniques
to set limits on that behavior. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1150 OBJ: 1 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 17. When a patient denies any problems related to addiction, what is the nurses most therapeutic response? a. What do you call this hospitalization? b. How can anybody help you if you dont see a problem? c. Would your family agree that you have no problems? d. Can you think of any time your behavior created an unpleasant situati ANS: D When the patient denies that his behavior is problematic, the nurse should ask the patient to recount incidences when the behavior had unpleasant consequences. PTS:1DIF:Cognitive Level: Analysis REF: Page 1151, Nursing Care Plan 35-1 OBJ: 1 TOP:AddictionKEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 18. Which drug is often used in date rape? a. Dalmane b. Xanax c. Narcan d. Rohypnol ANS: D Rohypnol has been abused as a date-rape drug and has not been approved for use in the United States. PTS: 1 DIF: Cognitive Level: Comprehension| Cognitive Level: Knowledge REFage 1154OBJ:6TOP:Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 19.A patient seems bewildered when he confides in the nurse that all of his friends and leisure time have been centered on a drug culture. Which would be the best response by the nurse?
a. What other sort of activities might you enjoy? b. You will need to get new friends. c. Returning to those activities will get you back here and in trouble. d. You need to get a hobby. ANS: A Encouraging the patient to imagine new activities is a start toward seeking them. Giving advice is not therapeutic. PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 1151-1152 OBJ: 1 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 20. When a patient is admitted with an overdose of an opioid narcotic, the nurse should anticipate an order for which drug to reverse the effects of the narcotic? a. Clonidine b. Narcan c. Orlaam d. Methadone ANS: B Opioid overdose treatment involves administering Narcan as prescribed to reverse the effects of the narcotic. PTS: 1 DIF: Cognitive Level: Application REF: Page 1155 OBJ: 6 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. The nurse concludes that a significant goal of the care plan for an alcoholic patient has been met when the patient makes which statement? a. I drink because Im lonely. b. All my difficulties are related to my drinking. c. I wouldnt need to drink if I had my family back. d. My drinking helps me cope with the stress of my job. ANS: B A major goal for the successful treatment of alcoholics is to have them express responsibility for their behavior. PTS:1DIF:Cognitive Level: Application
REF: Page 1151, Nursing Care Plan 35-1 OBJ: 5 TOP:AddictionKEY:Nursing Process Step: Evaluation MSC: NCLEX: Psychosocial Integrity 22. While creating a methadone protocol for a patient rehabilitating from heroin addiction, the nurse explains that the patient will take methadone for what length of time? a. Daily for the rest of his life b. Daily until stabilized, then gradually reduce the dose to zero c. Weekly for at least 6 months, then decrease the dose to once a month d. Monthly for 6 to 10 months, then decrease the dose to zero ANS: B Methadone is given daily until the patient is stabilized. The methadone is reduced gradually until the patient does not need to take any. PTS: 1 DIF: Cognitive Level: Application REF: Page 1155 OBJ: 5 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 23.A 22-year-old patient presents in the emergency department with thecharacteristics of severe Parkinson disease. The nurse should suspect anoverdose of what drug? a. Marijuana b. Cocaine c. Amphetamines d. Valium ANS: C Over time, dopamine depletion in the brain can cause Parkinson-like symptoms to occur in people who abuse amphetamines. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1156 OBJ: 6 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24.A college student has brought his hallucinating roommate to the college clinic. The young man says his roommate has been experimenting with phencyclidine (PCP). How long should the nurse expect the hallucinations to last?
a. 30 to 60 minutes b. 1 to 4 hours c. 4 to 6 hours d. 6 to 12 hours ANS: D Some hallucinogenic effects of PCP can last 6 to 12 hours. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1156 OBJ: 6 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. The mother of a young woman being treated for amphetamine overdose asks the nurse when the manifestations will subside. What would be the most correct answer by the nurse? a. Usually in 8 to 10 hours. b. She will snap out of it in a day or two. c. Usually in about 2 hours, but the effects will return in 2 to 3 days. d. The manifestations may be permanent. ANS: D The manifestations of overdose of amphetamines are frequently permanent. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1156 OBJ: 6 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 26. What nursing intervention should be included in the plan of care for a baby born to a drug-addicted mother? a. Swaddle the baby closely b. Place the baby in a brightly lit area c. Hold and rock the baby frequently d. Place the baby in a busy part of the nursery for stimulation ANS: A A baby born to a drug-addicted mother should be swaddled, placed in an area of low stimulation, and minimally handled. PTS: 1 DIF: Cognitive Level: Application REF: Page 1156 OBJ: 6 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
27. What is the greatest problem with lysergic acid diethylamide (LSD) use?
a. The drug is addictive. b. The drug stimulates drug-seeking behavior. c. The drug causes flashbacks. d. The drug sets off hypertensive episodes. ANS: C LSD causes flashbacks, or bad trips, unpredictably, and the flashbacks may occur years after ingestion of the drug. LSD is not considered an addictive drug and does not stimulate drug-seeking behavior. Hypertension is not a typical side effect of LSD. PTS: 1 DIF: Cognitive Level: Application REF: Page 1156 OBJ: 6 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 28. What should the nurse do to decrease the damage of bruxism seen in a patient who has been abusing the drug ecstasy? a. Turn the patient to his right side b. Elevate the head of the bed 30 degrees c. Provide the patient with a pacifier d. Administer a muscle relaxant ANS: C The use of an infant pacifier will reduce the damage to the teeth for a patient who is manifesting bruxism (grinding of the teeth). PTS: 1 DIF: Cognitive Level: Application REF: Page 1157 OBJ: 6 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. What should the nurse do when suspecting a co-worker of abusing drugs while at work? a. Confront the abuser b. Report observations to a supervisor c. Call the state board of nursing d. Discuss the problem with another co-worker ANS: B The nurses observations should be reported objectively, preferably in writing,
to the supervisor. PTS: 1 DIF: Cognitive Level: Application REF: Page 1161 OBJ:7TOP:Impaired nurse KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 30. Which statement describes the impaired nurse who is in a peer assistance program? a. The nurse has a revoked nursing license. b. The nurse does not have to notify her employer. c. The nurse will be allowed to work as a nurse under supervision. d. The nurse will be reported to the Healthcare Integrity and Protection ANS: C The peer assistance program allows the nurse to retain licensure and continue to work under supervision, although possibly in an area where access to controlled drugs is difficult. It is necessary for the employer to have information regarding the peer assistance assignment. Action is not reported to the Healthcare Integrity and Protection Data Bank until final adverse actions are taken, allowing the nurse to complete the peer assistance program. PTS: 1 DIF: Cognitive Level: Application REF: Page 1161 OBJ: 7 TOP: Impaired nurse KEY: Nursing Process Step: N/A MSC:NCLEX: N/A MULTIPLE RESPONSE 31. During the initial intake assessment of a drug user, the nurse should attempt to obtain which subjective data? (Select all that apply.) a. Usual pattern of use b. Specific drug c. Previous arrests d. Amount of drug used e. Time of last use ANS: A, B, D, E Determining the drug, strength, frequency, last use, and pattern of use is the basic database on a substance abuser. PTS: 1 DIF: Cognitive Level: Application REF: Page 1149
OBJ: 4 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 32. The nurse should assess a patient for which criteria of addiction? (Select all that apply.) a. Excessive use of the substance b. Increase in social function c. Uncontrollable consumption d. Increase in economic function e. Psychological disturbances ANS: A, C, E Criteria for addiction include excessive use of the substance, a decrease in social function, uncontrollable consumption, a decrease in economic function, and psychological disturbances. PTS: 1 DIF: Cognitive Level: Application REF: Page 1146 OBJ: 1 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 33.A nurse suspects her a co-worker is abusing drugs. Which of the following symptoms, noticed in the co-worker, would contribute to the suspicions? a. Spending more time with co-workers b. Frequently absent from the unit c. Rapid changes in mood and performance d. Increased somatic complaints e. Patients report they did not receive their medications ANS: B, C, D, E Signs of drug abuse in a nurse include the nurse becoming more isolated from co-workers, being frequently absent from the unit, rapidly changing mood and performance, increasing somatic complaints, and patients reporting they did not receive their medications. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1146 OBJ:7TOP:Mental illness KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity COMPLETION
34. When assessing an alcoholic patient, the nurse notes short-term memory
loss, painful extremities, footdrop, and muttered incoherent responses to questions. The nurse recognizes these symptoms as most likely related to a condition caused by long-term alcohol abuse, which is known as syndrome. ANS: Korsakoff Korsakoff syndrome is a permanent condition caused by long-term alcohol use. The patient mutters incoherently and experiences short-term memory loss, painful extremities, and footdrop. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1148 OBJ: 4 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 35. The nurse uses the CAGE questionnaire to assess a patient. The nurse suspects the patient is an alcoholic if there are affirmative answers for items on the questionnaire. ANS: 2 two An affirmative answer on two or more questions on the CAGE questionnaire is reason to assess more closely for possible alcohol abuse. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1149 OBJ: 4 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 36. The nurse cautions that a person who chronically abuses drugs may experience mental impairment. The area of the brain that can be affected and permanently damaged is the . ANS: limbic system The most commonly abused drugs act on the limbic system of the brain and can cause permanent damage. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1153 OBJ: 4 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Chapter 36: Home Health Nursing My Nursing Test Banks Chapter 36: Home Health Nursing Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What became effective in 1966 by an act of legislation that revolutionized home care? a. Life insurance b. Medicare c. Private insurance d. Social Security ANS: B When Medicare became effective in 1966, it revolutionized home care by changing it to a medical rather than nursing model of practice, defining and limiting services it would reimburse, and changing the payment source and even changing the reason home care was provided. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1165 OBJ: 2 TOP: Home health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 2.A major change to Medicare reimbursement was implemented in 1983. The new system paid a set rate according to diagnosis. What was the new payment system based upon? a. Interim payment systems b. Diagnosis-related groups c. Title XVIII d. Title XIX ANS: B The new payment system introduced in 1983 provided reimbursement based upon set rates that were determined by diagnosis-related groups (DRGs). PTS: 1 DIF: Cognitive Level: Application REF: Page 1165 OBJ: 2 TOP: Home health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 3. How often must the homecare treatment plan be recertified in order for the patient to continue to receive services? a. Every 3 days
b. Every 60 days c. Every 10 days d. Every 2 weeks ANS: B Medicare and Medicaid home care services are based on the medical model of treatment and depend on the physician for entry into the formalized system. Medicare requires a plan of treatment signed by the physician, outlining all disciplines, treatment, frequency, and duration. These orders must be recertified every 60 days. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1169 OBJ: 2 TOP: Home health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 4. Nurses who work in home settings rather than a hospital setting require a different level of ability to be technically proficient, self-motivated, and innovative. This requires a higher level of what quality? a. Knowledge b. Performance c. Independence d. Cooperation ANS: C The independence of home care practice can be difficult for nurses who depend on the security of the institutional setting. PTS: 1 DIF: Cognitive Level: Application REF: Pages 1169-1170 OBJ: 7 TOP: Home health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 5. The LPN/LVN may provide many services to the patient in the home. Several of these are high-level skills. Under whose supervision should these high-level skills be directed and performed? a. Physician b. Family c. Facility supervisor d. RN ANS: D
The LPN/LVN must always work under the supervision of an RN. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1170 OBJ: 7 TOP: Home health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 6. For physical therapy services to be reimbursed by Medicare, what must be the goal of the therapy? a. Preventive b. Restorative c. Maintenance d. Educational ANS: B The goals of treatment must be restorative in order for Medicare to provide reimbursement. In some cases, the goals can be preventive or maintenance for other payer sources. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1171 OBJ: 5 TOP: Services KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 7. Speech therapy goals include minimizing speech disorders and maximizing rehabilitation of speech abilities. To be reimbursed by Medicare, who must provide these services? a. Bachelors-level clinician b. Speech therapist c. Masters-level clinician d. Physiatrist ANS: C To be reimbursed by Medicare, speech therapy must be provided by a masters-prepared clinician. Other payers will sometimes reimburse services provided by a bachelors-level clinician. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1171 OBJ: 5 TOP: Services KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 8. Medical social services focus on the emotional and social aspects of illness. What is another area of service?
a. Home problems b. Marriage problems c. Crisis intervention d. Work problems ANS: C Coping with stress and crisis intervention are also part of medical social workers services. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1172 OBJ: 5 TOP: Services KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 9. If solely for this reason, Medicare will not cover home health aide visits. What is that reason? a. Physical assistance b. Physician orders c. Personal care d. Household chores ANS: D Medicare will not pay for visits made solely for household chores. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1172 OBJ: 5 TOP: Services KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 10. The patient, family, social service agency, hospital, physician, or another agency all can provide the entry point to the home health care system. What is the entry point for the home health care system called? a. Recommendation b. Survey c. Referral d. In-taking ANS: C The entry point for home health care system is by referral. This can come from the patient, family, social service agency, hospital, physician, or another agency. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1172
OBJ: 5 TOP: Home health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 11. The initial evaluation and admission visit is made by an RN, who has been provided with general orders by a physician before the visit. This visit must be made within how many hours of the referral? a. 4 to 8 b. 12 to 15 c. 18 to 24 d. 24 to 48 ANS: D The initial evaluation and admission visit made by an RN must be made within 24 to 48 hours of the referral. In some cases, if nursing will not be providing any services, the physical therapist may conduct the admission visit. PTS: 1 DIF: Cognitive Level: Application REF: Page 1172 OBJ: 8 TOP: Home health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 12. The evaluation and admission process for entry to the home health care system includes physical and psychosocial examination, explanation of the patients rights, and evaluation of family, home, and nursing interventions. What is the normal minimum time for the admission visit? a. 30 minutes b. 1 hour c. 2 hours d. 3 hours ANS: B The admission process typically takes a minimum of 1 hour. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1173 OBJ: 8 TOP: Home health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 13. After the patient is admitted to the home health services system, a treatment plan is drafted cooperatively with the physician and is signed. A separate, detailed care plan is always required for which disciplines?
a. Registered nurse b. Physical therapist c. Home health aide d. LPN/LVN ANS: C A separate, detailed care plan is always required for the home health aide. PTS: 1 DIF: Cognitive Level: Application | Cognitive Level: Knowledge REF: Page 1173 OBJ: 5 TOP: Home health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 14. How long is the average home health care visit by the skilled nurse? a. 10 to 15 minutes b. 20 to 30 minutes c. 30 to 45 minutes d. 45 to 60 minutes ANS: C Skilled nursing visits typically take 30 to 45 minutes. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1173 OBJ: 6 TOP: Home health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 15. Complete documentation is essential and must include an accurate picture of the type and quality of care given, as well as the effectiveness of the plan of care. Which model should be followed to best provide adequate documentation? a. Caretaker b. Nursing process c. Home health care d. Nursing efficiency ANS: B Documentation that follows the nursing process model provides an accurate picture of the type and quality of care. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1173 OBJ: 8 TOP: Home health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A
16. When should discharge planning begin for a patient receiving home care
services? a. A week before discharge b. Two days before discharge c. The day of discharge d. On admission ANS: D Discharge planning for home care begins on admission. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1173 OBJ: 8 TOP: Discharge KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 17. When implementing quality assurancespecific criteria, measurements are developed for three criteria: structural, process, and outcome. How is this method of assessment different from previous methods? a. It is objective b. It is specific c. It is subjective d. It is generalized ANS: A In the past, measurements of quality in an agency, the care delivered, and the staff were all subjective. The quality assurancespecific criteria measurements are objective. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1174 OBJ: 4 TOP: Quality assurance KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 18. What is an eligibility requirement for an individual to qualify for Medicare services? a. Retired b. At least 65 years old c. Low-income d. Poor health ANS: B Beneficiaries of service must be at least 65 years of age.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 1174-1175 OBJ: 9 TOP: Reimbursement KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 19. Medicaid pays for home care services for people who have low incomes. Who administers the Medicaid program? a. Federal government b. City government c. State government d. County government ANS: C Medicaid is administered by the state. Medicare is a federal program. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1175 OBJ: 9 TOP: Reimbursement KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 20. During a time of acute illness, the family may become extremely distressed and neglect the needs of other family members. On what does the family seem to focus? a. The outcomes b. The disease c. The physician d. The patient ANS: D During times of acute illness, the family may become extremely distressed and focus only on the patient. The nurse can refer family members to an appropriate resource. PTS: 1 DIF: Cognitive Level: Application REF: Page 1177 OBJ: 8 TOP: Nursing process KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 21. What should be the focus when the family and the patient work with the nurse to plan interventions? a. Determining actions b. Participating in care c. Setting goals
d. Celebrating achievements ANS: C When planning interventions, it is important that the nurse work with the patient and the family on setting goals. PTS: 1 DIF: Cognitive Level: Application REF: Page 1177 OBJ:8TOP:Nursing process KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 22. The nurse should provide the patient and family with accurate health information concerning diagnoses and progress. What will accurate information help the family to become? a. Active participants b. Effective caregivers c. Encouraged supporters d. Active providers ANS: B Providing accurate information about the diagnosis and progress helps the family to be effective caregivers. PTS: 1 DIF: Cognitive Level: Application REF: Page 1177 OBJ:8TOP:Nursing process KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 23. Because many illnesses are now controlled rather than cured, the number of people with chronic, debilitating illnesses has increased. What do home care nurses prevent by providing? a. Deaths b. Increased morbidity c. Increased hospitalization d. Acute episodes ANS: D Home care provides assessment and evaluation of chronic illnesses to prevent acute episodes. PTS: 1 DIF: Cognitive Level: Application REF: Page 1177
OBJ: 8 TOP: Home health KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 24. What is the fastest-growing group in the U.S. population today? a. 30- to 40-year-olds b. 40- to 50-year-olds c. 50- to 65-year-olds d. Those 85 and older ANS: D The age group older than 85 is the fastest-growing group in the United States today. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1177 OBJ: 8 TOP: Aging KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 25. By offering enteral, parenteral, intravenous, and blood transfusion therapies, what can home care services prevent? a. Morbidity b. Hospitalization c. Hospice care d. Mortality ANS: B Home care services can prevent hospitalization by offering enteral, parenteral, intravenous, and blood transfusion therapies. Morbidity, mortality, and hospice care cannot be prevented. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1177 OBJ: 6 TOP: Home health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 26. What has been influenced by the increase in home health providers supporting healthy living and illness prevention, and a movement toward deinstitutionalization of technology-dependent children and adults? a. Criteria for admission b. Age of eligibility c. Reimbursement criteria d. Length of financial support
ANS: C The increase in home health providers supporting healthy living and illness prevention and the movement toward deinstitutionalization of technologydependent children and adults resulted from Medicare and third-party payers changing reimbursement criteria. PTS: 1 DIF: Cognitive Level: Application REF: Page 1177 OBJ: 9 TOP: Home health KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 27. The licensed nurse can delegate which task(s) to the home health assistive personnel? a. Bathing the patient b. Assessing ability to void c. Administering an injection d. Teaching about medications ANS: A Bathing the patient is a task that can be delegated safely to the home health assistive personnel. Home health assistive personnel cannot assess, teach, or administer injections. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1172 OBJ: 5 TOP: Home health KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 28. The home health nurse plans interventions to meet which general service goals? (Select all that apply.) a. Restore function as is appropriate b. Improve level of function c. Maintain current health level d. Ensure return of health e. Teach healthy lifestyle ANS: A, B, C, E The general service goals are restoration, improvement, maintenance, and promotion of health. PTS: 1 DIF: Cognitive Level: Application REF: Page 1169
OBJ: 8 TOP: Home health KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance COMPLETION 29. The nurse describes a new technological service to the patient that will monitor several assessments remotely. This new intervention is known as home visits. ANS: electronic Electronic programs call and gather information from patients remotely. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1168 OBJ:3TOP:Electronic interviews KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 30. When the decision is made with the family to place the patient on hospice care, the home health nurse explains that the reimbursement changes from fee per visit to fee per . ANS: diem Medicare-supported hospice care is billed on a fee per diem. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1168 OBJ: 9 TOP: Hospice KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 31. The nurse can best confirm that the patient understands the communication by obtaining from the patient. ANS: feedback Feedback confirms that the patient has understood the communication. PTS: 1 DIF: Cognitive Level: Application REF: Page 1176 OBJ:4TOP:Communication KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance Chapter 37: Long-Term Care My Nursing Test Banks Chapter 37: Long-Term Care Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition
MULTIPLE CHOICE 1. The home health nurse is assisting a family to select a long-term care facility for an 80-year-old widow in good health who no longer drives, loves to play cards, can ambulate with a walker, and is oriented. Which facility would be the best selection for this patient? a. Subacute unit setting b. Long-term care facility (nursing home) c. Assisted living center d. Continuing care retirement center (CCRC) ANS: C The assisted living center provides meals, transportation, social interaction, and a home-like quality without the intrusion of the medical model. The patients age does not make her a reasonable candidate for a CCRC. The patient does not require acute skilled nursing care. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1184 OBJ:2TOP:Long-term care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. The home health nurse helps an older adult couple plan changes in their home that will facilitate care in their home as they age. What percentage of people over 65 live in a home setting? a. 42% b. 48% c. 55% d. 67% ANS: D The majority (67%) of people over the age of 65 live in a home or family setting. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1181 OBJ:2TOP:Long-term care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. The nurse confirms that the cost of caring for a relatively unimpaired older
adult in a private home is approximately what fraction of the cost of placing the older adult in a long-term care facility? a. b. 1/3 c. d. 2/3 ANS: C It costs approximately half as much to care for an older adult at home as it would cost in a long-term care facility. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1182 OBJ:4TOP:Long-term care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. What is the goal for services provided by home health care agencies? a. Self-care b. Assisted living c. Rehabilitation d. Improved function ANS: C Services provided by home health care agencies are aimed at rehabilitation. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1182 OBJ: 8 TOP: Home health KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. The nurse clarifies to the family of a patient that one of the roles of the LPN/LVN in the home care setting is to evaluate the care provided to the patient by which provider? a. The family b. Other licensed care providers c. Nonlicensed staff d. The physician ANS: C One of the roles of the LPN/LVN in the home care setting may be to evaluate the care provided by CNAs, HHAs, homemakers, and personal care
attendants. PTS: 1 DIF: Cognitive Level: Application | Cognitive Level: Comprehension REFage 1183OBJ:7TOP:Home health KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. The family caring for an older adult in their home feels that they need assistance from a hospice service. What is necessary for hospice service to be initiated? a. A family request b. A patient request c. Medical certification d. A referral by a hospice nurse ANS: C Hospice agencies provide care at the end of life. Medical certification is required for terminal care. PTS: 1 DIF: Cognitive Level: Application REF: Page 1183 OBJ: 8 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. The nurse suggests to a family caring for a member with early Alzheimer disease in their home that they investigate the services of an adult day carecenter. What is a major benefit of adult day care centers? a. It takes the patient out on recreational outings. b. It can provide daily hygiene. c. It expands social interaction. d. It is free to the public. ANS: C Adult day care centers are open a large part of the day and offer several modalities to enhance social interaction and also give the family respite. PTS: 1 DIF: Cognitive Level: Application REF: Page 1183 OBJ:8TOP:Adult day care KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8. What differentiates the services of a long-term care facility from that of an
assisted living facility? a. Skilled nursing care b. Personal care services c. Weekly visits by the staff physician d. Intensive rehabilitation services ANS: B Assisted living is a type of residential care setting where the resident receives personal care services. PTS: 1 DIF: Cognitive Level: Application REF: Page 1184 OBJ:8TOP:Long-term care KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. What would be the most appropriate guidance the nurse could provide an older adult couple that is considering a continuing care retirement community (CCRC)? a. Admittance is limited to people who are relatively unimpaired. b. A contract is usually a lifetime commitment. c. A contract is an acceptable tax shelter. d. Contracts can be signed on a month-to-month basis. ANS: B CCRCs offer a complete range of health care services, from independent living to 24-hour skilled nursing. In most cases, signing a contract with a CCRC is a lifetime commitment. PTS: 1 DIF: Cognitive Level: Application REF: Page 1185 OBJ:8TOP:Long-term care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 10. An 82-year-old patient recovering from a hip replacement could be expected to move from the acute care hospital to which setting for rehabilitation? a. A subacute care unit b. An assisted living center c. An adult day care center
d. A continuing care retirement community ANS: A Subacute units have a strong rehabilitative focus and a shorter length of stay than a long-term care center. PTS: 1 DIF: Cognitive Level: Application REF: Page 1185 OBJ: 1 TOP: Subacute KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 11. What is the correct term for people who live in long-term care facilities? a. Patients, because they will be receiving acute care b. Residents, because the facility has become their home c. Patients, because they seek professional medical services d. Customers, because they are purchasing care service ANS: B The older adult in a long-term care facility is referred to as a resident to reinforce the home-like environment. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1186 OBJ:2TOP:Long-term care KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. Which statement is true concerning a 50-year-old patient recovering from a stroke who is going to a long-term care facility for a short stay? a. Her regular hospitalization insurance will pay for the care. b. She will still have daily physician visits. c. She will need to contract outside physical therapy services. d. She will probably be discharged within 6 months. ANS: D A short-stay resident in a long-term care facility for rehabilitation will have residential physical therapy services and will usually be discharged within 6 months. Regular hospitalization insurance does not cover long-term care. Daily physician visits do not occur in the long-term care facility. PTS: 1 DIF: Cognitive Level: Application REF: Page 1186 OBJ:2TOP:Long-term care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion
and Maintenance 13. In the long-term care facility, health care professionals work together to meet the needs of older adults and to go over the care plan with the resident and family members. What is this approach called? a. Team approach b. Individualized approach c. Interdisciplinary approach d. Outgoing approach ANS: C The long-term care facility is an interdisciplinary setting. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1186 OBJ: 7 TOP: Long-term care KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 14. What is the time limit for the legal administration of medications? a. 30 minutes b. 1 hour c. 90 minutes d. 2 hours ANS: D In long-term care, there is a 2-hour window for legal administration of medications, 1 hour before and 1 hour after the official administration time. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1187 OBJ:3TOP:Long-term care KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 15. The Omnibus Budget Reconciliation Act (OBRA) defines the requirements for which aspect of care as it relates to long-term care? a. Nursing care b. Nutritional support c. Quality of care d. Staffing requirements ANS: C OBRA defines requirements for the quality of care given to residents of long-
term care facilities. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1188 OBJ:3TOP:Long-term care KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 16. The Health Care Financing Administration (HCFA) conducts unannounced institutional surveys annually to assess the quality of life for the patients. The findings of the surveys are reported to: a. various licensing boards. b. facility administrators. c. the public. d. the U.S. Department of Health and Human Services. ANS: C Surveyors are required by law to visit the long-term care facility unannounced, on an annual basis and as needed, and the report is made public. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1188 OBJ:3TOP:Long-term care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 17.A 48-year-old long-term care facility resident expresses concern that the cost of his care has used up his assets. For what program should the nurse suggest that the resident apply to cover the continued cost of living in a longterm facility? a. Medicare b. Hospitalization insurance c. Medicaid d. Public health funds ANS: C When adults have used all of their assets, they may then qualify for Medicaid. Medicaid is a federally funded, state-operated program of medical assistance for people with low incomes. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1188
OBJ:3TOP:Long-term care KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 18. Although the Occupational Safety and Health Act (OSHA) increases the cost of care, what is a benefit that it provides for long-term care? a. It ensures a safe environment for personnel. b. It ensures that medications are administered safely. c. It ensures that food is prepared safely. d. It ensures safe ambulation and transportation of patients. ANS: A The OSHA guidelines significantly increase costs, but they also ensure a safe environment for personnel, which is mandatory today. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1188 OBJ: 3 TOP: Long-term care KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 19.A nurse helps a family understand that once hospice service is initiated, the focus of care changes from rehabilitation and restoration to what type of care? a. Maintaining the patient at the optimal level b. Assisting with funeral planning c. Relieving the family of care d. Maintaining comfort as death approaches ANS: D Hospice care is focused on the provision of comfort to the person who is approaching death. While hospice will assist with funeral planning as needed, it is not the focus of care. Hospice provides respite for the family, but hospice does not relieve the family of care duties. PTS: 1 DIF: Cognitive Level: Application REF: Page 1183 OBJ: 8 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 20. What is included when the LVN/LPN completes the Resident Assessment Instrument (RAI)? a. Minimum Data Set (MDS) and the signature of the physician
b. Resident Assessment Protocols (RAPs) and the drug list c. Minimum Data Set, Resident Assessment Protocols, and the RNs sig d. Resident Assessment Protocols and the signature of the administrator ANS: C The RAI must be signed by the RN and contain the RAPs and MDS. PTS: 1 DIF: Cognitive Level: Application REF: Page 1189 OBJ:3TOP:Long-term care KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 21. The nurse assesses a patients ability to perform self-care activities, as well as more complex social and household activities. What is provided from this assessment? a. Physical status b. Emotional status c. Health status d. Functional status ANS: D The functional status is related to activities of daily living (ADLs) and instrumental activities of daily living (IADLs). PTS: 1 DIF: Cognitive Level: Application REF: Page 1189 OBJ:2TOP:Long-term care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 22. How often does the Omnibus Budget Reconciliation Act (OBRA) require that a summary (including vital signs and weight) be obtained in the longterm care setting? a. Daily b. Weekly c. Monthly d. Yearly ANS: C A summary, including vital signs and weight, is only required on a monthly basis.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1189 OBJ:3TOP:Long-term care KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 23. In a long-term care facility, the nurse takes an active part in formulating the residents plan of care. How often is the plan of care revised? a. Weekly b. Every 90 days c. Monthly d. Every six months ANS: B In long-term care, the residents plan of care is reviewed by the interdisciplinary team every 90 days for resolution of problems or revision of goals and interventions. PTS: 1 DIF: Cognitive Level: Application REF: Page 1190 OBJ:3TOP:Nursing process KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 24. The nurse recognizes that an ongoing assessment will help set priorities in the nursing care plan of a long-term care resident. What does this allow the planning process to become? a. Timely b. Patient-centered c. Preferential d. Categorized ANS: B The planning process must be patient-centered. PTS: 1 DIF: Cognitive Level: Application REF: Page 1191 OBJ:6TOP:Nursing process KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 25. The long-term care facility nurse recognizes that visiting the resident, changing his or her position, assessing for incontinence, providing skin care,
and offering fluids are part of the nurses responsibility. What does the initiation of these interventions provide? a. Continuity b. Safety c. Prevention d. Reassurance ANS: B Nursing interventions basic to long-term care include monitoring such safety measures as changing the residents position every two hours, assessing for incontinence, providing skin care when needed, and offering fluids. PTS: 1 DIF: Cognitive Level: Application REF: Page 1190 OBJ:6TOP:Nursing process KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 26. How often should the long-term care facility nurse make rounds and monitor residents for safety? a. Every 2 hours b. Every 4 hours c. Every 6 hours d. Once per shift ANS: A Nursing interventions related to long-term care include making rounds and monitoring for resident safety every 2 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 1190 OBJ:7TOP:Nursing process KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 27. When a patient asks why he must be transferred to a subacute unit from the hospital, what would be an appropriate response by the nurse? a. Reimbursement guidelines limit adults stays in an acute setting. b. The physician can oversee care more closely in a subacute setting. c. Financial restrictions of insurance limit time spent in an acute care se d. Cost and services at the acute care setting are the same as at the hosp
ANS: A In the acute care setting, strict rules about length of stay and limitations in cost reimbursement limit the amount of time adults can be hospitalized. These strict reimbursement rules for acute care do not apply, however, to subacute care provided in a skilled nursing facility setting. PTS: 1 DIF: Cognitive Level: Application REF: Page 1185 OBJ:3TOP:Nursing process KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 28. The LPN/LVN performs which function(s) when working as a staffing coordinator of a home health agency? (Select all that apply.) a. Scheduling appropriate care providers b. Reviewing documentation c. Verifying financial coverage d. Making referrals e. Performing comprehensive assessments ANS: A, C Reviewing documentation may be done by an LPN/LVN but not in the role of staffing coordinator but as a medical chart auditor or reviewer. Scheduling care providers and verifying financial coverage are among the duties of the staffing coordinator. Making referrals and performing comprehensive assessments are duties of the RN. PTS: 1 DIF: Cognitive Level: Application REF: Page 1183 OBJ:8TOP:Staffing coordinator KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 29. The LPN/LVN suggests to the RN that the nursing care plan be modified to include referral to an adult day care center. What benefits should the client expect to receive? (Select all that apply.) a. Overnight care b. Respite care for the family c. Social interaction for the patient
d. Mental stimulation for the patient e. Supporting maintenance of the ADLs ANS: B, C, D, E Overnight care is usually not offered from a day care center. PTS: 1 DIF: Cognitive Level: Application REF: Page 1183 OBJ:8TOP:Adult day care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 30.A daughter is assessing a nursing home before placing her mother there for what she feels will be a long-term stay. Which of the following are important aspects of quality to consider when selecting a nursing home? (Select all that apply.) a. Privacy is respected b. Staff members are task-focused c. The staff welcomes family visits d. There is a homelike environment e. Rooms are maintained like a hospital ANS: A, C, D It is important that privacy is respected, family members are welcomed, and a homelike environment is maintained. Staff members should be residentfocused, not task-focused. Rooms should be maintained like a home instead of like a hospital. PTS: 1 DIF: Cognitive Level: Application REF: Page 1187, Box 37-4 OBJ: 7 TOP: Quality Indicators KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 31. What impact will the Affordable Care Act have on nursing homes and long-term care centers when fully implemented? (Select all that apply.) a. A weaker consumer complaint system b. Better training for state inspectors c. Program to support national criminal background checks d. Public disclosure of nursing home owners and operators e. Training of nursing assistants in the care of people with dementia ANS: B, C, D, E
The Affordable Care Act will result in a stronger consumer complaint system, better training for state inspectors, a program to support national criminal background checks, public disclosure of nursing home owners and operators, and training for nursing assistants in the care of people with dementia. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1188, Box 37-5 OBJ: 3 TOP: Federal Regulations KEY: Nursing Process Step: N/A MSC:NCLEX: N/A COMPLETION 32. The nurse explains to a patient that shopping, using a phone, and administering his own medications are classified as activities of daily living. ANS: instrumental IADLs are more complex skills than ADLs and indicate a higher level of independent functioning. PTS: 1 DIF: Cognitive Level: Application REF: Page 1184 OBJ: 8 TOP: Instrumental activities of daily living (IADLs) KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 33. When a resident who is a Muslim becomes concerned about his religiously dictated dietary requirements, the nurse may refer this concern to the long-term care department. ANS: dietary Long-term facilities take into consideration the patients individual needs, including diet preferences. The dietary department is usually able to meet most requests. PTS:1DIF:Cognitive Level: Application REF: Page 1181, Cultural Considerations OBJ: 7 TOP: Ethnic considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 34. Two unique members of the caregiving team in a long-term care facility are the aide/technician and the assistant.
ANS: certified medication, restorative nursing These two members of the care team are unique to the long-term care facility. Both have had extra training over and above that of the certified nursing assistant. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 1187-1188 OBJ: 8 TOP: Long-term caregiving team KEY: Nursing Process Step: N/A MSC:NCLEX: N/A Chapter 38: Rehabilitation Nursing My Nursing Test Banks Chapter 38: Rehabilitation Nursing Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse who is part of a team focused on restoring an individual to the fullest physical, mental, social, vocational, and economic capacity is practicing what type of nursing? a. Holistic nursing b. Conscientious nursing c. Rehabilitation nursing d. Comprehensive nursing ANS: C Rehabilitation is the process of restoring an individual to the fullest physical, mental, social, vocational, and economic capacity of which he or she is capable. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1193 OBJ: 1 TOP: Rehabilitation KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 2. The nurse recognizes that the rehabilitation process involves the efforts of various disciplines. The focus of rehabilitation is to build on which area? a. A persons losses b. A persons long-term plans c. A persons drives d. A persons abilities ANS: D The underlying philosophy of rehabilitation is to focus on the abilities of the
patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 1193 OBJ:1TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. The nurse should tell a paraplegic that the rehabilitation experience will consist of: a. relearning former skills. b. learning to walk. c. learning new skills to adapt to a different lifestyle. d. developing muscle strength. ANS: C The type and the focus of rehabilitation are individualized to the patient, the injury, and abilities. Skills will be taught to enhance the patients adaptation to a new lifestyle. PTS: 1 DIF: Cognitive Level: Application REF: Page 1195 OBJ:3TOP:Rehabilitation KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. The nurse who helps a patient with a disability rejoice in the acquisition of the smallest new skill is embracing which rehabilitation philosophy? a. Resolving impairments b. Removing disabilities c. Increasing quality of life d. Eliminating complications ANS: C A philosophy of rehabilitation is to increase the quality of life. Impairments may not be able to be resolved, disabilities may not be able to be completely removed, and complications may not be totally eliminated. However, with rehabilitation, the individual can learn to adjust to the new lifestyle. PTS: 1 DIF: Cognitive Level: Application REF: Page 1195 OBJ:1TOP:Rehabilitation KEY:Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance 5.A patient with quadriplegia resulting from a spinal cord injury says to the rehabilitation nurse, Im sick of this therapy! What is an occupational therapist going to do for me? Can she give me an occupation? What response by the nurse would be the most helpful? a. No, but the occupational therapist can show you how to enjoy some re Yes, in a way. The occupational therapist provides training that streng b. can still control. Maybe. The occupational therapist recommends adaptive equipment t c. more independent. No, the voc-rehab counselor helps with employment. The occupationa d. you for improved communication skills. ANS: C The occupational therapist recommends adaptive equipment or helps in modifying skills to enhance independence. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1196, Table 38-1 OBJ:4TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 6. When caring for a patient with a disability, the rehabilitation nurse provides individual treatment to help the patient stay focused on which goals? a. Returning to normal b. Independence c. Employment d. Promotion of health ANS: B The focus on rehabilitation is on enabling the individual to move from a totally dependent state to a level of independence. PTS: 1 DIF: Cognitive Level: Application REF: Page 1197 OBJ:3TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. Following admission, how soon must a comprehension rehabilitation plan of care be implemented on a rehabilitation patient?
a. 12 hours b. 24 hours c. 3 days d. 1 week ANS: B A comprehensive rehabilitation plan must be initiated within 24 hours of admission to the rehabilitation service. The results of the interdisciplinary assessment provide the basis for development of the plan of care. The team has 3 days from admission to review and revise the plan of care. PTS: 1 DIF: Cognitive Level: Application REF: Page 1195 OBJ:4TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8. Which is a characteristic of the interdisciplinary approach to the rehabilitation team? a. Each discipline makes its own goals for the patient. b. There are clear boundaries between the disciplines. There is a combination of expanded problem solving beyond the boun c. individual disciplines. d. Cross-trained people are used who have functional ability in two or m ANS: C In the interdisciplinary approach, the team collaborates on the goals for the patient. In the multidisciplinary rehabilitation team approach, each discipline makes its own goals for the patient and there are clear boundaries between the disciplines. The transdisciplinary rehabilitation team is characterized by the blurring of boundaries between disciplines and the cross-training and flexibility to reduce a duplication of efforts. PTS: 1 DIF: Cognitive Level: Application REF: Page 1196 OBJ:4TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. When planning care for children, the nurse uses a concept that recognizes the pivotal role of the family in the lives of children with disabilities or other chronic conditions. What is this philosophy called?
a. Child-centered care b. Systems-centered care c. Family-centered care d. Individual-centered care ANS: C Family-centered care is an evolving concept that uses the family as equal partners in the rehabilitation process. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1198 OBJ:6TOP:Rehabilitation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 10. What is the primary difference between the rehabilitation of children and the rehabilitation of adults? a. Level of disability b. Body part involved c. Degree of disability d. Developmental potential ANS: D The primary difference between rehabilitation of children and rehabilitation of adults is the developmental potential of the child. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1206 OBJ:10TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 11. The acquisition of adaptive skills and behaviors by an individual who has been disabled since birth refers to: a. training. b. education. c. development. d. habilitation. ANS: D Habilitation refers to developing skills and behaviors in people who did not have the skills originally. Children who are disabled from birth have no skills
to relearn and are habilitated rather than rehabilitated. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1206 OBJ: 10 TOP: Habilitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. The nurse who is engaged in gerontological rehabilitation nursing has a dual challenge. The gerontological rehabilitation nurse must assess not only the debilitating factors of disease but also which other factor? a. Advancing age b. Reduced ability to learn c. Limited energy d. Eroded interest level ANS: A Gerontological rehabilitation nursing focuses on the unique requirements of older adult rehabilitation. The elderly, with their potential physical limitations, require specialized care. PTS: 1 DIF: Cognitive Level: Application REF: Page 1207 OBJ:10TOP:Rehabilitation KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 13. The nurse explains that the main roles of the gerontological rehabilitation nurse are to provide rehabilitative care and what other role? a. Provide restoration b. Teach prevention c. Teach adaptive skills d. Provide positive reinforcement ANS: B Teaching prevention is the dual role of the geriatric rehabilitation nurse. Restoration, adaptive skills, and positive reinforcements are all part of providing rehabilitative care. PTS: 1 DIF: Cognitive Level: Application REF: Page 1207 OBJ:10TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
14. What should the nurse do to reduce the incidence of postural hypotension
in a patient with a spinal cord injury? a. Monitor diastolic blood pressure closely b. Encourage the patient to remain in the bed c. Raise the head of the bed for 15 to 20 minutes before transfer to a wh d. Encourage adequate intake of fluids to expand fluid volume ANS: C Raising the head of the bed before transfer allows for gradual vessel accommodation from the supine position to the upright position. It is important to check the patients blood pressure, but it will not reduce the incidence of postural hypotension. It is important to encourage the patient to get out of bed. Postural hypotension is related to a pooling of blood in the lower extremities and is not related to a fluid volume deficit. PTS: 1 DIF: Cognitive Level: Application REF: Page 1202 OBJ:7TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse takes special care to be gentle in caring for patients with spinal cord injuries to avoid stimulating the autonomic nervous system and triggering which condition? a. Paresis b. Heterotopic ossification c. Postural hypotension d. Autonomic dysreflexia ANS: D Autonomic dysreflexia is a sudden and extreme elevation in blood pressure caused by a reflex action of the autonomic nervous system. It is the result of stimulation of the body below the level of the spinal cord injury. PTS: 1 DIF: Cognitive Level: Application REF: Page 1204 OBJ:7TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse instructs the mother of a 5-year-old who sustained a mild brain
injury that although all neurologic evaluations are normal, her child may exhibit postconcussive syndrome. What are common characteristics of this syndrome? a. Convulsions and high fever b. Irritability and memory deficits c. Muscular twitching and muscle pain d. Paresis of limbs and fatigue ANS: B Mild brain injury is characterized by brief or no loss of consciousness. This type constitutes the majority of head injuries. Neurologic examinations are often normal. Postconcussive syndrome can persist for months, years, or indefinitely. Signs and symptoms include fatigue, headache, vertigo, lethargy, irritability, personality changes, cognitive deficits, decreased information processing speed and memory, understanding, learning, and perceptual difficulties. PTS: 1 DIF: Cognitive Level: Application REF: Page 1204 OBJ:7TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. When changing the position of a patient with a spinal cord injury at T4, the nurse should recognize that what symptom is an indication of an episode of autonomic dysreflexia? a. Nausea b. Pallor c. Goose bumps d. Dizziness ANS: C Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure ulcers, position changes (from lying to
sitting), and even wrinkles in clothing or bed sheets. Other symptoms may include diaphoresis, shivering, goose bumps, flushing of the skin, and a severe pounding headache. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1204 OBJ:7TOP:Rehabilitation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18. When assessing a patient with a traumatic brain injury, the nurse notes that his memory is improving. The nurse should explain to the family that what other symptom may occur with memory improvement? a. Decrease in learning ability b. Depression c. Anger d. Increased concentration ANS: B Generally, the more memory improves in a patient with a brain injury, the more the patient becomes depressed. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1205 OBJ:7TOP:Rehabilitation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 19. When caring for a 32-year-old Hispanic male who has become disabled, on what should the rehabilitation team base the priority of treatment goals? a. Difficulty of the language barrier b. Cultural significance of the disability c. Depth of the patients support system d. Attitude toward rehabilitation ANS: B Culture defines the significance of disease and disability. Although all of the options must be addressed, the significance of the disability has highest priority. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1199 OBJ:2TOP:Rehabilitation
KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 20. What is the best way to define a handicap? a. Any loss of function b. A disability that interferes with ones normal functioning c. Any loss of ability to perform activities of daily living d. An irreversible lifelong impairment ANS: B A handicap is a disadvantage for a given individual from an impairment that limits his or her role performance. A particular handicap for one person might not pose any handicap for another with the same disability. An impairment is a loss of function. A functional limitation is a disability that interferes with ones normal functioning. A chronic illness is an irreversible lifelong impairment. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1194 OBJ:1TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 21. What should the nurse do to decrease the potential for a deep vein thrombosis (DVT) in a patient who is a paraplegic from a spinal cord injury? a. Massage the patients legs daily b. Perform passive range-of-motion exercises c. Encourage frequent warm baths d. Allow the patients legs to dangle for a period of 10 minutes several ti
ANS: B DVTs are a problem for patients with a spinal cord injury. Passive range-ofmotion exercises manipulate the muscles, which improves venous return, reducing the probability of DVT. PTS: 1 DIF: Cognitive Level: Application REF: Page 1204 OBJ:5TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 22. When the nurse observes a patient experiencing a severe episode of autonomic dysreflexia, what should be the initial intervention? a. Locate the cause of irritation b. Assess the blood pressure c. Cover the patient with several blankets d. Raise the head of the bed to a high Fowler position ANS: D The head of the bed should be raised immediately. Raising the head of the bed will reduce the blood pressure. Finding the cause of the episode is secondary to preventing the possibility of a stroke from the hypertension. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1204 OBJ:5TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. When speaking to a group of high school students, the rehabilitation nurse states that spinal cord injuries resulting in paralysis occur mainly as the result of traumatic accidents in which group of individuals? a. Middle-aged men b. Older adult females c. Young males d. Young females ANS: C Individuals paralyzed by spinal cord injuries are primarily young males. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1201 OBJ:2TOP:Rehabilitation
KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 24. The spinal cord injury patient has paralysis of all extremities and bowel and bladder disturbance. The nurse recognizes the injury as most likely occurring at what vertebral level? a. C1 to C2 b. C3 to C4 c. C2 to C7 d. C4 to C7 ANS: C The vertebral level of injury for a cervical cord is C2 to C7 if the patient has paralysis of all extremities and trunk, and has lost control of bowel and bladder function. PTS: 1 DIF: Cognitive Level: Application REF: Page 1201 OBJ:2TOP:Rehabilitation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. The rehabilitation nurse can use basic rehabilitation skills regardless of the origin of the disability. What intervention would be effective for a person with arthritis, a person with a brain injury, or a person with a spinal cord injury? a. Encouraging large fluid intake b. Seeking spiritual support from a higher being c. Using the spouse as a support system d. Positioning to maintain alignment ANS: D Alignment preservation is an implementation that is appropriate for a variety of rehabilitation patients, regardless of the origin of their disability. PTS: 1 DIF: Cognitive Level: Application REF: Page 1197 OBJ:5TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 26. What should a nurse explain to a patient as a cause of triggering
autonomic dysreflexia? a. Loud sound b. Distended bladder c. Leg cramp d. Sudden chilling ANS: B Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure ulcers, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1204 OBJ:5TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The rehabilitation nurse stresses to the family of a patient with a brain injury that difficult and painful rehabilitation will probably be required for what length of time? a. 1 to 2 years b. 2 to 4 years c. 5 to 10 years d. 6 to 12 years ANS: C Most brain-related disabilities, including physical, cognitive, and psychosocial difficulties, call for at least 5 to 10 years of difficult and painful rehabilitation; many require lifelong treatment and attention. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1204 OBJ:7TOP:Rehabilitation KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 28. The rehabilitation nurse recognizes that the majority of patients with head
injuries show no abnormal neurologic findings and experience no loss of consciousness. How should the nurse categorize this type of brain injury? a. Mild b. Moderate c. Severe d. Catastrophic ANS: A Mild brain injury is characterized by no loss of consciousness and no abnormal neurologic findings. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1204 OBJ:2TOP:Rehabilitation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29.A 33-year-old patient with a spinal cord injury says to the nurse, Ive let my family down. I dont know what to do. What would be the best response by the nurse? a. After your rehabilitation starts, youll feel better. b. You should be grateful you are alive. c. What does this injury mean to you? d. Technological advances are changing the future for spinal cord injury ANS: C The patient should be encouraged to express his or her feelings about the disability. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1201 OBJ:5TOP:Rehabilitation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychological Integrity 30. The nurse used a diagnosis of impaired cognition for a 40-year-old patient with a brain injury. Which assessment data would support the diagnosis? a. Frequently becomes violent b. Becomes easily fatigued c. Is depressed d. Cannot add three numbers in his head
ANS: D Impaired cognition includes problems in thinking, impaired concentration, and impaired information processing. PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 1204-1205 OBJ:5TOP:Rehabilitation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31. The patient with a brain injury is beginning to regain memory. The nurse explains to the family that what will most likely occur? a. The patient will become less combative. b. The patient will become angrier. c. The patient will become more depressed. d. The patient will wish to retire. ANS: C Generally, the more the memory improves, the more the patient becomes depressed. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1205 OBJ:7TOP:Rehabilitation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 32. The nurse explains that the Americans with Disabilities Act of 1990 defines a person as disabled if which criteria are met? (Select all that apply.) a. The person has a physical or mental impairment. b. The person is limited in at least one major life activity. c. The person has a medical record of the impairment. d. The person is unemployed. e. The person needs assistance in completion of ADLs. ANS: A, B, C The definition is that a disabled person may have a physical or mental impairment that limits the person in one or more major life activities and has a medical record of that disability. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1201
OBJ:2TOP:Americans with Disabilities Act (ADA) KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 33. The nurse is caring for a victim of post-traumatic stress syndrome. The nurse identifies which techniques as examples of therapeutic communication? (Select all that apply.) a. Listening b. Reframing c. Characterizing d. Normalizing responses e. Working to develop trust ANS: A, B, D, E The techniques of therapeutic communication that are important to use with the PTSD patient are listening, reframing, normalizing responses, and working to develop trust. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1201 OBJ: 9 TOP: PTSD KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 34. The rehabilitation nurse assesses localized edema around the knee of a patient with paraplegia. The nurse suspects that this is the first sign of . ANS: heterotopic ossification Heterotopic ossification is a bony growth in joints of spinal cord injury patients below the injury that ultimately limits range of motion. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1204 OBJ:7TOP:Rehabilitation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 35.A child who was struck by a car and suffered a closed head injury was unconscious for 24 hours before waking. The nurse recognizes this as a brain injury. ANS:
moderate A period of unconsciousness of 1 to 24 hours is characteristic of a moderate brain injury. PTS: 1 DIF: Cognitive Level: Application | Cognitive Level: Comprehension REFage 1204OBJ:7TOP:Rehabilitation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 36.The nurse who assesses for cultural influences, values cultural diversity, and incorporates cultural knowledge in practice is said to be . ANS: culturally competent A culturally competent nurse includes knowledge of cultural values and influences in their nursing practice. PTS: 1 DIF: Cognitive Level: Application REF: Page 1199 OBJ: 5 TOP: Culture KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion Chapter 39: Hospice Care My Nursing Test Banks Chapter 39: Hospice Care Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What is the overall objective of hospice service? a. Relieve symptoms of terminal disease b. Educate the patient about the process of death c. Keep the patient comfortable as death approaches d. Relieve the family of the stress of death ANS: C Hospice is a philosophy of care that provides support and comfort to patients who are dying. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1209 OBJ: 1 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 2. Who was responsible for renewing the hospice philosophy in the 1960s? a. Cicely Saunders
b. Lillian Wald c. Dorothea Dix d. Florence Nightingale ANS: A The idea of hospice originated in Europe. Dame Cicely Saunders renewed the idea of hospice in the 1960s. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1209 OBJ: 1 TOP: Hospice KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 3. The hospice nurse clarifies that hospice service is initiated when what type of treatment is no longer effective? a. Proactive b. Palliative c. Alternative d. Curative ANS: D Hospice care is appropriate when curative treatment is no longer effective. Hospice service is palliative, proactive, and an alternative to curative treatment. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1210 OBJ: 2 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 4. The nurse differentiates between curative and palliative care. What is true of curative treatment? a. Curative treatment is centered on symptom control. b. Curative treatment is focused on prolonging life. c. Curative treatment is not concerned with dying. d. Curative treatment is the only care covered by health insurance. ANS: B Curative treatment is aggressive care that aims to cure disease and prolong life. Palliative care is not curative in nature and is centered on symptom control. Both types of care are typically covered by health insurance. PTS: 1 DIF: Cognitive Level: Application REF: Page 1211
OBJ: 2 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 5. Because the family is confused about the meaning of palliative care, the hospice nurse needs to explain the focus of care. What is the focus of palliative care? a. An aggressive approach to prolong life b. A protocol of pain relief c. A form of organized care, which relieves the family of responsibility d. An integrated service of support for alleviation of symptoms ANS: D Palliative care is not curative but is an integrated plan designed to relieve pain and control symptoms. The goal is not to prolong life. While pain relief may be one aspect of hospice care, it is not what treatment is centered upon. The family is not relieved of their responsibility. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1211 OBJ: 2 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 6. The hospice nurse explains that to qualify for admission to a hospice, the attending physician must certify that the patient has a life expectancy of fewer than how many months? a. 2 months b. 3 months c. 4 months d. 6 months ANS: D The patient must meet certain criteria to be admitted to hospice, such as a prognosis of 6 months or fewer to live. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1211 OBJ: 3 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 7. The hospice nurse requests that the patient designate a primary caregiver for himself. What is true of the primary caregiver? a. Must be a relative
b. Has complete control over the patients care c. Assumes ongoing responsibility for health maintenance of the patien d. Must have power of attorney ANS: C A primary caregiver is one who assumes responsibility for health maintenance and therapy. It is not necessary that the primary caregiver be a relative. The primary caregiver does not have complete control over the patients care, and it is not necessary for the primary caregiver to have power of attorney. PTS: 1 DIF: Cognitive Level: Application REF: Page 1212 OBJ: 3 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 8. Why is it important for the hospice nurse to provide time to confer with the patient and family? a. To show concern b. To report changes in the plan of care designed by the team c. To confirm the ongoing reimbursement d. To plan for changes in the scope of care ANS: D No changes should be made to the patients plan of care without first discussing it with the entire family. The family should be involved in planning the changes in the scope of care. PTS: 1 DIF: Cognitive Level: Application REF: Page 1212 OBJ: 1 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 9. The patient informs the hospice nurse, Im not sold on this hospice thing. Im not looking for Jesus, Im just dying. What would be the most therapeutic response by the nurse? a. Spiritualism is as you define it. b. Rejecting the spiritual aspect of yourself may not be in your best inte c. Hospice service is about how to make your remaining time meaningf d. Based on what you say, hospice service may not answer your needs. ANS: C
The holistic approach of hospice pertains to the total patient care including physical, emotional, social, economic, and spiritual needs of the patient with no particular emphasis on any one of those aspects. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1212 OBJ: 1 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 10. What is the role of the hospice medical director? a. To design and direct the plan of care b. To evaluate the appropriateness of the care c. To function as mediator between the team and the attending physicia d. To take the place of the patients attending physician ANS: C The medical director is a mediator between the interdisciplinary team and the attending physician. The interdisciplinary team designs the plan of care. The primary team, along with the interdisciplinary team, evaluates the appropriateness of care. The medical director does not take the place of the attending physician, but instead acts as a consultant for the attending physician. PTS: 1 DIF: Cognitive Level: Application REF: Page 1213 OBJ: 4 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 11. The hospice nurse tells the family that the nurse coordinator, an RN, will visit them. What is the role of the nurse coordinator? a. Collect initial fees for the hospice service b. Officially admit the patient to the hospice service c. Assist with accessing community resources d. Assist with funeral planning ANS: B The role of the nurse coordinator is to do the initial assessment, admit the patient, and develop the plan of care with the interdisciplinary team. The nurse coordinator would not be responsible for collecting fees at the initiation of services. The social worker would assist with community resources. The spiritual coordinator would assist with funeral planning.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1213 OBJ: 4 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 12. The social worker evaluates and assesses the psychosocial needs of the patient. To work in a hospice, the social worker must have at least which degree? a. Associate b. Bachelors c. Masters d. Doctorate ANS: B The hospice social worker must have at least a bachelors degree. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1213, Table 39-1 OBJ: 4 TOP: Hospice KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 13. The hospice spiritual coordinator can be affiliated with any religion, assists with the spiritual assessment of the patient, and develops the plan of care regarding spiritual matters. To work in a hospice, what degree should the spiritual coordinator possess? a. Bachelors degree b. Masters degree c. Seminary degree d. Associate degree ANS: C The hospice spiritual coordinator must have a seminary degree. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1213, Table 39-1 OBJ: 4 TOP: Hospice KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 14. The hospice nurse introduced the family to the volunteer coordinator who will assign a volunteer to the patient. What can a hospice volunteer do for a patient and caregiver? a. Give the family respite b. Give necessary medication in the absence of the nurse
c. Be at the familys disposal 16 hours a week d. Bathe the patient ANS: A The volunteer coordinator assigns volunteers to the family to give the family respite. The volunteer cannot give medication. A dedicated number of hours per week is not mandated. It is not the role of the volunteer to provide personal care. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1214 OBJ: 4 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 15. The hospice nurse instructs the family that they have access to a bereavement coordinator who follows the plan of care focused on the caregiver after the death of the patient. For how long of a period of time will the caregiver and family have access to the bereavement coordinator? a. One week b. One month c. One year d. Two years ANS: C The bereavement coordinator follows the plan of care for the caregiver for at least a year following the death of the patient. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1214 OBJ: 4 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 16. The hospice nurse instructs the family that they have access to a hospice pharmacist, who is available for consultation on the drugs the hospice patient may be taking. What other role does the hospice pharmacist fill? a. Administer all drugs necessary for pain alleviation b. Evaluate drug interactions with food and other medications c. Evaluate the safety of the drug storage in the patients home d. Monitor drug effectiveness by frequent phone interviews with the fa ANS: B The hospice pharmacist is available to consult about drug interactions with
other drugs or food. The pharmacist does not administer the drugs. The nurse would evaluate the safety of drug storage in the home and monitor the drug effectiveness. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1215 OBJ: 4 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. Who conducts the nutritional assessment at the time of admission to hospice care? a. Physician b. Hospice nurse c. Caregiver d. Nursing assistant ANS: B The hospice nurse does the nutritional assessment during admission. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1215 OBJ: 4 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18. When a deficiency in nutritional status of a patient is assessed, what action should be taken by the hospice nurse? a. Make a comprehensive grocery list for the caregiver b. Alert the licensed medical nutritionist c. Seek culturally appropriate methods to increase nutrition d. Instruct the caregiver to give the patient multivitamins ANS: B The hospice nurse can call on the nutritionist for assistance for the patient who is assessed as having a nutritional deficit. The nutritionist can then provide assistance with meal planning and diet counseling. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1215 OBJ: 4 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. What symptom of hospice patients is the most dreaded and feared, and should be a priority of symptom management? a. Fear
b. Anger c. Grief d. Pain ANS: D While hospice patients experience all of these symptoms, pain is the most dreaded and feared. Pain disrupts the quality, activities, and enjoyment of life. Pain should be a priority of symptom management in hospice care. PTS: 1 DIF: Cognitive Level: Application REF: Page 1216 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 20. During a pain assessment, the patient tells the nurse that the pain is aching, stabbing, and throbbing. What type of pain is the patient describing? a. Visceral b. Neuropathic c. Somatic d. Psychogenic ANS: C Somatic pain arises from the musculoskeletal system and is aching, stabbing, or throbbing. Visceral pain arises from the internal organs and is described as cramping, dull, or squeezing. Neuropathic pain arises from the neurologic system and is described as tingling, burning, or shooting. PTS: 1 DIF: Cognitive Level: Application REF: Page 1216 OBJ: 6 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. What are the drugs of choice when caring for the hospice patient? a. Nonsteroidal anti-inflammatory drugs b. Anticholinergic drugs c. Duragesic patches d. Morphine derivatives ANS: D Morphine derivatives are popular drugs of choice when dealing with the hospice patient because they have a wide variety of modes of administration and provide good pain control.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1217 OBJ: 6 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The nurse should educate the patient and caregiver that large doses of narcotics are required to control pain. What is the optimal dose for pain medications? a. The smallest amount possible to achieve some effects b. The dose that provides pain relief c. The dose that is not addictive d. The dose that works for most people ANS: B The patient and caregiver should understand that pain can be controlled and that using large doses of opioids is common and necessary to achieve that control. It is good to educate the patient and caregiver that the dose that works is the dose that works. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1217 OBJ: 6 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse warns that nausea is a common side effect with opioid treatment. What is the best treatment for nausea caused by opioids? a. Antiemetics b. Ice chips c. Dry crackers d. Ginger ale ANS: A Rather than discontinuing the opioid, the nausea should be treated with an antiemetic. PTS: 1 DIF: Cognitive Level: Application REF: Page 1218 OBJ: 6 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. When educating a patient concerning ways to prevent nausea, the nurse suggests that eating slowly in a pleasant atmosphere will help, as well as taking an antiemetic before meals. How many minutes before meals should
the patient take the antiemetic? a. 10 b. 20 c. 30 d. 60 ANS: C Taking an antiemetic 30 minutes before meals reduces nausea and increases appetite. PTS: 1 DIF: Cognitive Level: Application REF: Page 1218 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. What is the most common problem of the terminally ill patient that is caused by narcotics? a. Malnutrition b. Constipation c. Fluid retention d. Dehydration ANS: B One of the most common opioid-induced problems of the terminally ill patient is constipation. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1219 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. The hospice nurse documents an assessment finding of cachexia in the patient record. What does cachexia describe? a. Deep sleep and unresponsiveness b. Marked weakness and emaciation c. Total addiction to opioids d. Renewed energy ANS: B Malnutrition marked by weakness and emaciation is called cachexia. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1219 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 27. Which of the following is an expected part of the end-of-dying process? a. Denial b. Despair c. Anorexia d. Depression ANS: C The nurse often has to reassure the patient and caregiver that anorexia is part of the end-of-dying process. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1219 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. Which medication relaxes the patients respiratory effort and thus increases the efficiency of the patients respiratory status? a. Aminophylline b. Theophylline c. Epinephrine d. Morphine ANS: D Respiratory distress may be relieved by morphine. PTS: 1 DIF: Cognitive Level: Application REF: Page 1220 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. Why should the hospice nurse delay the use of oropharyngeal suctioning? a. It will decrease mucus production b. It will be uncomfortable for the patient c. It is not necessary d. It puts the patient at risk for infection ANS: B Suctioning should only occur if the patient is choking because it causes an increase in mucus production and is uncomfortable for the patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 1220 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 30. The hospice nurse recommends that the patient prepare the document that provides guidance to the family concerning the patients wishes regarding lifesupport measures and organ donation. What is this document called? a. Power of attorney b. Living will c. Advance directive d. Conservatorship ANS: C An advance directive is a document prepared while the patient is alive and competent that provides guidance to the family and health care team in the event the person can no longer make decisions. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1222 OBJ: 8 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 31. The hospice nurse instructs caregivers in repositioning the patient because the patient spends most of the time reclining. What problem can this cause? a. Contractures b. Pressure ulcers c. Bruising d. Excoriation ANS: B Increased weakness is noted in the last stages of a terminal illness. With increased weakness, activity intolerance increases, and the patient spends most of the time reclining. This leads to risk for skin impairment and the formation of pressure ulcers. PTS: 1 DIF: Cognitive Level: Application REF: Page 1220 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 32. When air hunger is assessed in the dying patient, the nurse can perform which intervention(s)? (Select all that apply.) a. Circulate the air with a fan
b. Use a tranquilizer to decrease anxiety c. Provide good oral hygiene d. Perform careful suctioning e. Raise the head of the bed 30 degrees ANS: A, B, C, E Circulating the air with a fan, administering a tranquilizer to decrease anxiety, providing good oral hygiene, and raising the head of the bed 30 degrees are all interventions that can aid in relieving air hunger in the dying patient. Suctioning will increase mucus production, which will make the dyspnea worse. PTS: 1 DIF: Cognitive Level: Application REF: Page 1220 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. The hospice nurse educates the patient and family about the members of the interdisciplinary team. Which caregivers are included? (Select all that apply.) a. Medical director b. Nurse coordinator c. Social worker d. Spiritual coordinator e. Psychologist ANS: A, B, C, D The hospice interdisciplinary team includes the medical director, nurse coordinator, social worker, and spiritual coordinator. The interdisciplinary team does not include a psychologist. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1212 OBJ: 4 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 34. Which are signs and symptoms of approaching death? (Select all that apply.) a. Mottled extremities b. Significant increase in urine output c. Increased restlessness and pulling at bed linens
d. Alteration in rhythmic respiration e. Increased pulse rate ANS: A, C, D, E Mottled extremities, a significant decrease in urine output, an increased restlessness, alteration in rhythmic respirations, and increased pulse rate are all symptoms of approaching death. PTS: 1 DIF: Cognitive Level: Application REF: Page 1221, Table 39-4 OBJ: 7 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 35. What are the goals of hospice service? (Select all that apply.) a. Alleviating symptoms of approaching death b. Educating and supporting primary caregivers c. Using family input for designing a plan of care d. Encouraging patients and caregivers to enjoy life e. Focusing on the desires of the family in the plan of care ANS: A, B, C, D The plan of care should focus on the desires of the patient, not the desires of the family members. PTS: 1 DIF: Cognitive Level: Application REF: Page 1212 OBJ: 1 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 36. When the dying patient becomes confused, the nurse should him or her. ANS: reorient Reorientation regarding time, date, and location is the least distressing to the dying patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 1221, Table 39-4 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity Chapter 40: Introduction to Anatomy and Physiology My Nursing Test Banks Chapter 40: Introduction to Anatomy and Physiology
Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The anatomic term means toward the midline. a. anterior b. posterior c. medial d. cranial ANS: C The term medial indicates an anatomic direction toward the midline. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1226 OBJ:2TOP:Anatomic terminology KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. What are the smallest living components in our body? a. Cells b. Organs c. Electrons d. Osmosis ANS: A Cells are considered to be the smallest living units of structure and function in our body. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1229 OBJ: 6 TOP: Structural levels of organization KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 3. What is the largest organelle, responsible for cell reproduction and control of other organelles? a. Nucleus b. Ribosome c. Mitochondrion d. Golgi apparatus ANS: A The nucleus is the largest organelle within the cell.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1230 OBJ:8TOParts of the cell KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. When the patient complains of pain in the bladder, the patient will indicate discomfort in which body cavity? a. Pelvic b. Mediastinum c. Dorsal d. Abdominal ANS: A A subdivision called the pelvic cavity contains the lower portion of the large intestine (lower sigmoid colon, rectum), urinary bladder, and internal structures of the reproductive system. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1228, Figure 40-4 OBJ: 5 TOP: Body cavity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The four phases of cell division all occur in: a. diffusion. b. mitosis. c. osmosis. d. filtration. ANS: B During mitosis, the cell goes through four phases: prophase, metaphase, anaphase, and telophase. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1232 OBJ: 9 TOP: Cell division KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 6. Telophase is which phase of cell reproduction during mitosis? a. First phase b. Latent phase c. Final phase d. Spindle phase
ANS: C During mitosis, the cell goes through four phases: prophase, metaphase, anaphase, and telophase. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1232 OBJ: 9 TOP: Cell division KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 7. The nurse is aware that which muscle group is both striated and involuntary? a. Skeletal b. Glial c. Cardiac d. Visceral ANS: C The cardiac muscle is both striated and involuntary. PTS:1DIF:Cognitive Level: Knowledge REF: Pages 1234-1235, Figure 40-12 OBJ: 11 TOP: Tissues KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 8.What is a group of several different kinds of tissues arranged so that together they can perform a more complex function than any tissue alone? a. Organ b. System c. Cell d. Endoplasmic reticulum ANS: A When several kinds of tissues are united to perform a more complex function than any tissue alone, they are called organs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1236 OBJ: 7 TOP: Organs KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 9. What traits describe visceral muscles? a. Smooth and voluntary b. Smooth and involuntary c. Striated and voluntary
d. Striated and involuntary ANS: B Visceral (smooth) muscles will not function at will; thus, they act involuntarily. PTS:1DIF:Cognitive Level: Knowledge REF: Pages 1234-1235, Figure 40-12 OBJ: 7 TOP: Tissues KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. How are the thoracic and abdominal cavities separated? a. By the pleura b. By the diaphragm c. By the sagittal plane d. By the peritoneum ANS: B The diaphragm (a muscle directly beneath the lungs) separates the ventral cavity into the thoracic (chest) and abdominal cavities. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1236, Figure 40-123 OBJ:3TOP:Ventral cavity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. What is the broad section of biology dealing with the description of human structure? a. Hematology b. Anatomy c. Kinesiology d. Physiology ANS: B Anatomy is the study, classification, and description of the structure and organs of the body. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1226 OBJ: 1 TOP: Terminology KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 12. explains the processes and functions of many structures of the body
and how they interact with one another. a. Anatomy b. Mitosis c. Filtration d. Physiology ANS: D Physiology explains the processes and functions of the various structures and how they interrelate with one another. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1226 OBJ: 1 TOP: Terminology KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 13. The anatomic structure that is not in the thoracic cavity is/are the . a. Heart b. Lungs c. Blood vessels d. Transverse colon ANS: D The transverse colon is located in the abdominal cavity. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1227, Figure 40-3 OBJ:5TOP:Thoracic cavity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. When several organs and parts are grouped together for certain functions, they form: a. tissues. b. systems. c. cells. d. membranes. ANS: B A system is an organization of varying numbers and kinds of organs arranged so that together they can perform complex functions for the body. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1229 OBJ: 7 TOP: Systems KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 15. What are the distinct surface proteins of the plasma membrane essential in determining? a. Tissue typing b. Blood count c. Effectiveness of a drug d. Sexual maturity ANS: A The plasma membrane has distinct surface proteins as coming from one individual. This is the basis for the procedure of tissue typing to determine compatibility before an organ transplant. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1230 OBJ: 12 TOP: Cells KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. In anatomic terminology, posterior means toward the: a. tail. b. head. c. back. d. trunk. ANS: C The posterior is toward the back. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1226 OBJ:2TOP:Anatomic terminology KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. What does the transverse body plane divide? a. The front and back (coronal) of the body b. The body lengthwise (two equal halves) c. The superior and inferior portions of the body d. The body into axial and appendicular ANS: C The transverse plane cuts the body horizontally into the sagittal and the frontal planes, dividing the body into caudal and cranial portions.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1227, Figure 40-2 OBJ: 3 TOP: Body planes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18. Caudal is defined as toward the . a. head b. feet c. tail d. chest ANS: C Caudal is a directional word that indicates toward the tail, the distal portion of the spine. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1226 OBJ:3TOP:Anatomic terminology KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. What is the term for movement of water from an area of lower solute concentration to an area of higher solute concentration? a. Absorption b. Filtration c. Diffusion d. Osmosis ANS: D Osmosis is the passage of water from less concentrated solution to more concentrated solution. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1233, Table 40-4 OBJ:10TOP:Transport processes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. What is the type of tissue composed of cells that contract in response to a message from the brain or spinal cord? a. Epithelial b. Connective c. Membrane
d. Muscle ANS: D Muscle tissue is composed of cells that contract in response to a message from the brain or spinal cord. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1234 OBJ: 7 TOP: Tissues KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. What is the type of tissue associated with the storage of fat? a. Areolar tissue b. Adipose tissue c. Osseous tissue d. Muscle tissue ANS: B Adipose tissue is associated with the important function of storing fat. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 1235-1235,Table 40-5 OBJ: 11 TOP: Tissues KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22. What are the thin sheets of tissue that lubricate and line the body surfaces that open to the outside environment? a. Mucous membranes b. Serous membranes c. Cytoplasm d. Involuntary visceral muscles ANS: A Mucous membranes secrete mucus. They line the body surfaces that open to the outside environment. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1236 OBJ: 7 TOP: Tissues KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 23. What is the process by which a cell digests a foreign material by surrounding it? a. Pinocytosis b. Phagocytosis
c. Absorption d. Diffusion ANS: B Phagocytosis is the process that permits a cell to engulf or surround any foreign material and digest it. PTS:1DIF:Cognitive Level: Knowledge REF: Pages 1232-1233, Table 40-3 OBJ: 10 TOP: Active transport processes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. Active transport in the movement of ions and other water-soluble particles across cell membranes requires that the body uses its:: a. rapid filtration. b. charged diffusion. c. a chemical pump. d. osmosis. ANS: C Active transport of ions and other water-soluble particles of the cell membrane require a chemical pump, such as insulin, to move glucose into the cell. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1233, Table 40-4 OBJ:10TOP:Active transport processes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. What is the term for the passage of water containing dissolved materials through a membrane as the result of a greater mechanical force on one side? a. Metabolism b. Mitosis c. Filtration d. Osmosis ANS: C Filtration is the movement of water and particles through a membrane by a force from either pressure or gravity. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1233, Table 40-4
OBJ:10TOPassive transport processes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. The nurse is aware that when a patient complains of pain in the epigastric region, the source of the pain is most likely to be a disorder involving the: a. gallbladder. b. transverse colon. c. stomach. d. appendix. ANS: C The epigastric region of the abdomen is comprised of parts of the right and left lobes of the liver and a large portion of the stomach. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1228, Figure 40-4 OBJ:5TOP:Epigastric region KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 27. What are tissues that cover the outside of the body and some internal structures? a. Connective b. Epithelial c. Nerve d. Muscle ANS: B Epithelial tissue covers the outside of the body and some of the internal structures. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1234 OBJ: 7 TOP: Tissues KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. When the nurse assesses an arm in proximal to distal order, the assessment is performed from: a. the shoulder to the fingers. b. front to back. c. fingers to the center of the body.
d. center of the body to the fingers. ANS: A Proximal is nearest the origin of the structure. Distal is farthest from the origin of the structure. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1227 OBJ:3TOP:Anatomic terminology KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. What is the function of epithelial membranes? a. Secretes mucus, lines ends of bones, and lines bursae b. Lines ends of bones, secretes synovial fluid, and lines internal surface Covers the wall of lower digestive tract, secretes mucus, and lines lun c. pericardium d. Lines lungs, peritoneum, and pericardium, and secretes synovial fluid ANS: C The epithelial membrane secretes mucus, lines the lungs, peritoneum, and pericardium, and covers the wall of the lower digestive tract. The synovial membrane secretes synovial fluid to prevent friction between joints and the ends of bones, and lines the bursae found between moving body parts. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1236 OBJ: 7 TOP: Tissues KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. The nurse explains that pinocytosis is a process by which cells: a. divide. b. take in extracellular fluid. c. use a chemical pump. d. convert mitochondria. ANS: B Pinocytosis is a process by which the cell wall makes an indentation allowing extracellular fluid to fill in, then encloses it into the cell. PTS:1DIF:Cognitive Level: Comprehension REF: Pages 1232-1233, Table 40-3 OBJ: 10 TOP: Pinocytosis KEY:Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 31. Which are among the 11 body systems? (Select all that apply.) a. Lymphatic b. Cellular c. Digestive d. Reproductive e. Accessory f. Spinal cord ANS: A, C, D There are 11 body systems: integumentary, respiratory, skeletal, digestive, muscular, nervous, endocrine, urinary, reproductive, cardiovascular, and lymphatic. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1237, Table 40-6 OBJ:7TOP:Body systems KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 32. Which of the following are characteristics of visceral muscles? (Select all that apply.) a. Involuntary b. Smooth c. Striated d. Independent from the spinal cord e. Voluntary f. Present in the blood vessels ANS: A, B, F Smooth muscles are smooth, involuntary, and respond to messages from the spinal cord. PTS: 1 DIF: Cognitive Level: Application REF: Page 1234 OBJ:7TOP:Voluntary muscle KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 33. Which of the following are passive transport mechanisms that move
material across the cell membranes? (Select all that apply.) a. Diffusion b. Evaporation c. Filtration d. Osmosis e. Mitosis f. Anaphase ANS: A, C, D The passive transport systems are diffusion, filtration, and osmosis. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1233, Table 40-4 OBJ:10TOPassive transport system KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 34. The nurse clarifies that the dorsal cavity is composed of the (select all that apply) : a. Descending colon b. Kidneys c. Gallbladder d. Brain e. Pancreas f. Spinal cavities ANS: D, F The dorsal cavity is composed of the brain and the spinal cavities. The spinal cavities hold the cord and the meninges. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1228 OBJ:5TOPorsal cavity KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 35. The nurse clarifies that the three functions of epithelial tissue are , , and . ANS: protection, absorption, secretion
absorption, secretion, protection protection, secretion, absorption secretion, protection, absorption secretion, absorption, protection absorption, protection, secretion The function of epithelial tissue is protection by covering the body and preventing invasion; absorption by absorbing material; and secretion by secreting mucus to line and moisten the body surfaces. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1234 OBJ:7TOP:Epithelial tissue function KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 36. The nurse explains that are small saclike structures inside the cell that digest compounds that have invaded the cell. ANS: lysosomes Lysosomes are small saclike structures inside the cell that digest compounds that have invaded the cell. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1231 OBJ: 8 TOP: Lysosomes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 37. The body plane that divides the body into the ventral and dorsal section is the plane. ANS: coronal The coronal plane divides the body into ventral and dorsal (front and back) sections. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1227 OBJ:3TOP:Coronal plane KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity OTHER 38. List in order of increasing complexity the structural levels of organization of the body. (Separate letters by a comma and space as follows: A, B, C, D)
a. Body as a whole b. Cellular c. Organs d. Tissue e. Chemical f. System ANS: E, B, D, C, F, A The structural levels of organization progress from the least complex (chemical) through cells, tissues, organs, systems to the most complex (the body as a whole). PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1229 OBJ: 6 TOP: Structural levels of organization KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 39. Place the body structures in cranial-caudal priority. (Separate letters by a comma and space as follows: A, B, C, D) a. Ribs b. Neck c. Clavicle d. Mandible e. Radius f. Occiput ANS: F, D, B, C, A, E The top-to-bottom priority is occiput, mandible, neck, clavicle, ribs, and radius. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1227, Figure 40-3 OBJ:4TOP:Anatomic positions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 40. Using a poster, the nurse demonstrates the protection of the nucleus. Arrange the layers starting with the most superficial. (Separate letters by a comma and space as follows: A, B, C, D)
a. Endoplasmic reticulum b. Nuclear membrane c. Nucleus d. Plasma membrane e. Cytoplasm ANS: D, E, A, B, C The most superficial covering of the nucleus is the plasma membrane, under which is the cytoplasm containing the endoplasmic reticulum, nuclear membrane, and nucleus. PTS: 1 DIF: Cognitive Level: Application REF: Page 1230 OBJ:8TOProtective covering of nucleus KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity Chapter 41: Care of the Surgical Patient My Nursing Test Banks Chapter 41: Care of the Surgical Patient Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The patient who had a nephrectomy yesterday has not used the patientcontrolled analgesia (PCA) delivery system but admits to being in pain but fearful of addiction. What is the nurses best response? a. Modern analgesic drugs do not cause addiction. b. Pain relief is worth a short period of addiction. c. Addiction rarely occurs in the brief time postsurgical analgesia is req d. Addiction could be a real concern. ANS: C Addiction rarely occurs in the short time that it is required after surgery. Postsurgical analgesia, because of its brief application, does not usually produce a physical or a psychological dependence. PTS: 1 DIF: Cognitive Level: Application REF: Page 1259 OBJ:13TOP:Fear of addiction KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2.A 73-year-old patient with diabetes was admitted for below-the-knee
amputation of his right leg. Removal of his right leg is an example of which type of surgery? a. Palliative b. Diagnostic c. Reconstructive d. Ablative ANS: D Ablative is a type of surgery where an amputation, excision of any part of the body, or removal of a growth and harmful substance is performed. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1241, Table 41-1 OBJ:2TOP:Types of surgeries KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. In which situation might surgery be delayed? a. The patient has taken Dilantin today. b. An illegible signature is on the consent form. c. The patient is still taking anticoagulants. d. The admission office is unable to confirm insurance coverage. ANS: C All medications should be cancelled before surgery, except for drugs such as phenytoin (Dilantin). Anticoagulant therapy increases the threat of hemorrhage and may be a cause for delay. PTS:1DIF:Cognitive Level: Knowledge REF: Pages 1259, 1261, Table 41-6 OBJ: 7 TOP: Anticoagulant therapy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. Which circumstance could prevent the patient from signing his informed consent for a cholecystectomy? a. The patient complains of pain radiating to the scapula. b. The patient received an injection of Demerol, 75 mg IM, 1 hour ago. c. The patient is 85 years of age. d. The patient is concerned over his lack of insurance coverage. ANS: B
Informed consent should not be obtained if the patient is disoriented and under the influence of sedatives. Age, illegibility, and lack of insurance coverage do not prevent signing the consent. Pain into the scapula is a symptom of colitis. PTS: 1 DIF: Cognitive Level: Application REF: Page 1248 OBJ:7TOP:Informed consent KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The nurse anticipates that the patient will be given anesthesia because of the extensive tissue manipulation involved in a hysterectomy. a. general b. regional c. specific d. preoperative ANS: A An anesthesiologist gives general anesthetics by IV and inhalation routes through four stages of anesthesia when the procedure requires extensive tissue manipulation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1259 OBJ: 9 TOP: Anesthesia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse caring for a patient who had an epidural block for a vaginal repair should be alert for: a. a flushing of the face and torso. b. numbness of the perineum. c. complaint of thirst. d. a sudden drop in blood pressure. ANS: D Epidural anesthesia may cause a sudden drop in blood pressure or respiratory difficulty as the anesthetic agent moves up in the spinal cord. Elevating the patients torso may prevent respiratory paralysis. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1262
OBJ:9TOP:Epidural block KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. Why might the older adult patient not respond to surgical treatment as well as a younger adult patient? a. Poor skin turgor b. Fear of the unknown c. Response to physiological changes d. Decreased peristalsis related to anesthesia ANS: C Of specific concern in older adults is the bodys response to temperature changes, cardiovascular shifts, respiratory needs, and renal function. Fear of the unknown and decreased peristalsis are common to all ages. PTS: 1 DIF: Cognitive Level: Application REF: Page 1242 OBJ:5TOP:Older adult patients KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 8.The postoperative nursing intervention that would be contraindicated for a 45-year-old patient who has had a repair of a cerebral aneurysm and is presenting signs of increased intracranial pressure (ICP) would be: a. coughing every 2 hours. b. turning every 2 hours. c. monitoring intravenous therapy at 50 ml/hr. d. assessing vital signs every 2 hours. ANS: A Coughing increases ICP. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1252, Box 41-6 OBJ:12TOPostoperative complications KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse acting as a circulating nurse has a responsibility for: a. observing for breaks in sterile technique. b. identifying and handling surgical specimens correctly. c. assisting with surgical draping of the patient.
d. maintaining count of sponges, needles, and instruments during surge ANS: A The circulating nurse is responsible for observing breaks in sterile technique. The scrub nurse handles the surgical specimens, drapes the patient, and maintains needle and sponge count during surgery, then does a final sponge and needle check with the circulating nurse before closing. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1268, Box 41-7 OBJ:11TOPuties of circulating nurse KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 10. Which statement made by a patient during a preoperative assessment would be significant to report to the charge nurse and surgeon? a. I have been taking an herbal product of feverfew for my migraines. b. I exercise for 3 hours a day. c. I drink 2 glasses of wine a day. d. I use atropine eyedrops every day. ANS: A The herbal remedy of feverfew acts as an anticoagulant and increases the possibility of hemorrhage. The drug should be stopped before surgery, and bleeding and clotting times should be evaluated. PTS: 1 DIF: Cognitive Level: Application REF: Page 1246, Table 41-3 OBJ:14TOPreoperative assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11.A patient is on postoperative day 2 after a nephrectomy. What is the most effective way to increase her peristalsis? a. Ambulation b. An enema c. Encouraging hot liquids d. Administering a laxative ANS: A Encouraging activity (turning every 2 hours, early ambulation) assists GI activity.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1275 OBJ:13TOPostoperative complications KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 12.A patient is transferred from the operating room to the recovery room after undergoing an open reduction and internal fixation (ORIF) of his left ankle. Which is the first assessment to make? a. Check ankle dressings for hemorrhage. b. Check airway for patency. c. Check intravenous site. d. Check pedal pulse. ANS: B Evaluation of the patient follows the ABCs of immediate postoperative observation: airway, breathing, consciousness, and circulation. PTS:1DIF:Cognitive Level: Application REF: Pages 1267-1268, Table 41-7 OBJ: 12 TOP: Nursing assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 13. Frequent assessment of a postoperative patient is essential. What is one of the first signs and symptoms of hemorrhage? a. Increasing blood pressure b. Decreasing pulse c. Restlessness d. Weakness, apathy ANS: C A pulse that increases and becomes thready combined with a declining blood pressure, cool and clammy skin, reduced urine output, and restlessness may signal hypovolemic shock. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1270, Box 41-8 OBJ:12TOPostoperative complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. The nurse instructing a postsurgical patient in the use of thrombolytic deterrent stockings would include which of the following instructions?
a. Disregard appearance of edema above the stocking b. Massage legs to smooth wrinkles out of stockings c. Wring stockings thoroughly before hanging to dry d. Wash stockings in warm water and mild soap ANS: D Stockings should be washed gently in warm water and mild soap and laid over a surface to dry. They should not be wrung out or hung. Massaging legs may dislodge a clot and the appearance of edema indicates the stockings are too restrictive. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1256, Patient Teaching OBJ:13TOP:Thrombolytic deterrent stockings KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The patient is brought into PACU still unconscious. What should the nurse do when the nurse assesses an oral temperature of 94 F? a. Notify the charge nurse immediately b. Offer warm fluids through a straw c. Do nothing, this is a normal reaction to anesthesia d. Cover with a warm blanket ANS: D Hypothermia is a frequent assessment postsurgery. A warm blanket or a ventilated cover would be applied to bring up the temperature. Vital signs are checked every 15 minutes until stable. PTS:1DIF:Cognitive Level: Analysis REF: Pages 1268, 1270, Table 41-8 OBJ: 13 TOP: Hypothermia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 16.In which location are guidelines for ensuring that all nursing interventions on the day of surgery completed and documented? a. In the nurses notes b. In the anesthesia record c. In the preoperative checklist d. In the progress notes
ANS: C When the nurse signs the preoperative checklist, that nurse assumes responsibility for all areas of care included on the list. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1265 OBJ:6TOPreoperative checklist KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 17. While turning a patient who had a bowel resection yesterday, the wound eviscerated. What is the initial nursing intervention? a. Place the patient in the high Fowlers position. b. Give the patient fluids to prevent shock. c. Replace the dressing with sterile fluffy pads. d. Apply a warm, moist normal saline sterile dressing. ANS: D Cover the wound with a sterile towel moistened with sterile physiological saline (warm). PTS:1DIF:Cognitive Level: Application REF: Pages 1271-1272, Figure 41-13 OBJ: 13 TOP: Evisceration KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. When should the nurse offer prescribed analgesics to a patient who is 24 hours postoperative? a. Only when the patient asks. b. When the onset of pain is assessed. c. Sparingly to avoid drug dependence. d. Only when severe pain is assessed. ANS: B The nurse should assess for pain frequently to medicate at the onset of pain. PTS: 1 DIF: Cognitive Level: Application REF: Page 1273 OBJ:14TOP:Medication administration KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 19.What should the nurse do to minimize the potential for venous stasis? a. Place pillows under the knee in a position of comfort
b. Assist patient to sit with feet flat on the floor c. Assist with early ambulation d. Perform gentle leg massage ANS: C Early ambulation has been a significant factor in hastening postoperative recovery and preventing postoperative complications. PTS: 1 DIF: Cognitive Level: Application REF: Page 1274 OBJ:13TOP:Venous stasis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 20.The nurse clarifies that serum potassium levels are determined before surgery to: a. assess kidney function. b. determine respiratory insufficiency. c. prevent arrhythmias related to anesthesia. d. measure functional liver capability. ANS: C Serum electrolytes are evaluated if extensive surgery is planned or the patient has extenuating problems. One of the essential electrolytes examined is potassium; if potassium is not available in adequate amounts, arrhythmias can occur during anesthesia. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1248 OBJ:4TOPreoperative assessment KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. In performing the preoperative assessment, the nurse discovers that the patient is allergic to latex. What should the nurse do initially? a. Notify the diet kitchen to omit peaches from diet tray b. Apply a medical alert band to patients wrist c. Tag chart with allergy alert d. Place patient in an isolation room ANS: B The initial intervention would be to place a medical alert band on the patient, then tag the chart. The charge nurse and the surgeon should be notified in the
event the surgeon wants to order a preoperative prophylactic treatment. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 1250-1251, Box 41-5 OBJ:13TOP:Latex allergy KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 22. Which of the following early postoperative observations should be reported immediately? a. Coffee ground emesis b. Shivering c. Scanty urine output d. Evidence of pain ANS: A Any emesis that is red or coffee ground should be reported immediately as it indicates GI bleeding. Shivering, scanty urine output, and evidence of pain are within normal expectation of a postsurgical patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 1270 OBJ:10TOPostoperative assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 23. When the postoperative patient complains of sudden chest pain combined with dyspnea, cyanosis, and tachycardia, the nurse recognizes the signs of: a. hypovolemic shock. b. dehiscence. c. atelectasis. d. pulmonary embolus. ANS: D Sudden chest pain combined with dyspnea, tachycardia, cyanosis, diaphoresis, and hypotension is a sign of pulmonary embolism. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1272 OBJ: 13 TOP: Assessment and postoperative complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. The removal of a nondiseased appendix during a hysterectomy is
classified as: a. major, emergency, diagnostic b. major, urgent, palliative c. minor, elective, ablative d. minor, urgent, reconstructive ANS: C Surgery is classified as elective, urgent, or emergency. Surgery is performed for various purposes, which include diagnostic studies, ablation (an amputation or excision of any part of the body or removal of a growth or harmful substance), and palliative (therapy to relieve or reduce intensity of uncomfortable symptoms without cure), reconstructive, transplant, and constructive purposes. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1241, Table 41-1 OBJ:2TOP:Types of surgery KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 25.Which medication would cause surgery to be delayed if it had not been discontinued several days before surgery? a. Analgesic agent b. Antihypertensive agent c. Anticoagulant agent d. Antibiotic agent ANS: C Anticoagulants alter normal clotting factors and thus increase risk of hemorrhaging. They should be discontinued for 48 hours before surgery. PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 1261, Table 41-6 OBJ:4TOP:Individuals ability to tolerate surgery KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 26.The most appropriate intervention by the nurse to decrease the pain of an abdominal incision while coughing would be to: a. Support the surgical site with a pillow b. Position patient in a side-lying position c. Medicate with prescribed narcotic before coughing d. Ask the patient to cross arms over the chest to increase force of coug
ANS: A To ease the pressure on the incision, the nurse helps the patient support the surgical site with a pillow, rolled bath blanket, or the heel of the hand. PTS: 1 DIF: Cognitive Level: Application REF: Page 1272 OBJ:8TOPostoperative nursing interventions KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 27.The nurse would include the nursing diagnosis of deficient knowledge, postoperative, when the patient scheduled for a bowel resection tomorrow remarks: a. I am going to have adequate pain medication after surgery. b. I know you all are going to make me cough and walk soon after surg c. I am glad I will get to go home tomorrow evening. d. I will have to put up with dressing changes. ANS: C The patients lack of understanding about the length of time in the hospital following such a serious surgery indicates a knowledge deficit that needs to be addressed. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1277, Box 41-11 OBJ:16TOP:Nursing process/diagnosis KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 28. What instruction should a nurse give when teaching the patient to cough effectively after surgery? a. Breathe through the nose, hold breath, and exhale slowly. b. Take three deep breaths and cough from the chest. Inhale while contracting the abdominal muscles and exhale while cont c. diaphragm. Take short, frequent panting breaths and cough from the throat to clea d. mucus. ANS: B Because lung ventilation is vital, the nurse assists the patient to turn, cough, and breathe deeply every 1 to 2 hours until the chest is clear. Having practiced this combination preoperatively, the patient is usually adequately able to remove trapped mucus and surgical gases.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1253, Skill 41-3 OBJ:8TOPrevention of postoperative complications KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. What is the responsibility of the nurse as a witness to informed consent? a. Explain the surgical options b. Explain the operative risks c. Verify/obtain the patients signature d. Verify the patients understanding of the procedure ANS: C A witness is only verifying that this is the person who signed the consent and that it was a voluntary consent. The witness (often a nurse) is not verifying that the patient understands the procedure. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1248 OBJ:7TOP:Informed consent KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 30. On the patients return to the medical-surgical unit, the nurse performing an abdominal assessment can affirm an absence of bowel sounds after listening in each quadrant for at least: a. 30 seconds. b. 1 minute. c. 2 minutes. d. 3 minutes. ANS: D Normal peristalsis is gauged by hearing 5 to 30 gurgles per minute. Absence of bowel sounds may be recorded if the nurse has listened to each quadrant 3 to 5 minutes. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1275 OBJ:12TOP:Bowel sounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31. When the patient asks the nurse to make sure no one sees her with her
dentures out, the nurse recognizes the common preoperative fear of: a. anesthesia. b. loss of control. c. fear of separation from family. d. mutilation. ANS: B Fear of loss of control may be partially related to concerns about anesthesia, but this patients concern is about self-image. Preoperative anxiety from any cause may affect the amount of anesthesia and postoperative analgesia needed. PTS: 1 DIF: Cognitive Level: Assessment REF: Page 1245, Box 41-4 OBJ:4TOP:Nursing diagnosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 32. What is the ideal time for preoperative teaching? a. Immediately before surgery to eliminate fear b. 2 months in advance so the patient can prepare c. 1 to 2 days before the surgery when anxiety is not as high d. In the surgical holding area ANS: C Preoperative teaching is provided 1 to 2 days prior to surgery when anxiety is low. PTS: 1 DIF: Cognitive Level: Implementation REF: Page 1247 OBJ:4TOPreoperative teaching KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 33. In preparation for the return of the surgical patient, the patients bed and equipment should be in what position? a. Lowest position with side rails elevated with oxygen and suction equi b. Highest position with side rails elevated with IV pole and pump at be c. Lowest position with side rails down on the receiving side d. Highest position with the side rails down on receiving side and up on ANS: D
In preparation for the return of the surgical patient, the patients bed should be in the highest position to be level with the surgical gurney and should have the side rail down on the receiving side, with the opposite side rail up to prevent the patient from falling out of bed during transfer. PTS: 1 DIF: Cognitive Level: Implementation REF: Page 1265 OBJ:12TOPostoperative preparation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 34.A postoperative patient who had a left inguinal hernia repair is ready for his discharge instructions. Which information should the nurse provide? (Select all that apply.) a. Care of the wound site and any dressings b. When he may operate a motor vehicle c. Signs and symptoms to report to the physician d. Call the physicians office once he arrives home e. Report bowel movements to the physician f. Actions and side effects of any medications ANS: A, B, C, F As the day of discharge approaches, the nurse should be certain that the patient has vital information. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1278, Box 41-3 OBJ:15TOPischarge instructions KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 35. Which of the following are considerations for the older adult surgical patient? (Select all that apply.) a. The need for specific clear preoperative and postoperative teaching b. Awareness of lower morbidity and mortality rate c. Presence of coexisting conditions d. Increased risk of respiratory complications e. Expectation of normal recovery time ANS: A, C, D
Surgery places greater stress on older than on younger patients. Teaching should be given at the older persons level of understanding. Teaching should be specific and clear. Presence of coexisting conditions may delay recovery time and response to surgery. PTS:1DIF:Cognitive Level: Application REF: Page 1242, Life Span Considerations OBJ: 7 TOP: Older adult considerations KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 36. Which of the following are preoperative conditions that may affect the patients response to surgery? (Select all that apply.) a. Age b. Religion c. Mental status d. Occupation e. Nutritional status ANS: A, C, E Each system of the body is affected by the patients age, health, nutritional status, and mental state. Religion and occupation do not affect the physiological response to the surgery. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1242 OBJ:4TOP:Factors influencing toleration to surgery KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 37. Which interventions in preparing the patient for abdominal surgery may be delegated to unlicensed assistive personnel (UAP)? a. Vital signs b. Insertion of N/G tube c. Enema d. Height and weight e. Obtaining operative consent f. Sterile gowning ANS: A, C, D Vital signs, enema, and height and weight can be safely performed by UAP.
Insertion of an N/G tube, obtaining an operative consent, and sterile gloving are interventions requiring critical thinking and knowledge unique to a nurse. PTS: 1 DIF: Cognitive Level: Application REF: Page 1243, Box 41-2 OBJ: 3 TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 38. therapy is performed to alleviate or decrease uncomfortable symptoms without curing the problem. ANS: Palliative Palliative therapy is designed to relieve or reduce intensity of uncomfortable symptoms without cure. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1241, Table 41-1 OBJ:1TOPalliative therapy KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 39. Discharge planning for a surgical procedure begins in the period and continues through the period. ANS: preoperative, recuperative When discharge planning is begun in the preoperative period and all through the postoperative period, the patient can assume greater responsibility for self-care and will experience less stress about going home. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1277 OBJ:15TOPischarge planning KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 40. The type of anesthesia that uses a combination of drugs to reduce the level of consciousness and provides amnesia is . ANS: conscious sedation Conscious sedation uses a combination of drugs to produce a reduced level of consciousness and amnesia, as well as pain control, but allows the patient to control his or her own breathing. The recovery is more rapid than with
general anesthesia. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1273 OBJ:10TOP:Conscious sedation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 41.The nurse is aware that there is a loss of during catabolism after severe tissue injury. ANS: potassium The injured cells loose potassium as catabolism (tissue breakdown) occurs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1276 OBJ: 13 TOP: Catabolism KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 42. The nurse explains that to promote deep breathing and improve lung expansion and oxygenation the patient should use the at regular intervals during the day. ANS: incentive spirometer The incentive spirometer is a device to encourage deep breathing and lung expansion. The usual rate of usage is 8 to 10 breaths hourly during waking hours. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1251 OBJ:13TOP:Incentive spirometer KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 43. The nurse caring for a postsurgical patient is aware that the patient should void to hours postsurgery. ANS: 6 to 8 6, 8 Urinary output should be obvious 6 to 8 hours postsurgery. If urinary output has not begun, a catheter may be inserted. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1273 OBJ:13TOP:Resumption of urinary flow KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological
Integrity OTHER 44.A patient is transferred from the operating room to the recovery room after undergoing an amputation of his left foot. Place the interventions in the correct order for immediate assessment once the patient enters the PACU. (Separate letters by a comma and space as follows: A, B, C, D) a. System review b. Breathing c. Circulation d. Airway e. Level of consciousness ANS: D, B, E, C, A The assessment of an adequate airway is primary in the postanesthesia assessment, followed by breathing assessment, level of consciousness, circulation, and finally system review. PTS: 1 DIF: Cognitive Level: Application REF: Page 1269, Table 41-7 OBJ:12TOP:Nursing assessment KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 45.Place the instructions for controlled coughing in the correct sequence. (Separate letters by a comma and space as follows: A, B, C, D) a. Inhale deeply and hold breath for a count of three b. Document exercise and patient reaction c. Cough 2 or 3 times without inhaling then relax d. Take several deep breaths e. Inhale through nose f. Exhale through pursed lips ANS: D, E, F, A, C, B The patient should be instructed to take several deep breaths, inhale through the nose, exhale through pursed lips, inhale deeply and hold for a count of three, cough two or three times without exhaling, relax. The procedure may be repeated before documentation.
PTS: 1 DIF: Cognitive Level: Application REF: Pages 1254-1255, Skill 41-3 OBJ:13TOP:Controlled coughing KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity Chapter 42: Care of the Patient with an Integumentary Disorder My Nursing Test Banks Chapter 42: Care of the Patient with an Integumentary Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What should the nurse do when administering a therapeutic bath to a patient who has severe pruritus? a. Use Burows solution to help promote healing b. Rub the skin briskly to decrease pruritus c. Limit bathing to 3 times a week d. Ensure that bath area is at least 85 degrees and dehumidified ANS: A Pruritus is responsible for most of the discomfort. Wet dressings and using Burows solution help promote the healing process. A cool environment with increased humidity decreases the pruritus. Give daily baths with an application to cleanse the skin. PTS: 1 DIF: Cognitive Level: Application REF: Page 1305 OBJ: 14 TOP: Pruritus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2.A frail, older adult home health patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do? a. Assess frequently for herpes zoster b. Be aware of the patients immunity to chickenpox c. Encourage the patient to have a pneumonia vaccine d. Arrange for the patient to receive gamma globulin ANS: A Herpes zoster is caused by the same virus that causes chickenpox (Herpes varicella). The greatest risk occurs to patients who have a lowered resistance to infection, such as those on chemotherapy, aging, or receiving large doses
of prednisone, in whom the disease could be fatal because of the patients compromised immune system. PTS: 1 DIF: Cognitive Level: Application REF: Page 1297 OBJ: 5:00 TOP: Shingles KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3.A patient has herpes zoster (shingles) and is being treated with acyclovir (Zovirax). What should the nurse do when administering this drug? a. Apply lightly, being careful not to completely cover the lesion b. After application, wrap in warm wet dressings c. Use gloves d. Rub medication into lesions ANS: C The topical application requires that the nurse uses gloves, completely covers the lesion gently, then leaves it open to the air. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1295, Table 42-3 OBJ:5TOP:Anti-infective KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4.A child has been sent to the school nurse with pruritus and honey-colored crusts on the lower lip and chin. The nurse believes these lesions most likely are: a. chickenpox. b. impetigo. c. shingles. d. herpes simplex type I. ANS: B Impetigo is seen at all ages, but is particularly common in children. The crust is honey-colored and easily removed and is associated with pruritus. The disease is highly contagious and spreads by contact. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1301 OBJ: 6 TOP: Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5.A school nurse assesses a child who has an erythematous circular patch of vesicles on her scalp with alopecia and complains of pain and pruritus. Why
would the nurse use a Woods lamp? a. To dry out the lesions b. To reduce the pruritus c. To kill the fungus d. To cause fluorescence of the infected hairs ANS: D
Tinea capitis is commonly known as ringworm of the scalp. Microsporum audouinii is the major fungal pathogen. The use of the diagnostic Woods lamp causes the infected hairs to turn a brilliant blue green. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1304, Figure 42-7 OBJ: 6 TOP: Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6.A patient, age 46, reports to his physicians office with urticaria with elevated lesions that are white in the center with a pale red border on hands and arms. He says, It itches like crazy. Which type of lesion would the nurse include in her documentation? a. Macules b. Plaques c. Wheals d. Vesicles ANS: C Urticaria is the term applied to the presence of wheals or hives in an allergic reaction commonly caused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold. The lesions are elevated with a white center and a pale red border. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1307, Table 42-1 OBJ: 6 TOP: Urticaria KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The home health nurse assessing skin lesions uses the PQRST mnemonic as a guide. What does the S in this guide indicate? a. Severity of the symptoms b. Site of the lesions c. Symptomatology of the lesions d. Surface area of the lesions ANS: A The mnemonic PQRST stands for Provocative factors (causes), Quantity, Region of the body, Severity of the symptoms, Time (length of time the disorder has been present). PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1291
OBJ:4TOP:Skin Assessment KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. What would the nurse stress to the 17-year-old girl who has been prescribed Accutane for her acne? a. Avoid alcoholic beverages b. Drink at least 1000 mL of fluid daily c. Use dependable birth control to avoid pregnancy d. Avoid exposure to the sun ANS: C Accutane has a destructive effect on fetal development. Dependable birth control is important to avoid a pregnancy. PTS: 1 DIF: Cognitive Level: Application REF: Page 1304, Figure 42-7 OBJ:6TOP:Effects of Accutane KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9.A 30-year-old African American had surgery 6 months ago and the incision site is now raised, indurated, and shiny. This is most likely which type of tissue growth? a. Angioma b. Keloid c. Melanoma d. Nevus ANS: B Keloids, which originate in scars, are hard and shiny and are seen more often in African Americans than in whites. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1307, Table 42-1 OBJ: 9 TOP: Keloid KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 10.A patient, age 37, sustained partial- and full-thickness burns to 26% of the body surface area. When would the greatest fluid loss resulting from the burns occur? a. Within 12 hours after burn trauma
b. 24 to 36 hours after burn trauma c. 24 to 48 hours after burn trauma d. 48 to 72 hours after burn trauma ANS: A In a burn injury, usually the greatest fluid loss occurs within the first 12 hours. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1322 OBJ:12TOP:Burns: fluid loss KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 11.Most of the deaths from burn trauma in the emergent phase that require a referral to a burn center result from: a. infection. b. arrhythmias with cardiac arrest. c. hypovolemic shock and renal failure. d. adrenal failure. ANS: C Hypovolemic shock is frequently lethal in the emergent period of a severe burn because of the transfer of fluids into the interstitial tissue from the circulating volume. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1325 OBJ:10TOP:Burns: infection KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 12.The nurse takes into consideration that carbon monoxide intoxication secondary to smoke inhalation is often fatal because carbon monoxide: a. binds with hemoglobin in place of oxygen. b. interferes with oxygen intake. c. is a respiratory depressant. d. is a toxic agent. ANS: A Carbon monoxide poisoning is likely if the patient has been in an enclosed area. Carbon monoxide displaces oxygen by binding with hemoglobin. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1324 OBJ:12TOP:CO2 intoxication
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 13.A nurse arrives at an accident scene where the victim has just received an electrical burn. What is the nurses primary concern? a. The extent and depth of the burn b. The sites of entry and exit c. The likelihood of cardiac arrest d. Control of bleeding ANS: C Most electrical burns result in cardiac arrest, and the patient will require CPR or acute cardiac monitoring. PTS: 1 DIF: Cognitive Level: Application REF: Page 1324 OBJ: 10 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14.A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72 hours, the nurse will have to observe for the most common cause of burn-related deaths, which is: a. shock. b. respiratory arrest. c. hemorrhage. d. infection. ANS: D Infection is the most common complication and cause of death after the first 72 hours. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1325 OBJ: 14 TOP: Burns KEY: Nursing Process Step: Assessment MSC:NCLEX: Safe, Effective Care Environment 15. Two weeks after a severe burn of over 20% of the body, the patient vomits bright red blood. Which condition is most likely? a. Curling ulcer b. Paralytic ileus c. Hypoglycemia perforation of the stomach by the NG tube d. Gastritis ANS: A
Curling ulcer is a duodenal ulcer that develops 8 to 14 days after severe burns on the surface of the body. The first sign is usually vomiting of bright red blood. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1325 OBJ:12TOP:Curling ulcer KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. When providing the open method of treatment for a patient who is 52 years old with burns to the lower extremities, what would a nurse include in the nursing plan? a. Change the dressing using good medical asepsis b. Provide an analgesic immediately after the dressing change c. Perform circulation checks every 2 to 4 hours d. Keep the room temperature at 85 F (29.4 C) to prevent chilling ANS: D Chilling may be controlled by keeping the room temperature at 85 F (29.4 C). Strict surgical protocol is observed and analgesia should be given before the treatment. Frequent circulation checks are not a high priority with the open method. PTS: 1 DIF: Cognitive Level: Application REF: Page 1326 OBJ:12TOP:Burn treatment KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse has staged a pressure ulcer that has a shallow crater with a dry pink wound bed as a: a. stage I b. stage II c. stage III d. stage IV ANS: B Stage II pressure ulcers have a shallow crater with a dry pink wound bed without slough. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1292
OBJ:4TOPressure ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18. What would the nurse dressing a necrotic pressure ulcer with a minimal exudate most likely use? a. Hydrocolloid dressing b. Alginate dressing c. Hydrofiber dressing d. Transparent film ANS: A Hydrocolloid dressings are useful in necrotic wounds with little exudate. Alginate and hydrofiber dressings are used for wounds with copious exudate. Transparent film is not absorbent. PTS: 1 DIF: Cognitive Level: Application REF: Page 1293, Table 42-2 OBJ: 14 TOP: Eczema KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 19. The nurse is caring for a 26-year-old male patient who was burned 72 hours ago. He has partial-thickness burns to 24% of his body surface area. He begins to excrete large amounts of urine. What should the nurse do? a. Increase the IV rate and monitor for burn shock b. Monitor for signs of seizure activity. c. Assess for signs of fluid overload d. Raise the foot of the bed and apply blankets ANS: C As the blood volume increases, the cardiac output increases to increase renal perfusion. The result includes diuresis. However, a great risk for the patient includes fluid overload because of the rapid movement of fluid back into the intravascular space. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1322 OBJ: 12 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20.A patient with severe eczema is starting a coal tar derivative treatment. What should the nurse include in the teaching plan for the patient relative to
this treatment? a. Drink at least 1000 mL of fluid daily b. Avoid exposure to sunlight for 72 hours after use c. Bathe with an astringent soap d. Reduce intake of high calcium foods ANS: B Persons using coal tar derivatives should avoid exposure to sunlight for 72 hours after use. The product stains clothes and bathroom fixtures. PTS: 1 DIF: Cognitive Level: Application REF: Page 1296, Table 42-3 OBJ: 6 TOP: Eczema KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 21. What should the nurse examine in assessing a patient for tinea corporis? a. Soles of the feet b. Scalp c. Armpits d. Abdomen ANS: D Tinea corporis is known as ringworm of the body. It occurs on parts of the body with little or no hair. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1304, Figure 42-8 OBJ:7TOP:Tinea corporis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 22. What is the initial intervention for relief of the pruritus of dermatitis venenata? a. Apply baking soda to lesions b. Wash area with copious amounts of water c. Apply cool compresses continuously d. Expose area to air ANS: B In dermatitis venenata (poison oak or ivy), the patient should wash the affected part immediately after contact with the offending allergen. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1307
OBJ: 6 TOP: Pruritus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse debriding a burn wound explains that the purpose of debridement is to: a. increase the effectiveness of the skin graft. b. prevent infection and promote healing. c. promote suppuration of the wound. d. promote movement in the affected area. ANS: B Debridement is the removal of damaged tissue and cellular debris from a wound or burn to prevent infection and to promote healing. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1327 OBJ: 12 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24.A patient has been admitted to the hospital with burns to the upper chest. The nurse notes singed nasal hairs. The nurse needs to assess this patient frequently for which condition? a. Decreased activity b. Bradycardia c. Respiratory complications d. Hypertension ANS: C Signs and symptoms of inhalation injury include singed nasal hairs. Breathing difficulties may take several hours to occur. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1323 OBJ: 12 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. Which may indicate a malignant melanoma in a nevus on a patients arm? a. Even coloring of the mole b. Decrease in size of the mole c. Irregular border of the mole d. Symmetry of the mole ANS: C
Any change in color, size, or texture and any bleeding or pruritus of a nevus deserves investigation. A malignant melanoma is a cancerous neoplasm in which pigment cells or melanocytes invade the epidermis, dermis, and sometimes the subcutaneous tissue. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1319, Figure 42-15 OBJ: 8 TOP: Melanoma KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 26.A nurse can assess cyanosis in a dark-skinned patient by noting the color of the: a. conjunctiva. b. sclera. c. lips and mucous membranes. d. soles of the feet. ANS: C Assessment of color is more easily made in areas where the epidermis is thin, such as the lips and mucous membranes. PTS:1DIF:Cognitive Level: Comprehension REF: Page 1291, Cultural and Ethnic Considerations OBJ: 4 TOP:CyanosisKEY:Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 27.A patient developed a severe contact dermatitis of the hands, arms, and lower legs after spending an afternoon picking strawberries. The patient states that the itching is severe and cannot keep from scratching. Which instruction would be most helpful in managing the pruritus? a. Use cool, wet dressings and baths to promote vasoconstriction. b. Trim the fingernails short to prevent skin damage from scratching. c. Expose the areas to the sun to promote drying and healing of the lesio Wear cotton gloves and cover all other affected areas with clothing to d. environmental irritation. ANS: A Wet dressings and using Burows solution help promote the healing process. Cold compresses may be applied to decrease circulation to the area (vasoconstriction). Short nails prevent skin damage, but not pruritus. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1305
OBJ:6TOP:Contact dermatitis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. What is the best instruction by the nurse regarding reducing the risk factors for melanoma? a. Avoid exposure to the sun and use protective measures when exposur b. Have all nevi removed. c. Watch for changes in moles, especially on the back. d. Use a sun lamp for tanning. ANS: A Encourage the patient to protect skin from the sun by wearing protective clothing, including a hat with 4-inch brim, applying sunscreen all over the body, and avoiding the midday sun from 10 am to 4 pm. Sun lamps are just as damaging as the sun. PTS: 1 DIF: Cognitive Level: Application REF: Page 1317 OBJ: 8 TOP: Melanoma KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 29. Which patient instruction should the nurse include in the teaching plan relative to the management of systemic lupus erythematosus? a. Maintain a balance between rest and activity b. Increase activity to promote mobility c. Increase exposure to the sun to increase vitamin D absorption d. Increase sodium consumption ANS: A Balanced rest, activity, and diet will support medication management. Limited sunlight exposure is recommended to prevent photosensitivity. SLE often has kidney involvement, which would require reduction of sodium. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1314 OBJ:6TOP:Systemic lupus erythematosus KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 30. Which patient statement indicates that more teaching is needed regarding antibiotic therapy for the treatment of cellulitis?
a. b.
My skin is cleared up. I dont think I need the medication anymore. Cellulitis can come back at any time. If I had washed that scratch with soap and water, I probably would no c. cellulitis. d. Cellulitis is contagious. ANS: A The entire amount of antibiotic medication should be completed even if the symptoms have abated to ensure the eradication of the infectious agent. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1301 OBJ:6TOP:Bacterial disorders of the skin KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 31. What should a patient be assessed for upon the diagnosis of genital herpes? a. Hepatitis B b. Syphilis c. Human immunodeficiency virus (HIV). d. Cirrhosis ANS: C Persons with genital herpes should be assessed for HIV because the therapy for herpes is suppressive; persons with HIV are not candidates for suppressant therapy. PTS: 1 DIF: Cognitive Level: Implementation REF: Page 1294 OBJ:5TOP:Genitall herpes KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 32.The school nurse recognizes the signs of scabies when a child presents with: a. small fluid filled blisters that sting when scratched. b. dry scaly patches in body creases that itch. c. wavy threadlike lines on the body and pruritus. d. cluster of papular lesions with pruritus. ANS: C Scabies is manifested by brown threadlike lines on the body, especially the
hands, anus, and body folds. Pruritus is severe. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1316 OBJ:7TOParasite disorders of the skin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 33. Melanocytes give rise to the pigment melanin, which is responsible for skin color. Where can the melanocytes be found? a. Dermis b. Superficial fascia c. Epidermis d. Loose connective tissue ANS: C A layer in the epidermis contains highly specialized cells called melanocytes. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1284 OBJ:2TOP:Structure of the skin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 34. Which of the following are major functions of the skin? (Select all that apply.) a. Excretion of wastes b. Protection c. Vitamin C synthesis d. Temperature regulation e. Prevention of dehydration ANS: A, B, D, E Functions of the skin include protection from the environment (pathogenic organisms, foreign substances, natural barrier against infection), temperature regulation, prevention of dehydration, excretion of waste products, and vitamin D synthesis. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1283, Box 42-1 OBJ:1TOP:Functions of the skin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological
Integrity 35. During primary survey assessment of a burn patient, the nurse checks for which of the following as early signs of carbon monoxide poisoning? (Select all that apply.) a. Dizziness b. Urticaria c. Vomiting d. Headache e. Vertigo f. Unsteady gait ANS: C, D, F Early signs of carbon monoxide poisoning include headache, nausea, vomiting, and unsteady gait. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1324 OBJ:12TOP:Carbon monoxide KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 36. What is a common diagnostic criterion for identifying systemic lupus erythematosus (SLE)? (Select all that apply.) a. Butterfly rash over nose and cheeks b. Photosensitivity c. Severe abdominal pain d. Skin ulcers e. Polyarthralgias and polyarthritis f. Immobility ANS: A, B, E Butterfly rash on face, sensitivity to sunlight, polyarthralgias, and polyarthritis are some of the main criteria leading to the diagnosis of SLE. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1313, Box 42-2 OBJ:6TOP:Systemic lupus erythematosus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 37. Which of the following are nursing interventions and patient teaching for
the treatment of head lice and scabies? (Select all that apply.) a. Clothing, linens, and bath articles thoroughly cleaned in hot water b. Stress nature and transmission of the disease c. Special carbohydrate diet to promote healing d. Complete isolation from the public ANS: A, B Identify involved contacts while stressing importance of preventing transmission of disease. Washable and clothing items should be cleaned in hot water to prevent reinfection. No special diet is required. Isolation is not necessary once medical management is completed. PTS: 1 DIF: Cognitive Level: Application REF: Page 1316 OBJ:7TOParasitic diseases of the skin KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 38. The most deadly skin cancer is . ANS: melanoma Malignant melanoma is a cancerous neoplasm that invades the epidermis, dermis, and sometimes the subcutaneous tissue. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1318 OBJ:8TOP:Tumors of the skin KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 39. The three major glands of the skin are , , and . ANS: sudoriferous (sweat), ceruminous, and sebaceous (oil). Sudoriferous glandssweat glands open into pores on the skin surface and excrete sweat. Ceruminous glandssecrete a waxlike substance called cerumen and are located in the external ear canal. Sebaceous glandssecrete their substance, sebum (an oily secretion), through the hair follicles distributed on the body. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1318
OBJ:3TOP:Glands of the skin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 40. The nurse making the initial assessment of a burned patient in the emergency room observes that the entire right arm (anterior and posterior), right anterior leg, chest, and abdomen are covered with reddened skin and blisters. Using the Rule of Nines, the nurse estimates the percentage of burn to be %. ANS: 36% 36 Anterior and posterior are 9%, anterior leg = 9%, chest= 9%, abdomen = 9%. Total 36% PTS: 1 DIF: Cognitive Level: Application REF: Page 1324 OBJ:11TOP:Rule of Nines KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity OTHER 41. Prioritize the intervention of the first responder to the victim during the emergent phase of burn management. (Separate letters by a comma and space as follows: A, B, C, D.) a. Transport victim to hospital. b. Cover victim with clean cloth or sheet. c. Stop, drop, and roll. d. Remove all nonadherent clothing and jewelry. e. Provide an open airway. f. Control any bleeding. ANS: C, E, F, D, B, A The primary concern is to stop the burning process, arrest skin damage, provide an open airway, control any bleeding, prevent infection by covering with a clean cloth, and obtain medical help by transporting to the nearest hospital. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1324
OBJ: 12 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 42. Prioritize the interventions for a hospitalized severely burned victim during the emergent phase. (Separate letters by a comma and space as follows: A, B, C, D.) a. Tetanus prophylaxis b. Insert Foley catheter c. Insert nasogastric tube d. Establish airway e. Administer analgesics f. Initiate fluid therapy ANS: D, F, B, C, E, A The priority of care should proceed from the establishment of an airway, initiation of fluid therapy, insertion of Foley and NG tube, administration of analgesics, and tetanus prophylaxis. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1324 OBJ: 12 TOP: Burns KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance Chapter 43: Care of the Patient with a Musculoskeletal Disorder My Nursing Test Banks Chapter 43: Care of the Patient with a Musculoskeletal Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What is the movement of an extremity away from the midline of the body called? a. Abduction b. Adduction c. Flexion d. Extension ANS: A Abduction is movement of an extremity away from the midline of the body. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1339 OBJ: 6 TOP: Movements KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 2. What is the large, fan-shaped muscle that covers the anterior chest from the sternum to the proximal end of the humerus and acts on the joint of the shoulder to flex, adduct, and rotate? a. Serratus anterior b. Intercostal c. Transversus abdominis d. Pectoralis major ANS: D Pectoralis major is the large, fan-shaped muscle that covers the anterior chest and is an adductor muscle, which will cause the shoulder to flex. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1341, Figure 43-4 OBJ:4TOP:Muscle functions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. What should the nurse instruct the patient before a magnetic resonance imaging (MRI) procedure? a. Void to completely empty the bladder b. Omit all citrus food for 12 hours before the procedure c. Remove all metal, such as jewelry, glasses, and hair clips d. Wear only cotton garments for the procedure ANS: C MRI procedures require that the patient remove all metal because it will become magnetized. PTS: 1 DIF: Cognitive Level: Application REF: Page 1341 OBJ:7TOPiagnostic examinations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse instructs the patient who is to have a unicompartmental knee replacement that a major advantage of this partial knee replacement is that: a. the patient will be up and walking 2 to 3 hours after the operation. b. the kneecap is completely removed. c. the procedure is especially helpful in the treatment of rheumatoid art
d. a small titanium disk replaces the worn cartilage. ANS: A Unicompartmental knee arthroplasty is also referred to as partial knee replacement in which the worn cartilage is replaced with a plastic disk. It is not as invasive as a full knee replacement and does not disturb the kneecap so that the patient can be up and walking in 2 to 3 hours after surgery. It is not recommended for RA patients. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1361 OBJ:13TOP:Unicompartmental knee replacement KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5.A patient who has had a right below the knee amputation continues to complain of unpleasant sensation in the right foot. What can the nurse explain about this phantom pain? a. It only exists in the mind. b. It is a complication following an amputation and can be clarified by t c. It is related to the severed nerves that are still sending messages to the d. It occurs when the person becomes focused on the loss of the limb. ANS: C Phantom pain (pain felt in the missing extremity as if it were still present) may occur and be frightening to the patient. Phantom pain occurs because the nerve tracts that register pain in the amputated area continue to send a message to the brain (this is normal). PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1394 OBJ:21TOPhantom pain KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The patient that has a bipolar hip replacement following an intracapsular fracture has an order to be turned every 2 hours. The nurse understands that the correct nursing intervention is to keep the legs: a. together so they do not separate while turning. b. flexed to stabilize the prosthesis. c. abducted so the prosthesis does not become dislocated. d. adducted to prevent additional pain for the patient with turning.
ANS: C Nursing interventions also involve postoperative maintenance of leg abduction by using an abduction splint for 7 to 10 days to prevent dislocation of the prosthesis. PTS: 1 DIF: Cognitive Level: Application REF: Page 1367, Figure 43-13 OBJ:14TOP:Maintaining abduction KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7.A patient has been casted to stabilize a fracture of the right radius and ulna. The nurse assesses a capillary refill of 5 seconds and cold fingers of the right hand. Which initial intervention should the nurse deploy? a. Notify the charge nurse of a probable compartment syndrome b. Apply a warm compress to the fingers to relieve swelling c. Elevate the right hand to heart level to maintain arterial pressure d. Cut the cast off to release constriction ANS: C The nurse should first elevate the right hand to heart level and notify the charge nurse. Permanent damage can occur in as little time as 6 hours. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1375 OBJ:19TOP:Compartment syndrome KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8.A patient had an open reduction with internal fixation (ORIF) for a compound fracture of the left tibia and has been placed in a long leg cast. The assessments by the nurse are: left foot warm/pink, pedal pulse weaker than right, capillary refill 3 seconds, and small 1 cm area of blood on cast. What should the nurse do? a. Notify charge nurse of impending compartment syndrome b. Document that all assessments are within normal limits c. Inform charge nurse about probable hemorrhage d. Place warm compresses on left foot ANS: B All of the assessments are within normal limits. A small amount of blood on
the cast is expected and should be monitored. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1397 OBJ:19TOP:Compound fracture KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. When a patient recovering from a fractured tibia asks what callus formation is, the nurse tells her it is: a. when blood vessels of the bone are compressed. a part of the bone healing process after a fracture when new bone is be b. fracture site. c. the formation of a clot over the fracture site. d. when the hematoma becomes organized and a fibrin meshwork is form ANS: B Callus formation occurs when the osteoblasts continue to lay the network for bone buildup and osteoclasts destroy dead bone. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1371 OBJ:15TOP:Bone healing KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. Which patient statement indicates the need for additional teaching for a patient with rheumatoid arthritis who is taking meloxicam (Mobic)? a. I am keeping a daily record of my blood pressure. b. I take aspirin before I go to bed. c. I know I can take meloxicam with or without regard to meals. d. I weigh every day so I will be aware of any weight gain. ANS: B Aspirin or products containing aspirin should be avoided while taking meloxicam. PTS: 1 DIF: Cognitive Level: Application REF: Page 1346, Table 43-5 OBJ:9TOP:Rheumatoid arthritis KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 11. What should the nurse include in the plan of care for a patient following a myelogram?
a. Position in a semi-Fowler position for 8 hours to reduce potential of h b. Place patient flat on back to compress puncture site c. Ambulate for brief periods to lessen postmyelogram headache d. Limit fluids to increase absorption of the dye ANS: A The patient should be positioned in the semi-Fowler position for 8 hours to encourage the dye to stay in the lower spine and to reduce headache. PTS: 1 DIF: Cognitive Level: Application REF: Page 1340 OBJ: 7 TOP: Myelogram KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. Which finding would delay a computed tomography (CT) scan? a. Patients allergy to shellfish b. Patient in first trimester of a pregnancy c. Patients allergy to milk products d. Patients gluten intolerance ANS: A Allergy to shellfish predicts an allergy to the contrast media used in the CT scan. PTS: 1 DIF: Cognitive Level: Application REF: Page 1342 OBJ: 7 TOP: CT scan KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. Forty-eight hours after a patient sustained a fractured femur in a car accident, the nurse assessed a pulse of 110, respirations at 25, and labored crackles in both lung fields. The nurse immediately reports to the charge nurse the probability of a(n): a. impending pneumonia. b. atelectasis. c. fat embolism. d. anxiety attack. ANS: C A pulmonary fat embolism involves the embolization of fat tissue with platelets and circulation of free fatty acids within the pulmonary circulation. Dyspnea, tachypnea, and chest pain are symptomatic of a fat embolus.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1376 OBJ:17TOP:Fat embolism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. What is the first priority nursing intervention for an impending fat embolism? a. Administer oxygen in a respiratory emergency b. Increase intravenous fluids c. Position in flat position to ease decreased blood pressure d. Cover with warm blanket ANS: A The airway is always the first priority. If hypoxia is present, the physician will order the administration of oxygen. It is important for the nurse to check the liter flow of oxygen and educate patients and their families as to safety precautions necessary when oxygen is administered. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1377 OBJ:17TOP:Fat embolism KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15.A patient, age 68, has suffered an intertrochanteric fracture of the right hip. Before surgery, to provide support and comfort, an immobilizing device of a is applied. a. Thomas splint b. Bryant traction c. Russell traction d. Buck traction ANS: D Buck traction is a form of traction used as a temporary measure to provide support and comfort to a fractured extremity until a more definite treatment is initiated. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1383 OBJ: 21 TOP: Fracture KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
16. Which foods should the home health nurse suggest for the patient with
osteoporosis to help slow the disease? a. Leafy green vegetables b. Foods high in sodium c. Tea and coffee d. Vitamin A ANS: A To slow the bone loss, a patient with osteoporosis should eat green leafy vegetables, foods low in sodium, and also avoid caffeine. Vitamin A does not help with the absorption of calcium. PTS: 1 DIF: Cognitive Level: Application REF: Page 1357, Patient Teaching OBJ:11TOP:Osteoporosis diet KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. What should the nurse include in the teaching plan for a patient who is taking alendronate (Fosamax)? a. Take drug with any meal b. Take drug first thing in the morning c. Drink at least 5 oz of milk before taking drug d. Take drug with an antacid to avoid heartburn ANS: B Alendronate (Fosamax) should be taken on an empty stomach first thing in the morning with 6 oz of water, accompanied by no other medication. PTS: 1 DIF: Cognitive Level: Application REF: Page 1356, Table 43-6 OBJ:8TOP:Osteoporosis drug KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 18.The patient has been diagnosed as having gouty arthritis. The patient asks the nurse to explain the cause of the inflammation of the great toe. What is the most appropriate nursing response? a. You have calcium oxalate deposits that are seen in gouty arthritis. b. The inflammation is from small accumulations of uric acid crystals, w c. The small nodules are not related to the arthritis condition. d. You have fat deposits that are common with gouty arthritis.
ANS: B Gout is a metabolic disease resulting from an accumulation of uric acid in the blood. It is an acute inflammatory condition associated with ineffective metabolism of purines. PTS: 1 DIF: Cognitive Level: Application REF: Page 1353 OBJ:8TOP:Gouty arthritis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. When the patient with rheumatoid arthritis complains about the daily exercise, the nurse encouragingly reminds the patient that exercises: a. keeps the joints from freezing. b. will ensure better sleep. c. should be vigorous for joint stimulation. d. need not be done daily. ANS: A Daily gentle exercises keep the joints from freezing and keep the muscles from weakening. PTS: 1 DIF: Cognitive Level: Application REF: Page 1349 OBJ:8TOP:Rheumatoid arthritis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. The nurse clarifies to a patient who is being evaluated for possible rheumatoid arthritis that the elevated erythrocyte sedimentation rate indicates the presence of: a. immunoglobulin M. b. abnormal serum protein. c. increased inflammatory reaction in the body. d. C-reactive protein. ANS: C The ESR indicates an increase in the inflammatory reactions in the body. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1345 OBJ:8TOP:Rheumatoid arthritis KEY:Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 21. What should the nurse instruct the patient before the initiation of the antimalarial drug hydroxychloroquine (Plaquenil)? a. Get a complete blood count to assess anemia. b. Get a chest x-ray. c. Get an eye examination. d. Take prophylaxis for malaria. ANS: C An eye examination should be completed before starting the drug and an eye examination should be done every 6 months while on the drug, because the drug can damage the retina and lead to blindness. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1336, Table 43-5 OBJ: 8 TOP: Gout KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. What should the nurse do when a patient with osteomyelitis is admitted with an open wound that is draining? a. Enforce a low calorie diet b. Initiate drainage and secretion precautions c. Frequently do passive ROM on the elbow d. Ambulate several times daily ANS: B The patient with osteomyelitis should be at least in drainage and secretion precaution. The limb should be positioned for maximum comfort and left at rest. These patients are usually on bed rest and require a high-calorie, highprotein diet. PTS: 1 DIF: Cognitive Level: Application REF: Page 1358 OBJ:19TOP:Osteomyelitis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23.A 16-year-old male patient presents in the emergency room with a pathologic fracture of the left femur and complains of pain on weight bearing. These are cardinal indicators of: a. osteogenic sarcoma.
b. osteoporosis. c. rheumatoid arthritis. d. osteochondroma. ANS: A Osteogenic sarcoma occurs in young men aged 10 to 25. They are malignant bone tumors that can cause a pathologic fracture and they are accompanied by pain on weight bearing. Osteochondromas are benign and usually do not cause fractures. PTS: 1 DIF: Cognitive Level: Application REF: Page 1393 OBJ: 20 TOP: Bone tumor KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. The 14-year-old boy who is scheduled for left leg amputation says to the nurse, What in the world am I going to do with only one leg? What is the nurses most therapeutic response? a. What are you thinking about right now? b. With a prosthesis, you will be as good as new. c. It is way too early to be concerned about that now. d. When my brother had his leg removed, he did great! ANS: A The patients concern should be acknowledged and the patient encouraged to express feelings. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1394 OBJ:20TOP:Fracture of hip KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 25.A patient has undergone a bipolar hip repair (hemiarthroplasty). Which is the most appropriate instruction? a. Sit in whatever position is most comfortable b. Sit in a firm, straight-backed chair at a 90-degree angle c. Avoid crossing the legs d. Begin full weight bearing as soon as tolerated ANS: C Instructing the patient not to cross the legs is important because crossing the
legs can adduct the affected extremity and dislocate the hip. PTS: 1 DIF: Cognitive Level: Application REF: Page 1367, Figure 43-18 OBJ:14TOP:Hip replacement KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. The nurse explains to a patient who has had a knee replacement that warfarin (Coumadin) is ordered to: a. increase the red blood cells. b. reduce the threat of hemorrhage. c. prevent formation of emboli. d. help stabilize the prosthesis. ANS: C Warfarin (Coumadin) is a standard postsurgical drug to prevent the formation of emboli. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1367 OBJ:13TOP:Coumadin therapy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. What should the nurse stress to a posthip replacement patient in quadriceps setting exercises? a. Push knee down to mattress and raise heel off the bed b. Flex knee and extend foot c. Adduct leg and flex foot d. Lift leg and heel off the bed ANS: A Pushing the knee down into the mattress and raising the heel will strengthen the quadriceps muscles. PTS: 1 DIF: Cognitive Level: Application REF: Page 1367, Patient Teaching OBJ: 14 TOP: Quad setting KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. What should the home health nurse include assessment for in the plan of care for an 82-year-old female with severe kyphosis from ankylosis? a. Urinary output
b. Respiratory effort c. Sleep cycle d. Nutritional status ANS: B Severe kyphosis may hinder the patients ability to expand the ribcage and interfere with easy respiration. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1350 OBJ: 22 TOP: Kyphosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. What should the nurse stress to a patient who has had a hip replacement and is beginning strengthening exercises for the unaffected leg? a. Flex the knee and flex the foot b. Lift the leg from the mattress and rotate the foot c. Pull knee to chest and extend the foot d. Push foot down against the footboard for a count of five ANS: D The unaffected leg should be strengthened by pushing the foot down against the footboard for a count of five and repeating frequently during the day. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1367, Patient Teaching OBJ: 13 TOP: Exercise KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. The office nurse has noted the presence of an increase in lumbar curvature in a 20-year-old female patient. What is this condition known as? a. Scoliosis b. Lordosis c. Kyphosis d. Spondylitis ANS: B Common deformities include an increase in the curve at the lumbar space region that throws the shoulder back, making the lordly or kingly appearance that is known as lordosis. Scoliosis involves the S curvature of the spine. Kyphosis is the rounding of the thoracic spine.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1396 OBJ: 22 TOP: Lordosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31. How is rheumatoid arthritis distinguished from osteoarthritis? Rheumatoid arthritis is an autoimmune, systemic disease; osteoarthriti a. disease of the joints. Rheumatoid arthritis is an autoimmune, degenerative disease; osteoart b. inflammatory disease. People with osteoarthritis are considered to be genetically predisposed c. genetic component to rheumatoid arthritis. Osteoarthritis is often caused by a virus; viruses play no part in the pat d. rheumatoid arthritis. ANS: A RA is thought to be an autoimmune disorder. Degenerative joint disease is also known as osteoarthritis. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1344, Table 43-4 OBJ:8TOP:Rheumatoid arthritis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 32. Which patient is most likely to develop osteoporosis? a. 43-year-old African American woman b. 57-year-old white woman c. 48-year-old African American man d. 62-year-old Latino woman ANS: B White and Asian women have a higher incidence of osteoporosis than African American women or Hispanic women because of the greater bone density in the African American. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1356, Culture OBJ:11TOP:Osteoporosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 33. The patient, age 58, is diagnosed with osteoporosis after densitometry testing. She has been menopausal for 5 years and has been concerned about
her risk for osteoporosis because her mother has osteoporosis. In teaching her about her osteoporosis, which information does the nurse include? Even with a family history of osteoporosis, the calcium loss from bon a. increased calcium intake and exercise. Estrogen replacement therapy must be started to prevent rapid progres b. osteoporosis. With a family history of osteoporosis, there is no way to prevent or slo c. reabsorption. Continuous, low-dose corticosteroid treatment is effective in stopping d. osteoporosis. ANS: A To prevent osteoporosis, women are advised to have an adequate daily intake of calcium and vitamin D; exercise regularly; avoid smoking; decrease coffee intake; decrease excess protein in the diet; and engage in regular moderate activity such as walking, bike riding, or swimming at least 3 days a week. A contributing factor may be use of steroids. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1355 OBJ:11TOP:Osteoporosis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 34. Certain foods may increase the pain associated with gout. Which foods have the highest concentration of purines? a. Brain, liver, kidney b. Lettuce, corn, potatoes c. Beef, pork, chicken d. Fruits and fruit juices ANS: A Foods high in purines, such as brain, kidney, liver, and heart should be avoided, as well as alcohol. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1354 OBJ: 8 TOP: Gout KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 35. In order for a patient to flex the lower leg, which muscle must be contracted?
a. Quadriceps b. Gastrocnemius c. Biceps femoris d. Rectus femoris ANS: C The contraction of the biceps femoris allows for the contraction of the lower leg. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1335, Table 43-1 OBJ:4TOP:Muscle action KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 36. Calcium is a mineral found in many foods that can slow bone loss during the aging process. Which food is high in calcium? a. Oranges b. Bananas c. Spinach d. Eggs ANS: C Spinach and green vegetables, as well as yogurt, are considered calcium-rich foods. Fresh oranges, bananas, and eggs are not good calcium choices. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1355, Patient Teaching OBJ:11TOP:Osteoporosis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 37.A 56-year-old female patient is being seen for osteoarthritis of the knee in the clinic. What should the nurse recommend when discussing strengthening exercises? a. Jogging b. Walking rapidly on a treadmill c. Bicycling d. Aerobic exercises ANS: C Bicycling or swimming is recommended for osteoarthritis of the hip or knee.
Jogging would put undue stress on knee joints. Climbing stairs should be avoided. Walking should be done on level ground, not up or down elevations. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1351, Box 43-3 OBJ:10 | 11TOP:Osteoarthritis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 38. What does prolonged bed rest put the older adult at risk for? a. Ankylosing spondylitis b. Pathologic fractures c. Osteomyelitis d. Gout ANS: B Immobilization results in bone resorption, and the bone tissue becomes less dense. Prolonged bed rest puts the patient at risk for pathologic fracture. This is a serious concern for an older adult in terms of regaining mobility. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1344 OBJ:11TOPisorders of musculoskeletal system KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 39. Which of the following are the main purposes of traction? (Select all that apply.) a. Align and stabilize a fracture b. Prevent deformities c. Relieve muscle spasms d. Promote bed rest e. Increase circulation to the rest of the body ANS: A, B, C Skin and skeletal traction provide alignment and stabilize a fracture. This prevents deformities and relieves muscle spasms by putting muscles under tension until they are fatigued. PTS: 1 DIF: Cognitive Level: Application REF: Page 1383 OBJ: N/A TOP: Traction KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 40. The characteristics of osteoarthritis that should be included in a teaching plan would include that osteoarthritis (select all that apply): a. will cause the formation of Heberden nodes. b. can involve other organs. c. results from wear and tear. d. may affect only one side of the body. e. may cause constitutional symptoms of fatigue and fever. f. will cause marked erythema and edema of hands. ANS: A, C, D Osteoarthritis is a disease caused by wear and tear of the joints, causing the appearance of Heberden nodes on the fingers without marked edema or erythema. The disease may only affect one side of the body and does not cause constitutional symptoms. PTS: 1 DIF: Cognitive Level: Application REF: Page 1344, Table 43-4 OBJ:10TOP:Osteoarthritis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 41.What are the three vital functions muscles perform when they contract? (Select all that apply.) a. Absorb uric acid b. Maintenance of posture c. Motion d. Store minerals e. Production of heat f. To assist in return of venous blood to the left side of the heart ANS: B, C, E The three vital functions muscles perform when they contract are maintenance of posture, motion, and production of 85% of body heat. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1336 OBJ:6TOP:Functions of muscular system KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 42. Which instructions should the nurse include in a teaching plan for a person
with gouty arthritis? (Select all that apply.) a. Avoid excessive alcohol. b. Maintain rest and immobility while disease is symptomatic. c. Check urine and urine output for possible kidney stones. d. Include food high in purine in the diet. e. Use bed cradle to support linens. ANS: A, B, C, E The person with gout should avoid alcohol and food with high purine content, maintain rest and immobility while symptomatic, and check urine and urine output for possible kidney stones. PTS: 1 DIF: Cognitive Level: Application REF: Page 1354 OBJ: 8 TOP: Gout KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 43. The division of the skeletal system that comprises the skull, hyoid, vertebral column, and thorax is the division. ANS: axial The axial division of the skeletal system is comprised of the skull, hyoid, vertebral column, and the throat. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1336 OBJ:2TOP:Skeletal divisions KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 44.A patients patellar-femoral cartilage has deteriorated due to arthritis. The medial and lateral cartilage is undamaged. This patient is likely to undergo knee replacement surgery. ANS: partial, unicompartmental Unicompartmental knee arthroplasty is also referred to as partial knee replacement and is performed on patients who have only one of the compartments of the knee affected by arthritis. Topic: Partial knee replacement Nursing Process Step: Planning
Objective: 10 Cognitive Level: Comprehension NCLEX: Physiological Integrity Text Reference: Page 4-46 PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1361 OBJ:10TOPartial knee replacement KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 45.The emergency department nurse assesses the two cardinal signs of a hip fracture in a newly admitted patient, which are the of the injured leg and the rotation of that same leg. ANS: shortening, external The two cardinal signs of a fractured hip are the appearance of the shortening of the affected leg and the external rotation of that same leg. PTS: 1 DIF: Cognitive Level: Application REF: Page 1366 OBJ:N/ATOP:Signs of hip fracture KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 46. The nurse administering the drug colchicine for gout will give 0.5 mg hourly for hours. ANS: 12 Colchicine is given orally in a dose of 0.5 mg for a period of 12 hours or until relief from pain is achieved or diarrhea occurs. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1354 OBJ: 8 TOP: Colchicine KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 47. The nurse explains that the use of the brace allows a person with a cervical fracture to be mobile. ANS: halo Halo braces attach to the skull with pins, which stabilize a cervical vertebral fracture, allowing the patient to be mobile. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1372, Figure 43-21
OBJ: 15 TOP: Halo brace KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity OTHER 48. The nurse takes into consideration that a healing fracture progresses through several healing stages. Place the stages in order of healing. (Separate letters by a comma and space as follows: A, B, C, D) a. Development of fibrin meshwork b. Collagen fibers collect calcium c. Osteoblasts home fracture site form d. Callus e. Formation of hematoma f. Clot formation g. Vascularization ANS: F, E, A, C, G, B, D The healing stages of a fracture start with a clot formation, which leads to a hematoma. The development of a fibrin meshwork, which traps osteoblasts to keep the fracture site firm, vascularization, collagen fibers collect calcium to make the callus. Topic: Fracture healing Nursing Process Step: Planning Objective: 15 Cognitive Level: Analysis NCLEX: Physiological Integrity Text Reference: Page 4-64 PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1371 OBJ:15TOP:Fracture healing KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity Chapter 44: Care of the Patient with a Gastrointestinal Disorder My Nursing Test Banks Chapter 44: Care of the Patient with a Gastrointestinal Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse clarifies that the end product of carbohydrate metabolism is
absorbed and put into the blood stream by the: a. gastric lining of the stomach. b. villi of the small intestine. c. bile of the liver in the large intestine. d. excretion from the cecum. ANS: B The inner surface of the small intestine contains millions of tiny, fingerlike projections called villi, which contain small blood vessels. They are responsible for absorbing the products of digestion. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 5-6 OBJ: 2 TOP: Digestive KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2.A 56 -year-old man is admitted to the emergency room with an acute attack of diverticulitis. The patient has a temperature of 102 F, and has an elevated white count. Which assessment would alert the nurse to impending septic shock? a. Chest pain b. Seizure c. Tachycardia d. Massive diarrhea ANS: C The patient with diverticulitis who has fever and an elevated white count has an infection that could lead to septic shock, which will present as tachycardia and hypotension. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 5-98 OBJ:9TOPiverticulitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Because bowel contents from an ileostomy are virtually liquid, what should the nurse include in the plan of care? a. Evaluation and assessment of dietary intake of fiber b. Evaluation and assessment of patient cleanliness c. Evaluation and assessment of periostomal skin integrity
d. Evaluation and assessment of the adequacy of the collection device ANS: C The nurse should assess the periostomal skin for impairment of integrity. The fecal material is liquid and has a potential for severe skin excoriation from the digestive enzymes. PTS: 1 DIF: Cognitive Level: Application REF: Page 5-5-84 OBJ:8TOP:Ulcerative colitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The home health nurse caring for a patient who has dysarthria related to radiation therapy for an oral cancer would recommend that the family provide: a. a tablet and pencil as a communication aid. b. a TV for diversion. c. a bell to summon help. d. a walkie-talkie. ANS: A The provision of an alternative method of communicating will lessen the frustration of the patient who has trouble speaking understandably. The call bell would be helpful also, but without a way to communicate, the bell is not as essential as a method of communication. PTS: 1 DIF: Cognitive Level: Application REF: Page 5-28 OBJ:5TOP:Cancer of esophagus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. Which recommendation is most appropriate for a patient who has had an esophageal dilation related to achalasia? a. Consume only liquid b. Avoid fruit juices c. Drink 10 oz of fluid with each meal d. Lie down for 30 minutes after each meal ANS: C The patient should drink fluid with each meal to increase lower esophageal
pressure to push food into the stomach. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 5-41 OBJ:5TOP:Esophageal dilation KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6.A patient who is being evaluated for episodes of hematemesis and dyspepsia tells the nurse that pain occurs when he eats, but pain does not waken him. The nurse recognizes a diagnostic sign of which condition? a. Duodenal ulcer b. Gastritis c. Achalasia d. Peptic ulcer ANS: D A significant subjective data assessment for a peptic ulcer is the patient report that pain is associated with eating, but not with an empty stomach, because there would be pain with a duodenal ulcer. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 5-46 OBJ: 5 TOP: Peptic ulcer KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse anticipates that the patient who has had a subtotal gastrectomy will need supplemental: a. protein due to the loss of some of the digestive processes. b. vitamin B12 due to the loss of the intrinsic factor. c. bulk to prevent constipation. d. vitamin A due to the loss of the gastric lining. ANS: B
It is recommended that all patients with a gastrectomy have a blood serum vitamin B12 level measured every 1 to 2 years. Decreased absorption of vitamin B12 may cause pernicious anemia. PTS: 1 DIF: Cognitive Level: Application REF: Page 5-61
OBJ: 6 TOP: Gastrectomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. The home health nurse is caring for a patient who has frequent bouts of diverticulitis accompanied by increased flatulence, diarrhea, and nausea. Which of the following is the most appropriate suggestion to lessen these symptoms? a. Eat a diet high in fiber content b. Increase dietary fat intake c. Exercise to increase intra-abdominal pressure d. Take daily laxatives ANS: A The symptoms of diverticulitis can be reduced or prevented by eating a highfiber diet, reduction of meat and fats in the diet, and avoiding activities that increase intra-abdominal pressure. Although laxatives might be prescribed sparingly, daily laxatives are not recommended. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 5-99 OBJ:9TOPiverticulitis KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. The nurse caring for a patient with a peptic ulcer who has had a nasogastric tube inserted notes bright blood in the tube; the patient complains of pain and has become hypotensive. Which condition should the nurse recognize these as signs of? a. Hiatal hernia b. Gastritis c. Perforation d. Bowel obstruction ANS: C Perforation of the gastric wall causes pain, hypotension, and hematemesis. Immediate reporting to the charge nurse/physician is essential as peritonitis, potentially lethal, is the result of a perforation. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 5-47 OBJ:5TOP:Ulcer perforation
KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 10. Dumping syndrome after a Billroth II procedure occurs when highcarbohydrate foods are ingested over a period of less than 20 minutes. What would the nurse suggest to reduce the risk of dumping syndrome? a. Eating a high-carbohydrate diet b. Drinking 10 oz of fluids with meals c. Remaining upright for 2 hours after meals d. Eating six small daily meals high in protein and fat ANS: D Treatment for dumping syndrome includes eating six small meals daily that are high in protein and fat, and low in carbohydrates. Fluids should be avoided during meals. If possible, the patient should lie down for 1 hour after meals. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 5-60 OBJ:4TOPumping syndrome KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 11.The patient has come to the PACU following an ileostomy for the treatment of ulcerative colitis. The patient is conscious and has a nasogastric tube in place and a pouch over the stoma. What should be the nurses initial action? a. Turn patient to right side b. Give patient ice chips to moisten mouth c. Attach NG tube to suction d. Irrigate NG tube ANS: C Initially, the NG tube should be attached to suction to decompress the stomach and prevent nausea. Assessing the tube for the need of future irrigation will be part of the postoperative care. PTS: 1 DIF: Cognitive Level: Application REF: Page 5-85, Box 5-5 OBJ: 4 TOP: Appendicitis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 12. The home health nurse evaluates a patient being treated for a peptic ulcer
with Riopan (antacid) and famotidine (histamine receptor blocker). Which statement made by the patient indicates a need for further instruction? a. I know famotidine will not interfere with my Coumadin. b. I take the Riopan at least 2 hours after any of my other drugs. c. Boy! That Riopan keeps my stomach happy! d. I take both those meds at the same time every morning. ANS: D Antacids should not be taken with other drugs, because the absorption of the other drugs may be affected. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 5-49, Table 5-1 OBJ:4TOPharmacology KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 13. What should a nurse do when obtaining a stool specimen to be examined for ova and parasites? a. Use an oil retention enema to facilitate collection b. Refrigerate the specimen immediately c. Obtain three different stool specimens on subsequent days d. Check the specimen for the presence of occult blood ANS: C Diagnosing a parasitic infection requires three different stool specimens on subsequent days. Use only normal saline or tap water enemas to prevent alteration of results. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 5-18 OBJ:3TOPiagnostic studies KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse explains to the patient with Crohn disease that the tube feedings allow for: a. Rapid absorption in the upper GI tract b. Decompression of the stomach c. Reduction of diarrheic episodes d. A permanent nutritional support
ANS: A The tube feedings allow for rapid absorption of the nutrients in the upper GI tract. The tube feedings are not permanent and will be followed by oral intake of a low-residue, high-protein, high-calorie diet. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 5-91 OBJ:7TOP:Crohn disease KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15.A patient with a large inguinal hernia has abdominal distention and inguinal pain. The nurse recognizes these as indicators of which type of hernia? a. Strangulated b. Hiatal c. Ventral d. Umbilical ANS: A The hernia is strangulated when the blood supply and intestinal flow are occluded, which results in pain and distention. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 5-105 OBJ:10TOP:Inguinal hernia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16.A patient with a ruptured diverticulum in the descending colon has undergone a transverse loop colostomy. The patient is upset and says, I didnt know it was going to be this awful. I hate this! Which response made by the nurse would be most helpful? a. This is a temporary solution. It will be closed in 6 weeks. b. This seems awful now, but you wont have the problems you had befo c. If everything goes well the surgeon can close this colostomy in about d. With the appropriate pouch and loose clothing, no one will notice a t ANS: A The loop colostomy is a temporary colostomy that allows for complete bowel rest. It can be closed in as short a time as 6 weeks.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 5-100 OBJ:8TOPiverticulum KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 17.A male patient complains that he will never adjust to his colostomy. Which is the best action for the nurse in this situation? a. Encourage him to express his concern b. Suggest that he discuss his concerns with his physician c. Counsel him that everything will be all right d. Assure him that his concerns will diminish when he is able to care for ANS: A When a colostomy is performed, the patient or significant other should be able to verbalize and demonstrate understanding of ostomy care to the nurse. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 5-137 OBJ: 8 TOP: Colostomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 18. In caring for a patient with gastric bleeding who has a nasogastric tube in place, the nurse should include in the plan of care to ensure that the NG tube is: a. Clamped for 10 minutes every hour b. Kept patent with irrigation c. Frequently repositioned to the opposite nostril d. Changed every 72 hours ANS: B Irrigating the NG tube PRN will keep the tube patent and ensure effective decompression. PTS:1DIF:Cognitive Level: Application REF: Page 5-52, Nursing care plan 5-1 OBJ: 4 TOP: NG tube KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. What should the nurse include in a teaching plan for a patient with a hiatal hernia to reduce the frequency of heartburn? a. Drinking 10 oz of milk with every meal
b. Lie down after eating c. Panting through mouth when symptoms begin d. Eating small meals ANS: D Taking care not to overeat is the best defense again pyrosis (heartburn) for the person with a hiatal hernia. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 5-109 OBJ:10TOP:Hiatal hernia KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. The nurse points out which of the following as an example of a nonmechanical bowel obstruction? a. A paralytic ileus b. Narrowed bowel lumen from an inflammatory process c. Tumor of the bowel d. Fecal impaction ANS: A A nonmechanical bowel obstruction can be caused by a paralytic ileus. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 5-111 OBJ: 4 TOP: Cancer KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 21. Bowel sound assessment on a patient with an obstruction who has distention, nausea, and visible peristaltic waves would be: a. loud and clearly audible. b. high pitched. c. hyperactive. d. absent. ANS: B Because there are visible peristaltic waves, there will be bowel sounds that will be faint and high pitched. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 5-113 OBJ:11TOP:Bowel obstruction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological
Integrity 22. The patient with a peptic ulcer has been placed on regular doses of bismuth salicylate (Pepto-Bismol) to combat H. pylori. What color will this drug turn the stool? a. Gray-black b. Dark green c. Red-orange d. Yellow ANS: A Bismuth products turn the stool gray-black. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 5-49, Table 5-1 OBJ: 4 TOP: Shock KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 23. Which of the following should be included in the patient teaching of a patient with a peptic ulcer? a. Introducing irritating foods in minute amounts to desensitize the stom b. Restricting fluid to 1000 mL per day c. Eating 6 small meals a day d. Drinking alcohol and caffeine in moderation ANS: C The patient with a peptic ulcer should eat frequently to keep food in the stomach. Eating 6 small meals daily is helpful. Restriction of fluid is not necessary and irritating foods, alcohol, and caffeine should be discouraged. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 5-56 OBJ: 4 TOP: Peptic ulcer KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 24. Which of the following would be the most helpful nursing intervention to increase the comfort of a patient with appendicitis? a. Application of ice bag b. Administration of small tap water enema c. Warm compress over entire abdomen d. Ambulate for short periods in the room ANS: A
Application of an ice bag will decrease the flow of blood to the area and impede the inflammatory process. PTS: 1 DIF: Cognitive Level: Application REF: Page 5-95 OBJ: 9 TOP: Appendicitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. To assist a family with a bowel training program to reduce fecal incontinence, the nurse would suggest the use of a at an optimal time to stimulate defecation. a. Warm bath b. A tap water enema c. Glycerin suppository d. Large glass of warm lemonade ANS: C The use of a glycerin suppository for fecal stimulation is a helpful aid in a bowel-training program. The suppository is administered at what the family and patient have determined is the optimal time for a bowel movement. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 5-124 OBJ:13TOP:Bowel training KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. What is the most lethal complication of a peptic ulcer? a. Bleeding b. Perforation c. Severe pain d. Gastric outlet obstruction ANS: B Perforation is considered the most lethal complication of peptic ulcer. Bleeding may occur when the ulcer erodes into a blood vessel; however, perforation occurs when the ulcer crater penetrates the entire thickness of the wall of the stomach or duodenum. Gastric outlet obstruction can occur at any time and can be relieved by NG aspiration of stomach contents. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 5-47 OBJ:4TOPisorders of the stomach
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 27.The nurse takes into consideration that a proton pump inhibitor drug, such as , will completely eradicate gastric acid production. a. omeprazole (Prilosec) b. ranitidine (Zantac) c. sucralfate (Carafate) d. olsalazine (Dipentum) ANS: A Omeprazole (Prilosec) is a proton pump inhibitor that interferes with the production of gastric acid. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 5- 32 OBJ:4TOPisorders of the stomach KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 28.Which of the following is the purpose of antibiotic therapy in treating peptic ulcers? a. It eradicates H. pylori b. It inhibits gastric acid secretion c. It protects the gastric mucosa d. It neutralizes or reduces the acidity of stomach contents ANS: A Antibiotic therapy eradicates H. pylori. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 5-49, 5-50 OBJ: 4 TOP: Peptic ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. Why are peptic ulcers a common problem of aging? a. Because of overuse of antibiotics b. Because of overuse of antacids c. Because of overuse of NSAIDs d. Because of overuse of laxatives ANS: C Medications such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) taken for arthritis or degenerative joint conditions may contribute to ulcer formation.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 5-110 OBJ:4TOPisorders of the stomach KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. The patient with irritable bowel syndrome tells the home health nurse she is going to an acupuncturist for therapy for her condition. Which of the following would be the best nursing response? a. Go for it. Alternative medicine does great things. b. YIKES! An acupuncturist? c. It may help, but there has been no clinical proof of its effectiveness. d. You should confirm that the acupuncturist is licensed. ANS: C While it is true that some have found relief there is no evidence that these therapies relieve the symptoms of IBS. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 5-76 OBJ:4TOP:Alternative therapy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 31. Which of the following are indicators of colorectal cancer? (Select all that apply.) a. Constant diarrhea b. Excessive flatulence c. Cachexia d. Cramps e. Rectal bleeding f. Anemia ANS: B, C, D, E, F The indicators for colorectal cancer are changing bowel habits between diarrhea and constipation, flatulence, cachexia, cramps, rectal bleeding, and anemia. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 5-118
OBJ:12TOP:Colorectal cancer KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 32. How should the nurse counsel the 34-year-old woman who has been prescribed sulfasalazine (Azulfidine) for Crohn disease? (Select all that apply.) a. Expose her to sunlight at least 30 minutes a day for vitamin D synthe b. Tell her to drink at least 1500 mL of fluid a day c. Advise assessing self for rash d. Use alternate birth control methods to oral contraception e. Take drug on an empty stomach ANS: B, C, D Cautionary information about sulfasalazine (Azulfidine) would include having adequate fluid intake to prevent crystallization in the kidneys, avoiding exposure to the sun, and using alternate birth control methods as oral contraception is made unreliable by this drug. The drug should be taken with meals and the patient should be assessing for rash. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 5-49, Table 5-1, 5-82 OBJ:7TOP:Crohn disease KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 33. In designing a teaching plan to present to a group of older adults regarding the prevention of esophageal cancer, the nurse would include information about the significance of (select all that apply): a. cessation of smoking. b. good oral care. c. regular checkups if dysphagia is present. d. reducing excessive weight. e. limiting alcohol consumption. f. reduction of consumption of citrus fruits. ANS: A, B, C, E Preventative measures include cessation of smoking and alcohol consumption, good oral care, and medical evaluation of dysphagia. Weight
and reduction of citrus fruits are non-contributory to prevention of esophageal cancer. PTS: 1 DIF: Cognitive Level: Application REF: Pages 5-24, 5-25 OBJ:6TOP:Esophageal cancer KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 34. Which activities should the home health nurse suggest to an elderly patient to avoid constipation? (Select all that apply.) a. Increasing physical activity b. Taking bulk-forming laxatives c. Increasing fiber intake d. Drinking at least 1000 mL fluid e. Taking a daily stool softener f. Using tap water enemas for persons with altered mobility ANS: A, B, C, D Inactivity and changes in diet and fluid intake can contribute to constipation. A nutritional diet high in fiber and bulk-forming foods can promote normal elimination. Increasing fluids to 8 to 10 glasses per day will be beneficial in preventing constipation. A daily bowel routine will also benefit elimination. Use of daily stool softeners is no longer recommended for the older adult. Tap water enemas for persons with altered mobility are is helpful. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 5- 129 OBJ:4TOPisorders of intestine KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 35. The home health nurse is caring for a patient who has frequent abdominal pain and diarrhea. The nurse uses the Rome Criteria to direct assessment for irritable bowel syndrome. What is included in the Rome Criteria? (Select all that apply.) a. Discomfort at least 3 days a month b. Blood in stool c. Pain relieved by defecation d. Excessive flatulence
e. Nausea and vomiting associated with onset f. Onset associated with change in stool consistency or frequency ANS: A, C, F The Rome Criteria include that the patient experience discomfort at least 3 days a month within the last 3 months, pain relieved by defecation, onset associated with change in stool frequency, and onset in association with a change in stool appearance. Although increased flatus is associated with diverticulitis, it is not part of the Rome Criteria. PTS: 1 DIF: Cognitive Level: Application REF: Page 5-74 OBJ:5TOP:Rome Criteria KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION 36. Flexible sigmoidoscopy should be performed every years. ANS: 5 Flexible sigmoidoscopy should be performed every 5 years. Endoscopy of the lower GI tract allows visualization and, if indicated, access to obtain biopsy specimens of tumors, polyps, or ulcerations of the anus, rectum, and sigmoid colon. The lower GI tract is difficult to visualize radiographically, but sigmoidoscopy allows direct visualization. Topic: Screening for colorectal cancer Nursing Process Step: Planning Objective: 3 Cognitive Level: Knowledge NCLEX: Physiological Integrity Text Reference: Page 5-119 PTS:1DIF:Cognitive Level: Knowledge REFage 1448, Health PromotionOBJ:3 TOP: Screening for colorectal cancer KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 37. The nurse explains that , the chief enzyme of gastric juice, is activated by hydrochloric acid to begin digestion of protein. ANS:
pepsin Pepsin is activated by the hydrochloric acid to break down protein for digestion. Topic: Pepsin Nursing Process Step: Implementation Objective: 2 Cognitive Level: Knowledge NCLEX: Physiological Integrity Text Reference: Page 5-5 PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1403 OBJ: 2 TOP: Pepsin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 38. The nurse caring for a patient with Crohn disease will closely monitor the urinary output to ensure that the patient is excreting at least mL/day. ANS: 1500 The output of 1500 mL a day indicates good kidney perfusion. The disease allows such dramatic fluid loss that a constant watch on I&O is a major nursing intervention. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 5-91 OBJ:7TOP:Crohn disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 39. The nurse takes into consideration that long-term use of antibiotics can cause an antibiotic-associated pseudomembranous colitis from the organism . ANS: C. difficile C. difficile causes a type of colitis from long-term antibiotic use to which older adults are extremely susceptible. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 5-65 OBJ: 4 TOP: C. difficile KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 40. Due to frequent bouts of constipation, the nurse examines the bedfast
nursing home resident for ulceration of the anus, called . ANS: anal fissure Ulceration and laceration of the anal skin can occur because of overstretching with the passing of constipated stool. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 5-131 OBJ: N/A TOP: Anal fissure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity OTHER 41. The nurse uses a poster to show the process of bowel obstruction from diverticulitis. Arrange the pathophysiologic event in order. (Separate letters by a comma and space as follows: A, B, C, D) a. Increase in intra-abdominal pressure b. Weakened wall of sigmoid c. Pouch fills with fecal matter d. Pouch protrudes through smooth muscle e. Narrowing of bowel lumen f. Inflammation of diverticula ANS: B, A, D, C, F, E Bowel obstruction from diverticulitis follows a sequential path: The wall of the bowel is weakened (usually the sigmoid), increase in abdominal pressure from such activities as bending and carrying heavy loads causes a pouch to protrude through the smooth muscle of the colon, the pouch fills with fecal matter, becomes inflamed, and narrows the lumen of the bowel causing obstruction. Topic: Bowel Obstruction Nursing Process Step: Planning Objective: 9 Cognitive Analysis NCLEX: Health Promotion and Maintenance Text Reference: Pages 5-97, 5-98 PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1440
OBJ:9TOP:Bowel Obstruction KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 42. Celiac sprue in the adult can lead to systemic problems. Arrange the pathophysical events of this in order of their appearance. (Separate letters by a comma and space as follows: A, B, C, D) a. Malabsorption b. Weight loss/vitamin deficiency c. Systemic involvement d. Diarrhea e. Ingestion of gluten f. Destruction of villi in the small intestine ANS: E, F, A, D, B, C The ingestion of gluten in the small intestine damages the villi, which leads to malabsorption and diarrhea. Weight loss and vitamin deficiency, which occur from altered nutrition, can expand into systemic involvement. Topic: Celiac sprue Nursing Process Step: Planning Objective: 4 Cognitive Analysis NCLEX: Physiological Integrity Text Reference: Pages 5-70, 5-71 PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1430 OBJ: 4 TOP: Celiac sprue KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity Chapter 45: Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder My Nursing Test Banks Chapter 45: Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse clarifies that unconjugated bilirubin, which is made up of broken-down red cells, is:
a. stored in the gallbladder to make bile. b. water insoluble bilirubin that must be converted by the liver. c. a by-product which is excreted directly into the bowel for excretion. d. necessary for digestion of fats. ANS: B Unconjugated bilirubin is a water-insoluble product that must be converted in the liver to conjugated bilirubin (water soluble) so that it may be excreted through the bowel. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1458 OBJ: 1 TOP: Bilirubin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The patient with cirrhosis has an albumin of 2.8 g/dL. The nurse is aware that normal is 3.5 g/dL to 5 g/dL. Based on these findings, what would the nurse expect the patient to exhibit? a. Jaundice b. Edema c. Copious urine output d. Pallor ANS: B Low serum albumin levels result also from excessive loss of albumin into urine or into third-space volumes, causing ascites or edema. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1459 OBJ: 1 TOP: Cirrhosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. What is an essential nursing measure to prevent injury to the patient who is to receive a paracentesis? a. Have patient sign a permit b. Pad side rails c. Check for allergy to contrast media or to shellfish d. Have patient void immediately before procedure ANS: D To prevent the puncturing of the bladder, the patient must void immediately before the procedure. A permit is required but it is not a safety precaution for
the patient. There is no contrast media used in a paracentesis. PTS: 1 DIF: Cognitive Level: Application REF: Page 1467 OBJ: 2 TOP: Paracentesis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. What should the nurse expect of a patient with a malabsorption of vitamin K? a. Lowered hemoglobin b. Elevated hematocrit c. Increased prothrombin time d. Diminished white blood cell count ANS: C Prothrombin times are increased because malabsorption of vitamin K or inability to produce the clotting factors VII, IX, and X cause the patient to have bleeding tendencies. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1465 OBJ: 3 TOP: Cirrhosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5.A patient was scheduled for a laparoscopic cholecystectomy, but complications developed and he underwent an open cholecystectomy with a T-tube inserted into the common bile duct. What is the purpose of the Ttube? a. To decompress the duct and relieve pain caused by stimulation of the b. To improve diaphragmatic expansion and prevention of atelectasis. c. To shorten postoperative recovery and hasten the healing process. d. To keep the duct open and allow drainage of the bile until edema reso ANS: D If the stones are in the common bile duct and edema is present, a biliary drainage tube, or T-tube, will be inserted to keep the duct open and allow drainage of the bile until the edema resolves. PTS:1DIF:Cognitive Level: Comprehension REF: Page 1479, Figure 45-7 OBJ: 8 TOP: Cholecystectomy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
6. The nurse caring for a patient who has had an open cholecystectomy with a
T-Tube will: a. open the T-tube to the air so that it will drain freely. b. position and secure the drainage bag at the chest level. c. Place the collection bag so the tube is not kinked. d. Irrigate the T-tube with normal saline to ensure the free flow of bile. ANS: B The T-tube is placed below the level of the common bile duct to prevent the reflux of bile. The bag must be positioned so the tube is not kinked, or bile cannot drain from the liver. Normally T-tubes are not irrigated. PTS: 1 DIF: Cognitive Level: Application REF: Page 1480 OBJ:8TOP:Cholecystectomy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. Which nursing intervention should be completed immediately after the physician has performed a needle liver biopsy? a. Assisting to ambulate for the bathroom b. Keeping the patient on the right side for a minimum of 2 hours c. Taking vital signs every 4 hours d. Keeping the patient on the left side for a minimum of 4 hours ANS: B Keep the patient lying on the right side for minimum of 2 hours to splint the puncture site. It compresses the liver capsule against the chest wall to decrease the risk of hemorrhage or bile leak. Vital signs are taken every 15 minutes for 30 minutes, then every 30 minutes for 2 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 1461 OBJ: 2 TOP: Liver biopsy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. Immediately following a liver biopsy, the patient becomes dyspneic, the pulse increases to 100, and no breath sounds can be heard on the affected side. What should the nurse suspect? a. Peritonitis b. Pneumothorax
c. Hemorrhage of the liver d. Pleural effusion ANS: B Pneumothorax is a possible complication of paracentesis. The patients head of the bed should be raised slightly, but kept on the right side. Oxygen should be administered and the assessment reported to the charge nurse and documented. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1461 OBJ:1TOPneumothorax KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. Which patient statement indicates that the patient requires additional teaching about an endoscopic retrograde cholangiopancreatography? a. Right after the test, I want breakfast with black coffee. b. The instrument will be put down my throat. c. I havent had anything to eat or drink since 9 PM last night. d. My doctor said I could have medicine to relax me before the test. ANS: A After the procedure, keep the patient NPO until the gag reflex returns. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1464 OBJ:1TOPiagnostic procedures KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 10.The nurse assisting in the treatment of a patient with ruptured esophageal varices who has received vasopressin IV will carefully assess for: a. Muscular twitching/spasm b. Hematuria c. Macular rash on trunk and arms d. Evidence of cardiac ischemia ANS: D Vasopressin is a strong vasoconstrictor given to try to stop the hemorrhage of the varices. Unfortunately it also constricts all vessels and may cause cardiac ischemia. PTS: 1 DIF: Cognitive Level: Application REF: Page 1467
OBJ: 3 TOP: Vasopressin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. What should the nurse point out as a significant advantage of the laparoscopic cholecystectomy? a. Slightly more invasive, but there is less pain b. Can be performed on all patients of any age c. Can be performed even when there are large stones present in the bil d.
Less invasive procedure ANS: D The laparoscopic cholecystectomy is less invasive and causes less pain and a quick recovery. If there are large stones present a sphincterotomy is done before the laparoscopic cholecystectomy. Persons with bleeding tendencies, pathologic conditions of the abdomen, stones in the bile duct, and extensive adhesions are not good candidates. PTS: 1 DIF: Cognitive Level: Application REF: Page 1479 OBJ:2TOP:Laparoscopic cholecystectomy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. What should the nurse explain is the major purpose of the SengstakenBlakemore tube (S/B tube)? a. Decompress the stomach b. Control esophageal varices bleeding c. A route for tube feedings d. Obtain specimen for gastric analysis ANS: B The major purpose of the S/B tube is to control bleeding by pressure against the vessels in the esophagus. The two balloons of the tube are inflated to put direct pressure on the esophagus and are anchored by the inflated balloon in the stomach. The tube can suction blood from the stomach as well. PTS:1DIF:Cognitive Level: Analysis REF: Pages 1467-1468, Figure 45-4 OBJ: 2 TOP: SB tube KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. The patients cirrhosis of the liver has also caused a dilation of the veins of the lower esophagus secondary to portal hypertension, resulting in the development of the complication of: a. esophageal varices. b. diverticulosis. c. Crohn disease. d. esophageal reflux (GERD).
ANS: A Esophageal varices (a complex of longitudinal, tortuous veins at the lower end of the esophagus) enlarge and become edematous as the result of portal hypertension. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1467 OBJ: 3 TOP: Cirrhosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. The patient with cirrhosis has a rising ammonia level and is becoming disoriented. The patient waves to the nurse as she enters the room. How should the nurse interpret this? a. As an attempt to get the nurses attention b. As asterixis c. As an indication of respiratory obstruction from varices d. As spasticity ANS: B Asterixis is the flapping tremor seen as the patient deteriorates into ammonia intoxication or hepatic encephalopathy. PTS: 1 DIF: Cognitive Level: Application REF: Page 1469 OBJ:3TOP:Encephalopathy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. How does the administration of neomycin (Mycifradin) reduce the production of ammonia? a. By assisting the hepatic cells to regenerate b. By reducing ascites c. By decreasing the bacteria in the gut d. By helping to digest fats and proteins ANS: C The buildup of ammonia can be prevented with the use of lactulose (Chronulac) and neomycin. Ammonia is produced in the gut by bacterial action. By reducing the bacteria, less ammonia is produced. PTS:1DIF:Cognitive Level: Application REF: Pages 1468, 1464, Table 54-1 OBJ: 3 TOP: Encephalopathy
KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What is the most common procedure for the removal of the gallbladder? a. Laparoscopic cholecystectomy b. Cholangiography c. Open cholecystectomy d. Choledochostomy ANS: A The most recently developed operative procedure, which is now the most common treatment for cholecystitis and cholelithiasis, is done by way of endoscopy. It is called laparoscopic cholecystectomy and uses laser cautery to remove the gallbladder. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1479 OBJ:8TOP:Laparoscopic cholecystectomy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 17.What should the nurse do to prepare a patient for an oral cholecystography? a. Ensure that the patient drinks 500 mL of water before testing b. Give 4 Oragrafin (ipodate) 5 minutes apart starting at 6 AM c. Administer 6 Telepaque (iopanoic acid) tablets 5 minutes apart after t d. Give a fatty meal hour before the test is started ANS: C The patient is held NPO and given 6 tablets 5 minutes apart the evening before the procedure after the evening meal. A fatty meal is given to the patient after the test is started to stimulate emptying of the gallbladder. PTS: 1 DIF: Cognitive Level: Application REF: Page 1459 OBJ:1TOP:Oral cholecystography KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. Which of the following is a classic symptom of cholecystitis? a. Substernal, radiating to the left shoulder and arm b. Epigastric, radiating to the back c. Right upper abdomen, radiating to the back or right scapula
d. Left upper abdomen, radiating to the jaw and neck ANS: C It localizes in the right upper quadrant epigastric region. The pain radiates around the mid torso to the right scapular area. PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 1477-1478 OBJ:2TOP:Cholecystitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. What should the nurse avoid contamination from to prevent the transmission of hepatitis A? a. Food or water b. Blood transfusion c. Needles d. Sexual contact ANS: A Hepatitis A virus is transmitted when a person puts something in his or her mouth that is contaminated with fecal material (called fecal-oral transmission). Teach patients the importance of good handwashing after the bathroom or changing a diaper, as well as proper food preparation, to prevent the spread of HAV. PTS:1DIF:Cognitive Level: Comprehension REF: Page 1472, Box 54-1 OBJ: 5 TOP: Hepatitis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 20.What is the most appropriate method used by high-risk health workers to prevent hepatitis B? a. Hepatitis B vaccine b. Diligent handwashing c. Wearing protective gear d. Hb immune globulin injections ANS: A The best preventative measure against the contraction of hepatitis B is HBV vaccine. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1472, Safety
OBJ: 5 TOP: Hepatitis B KEY: Nursing Process Step: Planning MSC:NCLEX: Safe, Effective Care Environment 21. The nurse explains that the use of cyclosporine as an immunosuppressant has been successful in the reduction of rejection of liver transplants because the drug: a. increases the rate of the regeneration of liver cells. b. can overcome complications presented by hepatitis C. c. increases blood supply to transplant. d. does not suppress bone marrow. ANS: D Cyclosporine is an immunosuppressant that does not cause bone marrow suppression nor does it impede healing. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1474 OBJ:7TOP:Liver transplant KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22.A male patient states that he returned from a 2-week camping trip a few days ago. He complains of nausea and anorexia, and dark urine. What additional information would assist in diagnosing hepatitis A? a. Exposure to blood b. Recent ingestion of raw fish c. History of intravenous drug use d. Multiple sex partners ANS: B Hepatitis A spreads by direct contact through the oral-fecal route, usually by food and water contaminated with feces. PTS:1DIF:Cognitive Level: Analysis REF: Page 1472, Box 54-1 OBJ: 5 TOP: Hepatitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 23. When caring for an extremely jaundiced patient with cirrhosis, what should the nurse include provisions for in the plan of care? a. Encouraging consumption of a high-fat diet
b. Skin care to relieve pruritus c. Offering foods rich in fat-soluble vitamins d. Meticulous foot care ANS: B Jaundice causes pruritus and can lead to skin lesions and pressure ulcers. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1469 OBJ: 1 TOP: Cirrhosis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 24. The nurse is aware that an elevated serum amylase is diagnostic of pancreatitis at an early stage as an elevation can be assessed as early as after the onset of pancreatic disease. a. 2 hours b. 8 hours c. 24 hours d. 36 hours ANS: A An increase in the serum amylase can be detected as early as 2 hours after the onset of pancreatic disease. In simple acute pancreatitis, the level returns to normal in about 36 hours. In chronic disease it remains elevated. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1462 OBJ:1TOP:Serum amylase KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. The 100 lb patient who has been exposed to hepatitis A is to receive an injection of immune serum globulin. What should the dose (.02 mL/kg) be? a. 0.9 mL b. 1.4 mL c. 1.6 mL d. 1.8 mL ANS: A 100 lb/2.2 = 45.4. 45.4 0.02 = 0.90 PTS: 1 DIF: Cognitive Level: Application REF: Page 1473 OBJ:2TOP:Immune serum globulin
KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26.A family member of a patient asks the nurse about the protein-restricted diet ordered because of advanced liver disease with hepatic encephalopathy. What statement by the nurse would best explain the purpose of the diet? The liver cannot rid the body of ammonia that is made by the breakdo a. digestive system. b. The liver heals better with a high-carbohydrate diet rather than with a Most people have too much protein in their diets. The amount in this d c. healing. Because of portal hypertension, the blood flows around the liver, and d. protein collects in the brain, causing hallucinations. ANS: A The patient with hepatic encephalopathy is on a very low-protein to noprotein diet. The goal of management of hepatic encephalopathy is the reduction of ammonia formation in the intestines. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1461 OBJ: 3 TOP: Cirrhosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The nurse would make provisions in the plan of care for a person who has had a liver transplant to prevent: a. fluid congestion. b. fatigue. c. infection. d. urinary retention. ANS: C A critical aspect of nursing care following liver transplantation is monitoring for infection. The major postoperative complications of a liver transplant are rejection and infection. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1474 OBJ:1TOP:Liver transplant KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 28.The nurse is aware that the hepatitis A immunization provides immunity
in: a. 5 days. b. 10 days. c. 15 days. d. 30 days. ANS: D Primary immunization with hepatitis A vaccine provides immunity within 30 days. PTS: 1 DIF: Cognitive Level: Application REF: Page 1473 OBJ: 8 TOP: Hepatitis A KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 29. What is the challenge in encouraging coughing and deep breathing for a postoperative patient who had an open cholecystectomy? a. High placement of incision b. Excessive nausea c. Weakened abdominal muscles d. Poor oxygenation ANS: A The high placement of the incision of the cholecystectomy makes the patient reluctant to cough. Splinting the incision is beneficial. PTS: 1 DIF: Cognitive Level: Application REF: Page 1480 OBJ:2TOP:Cholecystectomy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. Why is it advantageous for a live person to be a liver donor? a. Because the donor is not at risk for any complication b. Because the recipient is more likely to avoid rejection c. Because the donor donates only a part of the liver d. Because the blood supply is more dependable in the donated liver ANS: C A live donor may donate only a portion of their liver and within weeks the donors liver has grown to the size to meet the bodys needs. The same is true for the recipient.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1474 OBJ:7TOP:Liver transplant KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31. Which factors are most commonly associated with pancreatitis? a. Coronary artery disease b. Alcoholism and biliary tract disease c. Cirrhosis d. History of myocardial infarction ANS: B Alcoholism and biliary tract disease are the two factors most commonly associated with pancreatitis. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1482 OBJ: 2 TOP: Pancreatitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 32.A patient with pancreatitis is NPO. The patient asks the nurse why he is unable to have anything by mouth. Which of the following is the best response? a. Diagnostic tests depend on you not eating anything. b. The pancreas is stimulated whenever you eat or drink, and causes pain c. Eating causes the need for a bowel movement, which excretes your m d. Resting your GI tract will cure your pancreatitis. ANS: B Food and fluids are withheld to avoid stimulating pancreatic activity, and IV fluids are administered. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1482 OBJ: 2 TOP: Pancreatitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. Why is morphine contraindicated in the patient with pancreatitis? a. Demerol (meperidine) is less expensive. b. Tylenol is more effective at managing this type of pain. c. Morphine may cause spasms of the sphincter of Oddi. d. These patients do not experience pain.
ANS: C A common complaint is constant, severe pain; in such cases, meperidine (Demerol) PCA is often administered. Morphine may cause spasms of the sphincter of Oddi. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1478 OBJ: 2 TOP: Pancreatitis KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 34. Which factors may increase a patients risk of developing cancer of the pancreas? a. Diet high in carbohydrates and dairy products b. Cardiovascular disease and glaucoma c. Tea and cola consumption d. Cigarette smokers and people with diabetes mellitus ANS: D The cause of cancer of the pancreas is unknown, but it is diagnosed more often in cigarette smokers, people exposed to chemical carcinogens, and people with diabetes mellitus and pancreatitis. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1484 OBJ:2TOP:Cancer of the pancreas KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 35. Which assessment would indicate possible gallbladder disease in an older adult? a. Dull pain in the right upper quadrant region b. Changes in color of urine or stool c. Distention of veins in upper part of body d. Aching muscles and tenderness in the liver ANS: B The incidence of cholelithiasis increases with aging. Assess older adults for history of changes in stool or urine color. Cirrhosis of the liver may cause distention in veins in the upper part of the body. PTS:1DIF:Cognitive Level: Knowledge REFage 1482, LifespanOBJ:2
TOP: Age-related changes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 36. What should the nurse monitor in caring for the patient undergoing a paracentesis? a. The urinary output b. Hypervolemia c. Fluid removal over at least 30 minutes d. Seizure ANS: C The fluid removed during a paracentesis is removed over a period of 30 to 90 minutes to prevent sudden changes in blood pressure leading to syncope. The bed should be in a high Fowler position. Food and fluid restriction is usually not necessary. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1467 OBJ: 1 TOP: Paracentesis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 37.A patient with a T-tube for an open cholecystectomy has resumed oral intake. The T-tube is clamped 2 hours before meals and unclamped 2 hours after meals to aid in the digestion of fat. During the time the tube is clamped the patient complains of abdominal pain and nausea. Which intervention is most appropriate? a. Notify the physician b. Unclamp the tube immediately c. Increase the IV fluids d. Change the T-tube dressing ANS: B While the tube is clamped, the patient may show signs of abdominal pain, nausea, vomiting, etc. Unclamp the tube immediately to allow for drainage and relief of both nausea and pain. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1480 OBJ:8TOP:Cancer of the pancreas KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE 38. What are the indications for a liver transplant? (Select all that apply.) a. Congenital biliary abnormalities b. Hepatic malignancy c. Chronic hepatitis d. Cirrhosis due to alcoholism e. Gallbladder disease ANS: A, B, C Indications for liver transplantation include congenital biliary abnormalities, inborn errors of metabolism, hepatic malignancy (confined to the liver), sclerosing cholangitis, and chronic end-stage liver disease. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1474 OBJ:7TOP:Liver transplant KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 39. Which medical interventions and management systems control the bleeding of esophageal varices? (Select all that apply.) a. Transfusions b. Sengstaken-Blakemore tube c. Band ligation d. Cryotherapy e. Portocaval shunt f. Large doses of vitamin B12 ANS: B, C, E Band ligation, insertion of the S/B tube, and various shunting surgeries are helpful in stopping the hemorrhage. Transfusions and water-soluble vitamins are not beneficial. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1467 OBJ:3TOP:Esophageal varices KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 40. Dietary teaching for a patient who is treated conservatively for cholecystitis is necessary to keep the patient comfortable. Which foods
should be avoided? (Select all that apply.) a. Peanut butter b. Grilled chicken c. Rice and pasta d. Bananas, apples, oranges e. Whole milk f. Glazed chocolate doughnuts ANS: A, E, F Peanut butter, nuts, chocolate, whole milk, fried foods, and cream and other fatty foods should be avoided. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1481 OBJ:2TOP:Cholecystitis and cholelithiasis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 41. Viral hepatitis may be treated at home. What should be taught to the patients family? (Select all that apply.) a. Clothes should be laundered separately with hot water. b. Personal items and drinking glasses should not be shared. c. Articles soiled with feces do not require extra care. d. Hands need to be thoroughly washed after toileting. e. Contaminated items may be disposed of with regular trash. ANS: A, B, D For the patient with viral hepatitis being cared for in the home, the family needs to be taught necessary precautions. Clothes should be laundered separately with hot water. Personal items used by the patient should not be shared. Articles soiled with feces must be disinfected. Any contaminated items should be disposed of properly. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1473 OBJ: 5 TOP: Hepatitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 42. The nurse is aware that the liver synthesizes products essential to health. Which products are synthesized by the liver? (Select all that apply.) a. Intrinsic factor
b. Protein c. Vitamin K d. Red blood cells e. Albumin ANS: B, E The liver synthesizes protein and albumin. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1459 OBJ:N/ATOProducts synthesized by liver KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 43.What should the nurse do as part of the preparation for an endoscopic retrograde cholangiopancreatography (ERCP)? (Select all that apply.) a. Confirm that a recent chest x-ray is on file b. Confirm the presence of a consent form c. Warn patient that the procedure will take about 3 hours d. Confirm the presence of a prothrombin time/INR e. Withhold food and drink for 4 hours ANS: B, D Before the ERCP the patient will be held NPO for 8 hours. It is necessary that a consent form be signed as well as evidence of a prothrombin time INR. PTS: 1 DIF: Cognitive Level: Application REF: Page 1463 OBJ: 1 TOP: ERCP KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment COMPLETION 44. is a condition characterized by yellowing of the sclera and the skin. ANS: Jaundice Jaundice is the discoloration of body tissues caused by abnormally high blood levels of bilirubin. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1466 OBJ: 4 TOP: Jaundice KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 45. The disease that is on the increase because of the growing obesity
population and is associated with coronary artery disease and use of corticosteroids is . ANS: nonalcoholic fatty liver disease (NAFLD) nonalcoholic fatty liver disease NAFLD NAFLD is a disease that is on the rise due to the increasing population of obese persons. The disease is also associated with CAD and the use of corticosteroids. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1465 OBJ: 2 TOP: NAFLD KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 46. The tumor marker that is elevated in patients with pancreatic cancer is . ANS: CA19-9 The tumor marker CA19-9 is elevated in the presence of pancreatic cancer. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1484 OBJ: 1 TOP: CA19-9 KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 47. Hepatitis D is usually seen as a co-infection with . ANS: hepatitis B Hepatitis D is usually seen as a coinfection with hepatitis B. PTS:1DIF:Cognitive Level: Knowledge REF: Page 1473, Box 54-1 OBJ: 6 TOP: Hepatitis KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 48.A occurs when the body encapsulates the autodigestive debris in the pancreatic tissue, frequently becoming an abscess. ANS: pseudocyst A pseudocyst occurs when the body encapsulates the autodigestive debris in the pancreatic tissue. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1482
OBJ: 2 TOP: Pseudocyst KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity OTHER 49. The nurse clarifies that deterioration progresses through stages before presenting with liver disease. Place the stages in order. (Separate letters by a comma and space as follows: A, B, C, D) a. Liver disease b. Inflammation c. Hepatic insufficiency d. Destruction e. Fibrotic regeneration ANS: D, B, E, C, A Liver deterioration follows a pattern of stages: destruction, inflammation, fibrotic regeneration; hepatic insufficiency then presents as liver disease. Topic: Liver destruction Nursing Process Step: Implementation PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1465 OBJ:2TOP:Liver destruction KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 50. Arrange the normal process of protein metabolism. (Separate letters by a comma and space as follows: A, B, C, D) a. Protein enters the blood stream b. Excreted by kidney c. Portal vein delivers blood to the liver d. Conversion to urea e. Ammonia produced in the bowel ANS: A, E, C, D, B Protein products enter the blood stream and are changed in the bowel to ammonia; the products then pass through the portal vein to the liver where the ammonia is converted to urea, which is then excreted by the kidneys. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1465
OBJ:2TOProtein metabolism KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity Chapter 46: Care of the Patient with a Blood or Lymphatic Disorder My Nursing Test Banks Chapter 46: Care of the Patient with a Blood or Lymphatic Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What is the process by which certain cells engulf and digest microorganisms and cellular debris? a. Erythrocytosis b. Hematocrit c. Phagocytosis d. Hemostasis ANS: C Phagocytosis is the process by which bacteria, cellular debris, and solid particles are destroyed and removed. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 7-6 OBJ:3TOPiagnostic procedures KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse explains that because it is a reliable and predictable indicator of the bodys level of infection or recovery the is a common diagnostic tool. a. Hemoglobin b. Hematocrit c. Mean cell volume (MCV) d. Differential ANS: D A differential white blood cell count is an examination in which the different kinds of WBCs are counted and reported as percentages of the total examined. It is a common diagnostic tool because of its reliability and the predictability of the bodys response to infection or its progress in recovery. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 7-6 OBJ: 4 TOP: Differential KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 3. The nurse assessing a differential sees an increase in immature neutrophils (bands) and is aware that this indicates: a. a significant hemorrhage. b. aplastic anemia. c. an overwhelming bacterial infection. d. beginning recovery from an infection. ANS: C An increase in immature neutrophils (bands) is called bandemia, and it indicates an overwhelming bacterial infection. PTS: 1 DIF: Cognitive Level: Application REF: Page 7-7 OBJ: 1 TOP: Bandemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4.B cells and T cells fit under which classification? a. Erythrocytes b. Basophils c. Lymphocytes d. Monocytes ANS: C B cells and T cells, the major players in the antigen/antibody conflict, are both lymphocytes. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 7-7 OBJ:1TOP:Lymphocytes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The nurse explains that in the event of an invasion of an allergen, the basophils release a strong vasodilator, which is: a. lysozyme. b. prothrombin. c. hematocrit. d. histamine. ANS: D Histamine is released by the basophils during the invasion of an allergen.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 7-7 OBJ: 1 TOP: Leukocytes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The presence of excess bands in the peripheral blood that indicate severe infection is called: a. shift to the left. b. shift to the right. c. bone marrow aspiration. d. thrombocytosis. ANS: A The presence of excess bands in the peripheral blood is called a shift to the left (i.e., a shift toward immature cells) and indicates severe infection. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 7-7 OBJ:8TOPiagnostic procedures KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
7.A patient who had a Schilling test shows a 20% excretion of the radioactive vitamin B12. What would this indicate? a. The patient has a low reserve of iron and has iron deficiency anemia. b. The patient has a normal finding and does not have pernicious anemi c. The patient has a deficiency of thrombocytes and has a clotting disor d. The patient has an excess of RBCs and has polycythemia. ANS: B
The Schilling test is a laboratory blood test for diagnosing pernicious anemia. The normal reading 24 hours after the administration of radioactive vitamin B12 is 8% to 40%. The test measures the absorption of radioactive vitamin B12. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 7-15 OBJ:8TOP:Schilling test
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. In an adult, where are erythrocytes continuously produced? a. Yellow bone marrow b. Lymphatic system c. Spleen d. Red bone marrow ANS: D Erythrocytes are continuously produced in the red bone marrow, principally in the vertebrae, ribs, and sternum. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 7-4 OBJ:9TOPiagnostic procedures KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 9.What does the elevation in the eosinophil count to 10% indicate? a. Anemia b. Allergy c. Infection d. Hypoxia ANS: B Normal values of eosinophils are 1% to 4%. An elevation to 10% would indicate the presence of an allergic reaction. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 7-7 OBJ: 1 TOP: Eosinophils KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. What would a nurse include in a teaching plan for a home health patient with a hemoglobin of 8.4 mg? a. Exercising for periods of 30 minutes daily b. Limiting fluid intake c. Alternating activity with rest periods d. Avoiding the use of oxygen ANS: C Severely anemic persons need to conserve their energy. Observing a rest period after a period of activity will reduce hypoxia. Oxygen may be used as
necessary. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page xxx OBJ: 1 TOP: Anemia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 11. Approximately how much blood is stored in the spleen that can be released in a hypovolemic emergency? a. 100 mL b. 300 mL c. 500 mL d. 1000 mL ANS: C The spleen stores 1 pint of blood, approximately 500 mL, which can be released during emergencies. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 7-13 OBJ: 11 TOP: Spleen KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse caring for a patient with pernicious anemia should make provisions for: a. frequent iced drinks. b. lightweight blanket. c. a fan to circulate the air. d. reverse isolation. ANS: B Persons with pernicious anemia are especially sensitive to cold. The provision of a light blanket is beneficial. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 7-29 OBJ:11TOPernicious anemia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 13.When instructing the patient taking an oral liquid iron preparation, what should the nurse include? a. Information relative to taking the iron with milk b. Information relative to the bowel movement color changing to dark re c. Information relative to taking preparation through a straw to prevent s
d. Information relative to taking a drug with meals or a snack ANS: C Liquid iron preparations should be drunk through a straw to prevent tooth staining. All oral iron preparations should be taken before meals. Dairy products interfere with the absorption of iron. PTS: 1 DIF: Cognitive Level: Application REF: Page 7-41 OBJ:9TOP:Oral iron administration KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 14.When the 14-year-old African American boy comes into the emergency room in sickle cell crisis, what should be the primary focus of care? a. Instruct patient about transfusion procedure b. Starting of IV fluids c. Pain control d. Relief of dyspnea ANS: C Pain control during the crisis is the focus. Continuous opioids are the mainstay of pain management. Certainly IV fluids to reduce viscosity of blood and oxygen for relief of dyspnea are important, but pain control is paramount in the acute phase. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 7-45 OBJ: 9 TOP: Leukemia KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity 15. The mother of a 4-year-old child with leukemia says to the nurse, I dont understand why he is crying about his legs hurting. The nurses most informative response would be based on the information that bone pain is related to: a. Elevated WBCs in differential b. Long periods of inactivity c. Splenomegaly d. Bone marrow congested with white cells ANS: D Long bone pain is the result of bone marrow that is congested with immature white cells.
PTS: 1 DIF: Cognitive Level: Application REF: Page 7-58 OBJ: 9 TOP: Leukemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What must a patient undergo before a bone marrow transplant? a. A thorough nutritional plan to support new marrow b. Total body irradiation to kill all the marrow cells c. A physical therapy program to strengthen the body d. Inhalation therapy to reduce possible pathogens in the lungs ANS: B Before the actual marrow transplant, the patient must undergo total body irradiation or chemotherapy to kill all the marrow cells and the leukemic cells. The patient is at a major risk for infection at this time. PTS: 1 DIF: Cognitive Level: Application REF: Page 7-60 OBJ:12TOP:Marrow transplant KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 17.The 9-year-old child with leukemia who is on palliative care has drawn a picture of a boy under a huge black cloud that has lightning coming out of it. Which of the following would be an appropriate intervention for the nurse? a. What is this picture about? b. Are you afraid of lightning? c. I bet this is a picture of you, isnt it? d. Is it about to rain in your picture? ANS: A Asking what the child has drawn is a neutral and nonthreatening question. Drawings can give a clue to perceptions and emotions that a young child may not be able to verbalize. The nurse should not try to interpret the drawing. PTS: 1 DIF: Cognitive Level: Application REF: Page xxx OBJ: 12 TOP: Leukemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The home health nurse recommends to the mother of a 12-year-old child with leukemia that the child should have: a. the series for prevention of hepatitis B. b. an annual influenza vaccine.
c.
an annual pneumococcal vaccine.
d. vitamin B12 shots. ANS: B Children with leukemia should have an annual influenza vaccine and a pneumococcal vaccine every 5 years. PTS: 1 DIF: Cognitive Level: Application REF: Page 7-62 OBJ:9TOPneumococcal vaccine KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 19. Which patient statement from a 15-year-old girl with thrombocytopenia would require more assessment to report to the charge nurse? a. I think these red spots on my skin are going away. b. I am so bored lying in bed I could scream. c. My bowel movement is brown and stinks. d. I have this really weird Coke-colored urine. ANS: D Coke-colored urine is hematuria that should be documented and reported to the charge nurse. The purpura will fade as they are absorbed. Boredom and smelly stools are normal for a 14-year-old. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 7-68 OBJ:16TOP:Thrombocytopenia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20.A 23-year-old male patient with hemophilia A says, How can I keep my children from having hemophilia A? Which of the following is the most informative response? a. You need to select a very dependable mode of birth control. b. You can only pass hemophilia B to your sons. Your daughter may be a carrier and her children may have hemophilia c. at risk. d. Your sons should have coagulation studies. ANS: C Hemophilia A is an X-linked trait. Females are carriers; therefore, the
patients daughter could pass the disease to her sons. The patients sons are not at risk for hemophilia A. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 7-70 OBJ:13TOP:Hemophilia A KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse caring for a child with hemophilia who is hospitalized with hemarthrosis should include which of the following in the plan of care? a. Splint the affected leg to maintain anatomic alignment b. Apply warm compresses to reduce hemorrhage in the joint c. Use analgesia sparingly d. Encourage vigorous ROM exercises several times a day to keep knee ANS: A Splinting the affected knee is necessary to retain anatomic alignment while the pain is severe. Analgesia should be given as needed. Physical therapy and ROM are appropriate after pain has subsided. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page xxx OBJ:13TOP:Hemarthrosis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 22.In caring for a patient with multiple myeloma, what should the nurse include in the daily care? a. Provisions for limiting fluid intake to less than 1000 mL/day b. Provisions for close supervision and assistance when ambulating c. Provisions for straining all urine d. Provisions for limiting use of an analgesic ANS: B Because of the constant threat of pathologic fractures, ambulation should be carefully supervised and assisted. Uric acid is increased and may crystalize in the kidney, but straining is not necessary. Analgesia is necessary for relief of bone pain. PTS: 1 DIF: Cognitive Level: Application REF: Page 7-85 OBJ:15TOP:Multiple myeloma KEY:Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 23. The nurse is aware that a person with Hodgkin disease, who has two or more abnormal lymph nodes on the same side of the diaphragm and involvement of extranodal involvement on the same side of the diaphragm, would be in: a. stage I b. stage II c. stage III d. stage IV ANS: B Stage II indicates that there are two or more abnormal lymph nodes on the same side of the diaphragm and extranodal involvement on the same side of the diaphragm. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 7-91, Box 7-7 OBJ:15TOP:Hodgkin disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. The nurse explains that a positron emission tomography (PET) has been ordered to: a. assess bone marrow depression. b. measure bone density. c. radiate and destroy diseased lymph nodes. d. measure lymph node response to therapy. ANS: D The PET can measure the effect of therapy on diseased nodes. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 7-92 OBJ: 15 TOP: PET KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 25. Which of the following foods would the nurse recommend to a person with iron deficiency anemia as an excellent meat source for erythropoiesis? a. Dark meat of chicken b. Cured ham c. Pork chops
d. Processed meat ANS: A The dark meat of poultry is a good meat source for erythropoiesis. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 7-40, Box 7-3 OBJ:9TOP:Iron deficiency anemia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 26.The peripheral smear is a diagnostic test that: a. assesses the level of hemoglobin. b. measures antibody production. c. examines the shape and structure of RBCs. d. identifies infection. ANS: C The peripheral smear allows the study of the size, structure, and shape of RBCs. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 7-14 OBJ:8TOPeripheral smear KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 27. The typical medical treatment of polycythemia vera involves repeated phlebotomies and medications such as busulfan (Myleran) in order to: a. stimulate bone marrow. b. inhibit bone marrow activity. c. increase hemoglobin. d. reduce gout. ANS: B Repeated phlebotomy decreases blood viscosity, and myelosuppressive agents such as busulfan (Myleran) are often given to inhibit bone marrow activity. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 7-51 OBJ:N/ATOPolycythemia vera KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 28.Which of the following would the nurse explain as the most common type of leukemia that affects children?
a. Chronic lymphocytic leukemia (CLL) b. Acute myeloid leukemia (AML) c. Acute lymphocytic leukemia (ALL) d. Chronic myeloid leukemia (CML) ANS: C The most common type of leukemia that affects children is the fast-advancing ALL. This leukemia can also affect adults. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 7-58 OBJ: 12 TOP: Leukemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. The nurse is aware that persons of the Jehovahs Witness faith accept which types of blood transfusions? a. No type of blood transfusion b. Blood that has been blessed by their religious leader c. Transfusions only for persons who have not yet been baptized d. Autologous blood transfusions ANS: D Jehovahs Witness followers are accepting of autologous blood transfusions and some will accept volume expanders such as colloids. PTS: 1 DIF: Cognitive Level: Application REF: Page 7-19 OBJ:9TOP:Jehovahs Witness KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. Which mandatory practice is the most effective and significant nursing practice to prevent the spread of infection? a. Strict and frequent handwashing by all people having contact with the Placement of patients in private rooms with high-efficiency particulate b. filtration c. Administration of combinations of prophylactic antibiotics d. Creation of a sterile environment for the patient with the use of lamina ANS: A Meticulous handwashing by medical and nursing personnel and strict asepsis are mandatory.
PTS:1DIF:Cognitive Level: Application REF: Page 7-56, Nursing Care Plan OBJ: 12 TOP: Handwashing KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 31.What is the average life span of an erythrocyte? a. 7 days b. 60 days c. 120 days d. Up to several years ANS: C The life span of an RBC is 120 days. A WBCs life span is days to several years. Platelets live 5 to 9 days. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 7-4 OBJ:2TOP:Anatomy and physiology of blood cells KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 32. Because older adults suffer from conditions such as colonic diverticula, hiatal hernia, and ulcerations that can cause occult bleeding, the nurse should assess for symptoms of: a. leukemia. b. iron deficiency anemia. c. sickle cell anemia. d. polycythemia. ANS: B Blood loss is a major cause of iron deficiency in adults. The major sources of chronic blood loss are from the GI and genitourinary systems. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 7-101 OBJ:9TOP:Anatomy and physiology of blood cells KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 33. The nurse explains that the treatment of hemophilia A has been revolutionized with the advent of the use of: a. corticosteroids.
b. large doses of testosterone. c. recombinant factor VIII. d. transfusion with packed red cells. ANS: C Recombinant factor VIII has been a major forward step in the treatment of hemophilia A. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 7-70 OBJ:13TOP:Hemophilia A KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 34. From which location would the bone marrow sample come in the aspiration of a 25-year-old patient? a. Sternum b. Posterior superior iliac crest c. Posterior iliac crest d. Femur ANS: C The preferred site for bone marrow aspiration puncture in adults is the posterior iliac crest. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 7-16 OBJ:8TOP:Bone marrow aspiration KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 35. What are the most likely matches for a bone marrow transplant to a 10year-old with leukemia? (Select all that apply.) a. Uncle b. Self c. Mother d. Brother e. Sister f. Father ANS: B, D, E
Specimens from twins, siblings, or self (autologous) while in remission are preferred. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 7-33 OBJ:12TOP:Bone marrow transplant KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 36.The spleen is a highly vascularized organ located in the left upper quadrant of the abdominal cavity. What are the main functions of the spleen? (Select all that apply.) a. Serve as reservoir for blood b. Destroy worn-out RBCs c. Promote phagocytosis d. Responsible for development of T lymphocytes e. Continuously produce RBCs during lifetime ANS: A, B, C The spleen stores 1 pint of blood, which can be released during emergencies, such as hemorrhage, in less than 60 seconds. The main functions of the spleen are (1) to serve as a reservoir for blood; (2) to form lymphocytes, monocytes, and plasma cells; (3) to destroy worn-out RBCs; (4) to remove bacteria by phagocytosis (engulfing and digesting); and (5) to produce RBCs before birth (the spleen is believed to produce RBCs after birth only in cases of extreme hemolytic anemia). PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 7-13 OBJ: 2 TOP: Anatomy and Physiology of the Hematological and Lymphatic System KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 37. The nurse examines the complete blood count (CBC) to assess (select all that apply): a. hematocrit. b. red cell count. c. differential white cell count. d. plasma level. e. blood type.
f. hemoglobin. ANS: A, B, C, F The CBC gives information relative to RBC, WBC, hematocrit, hemoglobin, erythrocyte indexes, WBC differential, and examination of the peripheral blood cells. PTS: 1 DIF: Cognitive Level: Application REF: Page: 7-14 OBJ: 8 TOP: CBC KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 38. Which of the following are necessary factors that support healthy erythropoiesis? (Select all that apply.) a. Dietary magnesium b. Healthy bone marrow c. Adequate oxygen source d. e. f. ANS: B, D, E, F
Vitamin B12 Amino acids
Vitamin B2
Erythropoiesis, red blood cell production, is dependent on the availability of healthy bone marrow, dietary supply of copper and iron, amino acids, vitamins B12 and B2, folic acid, and pyridoxine. PTS: 1 DIF: Cognitive Level: Analysis REF: Page: 7-4 OBJ:2TOP:Erythropoiesis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 39. The nurse caring for a patient in the emergency room with suspected internal injuries will assess for hypovolemic shock, which is evidenced by (select all that apply): a. irritability. b. restlessness. c. slow bounding pulse.
d. decreased respirations. e. pallor. f. hypotension. ANS: A, B, E, F Indicators of hypovolemia are restlessness, irritability, rapid thready pulse, increasing respirations, pale, cool moist skin, and hypotension, Should the blood loss continue, the patient could go into hypovolemic shock. PTS: 1 DIF: Cognitive Level: Application REF: Page: 7-22, Box 7-1 OBJ:10TOP:Hypovolemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 40. Which of the following are B symptoms of a patient with Hodgkin disease? (Select all that apply.) a. Hematuria b. Night sweats c. Severe diarrhea d. Weight gain from edema e. Fever f. Persistent dry cough ANS: B, E The B symptoms of Hodgkin disease are night sweats, fever, and weight loss. These symptoms are associated with a poor prognosis. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 7-91 OBJ:15TOP:B symptoms KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION 41. are leukocytes that destroy and remove cellular waste, bacteria, and solid particles. ANS: Neutrophils Neutrophils (granular circulating leukocytes essential for phagocytosis, the process by which bacteria, cellular debris, and solid particles are destroyed
and removed) ingest bacteria and dispose of dead tissue. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 7-6 OBJ: 1 TOP: Leukocytes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 42. The person with aplastic anemia is said to be because all three major blood elements (RBCs, WBCs, and platelets) are diminished or absent. ANS: pancytopenic Persons with aplastic anemia are deficient in all three of the major blood elements, a condition known as pancytopenia. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 7-31 OBJ:9TOP:Aplastic anemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 43. The nurse clarifies that replaces iron stores needed for red blood cell production. ANS: ferrous sulfate Ferrous sulfate replaces iron stores needed for red blood cell production. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 7-60, Table 7-2 OBJ:9TOP:Ferrous sulfate KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 44. Neutrophils release , an enzyme that destroys certain bacteria. ANS: lysozyme Lysozyme is an enzyme released by the neutrophils that kills certain bacteria when the bacteria is recognized in the body. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 77-6 OBJ: 1 TOP: Lysozyme KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 45. The Reed-Sternberg cell is the hallmark diagnostic indicator for
. ANS: Hodgkin disease The Reed-Sternberg cell, large abnormal multinucleated cells in the lymph nodes, is diagnostic of Hodgkin disease. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 7-92 OBJ: 15 TOP: Reed-Sternberg cells KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity OTHER 46. Arrange the process of hemostasis in sequence. (Separate letters by a comma and space as follows: A, B, C, D) a. Release of clotting factor from injured tissue b. Formation of thrombin c. Formation of fibrin d. Trapping of RBC and platelets e. Clot f. Release of thromboplastin ANS: A, F, B, C, D, E Clotting factors are released from the injured tissue causing the release of thromboplastin, which acts with calcium to form thrombin; fibrin is formed, which traps red cells and platelets to make the clot. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 7-6, Figure 7-3 OBJ: 5 TOP: Clot formation KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 47. Outline the sequence of the process that stimulates the increase in the production of red blood cells. (Separate letters by a comma and space as follows: A, B, C, D) a. Kidneys release erythropoietic factor b. Increase in red blood cell production c. Enzyme stimulates red bone marrow d. Oxygen delivery increased to the tissues e. Oxygen delivery decreased to the tissues f, Decrease in red blood cell production
ANS: E, A, C, B, D, F When the tissues of the body register a decrease of oxygen, the kidneys release the erythropoietic factor that stimulates the bone marrow to produce more RBCs, which increases the oxygen delivery to the tissues which then signals the bone marrow to decrease the RBC production. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 7-5 OBJ: 2 TOP: Erythropoiesis KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity Chapter 47: Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder My Nursing Test Banks Chapter 47: Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is aware that the muscle layer of the heart, which is responsible for the hearts contraction, is the: a. endocardium. b. pericardium. c. mediastinum. d. myocardium. ANS: D The myocardium is the specialized muscle layer that allows the heart to contract. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1533 OBJ: 2 TOP: Myocardium KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse clarifies that the master pacemaker of the heart is the: a. left ventricle. b. atrioventricular (AV) node. c. sinoatrial (SA) node. d. bundle of His. ANS: C The SA node is the master pacemaker of the heart.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1533 OBJ:10TOP:Acute myocardial infarction KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3.The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in women because acute chest pain is not present. Women are frequently misdiagnosed as having: a. hepatitis A. b. indigestion. c. urinary infection. d. menopausal complications. ANS: B Indigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses for women having an MI. PTS: 1 DIF: Cognitive Level: Application REF: Page 1559 OBJ:16TOP:MIs in women KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4.The nurse identifies the LUBB sound of the LUBB/DUBB of the cardiac cycle as the sound of the: a. AV valves closing. b. closure of the semilunar valves. c. contraction of the papillary muscles. d. contraction of the ventricles. ANS: A The LUBB is the first sound of a low pitch heard when the AV valves close. PTS: 1 DIF: Cognitive Level: Application REF: Page 1535 OBJ: 4 TOP: Lubb sound KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5.A patient is admitted from the emergency department. The emergency department physician notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV. This indicates the patients condition as: a. moderate heart failure. b. severe heart failure.
c. congestive heart failure. d. negligible heart failure. ANS: B Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina or symptoms of cardiac inefficiency may develop at rest. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1565, Box 47-3 OBJ:9TOP:Classification of heart failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse assesses that the home health patient has no signs or symptoms of heart failure, but does have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus. The nurse is aware that using the American College of Cardiology and the American Heart Association (ACC/AHA) staging, this patient would be a: a. stage A. b. stage B. c. stage C. d. stage D. ANS: A The ACC/AHA staging describes stage A as a person without symptoms of heart failure, but with primary conditions associated with the development of the disease. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1565, Box 47-3 OBJ: 9 TOP: Heart failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry recognizes the need for added instruction when the patient says: a. I can ambulate in the hallway with this gadget on. b. I always take off the telemetry device when I shower. c. My EKG is being watched by one of the nurses in CCU on the home d. I am able to sleep just fine with this device on. ANS: B
Remote telemetry allows the patient to be on a separate unit, but be monitored in a central location. The patients can be ambulatory and can sleep with the monitor on. They should not remove the monitor to shower. PTS: 1 DIF: Cognitive Level: Application REF: Page 1539 OBJ:6TOP:Remote telemetry KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 8. The nurse assesses pitting edema that can be depressed approximately inch and refills in 15 seconds. The nurse would document this assessment as: a. +1 edema. b. +2 edema. c. +3 edema. d. +4 edema. ANS: B A +2 edema can be documented if the skin can be depressed inch and respond within 15 seconds. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1565, Table 47-5 OBJ:9TOPitting edema KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. What do dark or cold spots on a thallium scan indicate? a. Tissue with adequate blood supply b. Dilated vessels c. Areas of neoplastic growth d. Tissue that has inadequate perfusion ANS: D Thallium scans show adequate perfused areas by the collection of thallium. Dark spots or cold spots indicate tissues that have inadequate perfusion. PTS: 1 DIF: Cognitive Level: Application REF: Page 1539 OBJ:6TOP:Thallium scan KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 10.The nurse recognizes the echocardiogram report that shows an ejection factor of 42% as an indication of:
a. normal heart action. b. mild heart failure. c. moderate heart failure. d. severe heart failure. ANS: C An ejection factor (cardiac output) of 42% indicates moderate heart failure. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1540 OBJ: 6 TOP: Heart failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. The nurse takes into consideration that age-related changes can affect the peripheral circulation because of: a. sclerosed blood vessels. b. hypotension. c. inactivity. d. poor nutrition. ANS: A Aging causes sclerotic changes in the blood vessels that lead to decreased elasticity and narrowing of the vessel lumen. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1542, Lifespan OBJ: 16 TOP: Endocarditis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 12. The nurse assessing a cardiac monitor notes that the cardiac complexes each have a P wave followed by a QRS and a T. The rate is 120. The nurse recognizes this arrhythmia as: a. sinus bradycardia. b. atrial fibrillation. c. sinus tachycardia. d. ventricular tachycardia. ANS: C Sinus tachycardia has a P wave followed by the QRS and the T. All the components of the complex are present and in the correct order, but the rate is over 100 beats a minute. PTS: 1 DIF: Cognitive Level: Application REF: Page 1545
OBJ: 8 TOP: Arrhythmias KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. After an influenza-like illness, the patient complains of chills and small petechiae in his mouth and his legs. A heart murmur is detectable. These are characteristic signs of: a. congestive heart failure. b. heart block. c. aortic stenosis. d. infective endocarditis. ANS: D Collection of subjective data includes noting patient complaints of influenzalike symptoms with recurrent fever, undue fatigue, chest pain, and chills. Objective data may reveal the significant signs of petechiae in the conjunctiva and mouth. Both subjective data and objective data are indicative of infective endocarditis. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1576 OBJ: 13 TOP: Endocarditis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. The nurse notes a run of three ventricular contractions (PVC) that are not preceded by a P wave. This particular arrhythmia can progress into: a. atrial fibrillation and possible emboli. b. sinus tachycardia and syncope. c. ventricular tachycardia and death. d. sinus bradycardia and fatigue. ANS: C PVCs are capable of progressing into ventricular tachycardia and death. PTS: 1 DIF: Cognitive Level: Application REF: Page 1547 OBJ: 10 TOP: PVCs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. The nurse reminds the patient who is on Coumadin for the treatment of atrial fibrillation that the ideal is to maintain the international normalized ratio (INR) at between: a. 1 and 2.
b. 2 and 3. c. 3 and 4. d. 4 and 5. ANS: B The desired INR for the monitoring of anticoagulant therapy is between 2 and 3. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1546 OBJ: 8 TOP: INR KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What should a person with unstable angina avoid? a. Walking outside b. Eating red meat c. Swimming in warm pool d. Shoveling snow ANS: D The person with angina should avoid exposure to cold, heavy exercise, eating heavy meals, and emotional stress. PTS: 1 DIF: Cognitive Level: Application REF: Page 1552 OBJ: 9 TOP: Angina KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 17. The elderly patient with angina pectoris says she is unsure how she should take nitroglycerin when she has an attack. The nurses most helpful response would be: a. Continue to take nitroglycerin sublingually at 5-minute intervals until If the pain is not relieved after three doses of nitroglycerin at 5-minute b. physician and come to the hospital. c. When nitroglycerin is not relieving the pain, lie down and rest. d. Use oxygen at home to relieve pain when nitroglycerin is not successf ANS: B Administer prescribed nitroglycerin. Repeat every 5 minutes, three times. If pain is unrelieved, notify the physician. Nitroglycerin administered sublingually usually relieves angina symptoms but does not relieve the pain from an MI. Administering nitroglycerin more than three times will probably
not relieve the pain. PTS: 1 DIF: Cognitive Level: Application REF: Page 1545 OBJ:9TOP:Angina pectoris KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The patient has been hospitalized for hypertensive episodes three times in the last months. While preparing the discharge teaching plan, the nurse assesses that he does not comply with his medication regimen. The nurses immediate course of action would be to: a. reteach him about his medications. b. have a serious talk with him and his family about compliance. c. arrange for home visits after discharge. d. collect more information to identify his reasons for noncompliance. ANS: D Nursing interventions include measures to prevent disease progression and complications. Reteaching about medication will not identify the cause of noncompliance. PTS: 1 DIF: Cognitive Level: Application REF: Page 1556 OBJ:18TOP:Noncompliance KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 19. What is the major cause of cardiac valve disease? a. Rheumatic fever b. Long history of malnutrition c. Drug abuse d. Obesity ANS: A Rheumatic fever, a streptococcal infection, is the major cause of cardiac valve disease. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1572 OBJ:10TOP:Valvular disease KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
20. The patient has a total cholesterol of 190 with a high-density lipid (HDL)
of 110 and a low-density lipid (LDL) of 80. The nurses reaction is one of: a. satisfaction. This is good cholesterol control. b. determination. This is evidence that more instruction is necessary. c. inquiry. This needs to clarified as to the cause of noncompliance with d. regret. This shows very poor cholesterol control. ANS: A Total cholesterol of less than 200 is desirable. The higher the number of HDLs the better. A high number of LDLs puts the patient at risk for heart disease. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1541, Box 47-1 OBJ:6TOP:Lipid studies KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 21.A patient, age 72, was admitted to the medical unit with a diagnosis of angina pectoris. Characteristic signs and symptoms of angina pectoris include: a. substernal pain that radiates down the left arm. b. epigastric pain that radiates to the jaw. c. indigestion, nausea, and eructation. d. fatigue, shortness of breath, and dyspnea. ANS: A The pain often radiates down the left inner arm to the little finger and also upward to the shoulder and jaw. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1553, figure 47-1 OBJ:9TOP:Angina pectoris KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22.A patient admitted to the emergency room with a possible myocardial infarction (MI) has reports back from the laboratory. Which laboratory report is specific for myocardial damage? a. CK-MB b. Elevated white count c. Elevated sedimentation rate
d. Low level of sodium ANS: A The CK-MB is elevated when there is infarcted myocardial muscle. The elevated white count, low sodium, and ESR are nonspecific. PTS: 1 DIF: Cognitive Level: Application REF: Page 1559 OBJ: 6 TOP: CK-MB KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 23. The patient, age 26, is hospitalized with cardiomyopathy. While obtaining a nursing history from her, the nurse recognizes that the increased incidence of cardiomyopathy in young adults who have minimal risk factors for cardiovascular disease is related to which factor(s)? a. Cocaine use b. Viral infections c.
Vitamin B1 deficiencies
d. Pregnancy ANS: A Cardiomyopathy caused by cocaine abuse is seen more frequently than ever before. Cocaine also causes high circulating levels of catecholamines, which may further damage myocardial cells, leading to ischemic or dilated cardiomyopathy. The cardiomyopathy produced is difficult to treat. Interventions deal mainly with the HF that ensues. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1578 OBJ:14TOP:Cardiomyopathy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. The patient has become very dyspneic, respirations are 32, and the pulse is 100. The patient is coughing up frothy red sputum. What should be the initial nursing intervention? a. Lay the patient flat to reduce hypotension and the symptoms of cardio b. Place patient in side-lying position to reduce the symptoms of atrial fi Place patient upright with legs in dependent position to reduce the sym c. edema.
d. Lay the patient flat and elevate the feet to increase venous return in ca ANS: C Signs and symptoms of pulmonary edema are restlessness; vague uneasiness; agitation; disorientation; diaphoresis; severe dyspnea; tachypnea; tachycardia; pallor or cyanosis; cough producing large quantities of blood-tinged, frothy sputum; audible wheezing and crackles; and cold extremities. The legs in a dependent position will decrease venous return and ease the pulmonary edema. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1572 OBJ:12TOPulmonary edema KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. The nurse caring for a patient recovering from a myocardial infarction (MI) teaches which method to avoid the Valsalva maneuver during a bowel movement? a. Mouth breathing b. Pursing the lips and whistling c. Taking a deep breath and holding it d. Breathing rapidly through the nose ANS: A Mouth breathing will lessen the severity of straining and will decrease the effect of the Valsalva maneuver on intrathoracic pressure. PTS: 1 DIF: Cognitive Level: Application REF: Page 1562 OBJ: 9 TOP: MI KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. The nurse reminds the patient that the National Heart, Lung, and Blood Institute recommends a lipid study every years. a.2 b.3 c.4 d.5 ANS: D The National Heart, Lung, and Blood Institute recommend a lipid study every
5 years for all Americans, but especially for the older adult. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1542 OBJ:6TOP:Lipid studies KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 27. During a health interview by the home health nurse, which patient complaint suggests left-sided heart failure? a. I have to sleep in my recliner and I have this hacking cough. b. I have no appetite and I have lost 3 lb in the last week. c. I have to urinate every 2 hours, even during the night. d. I go barefoot most of the time because my feet are so hot. ANS: A Left ventricular failure; the first is signs and symptoms of decreased cardiac output. The second is pulmonary congestion. Signs and symptoms of this condition include dyspnea, orthopnea, pulmonary crackles, hemoptysis, and cough. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1565, Box 47-3 OBJ: 9 TOP: Heart failure KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 28. The home health nurse caring for a patient with infective endocarditis overhears the patient making a dental appointment for an extraction next month. Which question is most important for the nurse to ask? a. Do you have a toothache? b. Have you contacted your physician about your dental appointment? c. Is your dentist board certified? d. Do you think you should wait that long for your tooth extraction? ANS: B Patients with endocarditis are put on a protocol of prophylactic antibiotics for any invasive procedure. The dentist and physician should be contacted before the extraction. PTS: 1 DIF: Cognitive Level: Application REF: Page 1574 OBJ: 13 TOP: Endocarditis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
29. The home health nurse warns the patient who is taking warfarin
(Coumadin) for anticoagulant therapy for thrombophlebitis to stop taking the herbal remedy of ginkgo because ginkgo can: a. cause severe episodes of diarrhea. b. cause a severe skin eruption if taken with Coumadin. c. increase the action of the Coumadin. d. cause the Coumadin to be less effective. ANS: C Herbal remedies such as ginkgo, garlic, angelica, and red clover can increase (potentiate) the action of the Coumadin. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1589 OBJ: 21 TOP: Coumadin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. What is the difference between primary and secondary hypertension? a. Secondary hypertension is caused by another disorder like renal dise b. Secondary hypertension is related to hereditary factors. c. Secondary hypertension cannot be treated effectively. d. Secondary hypertension is no real threat to health. ANS: A Secondary hypertension is a consistently elevated blood pressure that is caused by another disorder, such as renal disease, diabetes, or Cushing syndrome. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1584 OBJ:18TOP:Secondary hypertension KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 31.The nurse is treating a patient who has had a pacemaker inserted for the correction of atrial fibrillation. Which diagnostic test is no longer available to the patient because of the implanted device? a. MRI b. CT scan c. Thallium scan d. PET ANS: A
Because of the large magnets in the MRI cabinet, the pacemaker may be reset to a fixed mode and interfere with the functioning of the pacemaker. PTS: 1 DIF: Cognitive Level: Application REF: Page 1551 OBJ: 10 TOP: Pacemaker KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 32. Which assessment would lead the nurse to examine the leg closely for evidence of a stasis ulcer? a. Cool dry lower limb b. Edematous, red scaly skin on medial surface of the leg c. Lack of hair and shiny appearance of the lower leg d. Lack of a pedal pulse ANS: B Suggestion of a stasis ulcer in the making is an edematous, dry scaly area on the medial surface of the lower leg that has a darker pigmentation (rubor). Cool hairless limbs with absent or weak pedal pulses are indicative of arterial insufficiency. PTS: 1 DIF: Cognitive Level: Application REF: Page 1582 OBJ: 21 TOP: Medications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 33. What is the patient goal of the walking exercise program designed for the rehabilitation of a post-MI patient? a. Walk 2 miles in less than 60 minutes after 12 weeks. b. Jog mile in less than 30 minutes after 12 weeks. c. Fast walk 1 mile in less than 20 minutes after 12 weeks. d. Walk 1 mile in 15 minutes without dyspnea after 12 weeks. ANS: A The goal of the 12-week walking program is that the patient can walk 2 miles in less than 60 minutes. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1563, Home Care OBJ:11TOP:Cardiac rehab KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 34. The postsurgical patient has a painful and swollen right calf that appears
to be larger than the calf of the left leg. What is the nurse assessing for when she flexes the patients right leg and dorsiflexes the foot? a. Pain, which would be a positive Homans sign b. Muscular spasm, which would be a sign of hypocalcemia c. Rigidity, which would be a sign of ankylosis d. Crepitus, which would be a sign of a joint disorder ANS: A A positive Homans sign for deep vein thrombosis (DVT) is a report of pain when the affected leg is flexed and the foot is dorsiflexed. PTS: 1 DIF: Cognitive Level: Application REF: Page 1595 OBJ: 21 TOP: DVT KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 35. How should the nurse advise a patient with an international normalized ratio (INR) of 5.8? a. Make arrangements to go to the emergency room immediately b. Increase fluid intake to 2000 mL/day c. Stop taking the anticoagulant and notify health care provider d. Add more leafy green vegetables to patient diet ANS: C The INR that is desired should be maintained between 2 and 3. A reading of 5.8 puts the patient at risk for hemorrhage. The patient should stop taking the anticoagulant and contact the physician for further instruction. PTS: 1 DIF: Cognitive Level: Application REF: Page 1546 OBJ:6TOP:Myocardial infarction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 36. The nurse making a teaching plan for a patient with Buerger disease (thromboangiitis obliterans) will focus on the need for: a. reduction of alcohol intake. b. avoiding cold remedies. c. cessation of smoking. d. weight reduction. ANS: C
The hazards of cigarette smoking and its relationship to Buerger disease are the primary focus of patient teaching. None of the palliative treatments are effective if the patient does not stop smoking. Nowhere are the cause and effect of smoking so dramatically seen as with Buerger disease. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1594 OBJ:20TOP:Buerger disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 37. Which statement would lead the nurse to offer more instruction about taking warfarin (Coumadin)? a. I eat a banana every morning with breakfast. b. I try to eat more green leafy vegetables, especially broccoli, spinach, c. I try to eat a well-balanced, low-fat diet. d. I dont drink alcohol or caffeine. ANS: B Avoid marked changes in eating habits, such as dramatically increasing foods high in vitamin K (e.g., broccoli, spinach, kale, greens). Limit alcohol intake to small amounts. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1597 OBJ: 10 TOP: Warfarin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 38. The nurse caring for a 92-year-old patient with pneumonia who is receiving IV carefully monitors the flow rate of the IV infusion because rapid infusion can cause: a. hypotension. b. thrombophlebitis. c. pulmonary emboli. d. heart failure. ANS: D Heart failure can result from rapid infusion of intravenous fluids in older adults. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1542, Lifespan OBJ: 9 TOP: Heart failure KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 39. The nurse making the schedule for the daily dose of furosemide (Lasix) would schedule the administration for which of the following times? a. Late in the afternoon b. At bedtime c. With any meal d. In the morning ANS: D Diuretics should be scheduled for morning administration to avoid causing the patient nocturia. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1567, Table 47-6 OBJ: 12 TOP: Lasix KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 40. The nurse would assess closely for signs of right-sided heart failure which include (select all that apply): a. cough. b. increasing abdominal girth. c. shortness of breath. d. edema of feet and ankles. e. distended jugular veins. f. orthopnea. ANS: B, D, E Indicators of right-sided heart failure are distended jugular veins, anorexia, abdominal distention from ascites, liver enlargement with right upper quadrant pain, and edema of feet and ankles. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1563, Box 47-4 OBJ:9TOP:Right-sided heart failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 41. The nurse would design teaching for a patient with Raynaud disease to include which of the following? (Select all that apply.) a. Warming hands and feet with a heating pad
b. Using mittens in cold weather c. Practicing stress-reducing techniques d. Complete smoking cessation e. Using caution when cleaning the refrigerator or freezer ANS: B, C, D, E Nursing interventions include patient teaching in techniques for stress reduction, avoiding exposure to cold, and techniques for smoking cessation. PTS:1DIF:Cognitive Level: Analysis REF: Page 1595, Nursing Care Plan OBJ: 20 TOP: Raynaud disease KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 42.Which information should be taught to patients starting on anticoagulant therapy for a valvular disorder? (Select all that apply.) a. Increase the dose of aspirin for better therapy. b. Take medication at the same time each day. c. Report to physician cuts that do not stop bleeding with direct pressur d. No restrictions for food or drink. e. Report for prescribed blood tests (PTT, INR, CBC, blood sugar). ANS: B, C Aspirin should not be used with anticoagulant therapy because it will increase bleeding. Gums, nosebleeds, excessive bruising, and cuts that do not stop bleeding with direct pressure should be reported to the physician. Alcohol and dark green and yellow vegetables should be avoided because they contain vitamin K. Normal blood tests for anticoagulant therapy are PTT, INR, and PT. PTS:1DIF:Cognitive Level: Analysis REF: Page 1591, Nursing Care Plan OBJ: 10 TOP: Anticoagulant therapy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 43.What is the transesophageal echocardiogram (TEE) used for? (Select all that apply.) a. Detect thrombi before a cardioversion b. Check for cardiac arrhythmias c. Visualize vegetation on the heart valves d. Measure effectiveness of diuretic therapy
e. Visualize abscesses on the heart valves ANS: A, C, E The TEE is used to check for thrombi before cardioversion, and to visualize vegetation and abscesses on the valves of the heart. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1592 OBJ: 16 TOP: TEE KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 44. Which patient teaching would help to prevent venous stasis? (Select all that apply.) a. Dangle legs when sitting b. Avoid crossing legs at the knee c. Elevate legs when lying in bed or sitting d. Massage extremities to help maintain blood flow e. Wear elastic stockings when ambulating ANS: B, C, E Avoid prolonged sitting or standing. Avoid crossing the legs at the knee. Elevate legs when sitting. Wear elastic stockings when ambulatory. Do not massage extremities because of danger of embolization of clots (thrombus breaking off and becoming an embolus). PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1597 OBJ:16TOP:Thrombophlebitis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 45.The nurse points out which of the following as modifiable risks for coronary artery disease (CAD)? (Select all that apply.) a. Diabetes mellitus b. Heredity c. Smoking d. Hypertension e. Hyperlipidemia f. Age ANS: A, C, D, E Modifiable risks for the development of CAD include smoking, hyperlipidemia, hypertension, diabetes mellitus, obesity, sedentary lifestyle,
and stress. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1544-1545 OBJ:7TOP:Modifiable risks for CAD KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 46. The nurse outlines which of the following as conditions that would disqualify a candidate for a heart transplant? (Select all that apply.) a. Recent malignancy b. Dilated cardiomyopathy c. Peptic ulcer disease d. Diabetes type 2 e. Severe obesity f. Inoperable coronary artery disease ANS: A, C, E Contraindications for candidacy for cardiac transplant include recent malignancy, active peptic ulcer disease, severe obesity, diabetes type 1 with end-organ damage. Dilated cardiomyopathy and inoperable coronary artery disease are indications for transplant. PTS: 1 DIF: Cognitive Level: Application REF: Page 1579, Box 47-7 OBJ:15TOP:Contraindications for cardiac transplant KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 47. When assessing a patient with a possible MI, what should the nurse assess for? (Select all that apply.) a. Pain radiating to left arm and jaw b. Hypertension c. Pallor d. Diaphoresis e. Erratic behavior f. Cardiac rhythm changes ANS: B, C, D, E, F Hypertension, vomiting, diaphoresis, hypotension, pallor, and cardiac rhythm changes are objective data seen in patients with an MI.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1558, Table 47-2 OBJ:10TOP:Myocardial infarction KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 48. Which of the following are signs of digoxin (Lanoxin) toxicity? (Select all that apply.) a. Ringing in the ears b. Bradycardia c. Headache d. Visual disturbance e. Hematuria f. Gastrointestinal complaints ANS: B, C, D, F Major signs of digoxin toxicity are nausea, bradycardia (HR <60), headache, and visual disturbances, as well as fatigue and arrhythmias. PTS: 1 DIF: Cognitive Level: Application REF: Page 1548, Table 47-1 OBJ:10TOPigitoxin toxicity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 49. The nurse encourages the patient who is recovering from a myocardial infarct (MI) to ask the health care provider to prescribe a cardiac rehabilitation series in order to learn to (select all that apply): a. improve stamina. b. strengthen muscles. c. plan an appropriate diet. d. select herbal remedies. e. reduce risk of further problems. f. understand heart condition. ANS: A, B, E, F Cardiac rehabilitation offers exercise programs to increase strength and increase stamina. Educational opportunities are offered on reduction of risk and understanding the disease process. PTS: 1 DIF: Cognitive Level: Application REF: Page 1563
OBJ:11TOP:Cardiac rehab KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 50. Following an angiogram with the insertion site of the left groin, the nurse will include in the plan of care provisions for (select all that apply): a. checking pedal pulses. b. ambulating with assistance 2 hours after recovery. c. checking color and warmth of left leg frequently. d. sandbagging over insertion site. e. placing patient in semi-Fowler position. ANS: A, C, D The pulses below the insertion site are checked to ensure patency of the vessels; the color and warmth of the left extremity is checked to ensure adequate circulation. A sandbag or other pressure device is placed over the insertion site. The patient is maintained in a supine position for several hours postprocedure. PTS: 1 DIF: Cognitive Level: Application REF: Page 1537 OBJ: 6 TOP: Angiogram KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 51. The cardiac marker rises 3 hours after a myocardial infarct and measures myocardial contractile protein. ANS: troponin I Troponin I is a serum cardiac marker that rises 3 hours after an MI and can measure myocardial contractile tissue. Troponin I is not affected by skeletal muscle injury as is troponin T. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1541 OBJ: 6 TOP: Troponin I KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 52. The life support system that uses special techniques, ventilation equipment, and therapies for emergency situations is . ANS: advanced cardiac life support (ACLS)
advanced cardiac life support ACLS ACLS is a life support system that uses special techniques, ventilation equipment, and therapies for emergency situations. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1550 OBJ: 9 TOP: ACLS KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 53. The nurse explains that the heart has the ability to contract in a rhythmic pattern that is called . ANS: automaticity Automaticity is the special ability of the myocardium to contract in a rhythmic pattern. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1534
OBJ:2TOP:Automaticity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 54. The patient with congestive heart failure who is on a diuretic drug shows a weight loss of 6.6 lb. The nurse is aware that the patient has lost L of fluid. ANS: 3 A liter of fluid equals 2.2 lb. A loss of 6.6 lb would mean the loss of 3 L of fluid. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1564 OBJ: 9 TOP: Fluid loss KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 55. The pain that a person with arterial insufficiency feels on exertion, which is relieved by rest, is . ANS: intermittent claudication Intermittent claudication is a pain caused by ischemia when a person with arterial insufficiency exerts to the point that the tissues have inadequate oxygen-rich blood. The pain is relieved by rest. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1581 OBJ:9TOP:Intermittent claudication KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 56. The process by which a heart is shocked from a persistent arrhythmia back into sinus rhythm is called a . ANS: cardioversion Cardioversion is the restoration of the hearts normal sinus rhythm with the delivery of synchronized electric shock. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1540 OBJ: 10 TOP: Cardioversion KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity OTHER
57. Trace the impulse pattern of conduction in sequence through the heart.
(Separate letters by a comma and space as follows: A, B, C, D) a. Atrial wall b. Atrial-ventricular (AV) node c. Purkinje fibers d. Sinoatrial (SA) node e. Bundle branches f. Bundle of His ANS: B, A, D, F, E, C The conduction begins with the impulse from the SA node that travels down the atrial wall to the AV node, to the Bundle of His, to the bundle branches, and finally to the Purkinje fibers. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1535-1534 OBJ: 3 TOP: Conduction KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 58. Arrange in sequence the path of the blood through the coronary circulation. (Separate letters by a comma and space as follows: A, B, C, D) a. Right atrium b. Pulmonary artery c. Tricuspid valve d. Right ventricle e. Superior and inferior vena cava f. Pulmonary vein g. Left atrium h. Mitral valve i. Left ventricle j. Lungs ANS: E, A, C, D, B, J, F, G, H, I The blood travels through the vena cava to the right atrium, through the tricuspid valve to the right ventricle, through the pulmonary artery to the lungs. The pulmonary veins deliver the blood to the left atrium, then through the mitral valve to the left ventricle and out the aorta to the body.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1535, Figure 47-4 OBJ: 5 TOP: Path of blood through heart KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity Chapter 48: Care of the Patient with a Respiratory Disorder My Nursing Test Banks Chapter 48: Care of the Patient with a Respiratory Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What is the purpose of the cilia? a. Warm and moisturize inhaled air b. Sweep debris toward nasal cavity c. Stimulate cough reflex d. Produce mucus ANS: B The cilia are fine hairlike processes on the outer surfaces of small cells that produce a motion that sweeps the debris toward the nasal cavity. Large particles that are swept away stimulate the cough reflex, but not the cilia themselves. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1609 OBJ: 2 TOP: Secretions KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 2. What happens when there is a decrease in the oxygen level in the blood? a. Pituitary stimulates the respiratory system to increase respiratory rate b. The alveoli diffuse more oxygen into the blood Chemoreceptors in the carotid body and aortic body stimulate the resp c. modify respiratory rates d. The parietal pleura increases the negative pressure ANS: C The chemoreceptors in the carotid bodies and the aortic bodies send a message to the respiratory centers to modify respirations. PTS: 1 DIF: Cognitive Level: Application REF: Page 1611 OBJ:1TOP:Respiratory rate modification KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3.A nursing diagnosis for the patient with a new laryngectomy would be Social isolation related to impaired verbal communication related to removal of the larynx. What is an appropriate nursing intervention? a. Complete care quickly b. Provide a pad and pencil or magic slate c. Refrain from conversations with the patient to reduce stress level d. Offer books or jigsaw puzzles for entertainment ANS: B Provide patient with implements for communication. Rapidly completing care and provision of solitary activities does not reduce social isolation. PTS: 1 DIF: Cognitive Level: Application REF: Page 1534 OBJ:10TOP:Laryngectomy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4.A 55-year-old man comes to the health nurse at his place of work with epistaxis. He reports he has frequent nosebleeds that he can usually control himself. What would be the most helpful assessment after the nurse has stopped the bleeding? a. Obtain a blood pressure b. Record the approximate amount of blood lost c. Inquire about a headache d. Record the last episode of epistaxis ANS: A Check the blood pressure for hypotension to assess for hypovolemic shock. Adults can lose as much as 1 L of blood in an hour with heavy epistaxis. PTS: 1 DIF: Cognitive Level: Application REF: Page 1618 OBJ: 9 TOP: Epistaxis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse assessing an 11-year-old who is having an asthma attack expects to hear adventitious sounds of: a. friction rub. b. sibilant wheezes. c. crackles.
d. sonorous wheezes. ANS: B The narrowed bronchioles characteristic of an asthma attack would produce sibilant wheezes, which are high-pitched whistling sounds. PTS: 1 DIF: Cognitive Level: Application REF: Page 1612 OBJ: 16 TOP: Asthma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. How will the kidneys behave in respiratory acidosis? a. Retain bicarbonate to increase the pH b. Excrete more urine to reduce potassium c. Concentrate the urine to conserve circulating fluid in the blood strea d. Lower the pH by excretion of bicarbonate ANS: A In respiratory acidosis the pH is low. The kidneys will retain bicarbonate to increase the pH. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1617, Table 48-2 OBJ:11TOP:Respiratory acidosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. An 83-year-old patient is admitted with a temperature of 102 F (38.8 C), chest pain, and fatigue. What is the infected fluid that the physician removes called? a. Emboli b. Emphysema c. Sputum d. Empyema ANS: D If the fluid between the lung and the membrane lining the pleural cavity becomes infected, it is called empyema. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1642 OBJ: 11 TOP: Empyema KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. Which instruction by the nurse is inappropriate for teaching the proper
technique for collection of a sputum specimen? a. Bring the sputum up from the lungs b. Rinse mouth with water before expectorating in specimen cup c. Collect specimens before meals d. Send specimen to the lab without delay ANS: C Collecting specimens before meals will avoid possible emesis from coughing after eating. PTS: 1 DIF: Cognitive Level: Application REF: Page 1615, Box 48-2 OBJ:12TOPiagnostic procedures KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
9. When assessing the SaO2 with a pulse oximeter, the
nurse will place the oximeter on a finger: a. on the same side as the blood pressure cuff. b. while exercising the arm to stimulate circulation. c. that is a normal temperature. d. on the same side as an arterial catheter. ANS: C The pulse oximeter should be placed on a finger of the hand that is normal temperature because hypothermia will affect the reading. The device should not be put on a finger on the same side as a blood pressure cuff or arterial line. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1617, Safety Alert OBJ:9TOPulse oximeter KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10.A patient, age 69, has emphysema. On assessment, the nurse notes the presence of a barrel chest. What does this pathology result from? a. An increase in the lateromedial area from hypertrophy of mucous glan b. An increased anteroposterior diameter caused by overinflation of the a c. A decrease in anteroposterior diameter caused by chronic dilation of t
A widening of the sternocostal area secondary to chronic constriction the airways leading to bronchospasms ANS: B The patient will eventually appear barrel chested (an increased anteroposterior diameter caused by overinflation). PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1658, Figure 48-16 OBJ: 16 TOP: Emphysema KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity d.
11.A patient, age 22, is admitted with acute asthma. The patient shows a pulse oximetry level of SaO2 of 82%. How should the nurse interpret this? a.
Only 82% of the red blood cells are able to use oxygen. There is only 82% of oxygen bound to the hemoglobin compared with b. available. c. Eighteen percent of oxygen is not dissolved in the blood. d. The muscular respiratory effort is only 18% effective. ANS: B
An SaO2 indicates that only 82% of the available oxygen is bound to the hemoglobin. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1616 OBJ: 8 TOP: SaO2 KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. What is the appropriate nursing intervention for a patient, age 40, who is diagnosed with active tuberculosis? a. Place the patient in drainage and secretion precautions b. Place the patient in acid-fast bacillus (AFB) Isolation Precautions c. Maintain the patient in enteric isolation d. Place the patient in any Isolation Precautions ANS: B If TB is suspected, permission to place the patient in acid-fast bacillus (AFB) Isolation Precautions should be requested immediately. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1636
OBJ:13TOP:Tuberculosis KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 13. How should the newly diagnosed patient who has been prescribed isoniazid (INH) for the treatment of active tuberculosis (TB) be advised? a. Report redness and swelling of extremities b. Accept that the therapy is long term c. Monitor renal function every several months d. Rise slowly to avoid dizziness ANS: B INH therapy is long term. The patient should be advised to get regular liver studies and report tingling and numbness of the extremities. PTS: 1 DIF: Cognitive Level: Application REF: Page 1637, Table 48-2 OBJ: 13 TOP: INH KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 14. The patient has advanced emphysema and complains of dyspnea and fatigue. What would the most appropriate nursing intervention be for the nursing diagnosis of Activity intolerance related to an imbalance between the oxygen supply and demand? a. Direct patient in vigorous independent ROM. b. Allow to exercise until respirations are over 20 breaths/min over base c. Plan care to provide optimum rest. d. Provide frequent cool showers. ANS: C Nursing interventions will be directed at attempting to decrease the patients anxiety and promote optimal air exchange. The nurse should allow sufficient rest periods and should assist the patient in activities of daily living. PTS:1DIF:Cognitive Level: Application REFage 1649, Nursing Care PlanOBJ:16 TOP:Chronic obstructive pulmonary disease (COPD) KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 15.A patient is on postoperative day 2 after undergoing a total hip replacement. The patient suddenly complains of chest pain and is coughing
up blood-tinged sputum. What should be the nurses initial intervention? a. Report signs to the charge nurse. b. Elevate head of bed and administer oxygen. c. Prevent patient from excessive coughing. d. Increase IV flow rate. ANS: B When a pulmonary embolus is suspected, the head of the bed should be elevated to facilitate respiration and oxygen is administered. The charge nurse and the physician should be notified, but only after the patient is stabilized and oxygenated. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 1654, 1655 OBJ:15TOPulmonary embolism KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What is true about activities such as walking for the patient with emphysema? a. Repair dilated alveoli b. Increase capacity to use oxygen c. Lessen the oxygen needs d. Lessen metabolic oxygen needs ANS: B Aerobic exercises such as walking will increase the bodys ability to use oxygen through sustained rhythmic contractions of large muscles. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1559 OBJ: 16 TOP: Emphysema KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The patient with long-term emphysema is admitted with a secondary diagnosis of cor pulmonale. What should the nurse anticipate? The patient will present with edema of the lower extremities and exten a. to hypertension of the pulmonary circulation. The patient will present with a dry hacking cough and chest pain due t b. pulmonary vein. The patient will present with hypertension and a headache related to p c. hypertension.
d. The patient will present with unlabored respiration and cyanosis aroun ANS: A COPD can lead to cor pulmonale, an abnormal cardiac condition characterized by hypertrophy of the right ventricle of the heart as a result of hypertension of the pulmonary circulation. Cor pulmonale results in the presence of edema in the lower extremities, as well as in the sacral and perineal area, distended neck veins, and enlargement of the liver with ascites. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1658 OBJ: 16 TOP: Chronic obstructive pulmonary disease (COPD) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. What is a major advantage of video assisted thoracoscopic surgery (VATS)? a. The surgeon can record entire surgical procedure on a video. b. The surgeon can remove tumors of the lung through a small keyhole i c. The surgeon can x-ray and excise tumor in the same procedure. d. The surgeon can avoid the use of a closed chest drainage system after ANS: B The video assisted thoracoscopic surgery allows surgeons to remove tumors through a small keyhole incision. Although the incisions are small, a closed chest drainage system will still be necessary after the surgery. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1650 OBJ: 19 TOP: VATS KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. How would the nurse examining a patient with pleurisy document a lowpitched grating lung sound? a. Sonorous wheeze b. Friction rub c. Coarse crackles d. Crackles ANS: B A low-pitched grating sound in the presence of an inflammatory disorder is a friction rub.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1612, Table 48-1 OBJ:6TOP:Adventitious sounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. What is inspiratory capacity? a. The amount of air in the lung after a maximal inhalation b. The amount of air moved with each normal inhalation and expiration c. The amount of air that can be inhaled in one breath from the resting e d. The amount of air that can be forcefully exhaled after maximum inhal ANS: C Inspiratory capacity is the volume of air that can be inhaled in one breath from the resting expiratory level. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1613 OBJ:7TOP:Inspiratory capacity KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. The older adult patient with long-term emphysema complains of a sharp pleuritic pain after a severe period of coughing. The patients heart rate and respiratory rate have increased. Auscultation reveals no breath sounds on the left side. These are signs and symptoms of what condition? a. Pulmonary embolus b. Spontaneous pneumothorax c. Early signs of unilateral pneumonia d. An attack of asthma ANS: B Spontaneous pneumothorax can be caused by a ruptured bleb in a patient with long-term emphysema. The disorder causes chest pain, dyspnea, and anxiety associated with air hunger. PTS: 1 DIF: Cognitive Level: Application REF: Page 1648, Figure 48-13 OBJ:11TOPostoperative complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22. Which important precaution should the nurse include when instructing an
emphysema patient on the use of home oxygen? a. Use oxygen only when extremely short of breath b. Keep the home oxygen regulator set on 6 L c. Use home oxygen at night while sleeping d. Limit to 1 to 2 L oxygen flow ANS: D Low-flow oxygen therapy is required for patients with COPD, because higher oxygen concentrations depress the bodys own respiratory regulatory centers and can cause respiratory failure. PTS: 1 DIF: Cognitive Level: Application REF: Page 1659 OBJ: 16 TOP: Chronic obstructive pulmonary disease (COPD) KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 23. The young man who had a bronchoscopy 1 hour ago asks when he can eat. Which response would be most helpful? a. In 24 hours, but must take cold liquids for the rest of the day b. If there is no blood in his sputum c. In 8 hours after a period of nothing by mouth d. When the gag reflex returns ANS: D Following a bronchoscopy, the patient can eat as soon as the gag reflex returns, usually in about 2 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 1614 OBJ:7TOP:Bronchoscopy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. The nurse caring for a patient who has a closed chest drainage system notes that there is fluctuation (tidaling) in the water seal chamber. What is the most appropriate nursing action based on this assessment? a. Document the tidaling b. Elevate the head of the bed and notify charge nurse of malfunction of c. Add more sterile water to the water seal chamber d. Turn patient to the affected side
ANS: A Tidaling or fluctuation in the water seal drainage is an indicator that the negative pressure is preserved and the system is working normally. Document this normal finding. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1646, Box 48-6 OBJ:14TOP:Closed chest drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. How does pursed lip breathing assist patients with asthma during an attack? a. It distracts the patient with breathing technique to reduce anxiety. b. c.
It gets rid of CO2 faster. It opens bronchioles by backflow air pressure.
d. It increases PACO2.. ANS: C The resistance or the expiration through the pursed lips causes a backflow of air and helps to open the bronchioles. PTS: 1 DIF: Cognitive Level: Application REF: Page 1664 OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. How do leukotriene modifiers reduce the symptoms of asthma? a. By drying up mucus b. By causing bronchodilation and anti-inflammation effects c. By suppressing cough d. By liquefying mucus ANS: B Leukotriene modifiers reduce the symptoms of asthma by causing bronchodilation and anti-inflammatory processes. PTS: 1 DIF: Cognitive Level: Application REF: Page 1637, Table 48-3 OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 27. How should a patient be positioned after a thoracentesis is completed and
the dressing applied? a. High Fowler b. Semi-Fowler c. Side lying on unaffected side d. Prone ANS: C After a thoracentesis the patient is placed in a side-lying position on the unaffected side. PTS: 1 DIF: Cognitive Level: Application REF: Page 1616 OBJ:11TOPleural Effusion KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. What should the nurse do to keep the chest tubes from becoming occluded? a. Irrigate tubes as needed b. Prevent dependent loops c. Loop the tube over the bed rail d. Milk the tube frequently ANS: B To keep the tubes patent, the tubes should be kept straight without dependent loops. These tubes are not irrigated and should not be milked frequently. PTS: 1 DIF: Cognitive Level: Application REF: Page 1645 OBJ:1 | 14TOP:Closed chest drainage KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 29.Which patient assessment indicates the most severe respiratory distress?
a. b. c. d.
Nasal flaring, symmetrical chest wall expansion, Abdominal breathing, SaO2 97% Substernal retraction, SaO2 84% Substernal retraction, SaO2 90%
ANS: C
Observe the patients facial expressions and signs of
respiratory distress, such as flaring nostrils, substernal or clavicular retractions, asymmetrical chest wall expansion, and abdominal breathing. The lower the SaO2, the more severe the respiratory distress. PTS: 1 DIF: Cognitive Level: Application REF: Page 1616 OBJ:5TOPneumothorax KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 30. Which preoperative teaching should a nurse include for a person scheduled for a partial laryngectomy? (Select all that apply.) a. Tracheal suction will be frequent b. The presence of a temporary tracheotomy c. That isolation will be required for 24 hours d. The surgery involves removal of a diseased vocal cord e. Some speech will be retained f. The sense of smell and taste will be lost ANS: A, B, D, E A partial laryngectomy involves the removal of the diseased cord and possible thyroid cartilage. There will be a temporary tracheostomy that will be closed once edema is under control. Tracheal suctioning will be done frequently. There will be some vocal ability retained. Isolation is not required. Sense of smell and taste are lost with a total laryngectomy. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1623 OBJ:10TOPatient teaching KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31. Which independent nursing measures are effective in aiding a patient to expectorate? (Select all that apply.) a. Positioning in orthopneic position b. Suctioning c. Assisting to cough
d. Providing hydration e. Starting IV fluids f. Starting mucolytic agents ANS: A, B, C, D Independent nursing intervention to help a patient to expectorate would include positioning, assisting to cough, suctioning, and providing hydration IV therapy; provision of a mucolytic agent requires a physicians order and is not an independent nursing action.. PTS: 1 DIF: Cognitive Level: Application REF: Page 1642 OBJ:12TOP:Assisting expectoration KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 32.Identify the purposes of chest drainage. (Select all that apply.) a. Drains air, blood, and fluid from pleural space b. Restores positive pressure in chest cavity c. Restores negative intrapleural pressure d. Allows lung to collapse and rest e. Allows route for medication administration ANS: A, C A chest tube or tubes may be inserted for continuous drainage of fluid, blood, or air from the pleural cavity and for medication instillation. To prevent the lung from collapsing, a closed drainage system is used, which maintains the lung cavitys normal negative pressure. The chest tubes are connected to a pleural drainage system with collection, water seal, and suction control chambers to drain secretions and reestablish negative pressure in the pleural space. PTS: 1 DIF: Cognitive Level: Application REF: Page 1644 OBJ:14TOP:Closed chest drainage KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 33.What are age-related changes in the older adult that make them at risk for respiratory diseases? (Select all that apply.) a. Moist mucous membranes b. Kyphosis c. Decrease in pulmonary blood flow
d. Stasis pooling of secretions e. Reduced number of cilia ANS: B, C, D, E Age-related changes that affect the respiratory system are dryer mucous membranes, which reduce ability to humidify inspired air, kyphosis, which restricts the expansion of the lung, stasis pooling of respiratory secretions, and reduced number of cilia, which make infection of the upper and lower airway more likely. PTS: 1 DIF: Cognitive Level: Application REF: Page 1641, Lifespan OBJ: 9 TOP: Pneumonia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 34. The nurse explains to the person with pneumonia in the left lung that being positioned in the good lung down offers the advantage of (select all that apply): a.
PaO2 rising in the good lung.
b. blood flow to bad lung being increased. c. the dependent lung being better perfused. d. dyspnea disappearing. e. decreased hypoxia. ANS: A, C, E
The good lung down position increases the PaO2 in the good lung and also allows for better perfusion, consequently decreasing hypoxia, although dyspnea may still be evident. PTS: 1 DIF: Cognitive Level: Application REF: Page 1642 OBJ: 11 TOP: Pneumonia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 35. The are the structures of the lung in which gas exchange occurs. ANS: alveoli
The end structures of the bronchial tree are called alveoli. It is in these terminal structures of the bronchial tree that gas exchange takes place. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1609 OBJ:2TOP:Lower respiratory tract KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 36. The nurse prepares a patient for the procedure of a(n) , which will remove the fluid from around the lung to improve respiration and obtain a specimen. ANS: thoracentesis Often a thoracentesis will be done not only to obtain a specimen for culture to identify the causative agent, but to relieve the dyspnea and discomfort. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1615 OBJ:7TOP:Thoracentesis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 37. The nurse explains that the opening between the vocal cords is the . ANS: glottis The glottis is the opening between the vocal cords. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1608 OBJ: 2 TOP: Glottis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 38. The nurse recognizes that the reading in an arterial gas report indicates the amount of oxygen dissolved in the plasma. ANS:
PaO2 The PaO2 reading indicates the amount of oxygen dissolved in the plasma. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1616 OBJ: 8 TOP: Blood gases KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 39. The nurse explains that the diagnostic test that can scan the chest and the abdomen in less than 30 seconds is the . ANS: spiral CT scan helical CT scan The spiral or helical CT scan can scan the chest and the abdomen in less than 30 seconds. This test is faster and more accurate. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1613 OBJ:7TOP:Spiral or helical CT scan KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity OTHER 40. The nurse traces the path of unoxygenated blood through the respiratory system to the distribution of oxygenated blood to the body. Place the events of reoxygenation in order. (Separate letters by a comma and space as follows: A, B, C, D) a. Pulmonary artery takes blood to capillary system of the alveoli b. Blood enters the left atria via the pulmonary vein c. Blood enter the left ventricle d. Unoxygenated blood enters the right ventricle e. Blood enters the aorta
f. CO2 diffused and oxygen infused into the blood in alveoli g. Unoxygenated blood enters the right atrium ANS: G, D, A, F, B, C, E
The unoxygenated blood enters the right atria via the vena cava, then to the right ventricle and out the pulmonary artery into the capillary bed of the alveoli, CO2 and O2 are exchanged in the alveoli, the
CO2 being exhaled and the oxygenated blood continues to the right atria via the pulmonary vein, then to the left ventricle and out the aorta to the body. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1613 OBJ:3TOP:Reoxygenation of blood KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 41. The nurse describes the pathophysiologic process of an asthma attack. Place the events in their proper sequence. (Separate letters by a comma and space as follows: A, B, C, D) a. Inflammatory process in the mast cells of the lungs b. Increase in edema and mucus production in the bronchioles c. Release of histamine d. Narrowing of the airways e. Exposure to allergen ANS: E, A, C, B, D The allergen activates the mast cells in the lungs, which release histamine, causing an increase in edema and mucus production that narrows the airways and causes the classic signs of asthma. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1663, Figure 48-14 OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity Chapter 49: Care of the Patient with a Urinary Disorder My Nursing Test Banks Chapter 49: Care of the Patient with a Urinary Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What is the hormone from the posterior pituitary gland that influences the amount of water that is eliminated with the urine? a. Pitocin b. Renin hormone c. Antidiuretic hormone (ADH)
d. ACTH ANS: C ADH causes the cells of the distal convoluted tubules to increase their rate of water reabsorption. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1674 OBJ:3TOP:Urine production KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. As the body breaks down protein, nitrogen wastes are broken down into urea, ammonia, and: a. nitrogen. b. uric acid. c. nitrates. d. creatinine. ANS: D As proteins break down, nitrogenous wastesurea, ammonia, and creatinineare produced. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1671 OBJ: 4 TOP: Physiology KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Because the kidneys are located in proximity to the vertebrae and are protected by the ribs, their location in documentation is referred to as: a. retroperitoneal. b. diaphragm-vertebral. c. costovertebral. d. urachal-peritoneal. ANS: A The kidneys lie behind the parietal peritoneum (retroperitoneal). PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1672 OBJ:1TOP:Location of kidneys KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4.A home health patient with end-stage renal disease (ESRD) has a nursing
diagnosis of powerlessness related to life-altering disease. Which nursing intervention would be most helpful? a. Ensure restricted protein intake to prevent nitrogenous product accum b. Include the patient in making the plan of care. c. Counsel patient about end-of-life provisions. d. Write out a detailed schedule of physicians appointments. ANS: B Listen to the patient and allow time for discussion about concerns and the plan of care to return some sense of control. End-of-life discussions are premature. PTS:1DIF:Cognitive Level: Analysis REF: Page 1713, Nursing Care Plan OBJ: 12 TOP: ESRD KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 5.What portion of the nephron is involved with filtration? a. Glomerulus of the Bowman capsule b. Henle loop c. Proximal convoluted tubule d. Distal convoluted tubule ANS: A Filtration of water and blood products occurs in the glomerulus of the Bowman capsule. PTS:1DIF:Cognitive Level: Application REF: Page 1673, Health Promotion OBJ: 8 TOP: Coping KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 6. When the home health patient is started on dialysis, the home health nurse refers the patient to a community support group that assists with the adjustments necessary to living with dialysis. Which group offers this service? a. National Kidney Foundation b. American Association of Kidney Patients c. American Red Cross d. Veterans Administration
ANS: B The American Association of Kidney Patients offer support to the patient and family as they adapt to living with dialysis. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1518 OBJ:11TOP:Community resources KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity 7.The nurse is aware that as a person ages there is a loss of the mechanism of the kidney due to a decrease in blood supply to the kidneys and loss of nephrons. a. filtering b. reabsorption c. sterile water. d. concentrating ANS: A The filtering mechanism is most affected with aging. By the age of 70, the filtering mechanism is only 50% as efficient as at 40 years of age. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1675 OBJ:5TOP:Effect of aging KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 8.A patient who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP) complains of spasm-like pain over his lower abdomen. What should the initial intervention be by the nurse? a. Inform the nurse in charge b. Decrease the continuous bladder irrigation flow c. Administer the prescribed analgesic d. Check the catheter and drainage system for obstruction ANS: D The patient who has a TURP may have continuous closed bladder irrigation or intermittent irrigation to prevent occlusion of the catheter with blood clots, which would cause bladder spasms. PTS: 1 DIF: Cognitive Level: Application REF: Page 1702 OBJ:8TOP:Transurethral resection of prostate (TURP) KEY:Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 9.A 56-year-old patient with cancer of the bladder is recovering from a cystectomy with an ileal conduit. What is an important aspect in nursing interventions of the patient with an ileal conduit? a. Instructing the patient to void when the urge is felt. b. Maintaining skin integrity. c. Limiting oral intake to 1000 mL/day d. Limiting acid-ash foods. ANS: B Care of the patient with an ileal conduit is a nursing challenge because of the continual drainage of urine through the stoma. Complications of this procedure are wound infection, dehiscence, and urinary leakage. The patient is urged to drink adequate fluids to flush the conduit. PTS: 1 DIF: Cognitive Level: Application REF: Page 1719 OBJ: 8 TOP: Cystectomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. It is 2 days after a 42-year-old male patients urinary diversion surgery. He continues to be critical of the hospital and the nursing care, even though the staff has spent time explaining the care to him. What is the most likely explanation for his behavior? a. He is angry about hospital policy. b. He is feeling neglected by the nursing staff. c. He is in denial of the effects of the surgery. d. He is reacting to the loss of self-esteem and altered body image. ANS: D Persons with altered body image may react to the loss of self-esteem by behaving in a critical or derogatory manner. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1675 OBJ: 10 TOP: Coping KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 11. What should the nurse encourage, barring any other contraindication, when teaching a patient how to decrease the chance of further problems with urolithiasis?
a. Increase his fluid intake b. Increase intake of dairy products c. Restrict his protein intake d. Take one baby aspirin daily ANS: A Fluid intake should be encouraged to at least 2000 mL of fluid in 24 hours, unless contraindicated. PTS: 1 DIF: Cognitive Level: Application REF: Page 1682 OBJ: 8 TOP: Urolithiasis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse notes the amount and color of the urine the patient with urolithiasis has voided. While using Standard Precautions, what should be the nurses next action? a. Discard the urine b. Add the urine to a 24-hour collector c. Send the urine to the laboratory d. Strain the urine ANS: D All urine should be strained. Because stones may be any size, even the smallest speck must be saved for assessment by the laboratory. PTS: 1 DIF: Cognitive Level: Application REF: Page 1697 OBJ: 8 TOP: Urolithiasis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 13. The nurse assessing a patient who is taking furosemide (Lasix) finds an irregular pulse. This is likely a sign of: a. hypomagnesemia. b. hypernatremia. c. hypokalemia. d. hypercalcemia. ANS: C The loop diuretic prototype, furosemide (Lasix), affects electrolytes and causes hypokalemia; the deficiency of the electrolyte can cause arrhythmias and muscle weakness.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1680 OBJ: 7 TOP: Medications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. The patient with nephrosis complains about the need for bed rest. How would the nurse explain the benefit of bed rest? a. The recumbent position may initiate diuresis. b. It preserves the skin integrity. c. It lowers the level of albuminuria. d. It saves stress on joints. ANS: A It is believed that the recumbent position helps initiate diuresis. PTS: 1 DIF: Cognitive Level: Application REF: Page 1707 OBJ:8TOPiagnostic procedures KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. What should the nurse instruct the patient to do before obtaining the urine specimen for a urine culture? a. Collect the urine for a 24-hour period b. Obtain a clean-catch specimen c. Bring in an early morning specimen d. Limit fluid intake to concentrate the urine ANS: B Urine cultures are dependent on a clean-catch or catheterized specimen. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1691 OBJ:8TOPiagnostic procedures KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The patient is scheduled for a transurethral resection of the prostate. During preoperative teaching, what should the nurse emphasize about what the patient can expect after the procedure? a. Red drainage from the catheter b. Limited intake of fluids c. A sodium-restricted diet
d. Incisional drainage ANS: A The patient and family need to know that hematuria is expected after prostatic surgery. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1702 OBJ:8TOP:Transurethral resection of prostate (TURP) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17.A male patient, age 71, has benign prostatic hypertrophy. He is recovering from a trans-urethral prostatic resection. The physician orders removal of the indwelling catheter 2 days after the TURP procedure. What might the patientexperience after the catheter is removed? a. Burning on urination b. Passing of blood clots in the urine c. Dribbling of urine d. Coffee-colored urine ANS: C The patient is informed that initially he may experience frequency and voiding small amounts with some dribbling. There should be no hematuria or clots after 2 days. PTS: 1 DIF: Cognitive Level: Application REF: Page 1702 OBJ:8TOP:Transurethral resection of prostate (TURP) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18.A patient, age 69, is admitted to the hospital with gross hematuria and history of a 20-lb weight loss during the last 3 months. The physician suspects renal cancer. In obtaining a nursing history from this patient, the nurse recognizes which of the following as a significant risk factor for renal cancer? a. High caffeine intake b. Cigarette smoking c. Use of artificial sweeteners d. Chronic cystitis
ANS: B Risk factors include smoking; familial incidence; and preexisting renal disorders, such as adult polycystic kidney disease and renal cystic disease secondary to renal failure. PTS: 1 DIF: Cognitive Level: Application REF: Page 1698 OBJ:8TOP:Renal cancer KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. As the nurse and the dietitian review a female patients diet plan with her, she shouts that with her diabetes and now the kidney failure, there is just nothing she can eat. She says she might as well eat what she wants, because there is nothing she can do to help herself. Based on the patients response, which nursing diagnosis does the nurse identify? a. Noncompliance, risk for, related to feelings of anger b. Imbalanced nutrition less than body requirements, related to knowled c. Anticipatory grieving, related to actual and perceived losses d. Ineffective coping, related to sense of powerlessness ANS: D Ineffective coping due to the feeling of powerlessness against the multiorgan failure may result in aggressive or infantile behavior. PTS:1DIF:Cognitive Level: Analysis REF: Pages 1712-1713, Nursing Care Plan OBJ: 12 TOP:CopingKEY:Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity 20. The patient is on postoperative day 1 after having undergone a TURP procedure. He has continuous bladder irrigation (CBI). Actual urine output during continuous bladder irrigation is calculated by: a. measuring and recording all fluid output in the drainage bag. measuring the total output and deducting the total of the irrigating and b. solutions. adding the total of the intravenous and irrigating solutions and then de c. of output. d. measuring total output and deducting the amount of irrigating solution ANS: D
To determine urine output, the nurse will subtract the amount of irrigation fluid used with the Foley catheter output to calculate urine output. PTS: 1 DIF: Cognitive Level: Application REF: Page 1702 OBJ:8TOP:Transurethral resection of prostate (TURP) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21.A patient has nephrotic syndrome. Which statement made by the patient indicates understanding of the necessary diet modifications? a. I will need to increase protein and decrease sodium intake. b. I will need to drink more milk to get my calcium. c. Carbohydrate restriction will be difficult. d. Potassium restriction wont be hard since I dont like fruit. ANS: A Medical management for nephrotic syndrome depends on the extent of tissue involvement and may include the use of corticosteroids and a low-sodium, high-protein diet. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1707 OBJ:8TOP:Nephrotic syndrome KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 22. What should the patient be encouraged to eat during the active phase of acute renal failure? a. A diet high in sodium b. A diet high in potassium c. A diet high in fats d. A diet high in fluid sources ANS: C The patient with acute glomerulonephritis would need a high carbohydrate, high fat diet to maintain weight. Potassium and sodium are restricted as well as excess fluids. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1708 OBJ:9TOPiagnostic procedures KEY:Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 23. The patient has end-stage renal disease (ESRD) and is admitted to the hospital with a blood urea nitrogen (BUN) level of 48 mg/dL. An excessive elevation of BUN could result from: a. dehydration. b. disorientation. c. edema. d. catabolism. ANS: B If the BUN is elevated, preventive nursing measures should be instituted to protect the patient from possible disorientation or seizures. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1711 OBJ: 8 TOP: ESRD KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. An intravenous pyelogram confirms the presence of a 4-mm renal calculus in the proximal left ureter of a newly admitted patient. Physician orders include meperidine (Demerol) 100 mg IM q4h PRN, strain all urine, and encourage fluids to 4000 mL/day. What should be the nurses highest priority when planning care for this patient? a. Pain related to irritation of a stone b. Anxiety related to unclear outcome of condition c. Ineffective health maintenance related to lack of knowledge about pre d. Risk for injury related to disorientation ANS: A Nursing diagnoses directed at pain control are of primary importance at the early stages of care. Opioid medications manage the pain well. PTS: 1 DIF: Cognitive Level: Application REF: Page 1677 OBJ:8TOP:Renal calculi KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 25.A patient is receiving chlorothiazide (Diuril), a thiazide diuretic for hypertension. What nursing action is most important for prevention of complications? a. Measure output
b. Increase fluid intake c. Assess for hypokalemia d. Assess for hypernatremia ANS: C The thiazide diuretic, chlorothiazide (Diuril), affects electrolytes to cause hypokalemia (extreme potassium depletion in blood). PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1680 OBJ: 7 TOP: Medications KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 26.A patient with cystitis is receiving phenazopyridine (Pyridium) for pain and is voiding a bright red-orange urine. What should the nurse do? a. Report this immediately b. Explain to the patient that this is normal c. Increase fluid intake d. Collect a specimen ANS: B Pyridium will turn the urine reddish-orange. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1680, Table 49-3 OBJ: 7 TOP: Cystitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The patient, age 43, has cancer of the urinary bladder. He has received a cystectomy with an ileal conduit. Which characteristics would be considered normal for his urine? a. Hematuria b. Clear amber with mucus shreds c. Dark bile-colored d. Dark amber ANS: B There will be mucus present in the urine from the intestinal secretions. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1720 OBJ: 6 TOP: Ileal conduit KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28.A patient, age 78, has been admitted to the hospital with dehydration and
electrolyte imbalance. She is confused and incontinent of urine on admission. Which nursing intervention does the nurse include in developing a plan of care? a. Restrict fluids after the evening meal b. Insert an indwelling catheter c. Assist the patient to the bathroom every 2 hours d. Apply absorbent incontinence pads ANS: D Use of protective undergarments may help to keep the patient and the patients clothing dry. Confused patients are high risk for falls. Restricting fluids will only decrease incontinence during the night and will exacerbate the dehydration and electrolyte imbalance. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1689 OBJ: 8 TOP: Incontinence KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. The home health nurse suggests the use of complementary and alternative therapies to prevent and/or treat urinary tract infections (UTIs). Which of the following is an example of such therapies? a. Grape juice b. Caffeine c. Tea d. Cranberry juice ANS: D Cranberry (Cranberry Plus, Ultra Cranberry) has been used to prevent urinary tract infections (UTIs), particularly in women prone to recurrent infection. It has also been used to treat acute UTI. Monitor patients for lack of therapeutic effect. Caffeine and tea will increase diuresis but not prevent UTI. PTS:1DIF:Cognitive Level: Application REF: Page 1689, Complementary and Alternative Therapy OBJ: 7 TOP:Complementary and alternative therapy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. Which action can reduce the risk of skin impairment secondary to urinary
incontinence? a. Decreasing fluid intake b. Catheterization of the elderly patient c. Limiting the use of medication (diuretics, etc.) d. Frequent toileting and meticulous skin care ANS: D Frequent toileting of the incontinent patient will prevent retained moisture in undergarments and bed linens and will preserve the integrity of the skin. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1676, Lifespan OBJ:8TOP:Urinary frequency KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31. Why are pediatric patients, especially girls, susceptible to urinary tract infections? a. Genetically females have a weaker immune system b. Females have a short and proximal urethra in relation to the vagina c. Girls are more sexually active than males d. Girls have a weakened musculature and sphincter tone ANS: B Pediatric patients, especially girls, are susceptible to urinary tract infections because of the short urethra. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1691 OBJ:1TOP:Urinary anatomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 32. Which foods should the home health nurse counsel hypokalemic patients to include in their diet? a. Bananas, oranges, cantaloupe b. Carrots, summer squash, green beans c. Apples, pineapple, watermelon d. Winter squash, cauliflower, lettuce ANS: A The use of most diuretics, with the exception of the potassium-sparing
diuretics, requires adding daily potassium sources (e.g., baked potatoes, raw bananas, apricots, or navel oranges, cantaloupe, winter squash). PTS: 1 DIF: Cognitive Level: Application REF: Page 1681 OBJ:7TOP:Hypokalemia KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. To help a patient control incontinence, what should the nurse recommend the patient avoid? a. Spicy foods b. Citrus fruits c. Organ meats d. Shellfish ANS: A Incontinence may be improved by omitting spicy foods, alcohol, and caffeine from the diet. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1687 OBJ: 8 TOP: Incontinence KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 34. What should the nurse counsel the young man with chronic prostatitis to avoid? a. Cessation of intercourse b. Warm baths c. Stool softeners d. Continuing antibiotics when symptoms abate ANS: A Frequent intercourse may be beneficial to the treatment of chronic prostatitis. Warm baths, stool softeners, and antibiotic therapy are also part of the medical treatment. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1693 OBJ: 8 TOP: Urinalysis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 35. The nurse reassures the patient recovering from acute glomerulonephritis
that after all other signs and symptoms of the disease subside, it is normal to have some residual (select all that apply): a. proteinuria b. oliguria c. hematuria d. anasarca e. oliguria ANS: A, C Proteinuria and hematuria may exist microscopically even when other symptoms subside. PTS: 1 DIF: Cognitive Level: Application REF: Page 1709 OBJ:8TOP:Acute glomerulonephritis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 36. Why are urinary tract infections (UTI) common in older adults? (Select all that apply.) a. Older adults have weakened musculature in the bladder and urethra. b. Older adults have urinary stasis. c. Older adults have increased bladder capacity. d. Older adults have diminished neurologic sensation. e. The effects of medications such as diuretics that many older adults ta ANS: A, B, D, E Urinary frequency, urgency, nocturia, retention, and incontinence are common with aging. These occur because of weakened musculature in the bladder and urethra, diminished neurologic sensation combined with decreased bladder capacity, and the effects of medications such as diuretics. Older women are at risk for stress incontinence because of hormonal changes and weakened pelvic musculature. Inadequate fluid intake (less than 1000 to 2000 mL per 24 hours) can lead to urinary stasis. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1675, Lifespan OBJ:8TOP:Urinary frequency KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
37. Which of the following are signs of fluid overload in the patient with
nephrosis? (Select all that apply.) a. Increase in pulse rate b. Increase in daily weight c. Clear lung sounds d. Edema e. Labored respirations ANS: A, B, D, E Signs and symptoms of fluid overload: changes in pulse rate, respirations, cardiac sounds, and lung fields. Increase in daily morning weights. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1681 OBJ:7TOP:Fluid overload KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 38. The nurse is reviewing the urinalysis report on an assigned patient. The nurse recognizes which findings to be normal? (Select all that apply.) a. Turbidity clear b. pH 6.0 c. Glucose negative d. Red blood cells, 15 to 20 e. White blood cells ANS: A, C The type and size of urinary catheter are determined by the location and cause of the urinary tract problem. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1676, Table 49-2 OBJ: 4 TOP: Urinalysis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION 39. Exercises to increase muscle tone of the pelvic floor are known as exercises. ANS: Kegel Women with weakened structures of the pelvic floor are prone to stress
incontinence. For the female patient, Kegel exercises are helpful; 10 repetitions, 5 to 10 times a day, are suggested to improve muscle tone. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1685 OBJ:8TOP:Kegel exercises KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 40. is a term for severe generalized edema. ANS: Anasarca The patient with nephritic syndrome has severe generalized edema (anasarca), anorexia, fatigue, and impaired renal function. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1707 OBJ: 8 TOP: Key term KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 41. Acute glomerulonephritis is commonly a result of a preexisting infection of . ANS: beta-hemolytic streptococci The health history commonly reveals that the onset of acute glomerulonephritis is preceded by beta-hemolytic streptococcal infection. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1708 OBJ:8TOP:Acute glomerulonephritis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 42. The prostatectomy technique, which involves an incision through the abdomen and the bladder, is a prostatectomy. ANS: suprapubic A suprapubic prostatectomy involves an incision through the abdomen and the bladder with removal of the gland with the finger. PTS:1DIF:Cognitive Level: Knowledge REF: Pages 1702-1703, Table 49-3 OBJ: 3 TOP: Prostatectomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
43.
is a prostatic pain without evidence of infection or
inflammation. ANS: Prostatodynia Prostatodynia is a prostatic pain without evidence of infection of inflammation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1692 OBJ:8TOProstatodynia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 44. In the nephrotic syndrome, the glomeruli are damaged by inflammation and allow small to pass through into the urine. ANS: proteins In nephrotic syndrome, the glomeruli are damaged by inflammation and allow small proteins such as albumin to enter the urine. This creates a deficit of protein in the circulation volume (hypoalbuminemia), which leads to massive edema. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1707 OBJ:8TOP:Nephrotic syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity OTHER 45. Put the sequence of blood flow in order of flow through the nephron. (Separate letters by a comma and space as follows: A, B, C, D) a. Reabsorption in loop of Henle b. Efferent arteriole c. Filtration in the glomerulus d. Reabsorption in proximal convoluted tubule e. Afferent arteriole f. Secretion in the distal convoluted tubule ANS: E, C, D, A, F, B The blood enters the nephron via the afferent arteriole, is filtered through the
glomerulus, reabsorption occurs in the proximal convoluted tubule, then the loop of Henle, then the distal convoluted tubule, and then out the efferent arteriole. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1673, Figure 49-3 OBJ:2TOP:Nephron action KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity Chapter 50: Care of the Patient with an Endocrine Disorder My Nursing Test Banks Chapter 50: Care of the Patient with an Endocrine Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse explains that the negative feedback system controls hormone release by communication between: a. the pituitary and the target organ. b. the thymus and the blood stream. c. lymphatic system and the target organ. d. central nervous system and the blood stream. ANS: A The amount of hormone released is controlled by a negative feedback system. When the level of the particular hormone is appropriate, the target organ signals the pituitary to stop the stimulation of the target organ. PTS: 1 DIF: Cognitive Level: Implementation REF: Page 1725 OBJ: 2 TOP: Anatomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Which diagnostic test for diabetes mellitus provides a measure of glucose levels for the previous 8 to 12 weeks? a. Fasting blood sugar (FBS) b. Oral glucose tolerance test (OGT) c. d. ANS: C
Glycosylated hemoglobin (HbA1c) Postprandial glucose test (PPBG)
Glycosylated hemoglobin (HbA1c)This blood test
measures the amount of glucose that has become incorporated into the hemoglobin within an erythrocyte. Because glycosylation occurs constantly during the 120-day life span of the erythrocyte, this test reveals the effectiveness of diabetes therapy for the preceding 8 to 12 weeks. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1764, Box 50-2 OBJ:8TOP:Glucose monitoring KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Which test will furnish immediate feedback for a newly diagnosed diabetic who is not yet under control? a. Fasting blood sugar (FBS) b. Glycosylated hemoglobin (HgbA1c) c. Oral glucose tolerance test (OGTT) d. Clinitest ANS: A
Diabetics should do a fingerstick blood glucose level test before each meal and at bedtime each day until their disease is under control. The HgbA1c serum test reveals the effectiveness of diabetes therapy for the preceding 8 to 12 weeks. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1764, Box 50-2 OBJ:9TOPiabetes mellitus KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4.To which diet should a patient with Cushing syndrome adhere? a. Less sodium b. More calories c. Less potassium d. More carbohydrates
ANS: A The diet should be lower in sodium to help decrease edema. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1749, Table 50-3 OBJ:5TOP:Cushing syndrome KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 5.The patient is a 20-year-old college student who has type 1 diabetes and normally walks each evening as part of an exercise regimen. The patient plans to enroll in a swimming class. Which adjustment should be made based on this information? Time the morning insulin injection so that the peak action will occur d a. class. b. Delete normal walks on swimming class days. c. Delay the meal before the swimming class until the session is over. Monitor glucose level before, during, and after swimming to determin d. alterations in food or insulin. ANS: D Exercise can reduce insulin resistance and increase glucose uptake for as long as 72 hours, as well as reducing blood pressure and lipid levels. However, exercise can carry some risks for patients with diabetes, including hypoglycemia. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1755 OBJ:11TOPiabetes mellitus KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 6.What is a long-term complication of diabetes mellitus? a. Diverticulitis b. Renal failure c. Hypothyroidism d. Hyperglycemia ANS: B Long-term complications of diabetes include blindness, cardiovascular problems, and renal failure. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1763 OBJ:15TOPiabetes mellitus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological
Integrity 7.A patient has returned to his room after a thyroidectomy with signs of thyroid crisis. During thyroid crisis, exaggerated hyperthyroid manifestations may lead to the development of the potentially lethal complication of: a. severe nausea and vomiting. b. bradycardia. c. delirium with restlessness. d. congestive heart failure. ANS: D In thyroid crisis, all the signs and symptoms of hyperthyroidism are exaggerated. The patient may develop congestive heart failure and die. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1738 OBJ:7TOP:Thyroidectomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. In diabetes insipidus, a deficiency of which hormone causes clinical manifestations? a. antidiuretic hormone (ADH) b. follicle-stimulating hormone (FSH) c. thyroid-stimulating hormone (TSH) d. adrenocorticotropic hormone (ACTH) ANS: A Diabetes insipidus is a transient or permanent metabolic disorder of the posterior pituitary in which ADH is deficient. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1732 OBJ:5TOPiabetes insipidus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. What is an appropriate nursing diagnosis for a patient who has recently been diagnosed with acromegaly? a. Ineffective coping b. Activity intolerance c. Risk for trauma
d. Chronic low self-esteem ANS: C Nursing interventions are mainly supportive. The presence of muscle weakness, joint pain, or stiffness warrants assessment of the ability to perform activities of daily living (ADLs). PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1728 OBJ: 5 TOP: Acromegaly KEY: Nursing Process Step: Planning MSC:NCLEX: Safe, Effective Care Environment 10. The purpose of the use of radioactive iodine in the treatment of hyperthyroidism is to: a. stimulate the thyroid gland. b. depress the pituitary. c. destroy some of the thyroid tissue. d. alter the stimulus from the pituitary. ANS: C Radioactive iodine 131 destroys some of the hyperactive thyroid gland to produce a more normally functioning gland. PTS: 1 DIF: Cognitive Level: Application REF: Page 1736, Box 50-1 OBJ:5TOP:Radioactive iodine 131 KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. Which precaution(s) should the nurse take when caring for a patient who is being treated with radioactive iodine 131 (RAIU)? a. Initiate radioactive safety precautions b. Avoid assigning any young woman to the patient c. Wait three days after dose before assigning a pregnant nurse to care f d. Advise visitors to sit at least 10 feet away from the patient ANS: C The dose is patient specific and at a very low level. No radioactive safety precautions are necessary and pregnant nurses can be assigned 3 days after the dose. RAIU is not harmful to nonpregnant women. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1736, Box 50-1 OBJ:5TOP:Thyroid disorders
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. Why would a patient with hyperthyroidism be prescribed the drug methimazole (Tapa-zole)? a. To limit the effect of the pituitary on the thyroid b. To destroy part of the hyperactive thyroid tissue c. To stimulate the pineal gland d. To block the production of thyroid hormones ANS: D Medical management for hyperthyroidism may include administration of drugs that block the production of thyroid hormones, such as propylthiouracil or methimazole. PTS: 1 DIF: Cognitive Level: Application REF: Page 1736, Table 50-2 OBJ:5TOP:Hyperthyroidism KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. What is the postoperative position for a person who has had a thyroidectomy? a. Prone b. Semi-Fowler c. Side-lying d. Supine ANS: B Postoperative management of this patient includes keeping the bed in a semiFowler position, with pillows supporting the head and shoulders. There should be a suction apparatus and tracheotomy tray available for emergency use. PTS: 1 DIF: Cognitive Level: Application REF: Page 1738 OBJ:7TOP:Thyroidectomy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. What extra equipment should the nurse provide at the bedside of a new postoperative thyroidectomy patient?
a. Large bandage scissors b. Tracheotomy tray c. Ventilator d. Water-sealed drainage system ANS: B There should be a suction apparatus and tracheotomy tray available for emergency use. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1738 OBJ:7TOP:Thyroidectomy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 15.As the nurse is shaving a patient who is 2 days postoperative from a thyroidectomy, the patient has a spasm of the facial muscles. What should the nurse recognize this as? a. Chvostek sign b. Montgomery sign c. Trousseau sign d. Homans sign ANS: A The spasm of facial muscles when stimulated is the Chvostek sign, an indication of hypocalcemic tetany. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1738 OBJ:5TOP:Chvostek sign KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 16.The human insulin whose onset of action occurs within minutes is lispro (Humalog). a. 30 b. 60 c. 15 d. 45 ANS: C Humalog begins to take effect in less than half the time of regular, fast-acting insulin. The new formula can be injected 15 minutes before a meal.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1768, Table 50-5 OBJ: 13 TOP: Insulin KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 17. What should the nurse caution a type I diabetic about excessive exercise? a. It can increase the need for insulin and may result in hyperglycemia. b. It can decrease the need for insulin and may result in hypoglycemia. c. It can increase muscle bulk and may result in malabsorption of insuli d. It can decrease metabolic demand and may result in metabolic acido ANS: B The patient with diabetes should exercise regularly. Exercise can reduce insulin resistance and increase glucose uptake for as long as 72 hours, as well as reducing blood pressure and lipid levels. However, exercise can carry some risks for patients with diabetes, including hypoglycemia. PTS: 1 DIF: Cognitive Level: Application REF: Page 1755 OBJ:11TOPiabetes mellitus KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. What do the Chvostek sign and the Trousseau sign indicate? a. Low levels of serum calcium b. High levels of blood sugar c. Low levels of serum sodium d. High levels of serum aldosterone ANS: A Low levels of blood calcium may cause the Chvostek sign and Trousseau sign. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1738 OBJ:6TOP:Chvostek sign KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19.A patient has undergone tests that indicate a deficiency of the parathyroid hormone secretion. She should be informed of which potential complication? a. Osteoporosis b. Lethargy
c. Laryngeal spasms d. Kidney stones ANS: C Decreased parathyroid hormone levels in the blood stream cause a decreased calcium level. Severe hypocalcemia may result in laryngeal spasm, stridor, cyanosis, and increased possibility of asphyxia. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1745 OBJ:5TOP:Hypoparathyroidism KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. The nurse caring for a 75-year-old man who has developed diabetes insipidus following a head injury will include in the plan of care provisions for: a. limiting fluids to 1500 mL a day. b. encouraging physical exercise. c. protecting patient from injury. d. discouraging daytime naps. ANS: C The patients need protection from injury because they are often exhausted from sleep deprivation and having to get up frequently at night. Fluids should not be limited and their energy should be preserved. PTS: 1 DIF: Cognitive Level: Application REF: Page 1733 OBJ:5TOPiabetes insipidus KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 21. The physician orders an 1800-calorie diabetic diet and 40 units of (Humulin N) insulin U-100 subcutaneously daily for a patient with diabetes mellitus. Why would a mid-afternoon snack of milk and crackers be given? a. To improve nutrition b. To improve carbohydrate metabolism c. To prevent an insulin reaction d. To prevent diabetic coma ANS: C
Humulin N insulin starts to peak in 4 hours. The nurse should be alert for signs of hypoglycemia (a less-than-normal amount of glucose in the blood, usually caused by administration of too much insulin, excessive secretion of insulin by the islet cells of the pancreas, or dietary deficiency) at the peak of action of whatever type of insulin the patient is taking. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1768, Table 50-5 OBJ:13TOPiabetes mellitus KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The nurse teaching a patient with type 1 diabetes mellitus (IDDM) about early signs of insulin reaction would include information about: a. abdominal pain and nausea. b. dyspnea and pallor. c. flushing of the skin and headache. d. hunger and a trembling sensation. ANS: D The patient should be instructed to notify a member of the nursing staff if any signs of hypoglycemic (low insulin) reaction occur: excessive perspiration or trembling. PTS: 1 DIF: Cognitive Level: Application REF: Page 1765, Table 50-6 OBJ:9TOP:Insulin reaction KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse discovers the type 1 diabetic (IDDM) patient drowsy and tremulous, the skin is cool and moist, and the respirations are 32 and shallow. These are signs of: a. hypoglycemic reaction; give 6 oz of orange juice. b. hyperglycemic reaction; give ordered regular insulin. c. hyperglycemic hyperosmolar nonketotic reaction; squeeze glucagon g d. hypoglycemic reaction; give ordered insulin. ANS: A Hypoglycemic reaction is due to not enough food for the insulin. Quick
acting carbohydratessuch as orange juice or longer acting foods such as milk, crackers, and cheeseare beneficial. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1765, Table 50-6 OBJ:9TOPiabetes mellitus complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24.A patient has come to the clinic because of enlarged hands and feet, amenorrhea, and increased hair growth. These symptoms most likely indicate problems with the: a. pituitary gland. b. adrenal glands. c. thyroid gland. d. pancreas. ANS: A The pituitary gland may produce an overabundance of growth hormone. This overproduction of hormones may cause changes throughout the patients body, including enlargement of the pituitary gland and hands and feet. Female patients may develop a deepened voice, increased facial hair growth, and amenorrhea. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1728 OBJ: 5 TOP: Acromegaly KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. What instructions should a nurse give to a diabetic patient to prevent injury to the feet? a. Soak feet in warm water every day. b. Avoid going barefoot and always wear shoes with soles. Use of commercial keratolytic agents to remove corns and calluses are c. off corns and calluses. d. Use a heating pad to warm feet when they feel cool to the touch. ANS: B Sturdy, properly fitting shoes should be worn. Use of corn removers and heating pads is not beneficial to preserve the health of a diabetics feet. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1762 OBJ: 8 TOP: Foot care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance 26. The physician prescribes glyburide (Micronase, DiaBeta, Glynase) for a patient, age 57, when diet and exercise have not been able to control type 2 diabetes. What should the nurse include in the teaching plan about this medication? a. It is a substitute for insulin and acts by directly stimulating glucose up b. It does not cause the hypoglycemic reactions that may occur with insu It is thought to stimulate insulin production and increase sensitivity to c. sites. It lowers blood sugar by inhibiting glucagon release from the liver, pr d. gluconeogenesis. ANS: C Oral hypoglycemics are compounds that stimulate the beta cells in the pancreas to increase insulin release. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1769, Table 50-7 OBJ: 8 TOP: Medications KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 27.A 27-year-old patient with hypothyroidism is referred to the dietitian for dietary consultation. What should nutritional interventions include? a. Frequent small meals high in carbohydrates b. Calorie-restricted meals c. Caffeine-rich beverages d. Fluid restrictions ANS: B A high-protein, high-fiber, lower calorie diet is given. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1740 OBJ:5TOP:Hypothyroidism KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 28.What instructions should be included in the discharge instructions for a 47- year-old patient with hypothyroidism? a. Taking medication whenever symptoms cause discomfort b. Decreasing fluid and fiber intake c. Consuming foods rich in iron
d. Seeing the physician regularly for follow-up care ANS: D Regular checkups are essential, because drug dosage may have to be adjusted from time to time. PTS: 1 DIF: Cognitive Level: Application REF: Page 1740 OBJ:5TOP:Hypothyroidism KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 29. How should the nurse administer insulin to prevent lipohypertrophy? a. At room temperature b. At body temperature c. Straight from the refrigerator d. After rolling bottle between hands to warm ANS: A In fact, it is now believed that insulin should be administered at room temperature, not straight from the refrigerator, to help prevent insulin lipohypertrophy. PTS: 1 DIF: Cognitive Level: Application REF: Page 1759 OBJ:8TOPiabetes mellitus KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30.A patient with a history of Graves disease is admitted to the unit with shortness of breath. The nurse notes the patients vital signs: T 103 F, P 160, R 24, BP 160/80. The nurse also notes distended neck veins. What does the patient most likely have? a. Pulmonary embolism b. Hypertensive crisis c. Thyroid storm d. Cushing crisis ANS: C In a thyroid crisis, all the signs and symptoms of hyperthyroidism are exaggerated. Additionally, the patient may develop nausea, vomiting, severe tachycardia, severe hypertension, and occasionally hyperthermia up to 41 C
(106 F). Extreme restlessness, cardiac arrhythmia, and delirium may also occur. The patient may develop heart failure and may die. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1738 OBJ:8TOP:Hyperthyroidism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31. What is the master gland of the endocrine system? a. Thyroid b. Parathyroid c. Pancreas d. Pituitary ANS: D The pituitary gland, located in the brain, is the master gland of the endocrine system. It has been called the master gland because through the negative feedback system, it exerts its control over the other endocrine glands. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1725 OBJ:1TOPituitary gland KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 32. What information should be obtained from the patient before an iodine131 test? a. Presence of metal in the body b. Allergy to sulfa drugs c. Status of possible pregnancy d. Use of prescription drugs for hypertension ANS: C Iodine-131 is not a radiation hazard to the nonpregnant patient but is absolutely contraindicated during pregnancy. Pregnant nurses should not care for this patient for several days. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1736 OBJ: 5 TOP: Iodine-131 KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 33. The patient being treated for hypothyroidism should be instructed to eat
well-balanced meals including intake of iodine. Which of the following foods contains iodine? a. Eggs b. Pork c. White bread d. Skinless chicken ANS: A The hypothyroid diet should be adequate in intake of iodine, in foods such as saltwater fish, milk, and eggs; fluids should be increased to help prevent constipation. PTS: 1 DIF: Cognitive Level: Application REF: Page 1740 OBJ:8TOP:Hypothyroidism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 34. The nurse is caring for a patient who is receiving calcium gluconate for treatment of hypoparathyroid tetany. Which assessment would indicate an adverse reaction to the drug? a. Increase in heart rate b. Flushing of face and neck c. Drop in blood pressure d. Urticaria ANS: C Indications of an adverse effect of calcium gluconate are dyspnea, bradycardia, and hypotension. PTS: 1 DIF: Cognitive Level: Application REF: Page 1745 OBJ:5TOP:Calcium gluconate for tetany KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 35. The nurse cautions the patient who is being instructed on self-medication with insulin to be aware that there are 25-, 30-, 50-, and 100-unit syringes. How is the 100-unit syringe marked? a. 1-unit increments b. 2-unitt increments
c. 4-unit increments d. 5-unit increments ANS: B The 100-unit syringe is marked in 2-unit increments while the smaller syringes are marked in 1-unit increments. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1759 OBJ:14TOP:Insulin administration KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 36. Which of the following are signs and symptoms of hypoglycemia? (Select all that apply.) a. Irritability b. Dry mouth c. Tremors d. Diaphoresis e. Fruity breath f. Deep respirations ANS: A, C, D Hypoglycemic reaction: rapid shallow respirations, irritability, tremors, excessive perspiration, and possibly loss of consciousness. PTS: 1 DIF: Cognitive Level: Application REF: Page 1765, Table 50-6 OBJ:9TOP:Hypoglycemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 37. What are the three major life-threatening complications postoperatively of a thyroidectomy? (Select all that apply.) a. Hemorrhaging b. Seizures c. Tetany d. Hypoglycemia e. Thyroid crisis (storm) f. SIADH
ANS: A, C, E The nurse must be alert for signs of internal or external bleeding. In addition to hemorrhage, two significant postoperative complications exist after thyroidectomy. The first is tetany. The second is thyroid crisis. Manipulation of the thyroid during surgery may cause the release of large amounts of thyroid hormones into the blood stream, creating a thyroid crisis (storm). PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1738 OBJ:7TOP:Thyroidectomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 38. The adrenal cortex secretes glucocorticoids. The most important is cortisol. What is it involved in? (Select all that apply.) a. Glucose metabolism b. Releasing androgens and estrogens c. Providing extra reserve energy during stress d. Decreasing the level of potassium in the blood stream e. Increasing retention of sodium in the blood stream ANS: A, C Cortisol is involved in glucose metabolism and provides extra reserve energy in times of stress. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1727 OBJ:3TOP:Adrenal cortex KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 39. What should the nurse include in provisions for the postoperative care of the patient who had a thyroidectomy? (Select all that apply.) a. Assessing ability to speak by asking him or her to recite name and add b. Maintaining anatomic position of the head when moving a patient c. Assisting a patient to hyperextend the head to assess for muscle dama d. Doing voice check every 2 hours e. Turning, coughing every hour f. Checking for bleeding at the sides and the back of the head ANS: B, D, F
The nurse should hold the head in an anatomic position when moving the patient to prevent tension on the suture line, do a voice check every 2 to 4 hours by asking the patient to say ah; the patient is not turned nor is coughing recommended immediately after a thyroidectomy. PTS: 1 DIF: Cognitive Level: Application REF: Page 1738 OBJ:7TOPostoperative thyroidectomy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 40.The nurse would instruct a patient with hyperthyroidism (Graves disease) to select which of the following nutritious foods because of the increased metabolism related to the disease. (Select all that apply.) a. Coffee with cream b. Lean meat c. White bread d. Leafy green vegetables e. Supplemental vitamin D ANS: B, D, E Nutritious food sources, such as food high in protein (e.g., lean meat), sources of vitamin B (e.g., leafy green vegetables), and vitamin D supplements are helpful to meet the metabolic needs of the patient with hyperthyroidism. PTS: 1 DIF: Cognitive Level: Application REF: Page 1737 OBJ:5TOPiet for hyperthyroidism KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 41. The nurse would instruct a patient who is hypocalcemic from hypoparathyroidism about a diet that should include (select all that apply): a. High phosphorus foods b. Canned fish with the bones c. Cucumbers d. Tofu e. Bananas f. Vitamin D supplements ANS: B, C, D, F
The hypocalcemic patient should eat a high-calcium, low-phosphorus diet that includes canned fish, cucumbers, tofu, and vitamin D supplements as an aid to the absorption of the calcium. PTS: 1 DIF: Cognitive Level: Application REF: Page 1737 OBJ:5TOPiet for hypocalcaemia KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 42. The nurse is administering long-acting insulin once a day, which provides insulin coverage for 24 hours. This insulin is . ANS: Lantus Lantus is a long-acting synthetic (recombinant DNA origin, human-made) human insulin. It is used once a day at bedtime and works around the clock for 24 hours. PTS: 1 DIF: Cognitive Level: Implementation REF: Page 1768, Table 50-5 OBJ: 3 TOP: Insulin KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 43. Another term for hyperglycemic reaction is . ANS: diabetic ketoacidosis (DKA) diabetic ketoacidosis DKA Hyperglycemic reactionthe body eliminates the excess glucose by the kidneys releasing it in the urine. Diabetic ketoacidosis (DKA) (acidosis accompanied by an accumulation of ketones in the blood), formerly called diabetic coma, may develop and the patient could die. DKA is a severe metabolic disturbance caused by an acute insulin deficiency, decreased peripheral glucose use, and increased fat mobilization and ketogenesis. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1765, Table 50-6 OBJ:10TOP:Hyperglycemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
44. Only
insulin can be administered intravenously.
ANS: regular Insulin is given subcutaneously, although intravenous (IV) administration of regular insulin can be done when immediate onset of action is desired. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1768, Table 50-5 OBJ: 13 TOP: Insulin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 45.A condition with a deficiency in growth hormone is called . ANS: hypopituitary dwarfism A condition with a deficiency in growth hormone is called hypopituitary dwarfism. Most cases are idiopathic, but a small number can be attributed to an autosomal-recessive trait. In some cases there is also a lack of adrenocorticotropic hormone (ACTH), TSH, and the gonadotropins. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1731 OBJ: 5 TOP: Dwarfism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 46. is the term that describes a condition of normal thyroid function. ANS: Euthyroid Euthyroid is the term that describes a condition of normal thyroid function. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1737 OBJ: 5 TOP: Euthyroid KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 47. When the nurse inflates the sphygmomanometer cuff exceeding the systolic blood pressure and observes a carpal spasm, this is a(n) . ANS: Trousseau sign Trousseau sign is a carpal spasm brought on by pressure of a cuff. This is an indicator for hypocalcemia and hypomagnesemia.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1738 OBJ:6TOP:Trousseau sign KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity OTHER 48. Arrange the steps of the negative feedback system in the control of blood glucose in chronologic order. (Separate letters by a comma and space as follows: A, B, C, D): a. Elevation of blood glucose b. Decrease in blood glucose c. Beta cells repressed d. Beta cells of pancreas stimulated to excrete insulin e. Intake of nutrients ANS: E, A, D, B, C After the intake of food the blood glucose increases, which stimulates the beta cells of the pancreas to excrete insulin. Insulin decreases the blood glucose and the negative feedback system represses the beta cells of the pancreas. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1728 OBJ: 2 TOP: Negative feedback system KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 49. Arrange the steps of drawing up a short-acting and a long-acting insulin in the same syringe. (Separate letters by a comma and space as follows: A, B, C, D) a. Draw up amount of shorter-acting insulin b. Check insulin dose with a second licensed nurse c. Inject the desired amount of air into the long-acting insulin d. Clean rubber stopper of both vials with alcohol e. Draw up desired amount of longer-acting insulin f. Inject the desired amount of air into the short-acting insulin ANS: D, C, F, A, E, B When drawing up two different types of insulin, the two vials are prepared by
cleansing the tops, air is injected in the longer-acting insulin, air is injected into the short-acting insulin, and the required dose is drawn up. Set the vial of short-acting insulin out of reach to prevent accidental reuse. Handing the plunger securely, insert the needle in the long-acting insulin and withdraw the dose very carefully. Check the dose with a licensed nurse before administering. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1759, Box 50-3 OBJ:14TOP:Mixing insulin KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity Chapter 51: Care of the Patient with a Reproductive Disorder My Nursing Test Banks Chapter 51: Care of the Patient with a Reproductive Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. Which condition would prevent the use of a vaginal hysterectomy? a. A woman with more than four pregnancies b. Large uterine fibroids c. Menorrhagia for over 6 months d. Women over the age of 50 ANS: B In the case of large uterine fibroids, a vaginal hysterectomy is not an option. PTS: 1 DIF: Cognitive Level: Application REF: Page 1813 OBJ:14TOP:Hysterectomy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. On the second postoperative day, a patient who has had an abdominal hysterectomy complains of gas and abdominal distention. Which intervention would be most appropriate to stimulate a bowel movement? a. Offering carbonated beverages b. Encouraging ambulation at least four times per day c. Administering a 1000-mL soapsuds enema d. Applying an abdominal binder ANS: B
Early ambulation is very helpful to return the bowel to normal function. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1813 OBJ:14TOP:Hysterectomy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The young husband of a patient who has been scheduled for a hysterectomy because of the discovery of ovarian cancer in both ovaries says to the nurse, Please go talk to my wife. She is real upset and says she wont be a woman anymore. What is the nurses most therapeutic response? a. Dont be concerned. All young women get upset before this kind of sur b. Certainly, I will be glad to tell her about hormone replacement. c. She will get over this feeling soon. No matter what I may say to her, it is you that needs to listen to her co d. her. ANS: D Assisting patients with recognizing and clarifying fears and with developing coping strategies for those fears by listening is helpful. PTS:1DIF:Cognitive Level: Application REF: Page 1822, Nursing Care Plan OBJ: 12 TOP: Ovarian cancer KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 4.A patient, age 41, has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. She asks the nurse if she will have hot flashes. What knowledge will guide the nurses response?
Only the uterus was removed, and the ovaries are still producing estro a. have hot flashes. b. The patient is too young to have hot flashes associated with menopaus The uterus, ovaries, and fallopian tubes were removed, and she will ha c. induced menopause and may have hot flashes. d. The uterus and fallopian tubes were removed, and she will not experie ANS: C A total abdominal hysterectomy with bilateral salpingo-oophorectomy is the removal of the uterus, fallopian tubes, and ovaries. If the ovaries are removed in these surgeries, the surgery will induce menopause and hot flashes may occur. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1813 OBJ:14TOP:Hysterectomy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. On the fourth postoperative day after a modified radical mastectomy, the nurse finds the patient with her back to the nurse. She is crying and tells the nurse she feels ugly and is worried that her husband will not be in love with her anymore. The nurse bases subsequent nursing interventions on what diagnosis? a. Disturbed body image related to removal of her breast b. Deficient knowledge related to inadequate education c. Impaired social interaction related to depression d. Fear related to the cancer diagnosis and surgical intervention ANS: A After losing a breast, many patients experience grief over the loss of a body part. The process of grieving is essential for personal adaptation to the loss. The nurse can assist the patient to find helpful coping mechanisms. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1824 OBJ: 18 TOP: Mastectomy KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity 6. Why would the nurse encourage the patient who is recovering from a modified radical mastectomy to exercise the affected arm? a. To reduce pain
b. To stimulate appetite c. To reduce lymphedema d. To increase muscle tension ANS: C An exercise regimen, built up gradually, can help reduce lymphedema following a modified radical mastectomy. PTS: 1 DIF: Cognitive Level: Application REF: Page 1823-1824, Box 51-7 OBJ:19TOPostmastectomy exercises KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 7.A 20-year-old patient presents in the emergency room with a temperature of 103 F, blood pressure of 92/58, headache, and desquamation of both palms. What should the nurse make sure to ask about during the interview? a. Any recent traveling outside the country b. Immunization against influenza c. Method of birth control d. Use of tampons ANS: D These are signs of toxic shock frequently brought on by leaving a tampon in place too long. The nurse should inquire about tampon use, headache, muscle pain, and fatigue. PTS: 1 DIF: Cognitive Level: Application REF: Page 1802 OBJ:6TOP:Toxic shock syndrome (TSS) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. At what age should a male be taught testicular self-examination (TSE)? a. 10 b. 13 c. 15 d. 20 ANS: C Young men should be taught to perform TSE monthly beginning at 15 years of age. PTS: 1 DIF: Cognitive Level: Application REF: Page 1830
OBJ:22TOP:Testicular self-examination KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 9. Which statement made by a patient who has been taught the technique of testicular self-examination indicates the need for further teaching? a. The testes feel smooth and egg-shaped. b. The best time to perform TSE is after a shower. c. I will examine my scrotum after every ejaculation. d. The epididymis feels like a soft tube. ANS: C It is not recommended for a patient to perform a testicular self-examination after every ejaculation. Perform testicular self-examination after a bath or shower when the scrotum is warm and most relaxed. The testes should feel smooth and be firm to the touch. The epididymis feels like a soft tube. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1830, Figure 51-16 OBJ:22TOP:Testicular self-examination KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance 10. Which patient is most at risk for the infection of epididymitis? a. 17-year-old athlete who trains for several hours a day b. 22-year-old who has been exposed to mumps c. 45-year-old who was circumcised at the age of 10 d. 50-year-old who has smoked for 30 years ANS: A Symptoms can occur after trauma to the genital area, after instrumentation of the urethra and cystoscopy, and after physical exertion or prolonged sexual activity. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1828 OBJ: 20 TOP: Epididymitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11.A patient, age 26, has had a tubal insufflation (Rubin test) to ascertain whether her fallopian tubes are patent. She complains of pain in her rightshoulder. Which response is most appropriate?
a. Dont worry, that is a normal reaction. b. Ill report the findings immediately to the head nurse. c. That is a symptom that resulted from your position on the operating ta d. That is from the carbon dioxide passing from the fallopian tubes into ANS: D The Rubin insufflation test determines tubal patency. Carbon dioxide escapes into the abdominal cavity through the patent left fallopian tube. PTS: 1 DIF: Cognitive Level: Application REF: Page 1786 OBJ:4TOPiagnostic procedures KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse provides discharge teaching for a patient regarding her activity level as she recovers from her modified radical mastectomy. Which statement by her indicates to the nurse that the teaching has been successful? a. I should sleep on the side opposite my mastectomy. I should keep my right arm supported in a sling when I am up and aro b. is healed. I can do whatever exercises and activities I want as long as I dont elev c. above my head. I should take aspirin before moving or exercising my arm to prevent p d. exercises. ANS: A The patient should be instructed to avoid sleeping on the involved arm. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1823-1824, Box 51-7 OBJ: 18 TOP: Mastectomy KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 13.A female patient, age 48, is undergoing a routine physical examination for the first time in 5 years. Which procedure would be included in this examination? a. Culdoscopy b. Colposcopy c. Cervical biopsy d. Papanicolaou smear
ANS: D The American Cancer Society recommends that all women who are or have been sexually active or who are at least 18 years of age have an annual Pap smear for 3 consecutive years and then every 3 years until middle age. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1783 OBJ:5TOP:Routine examination KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 14. What is the recommended age range for a baseline mammogram? a. 25 and 30 years b. 31 and 34 years c. 35 and 39 years d. 40 and 45 years ANS: C The American Cancer Society recommends that mammograms be performed on women between 35 and 39, and annually for women 40 years of age and older. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 1816-1817 OBJ:5TOP:Routine examination KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 15. What does the diagnosis of secondary infertility refer to? a. Has never conceived b. Is infertile because of repeated infection c. Has conceived but is now unable to do so d. Is over the age of 38 ANS: C Secondary infertility refers to a woman who has conceived in the past and now is unable to do so. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1797 OBJ: 7 TOP: Infertility KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What instruction should a nurse give a patient with congenital herpes who
does not have lesions at the present? a. Continued use of acyclovir (Zovirax) will prevent reinfection by the v Condoms should be used during all sexual activity to prevent transmis b. even when lesions are not present. c. Acyclovir ointment should be applied to the lesions to increase comfo d. Recurrent genital herpes is promoted by any sexual stimulation. ANS: B Sexual transmission of HSV (genital herpes, a virus) has been documented even in the absence of clinical lesions, and the use of condoms should be encouraged. Acyclovir does not cure the disease but makes the attacks less virulent. PTS: 1 DIF: Cognitive Level: Application REF: Page 1831, Safety Alert OBJ:23TOP:Genital herpes KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 17. The 10-year-old clinic patient reports that she is free of gonorrhea and can now engage in sexual activity. Which response is most appropriate? a. If you have been free of symptoms for 2 weeks you are cured. b. You should get a rapid plasma reagin (RPR) just to make sure. c. No case is considered cured until you have had three consecutive nega d. To confirm your cure, you should get a Venereal Disease Research La ANS: C No case of gonorrhea is considered cured until you have had three consecutive negative cervical smears. The RPR and the VDRL are tests for syphilis. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1835 OBJ:8TOPelvic inflammatory disease (PID) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18.A Gram stain smear of the patients discharge reveals the presence of N. gonorrhoeae. He tells the nurse that he had sexual contact with a new girlfriend but does not think he was exposed to gonorrhea because she did not appear to have any disease. Which information should the nurse include in response to his comment?
Women do not develop gonorrhea infections but can serve as carriers a. to males. When gonorrhea infections occur in women, the disease affects only t b. the other genital organs. Many women are not aware that they have gonorrhea because they oft c. symptoms of infection. Women develop subclinical cases of gonorrhea that do not cause tissu d. symptoms. ANS: C Most women remain asymptomatic but may show a greenish-yellow discharge from the cervix. PTS: 1 DIF: Cognitive Level: Application REF: Page 1834 OBJ:23TOP:Infectious diseases KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 19.The patient who had a colporrhaphy for the repair of a cystocele and rectocele asks that the catheter be removed as it is bothersome to her. How should the nurse explain the reason for the catheter? a. It replaces uncomfortable gauze packing b. It will prevent adhesions and will be in place for about 2 weeks c. It allows for quick urine sample collection d. It keeps the bladder empty, and prevents stress on the sutures ANS: D A retention catheter is usually inserted into the bladder to keep it empty and prevent pressure on sutures. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1806 OBJ:14TOPostoperative care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. Why is a mammogram the most useful method of diagnosing breast cancer? a. It is the most reliable method of detecting breast cancer before it beco b. It is inexpensive and covered by most medical insurance plans. c. It involves no radiation and takes only a few minutes. d. It involves no pain or discomfort and is readily available.
ANS: A Mammography is radiography of the soft tissue of the breast to allow identification of various benign and neoplastic processes, especially those not palpable on physical examination. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1817 OBJ:5TOPiagnostic procedures KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 21. The patient, age 52, is recovering from a modified radical mastectomy. Why is postoperative elevation of the patients arm important after this procedure? a. To prevent vascular and lymph stasis, thus lymphedema b. To prevent drainage accumulation at the incisional site c. To prevent wound infection and dehiscence d. To prevent pleural effusion and respiratory distress ANS: A If the arm is not restricted by dressings, it may be elevated on a pillow with the hand and wrist higher than the elbow and the elbow higher than the shoulder joint. This will facilitate the flow of fluids through the lymph and venous routes and prevent lymphedema. PTS: 1 DIF: Cognitive Level: Application REF: Page 1823 OBJ: 18 TOP: Mastectomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22.A patient, age 46, is recovering from an abdominal hysterectomy. Postoperative nursing assessment findings include a urinary output of 100 mL in 4 hours. What should the nurse do? a. Force fluids b. Report urinary retention to the charge nurse c. Milk the urinary catheter d. Turn the patient onto her right side ANS: B Postoperative nursing interventions for patients with abdominal hysterectomy focus on monitoring vital signs and preventing urinary retention. The patient
should have an output of at least 30 mL/hr. Anything less than that should be reported. PTS: 1 DIF: Cognitive Level: Application REF: Page 1813 OBJ:14TOP:Hysterectomy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. When should postmenopausal women be instructed to perform breast selfexamination (BSE)? a. On the same date of their choice each month b. Every 3 months c. Every day, because they are at high risk for breast cancer d. Whenever they begin to take estrogen supplements ANS: A More than 90% of breast cancers are detected by the patient. BSE for postmenopausal women should be done on the same day of the month each month. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1816 OBJ:15TOP:Breast self-examination (BSE) KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 24. Which statement indicates that the patient who has had an abdominal hysterectomy needs further home teaching? a. I understand I can lift as much as 20 lb. Im leaving today to stay with my daughter, who lives 20 miles away. b. drive the family car. c. The doctor said I cant have sexual intercourse for 4 to 6 weeks. d. Im going to miss wearing my girdle or knee-high hose. ANS: A If there has been an abdominal incision, there may be further restrictions on heavy lifting (nothing over 10 lb). PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1814 OBJ:14TOP:Hysterectomy KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
25. The patient with a swollen scrotum is amazed that diagnosis of the
condition of hydrocele is such a simple thing as: a. placing the scrotum on a warm pad. b. shining a flashlight through the scrotum. c. squatting and letting the scrotum hang dependently. d. packing the scrotum in ice. ANS: B Shining a flashlight from behind the scrotum and visualizing the testes surrounded by fluid is called transillumination. That process is the simple diagnostic test for hydrocele. PTS: 1 DIF: Cognitive Level: Application REF: Page 1829 OBJ: 11 TOP: Hydrocele KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26.A patient, age 36, is scheduled for a unilateral orchiectomy for treatment of testicular cancer. He is withdrawn and does not initiate interaction with the nurse. What is the most appropriate nursing action at this time? a. Carefully explain the postoperative activity restrictions. b. Show him a diagram of what the orchiectomy will accomplish. c. Assure him that he will have adequate future sexual functioning. d. Assess his concerns related to his diagnosis and treatment. ANS: D An appropriate nursing diagnosis for a patient with a reproductive disorder is Disturbed body image and Ineffective coping. It is beneficial to listen to the concerns about this treatment. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1830 OBJ:20TOP:Orchiectomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 27. The 69-year-old patient laughs at the nurse when the nurse suggests that she should have a Pap smear and says, I had my uterus removed except for the cervix 30 years ago and I am almost 70. Why in the world would I want to get a Pap smear at my age? What is the nurses most informative reply? a. All persons who have a cervix remaining should be screened up to the
b.
Well, you have one more year to go to get a Pap smear. My goodness, you look so young I thought you were still in the age br c. screens. d. You are right. If you had no trouble so far, there is no need to do the s ANS: B Persons who have a hysterectomy without the removal of the cervix should continue to be screened at least until the age of 70. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1809 OBJ: 12 TOP: Anatomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 28.A male patient, age 23, seeks care at the health clinic because he has developed a profuse, purulent urethral discharge, and urination is painful. During assessment of the patient, it is most important that the nurse gather information related to his history of: a. recent urinary infections. b. episodes of prostatitis. c. contagious diseases like mumps. d. present and past sexual partners, and notify them to get treatment. ANS: D The nurse should encourage notification of present and past sexual partners of the diagnosis, and stress the need for them promptly to seek medical care. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1835 OBJ:23TOP:Sexually transmitted diseases (STDs) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29.A 25-year-old woman comes to the clinic with a yellowish-green malodorous vaginal discharge. She says it makes her itch and makes it hard to urinate. After a microscopic examination that confirms trichomoniasis, the patient is placed on metronidazole (Flagyl) for 7 days. How should the nurse advise the patient? a. Avoid alcohol while on Flagyl b. Be aware that her urine may turn blue and will stain clothing c. Wear snug underwear during treatment
d. Be aware that she need not notify her sexual partners as trichomoniasi ANS: A Alcohol should be avoided as it can cause disorientation, cramps, and possibly convulsions. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1835 OBJ:23TOP:Trichomoniasis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. The young woman comes to the free clinic for the complaint of stomach cramps. During the examination, the nurse recommends that she be tested for chlamydia. The woman says I dont need any testI dont have any symptoms for a sexual infectionI just came for my stomach. Which response is most informative? a. Well, if you get more symptoms come back for testing. The doctor may have to order medicine for syphilis and chlamydia. Y b. that too. You need to be tested today! c. Testing is not mandatoryI probably wouldnt bother either since you ha That stomachache may be part of a chlamydia infection. Many women d. discharge, but are carriers. ANS: D Chlamydia frequently displays no signs or symptoms in women. The Centers for Disease Control and Prevention (CDC) recommends an annual screening for all women over 25 who are at risk for STDs. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1836 OBJ: 14 TOP: Chlamydia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 31. What factor influences older womens reluctance to seek medical care for problems of the reproductive system? a. Embarrassment and cultural factors b. Denial c. Religious convictions d. Lack of free time ANS: A Many older women are reluctant to seek medical care for problems of the
reproductive system. This may be related to cultural factors, embarrassment, or lack of knowledge. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1780, Lifespan OBJ: N/A TOP: Age KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 32. Although menopause is a normal part of aging, why do many women enter menopause at an earlier age? a. Having become sexually active at an early age b. Living at high altitudes c. Excessive use of alcohol d. Morbid obesity ANS: B Early menopause may be brought on at an earlier age because of living in high altitudes, smoking, cancer treatment, and family history. PTS: 1 DIF: Cognitive Level: Application REF: Page 1780 OBJ: 5 TOP: Early menopause KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 33. Why do false-negative results in mammography occur in specific age groups? a. Older women have greater density of breast tissue. b. Older women have less density of breast tissue. c. Younger women have greater density of breast tissue. d. Younger women have less density of breast tissue. ANS: C Because of the greater density of breast tissue, mammography is less sensitive in younger women, which may result in more false-negative results. PTS: 1 DIF: Cognitive Level: Application REF: Page 1817 OBJ:5TOPiagnostic tests KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 34. Vaginal fistulas are caused by an ulcerating process resulting from (select all that apply): a. Cancer
b. Radiation c. Poor hygiene d. Multiple sexual partners e. Weakening of tissue from pregnancies f. Surgical interventions ANS: A, B, E, F Vaginal fistulas are caused by an ulcerating process resulting from cancer, radiation, weakening of tissue by pregnancies, and surgical interventions. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1804 OBJ:10TOP:Vaginal fistulas KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 35. Select the interventions that should be performed with caution, in the affected arm, on patients who have undergone a modified radical mastectomy. (Select all that apply.) a. Vaccinations b. Taking of blood pressure or samples c. Insertion of IV line d. Physical therapy on uninvolved arm e. Wear watch and jewelry on involved arm f. Carry purse on involved arm or shoulder ANS: A, B, C Patients should be taught not to have any procedures involving the arm on the affected sideBP readings, injections, intravenous infusion of fluids, or the drawing of blood, which may cause edema or infectionand to guard against infections from burns, needle pricks (sewing), and gardening injuries. PTS:1DIF:Cognitive Level: Application REF: Page 1823, Nursing Care Plan OBJ: 18 TOP: Radical mastectomy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 36.What are some advantages of a vaginal hysterectomy over the abdominal hysterectomy? (Select all that apply.) a. Less postoperative discomfort b. Reduced hospital stay
c. Less expensive d. Better visualization of the intrapelvic area e. Faster recovery ANS: A, B, C, E The vaginal approach allows for less postoperative discomfort, a reduced hospital stay, is less expensive, and offers a faster recovery. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1813 OBJ:7TOP:Vaginal hysterectomy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 37. The nurse instructs a group of women who attend the health clinic that persons who are particularly at risk for cervical cancer are persons who (select all that apply): a. Smoke b. Wear tampons c. Have been sexually active since their teens d. Have multiple sexual partners e. Had chickenpox as a child f. Have a history of sexually transmitted diseases (STD) ANS: A, C, D, F Women who have been sexually active since their teens, have multiple sexual partners, and have a history of STDs are more at risk for cancer of the cervix. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1808 OBJ:7TOP:Cervical cancer KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 38. Which of the following are true of the Gardasil vaccine? (Select all that apply.) a. It requires two more immunizations at 6 months after the first dose b. It reduces incidence of cervical cancer c. It reduces the incidence of human papilloma virus (HPV) d. It can be given only to females e. It should be given before a person becomes sexually active
f. It is safe for people as young as 8 years of age ANS: A, B, C, E Gardasil is a vaccine that is effective against HPV and also reduces the incidence of cervical cancer; it can be given to males and females before they become sexually active. It is not recommended for children under 11 years of age. PTS: 1 DIF: Cognitive Level: Application REF: Page 1809 OBJ: 7 TOP: Gardasil KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 39.A is performed to evaluate living tissue to establish or confirm a diagnosis or to follow the course of a disease. ANS: biopsy Biopsies are procedures in which samples of tissue are taken for evaluation to confirm or locate a lesion. PTS: 1 DIF: Cognitive Level: Application REF: Page 1818 OBJ: 14 TOP: Biopsy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 40. The nurse is assisting the physician in removing a small sample of tissue from the patients cervix to have it evaluated. This procedure is called a cervical . ANS: conization Conization of the cervix is indicated when eroded or infected tissue is to be removed or when there is a need for confirmation of cervical cancer. A coneshaped section is removed when the mass is confined to the epithelial tissue. PTS: 1 DIF: Cognitive Level: Application REF: Page 1809 OBJ: 6 TOP: Conization KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 41. are the most benign tumors of the uterus and arise from the uterine muscle tissue. ANS: Fibroids
Fibroids are benign tumors arising from the muscle tissue of the uterus. PTS: 1 DIF: Cognitive Level: Application REF: Page 1806 OBJ: N/A TOP: Fibroids KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 42. are produced in the seminiferous tubules and stored in the epididymis. ANS: Sperm The two oval testes (gonads) are enclosed in the scrotum, a saclike structure that lies suspended from the exterior abdominal wall. This position keeps the temperature in the testes below normal body temperature, which is necessary for viable sperm production and storage. Each testis contains one to three coiled seminiferous tubules that produce the sperm cells. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1775 OBJ:1TOP:Male reproductive tract KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 43. An alternative remedy, , is used by men for the treatment of impotence. ANS: yohimbine, Pausinystalia yohimbe yohimbine Pausinystalia yohimbe Yohimbine is an alternative remedy for the treatment of male impotence. PTS:1DIF:Cognitive Level: Knowledge REF: Page 1841, Complementary and Alternative OBJ: 21 TOP: Alternative remedy KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 44. When the veins in the scrotum become dilated, and the scrotum becomes enlarged and dilated, the condition is called a . ANS: varicocele A varicocele is a condition in which the scrotum becomes enlarged and dilated, from obstructed vessels.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1829 OBJ: 21 TOP: Varicocele KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity OTHER 45. Arrange the process of the menstrual cycle in order of their function to produce menses. (Separate letters by a comma and space as follows: A, B, C, D) a. Egg matures in the graafian follicle b. Corpus luteum is formed from old follicle c. Estrogen from the maturing follicle causes vascularization of the uterine lining d. Anterior pituitary releases luteinizing hormone (LH), releasing the ovum e. Anterior pituitary releases follicle-stimulating hormone (FSH) f. Corpus luteum releases estrogen and progesterone g. Corpus luteum disintegrates causing a decrease in progesterone h. Lining of uterus is shed as menses ANS: E, A, C, D, B, F, G, H The anterior pituitary releases FHS, which allows the egg to mature in the graafian follicle; estrogen from the maturing follicle causes vascularization of the uterine lining; the anterior pituitary releases LS to release the ovum into the fallopian tubes and into the uterus; corpus luteum (made up of the old graafian follicle) releases estrogen and progesterone. The corpus luteum disintegrates, causing a decrease in progesterone and the lining of the uterus is shed as menses. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1779 OBJ: 2 TOP: Menstrual cycle KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 46. The nurse gives discharge instructions to a person who has had a modified radical mastectomy of the right side to perform the elbow pull-in. Place the steps of the exercise in appropriate order. (Separate letters by a comma and space as follows: A, B, C, D) a. Pull elbows forward until they touch b. Lower and straighten the arms
c. Extend arms sideways to shoulder level d. Bring elbows back and extend arms e. Clasp hands behind neck ANS: C, E, A, D, B The exercise requires that you bring the arms out at shoulder level, clasp hands behind head and bring elbows to touch, then bring elbows back and extend arms lower and straighten arms. PTS: 1 DIF: Cognitive Level: Application REF: Page 1823-1824, Box 51-7 OBJ: 19 TOP: Post-mastectomy exercise KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance Chapter 52: Care of the Patient with a Sensory Disorder My Nursing Test Banks Chapter 52: Care of the Patient with a Sensory Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20 feet what the normal eye can see at feet. a. 100 b. 200 c. 300 d. 400 ANS: B The Snellen Eye Chart tests visual acuity. A vision evaluation of 20/40 means that the patient can see at 20 feet what the person with normal vision can see at 200 feet. PTS: 1 DIF: Cognitive Level: Application REF: Page 1850 OBJ:7TOP:Snellen evaluation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The patient tells the nurse that he is legally blind. How would this information impact the nurses plan of care for this patient? a. The patient would be considered totally blind. b. This patient probably has some light perception, but no usable vision.
c.
This patient has some usable vision, which enables function at an acce The nurse would need to determine how this patients visual impairme d. functioning. ANS: D Legal blindness refers to individuals with a maximum visual acuity of 20/200 with corrective eyewear and/or visual field sight capacity reduced by 20 degrees. Categories have been established to help determine the exact extent of the vision loss and what assistive measures are appropriate for the individual. The nurse will need more information as to the exact extent of the vision loss for this patient. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1851 OBJ:N/ATOP:Legal blindness KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3.One of the housekeepers splashes a chemical in the eyes. What should be the first priority? a. Transport to a physician immediately b. Cover the eyes with a sterile gauze c.
Irrigate with H2O for 5 minutes
d. Irrigate with normal saline solution for 20 minutes ANS: D Burns are medically treated with a prolonged, 15- to 20-minute or longer normal saline flush immediately after burn exposure. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1871 OBJ:11TOP:Chemical burn of eye KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4.What does a tympanoplasty correct? a. Conductive hearing loss b. Sensorineural hearing loss c. Congenital hearing loss d. Functional hearing loss ANS: A Tympanoplasty can correct a conductive hearing loss.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1889 OBJ:17TOP:Tympanoplasty KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The 62-year-old home health patient who is recovering from eye surgery complains of a feeling of grittiness in the eye and is having blurred vision. The eyes are reddened and have stringy mucus. What do these complaints indicate? a. Sjgren syndrome b. Early cataracts c. Macular degeneration d. Retinal detachment ANS: A The Sjgren syndrome of dry eye frequently appears after eye surgery. There is insufficient production of tears. Excessive use of antihistamines, antidepressants, and decongestants may cause this syndrome to appear. PTS: 1 DIF: Cognitive Level: Application REF: Page 1858 OBJ:8TOP:Sjgren syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. Four hours after a stapedectomy the patient complains that hearing has not improved at all. What knowledge would the nurse use to shape a response? a. A large percentage of stapedectomies are not successful b. It will take at least 10 days for the graft to heal c. Hearing will not return until edema subsides d. Hearing will improve after irrigation of the ear ANS: C Hearing improvement will not be noted until edema subsides and the packing is removed. PTS: 1 DIF: Cognitive Level: Application REF: Page 1887 OBJ:17TOP:Stapedectomy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
7. What is a common mistake that hinders communication when
communicating with the hearing impaired? a. Overaccentuating words b. Facing the patient when speaking c. Speaking in conversational tones d. Speaking into the ear with the hearing aid ANS: A Do not overaccentuate words. Speak in a normal tone; do not shout or raise the pitch of voice. PTS:1DIF:Cognitive Level: Analysis REF: Page 1870, Health Promotion OBJ: 14 TOP: Communication KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. What is the process when the lens of the eye changes its curvature to focus on the retina? a. Accommodation b. Constriction c. Convergence d. Refraction ANS: A The ability of the lens to alter its curvature as it focuses on the retina is accommodation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1849 OBJ:16TOP:Accommodation KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. When the newly blind male home health patient asks the nurse how he might get assistance, who might the nurse suggest he contact? a. American Red Cross b. American Foundation for the Blind for a list of agencies c. Local hospital social worker d. The public health department ANS: B
The American Foundation for the Blind has lists of agencies to assist and educate the visually impaired patient. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1852 OBJ: 15 TOP: Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse clarifies that the difference between a photorefractive keratectomy (PRK) and a laser in-situ keratomileusis (LASIK) is that a LASIK: a. reshapes the central cornea. b. makes partial-thickness radial incisions in the cornea. c. removes some internal layers of the cornea. d. implants intracorneal rings. ANS: C The LASIK procedure removes some of the internal layers of the cornea affecting the central zone of vision. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1853 OBJ:11TOP:Visual acuity KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. What does the cataract treatment of phacoemulsification involve? a. Drying the cataract with hypertonic saline b. Removing the lens through the anterior capsule c. The insertion of a new lens d. Breaking the cataract with ultrasound ANS: D Phacoemulsification uses ultrasound to break up the cataract. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1860 OBJ:11TOP:Infectious/inflammatory disorders KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 12.Which complaint made by a 64-year-old patient during a health interview would alert the nurse to the possibility of cataracts? a. Pain in the eyes b. Difficulty driving at night
14.
c. Loss of peripheral vision d. Dry eyes ANS: B Blurring of vision and difficulty driving at night is often the first subjective symptom reported by a patient who has cataracts. PTS: 1 DIF: Cognitive Level: Application REF: Page 1860 OBJ: 9 TOP: Cataracts KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. What should a patient who has had a cataract repair avoid? a. The use of eye patches b. The use of sunglasses c. The lifting of heavy objects d. Reading for long periods of time ANS: C Postcataract patients should avoid any activity that increases the intraocular pressure, such as lifting heavy objects, stooping, and bending. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1860 OBJ: 11 TOP: Blindness KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity What does diabetes retinopathy result from? a. Capillaries in retina hemorrhage b. Long-term overdosing of insulin c. Retinal detachment d. Aging ANS: A Retinopathy is caused when the capillaries in the retina have aneurysms or hemorrhage. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1861 OBJ: 9 TOP: Glaucoma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. When the patient in the emergency room complains of seeing flashing lights and a curtain down over his right eye, the nurse recognizes this as a symptom of which condition?
a. Detached retina b. Macular degeneration c. Early sign of cataract d. Diabetic retinopathy ANS: A The standard complaint of a detached retina is the report of seeing flashing lights and having a curtain being drawn over the eyes. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1865 OBJ:9TOPetached retina KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse will assess for when the older adult home health patient complains that the entire right side of his head hurts and he cannot chew without pain. a. mumps b. external otitis c. otitis media d. labyrinthitis ANS: B The symptoms of painful head, painful chewing, and pain when the auricle is moved all indicate external otitis, frequently caused by compacted cerumen. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1880 OBJ:16TOP:External otitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. The nurse takes into consideration that the Weber test indicated a conductive hearing loss in a patient because the patient reported hearing the tone: a. equally in both ears. b. as a shrill noise. c. louder in his affected ear. d. very faintly. ANS: C
A conductive hearing loss can be diagnosed by the Weber test. A person with a conductive loss will hear the noise louder in his affected ear. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1885 OBJ: 16 TOP: Weber test KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18. What should the nurse remind the hearing aid wearer to do when the nurse hears a whistling hearing aid? a. Reinsert the ear mold b. Change the battery c. Recharge the hearing aid d. Wash the ear mold with warm water ANS: A The whistling hearing aid is usually caused by a poor fit of the ear mold. Reinsertion of the ear mold usually stops the whistling. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1880, Box 52-3 OBJ: 13 TOP: Hearing aid KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. What should the nurse advise the 20-year-old to do who has been put on cefaclor (Ceclor) for a resistant otitis media? a. Store suspension at room temperature b. Discontinue drug when symptoms abate c. Avoid alcoholic beverages d. Take with meals only ANS: C Drinking alcohol is discouraged while on Ceclor. The drug should be taken in its entirety and stored in the refrigerator. The drug can be taken with or without meals. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1880, Table 52-5 OBJ: 16 TOP: Ceclor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. How should the nurse advise a patient who has severe vertigo from labyrinthitis? a. Lean against a wall and not head forward until vertigo lessens.
b. Bend at the waist and take several deep breaths. c. Drink an iced drink slowly. d. Lie immobile and hold the head in one position until the vertigo lesse ANS: D Lying immobile and holding the head in one position will lessen vertigo. PTS: 1 DIF: Cognitive Level: Application REF: Page 1880, Patient Teaching OBJ: 16 TOP: Vertigo KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. What do miotic eyedrops do for a patient with glaucoma? a. Dilate the pupil and sharpen vision b. Lubricate and moisten the dry eye c. Irrigate the surface of the eye d. Constrict the pupil and open the canal of Schlemm ANS: D Miotic eyedrops allow the pupil to constrict and open the canal of Schlemm to drain the excess fluid. PTS: 1 DIF: Cognitive Level: Application REF: Page 1868 OBJ: 4 TOP: Aging KEY: Nursing Process Step: Assessment MSC:NCLEX: Safe, Effective Care Environment 22. What should the nurse include in the plan of care following a tympanoplasty? a. Elevating head of bed with operative side facing upward b. Enforcing bed rest for 72 hours c. Frequent turning, coughing, and deep breathing d. Continuous irrigation of the ear canal with antibiotic solutions ANS: A Postoperative management for patients who have had a tympanoplasty consists of bed rest until the next morning. The head of the bed is elevated 40 degrees, and the operative side faces upward. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1889 OBJ: 17 TOP: Otitis media KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. When the patient stares at the black dot on an Amsler grid, what should
the nurse ask him to report? a. Any color visible on the grid b. Fading of the edges of the grid c. Any distortion of the grid d. Movement of the black dot ANS: C Amsler grid, a diagnostic tool for retinal disorders, requires that the patient look at the dot on the grid and report any distortion in the grid lines. PTS: 1 DIF: Cognitive Level: Application REF: Page 1850, Figure 52-3 OBJ: 9 TOP: Aging KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24.A patient who had an enucleation of the right eye has been admitted PACU. What should the nurse include in the plan of care? a. Turn, cough, and deep breathe every 3 hours b. Apply a pressure dressing over the right eye socket c. Document dressing assessment every 2 hours d. Turn on the affected side ANS: B A pressure dressing will be applied to the right eye socket and the dressing should be checked every hour for the first 24 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 1872 OBJ:11TOP:Infections/inflammatory disorders KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. What must a patient do following a left vitrectomy? a. Remain flat in bed for 48 hours b. Position self in a face-down position for 4 to 5 days c. Assume a side-lying position with the left side down for 3 days d. Keep head upright and cushioned with pillows for 24 hours ANS: B Following a vitrectomy, the patient must assume a face-down position or turn the face to the right side for 4 to 5 days. PTS: 1 DIF: Cognitive Level: Application REF: Page 1874
OBJ: 11 TOP: Vitrectomy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 26. How would the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy? a. The procedure will destroy the retina, which is not getting enough blo b. The procedure will reduce edema in the macula of the eye. c. The procedure will vaporize fatty deposits that appear in the retina. The procedure will destroy new blood vessels, seal leaking vessels, an d. retinal edema. ANS: D Photocoagulation is useful in diabetic retinopathy to cauterize hemorrhaging vessels and to destroy new vessels. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1863 OBJ:9TOPiabetic retinopathy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. What is the first indication of macular degeneration? a. The loss of peripheral vision b. The loss of central vision c. The loss of color discrimination d. Eye fatigue ANS: B Macular degeneration is characterized by the slow loss of central and near vision. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1864 OBJ:9TOP:Macular degeneration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. Which is a sign of acute angle closure glaucoma (AACG)? a. Large fixed pupil b. Nystagmus c. Bluish color in sclera d. Drooping eyelid
ANS: A Signs of AACG would be eye pain, large fixed pupil with reddened sclera, decreased vision, nausea, and vomiting. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1867 OBJ: 9 TOP: Glaucoma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. Why is otitis media found more frequently in children 6 to 36 months? a. Eustachian tubes in children are shorter and straighter. b. Infection descends via the eustachian tube to the throat. c. Childrens eustachian tubes are more vertical and longer. d. Otitis media is seen equally in both children and adults. ANS: A Childrens shorter and straighter eustachian tubes provide easier access of the organisms from the nasopharynx to travel to the middle ear. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1881 OBJ: 16 TOP: Otitis media KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 30. Why would the nurse encourage a group of teenagers to protect their eyes with dark sunglasses while using a UV lamp? a. The lamp can cause cataracts. b. The lamp can cause presbycusis. c. The lamp can cause keratitis. d. The lamp can cause ectropion. ANS: A The proteins in the lens of the eye are vulnerable to UV light and can develop cataracts. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1890 OBJ:9TOP:Health promotion KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 31. The nurse counsels the 16-year-old boy that playing his music at high volume can result in impairment in hearing related to: a. damaged tympanic membrane.
b. protective buildup of cerumen. c. damage of the fine hair cells in the organ of Corti. d. rupture of the oval window. ANS: C Long-term exposure to loud noises can damage the fine hair cells in the organ of Corti, which causes a conductive hearing loss. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1890 OBJ:12TOP:Health promotion KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 32. Select all the conditions that may cause conductive hearing loss. (Select all that apply.) a. Buildup of cerumen b. Foreign bodies c. Otosclerosis of external auditory canal d. Trauma e. Exposure to ototoxic drugs f. Otitis media with effusion ANS: A, B, C, F Common causes of conductive hearing loss are buildup of cerumen and otitis media with effusion (escape of effusion). Other conditions that may result in conductive hearing loss are foreign bodies, otosclerosis, and stenosis of the external auditory canal. Sensorineural hearing loss is usually due to trauma, infectious processes, or exposure to ototoxic drugs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1878 OBJ: 12 TOP: Hearing loss KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 33. Which may contribute to otitis media? (Select all that apply.) a. Exposure to cigarette smoke b. Allergies c. Upper respiratory infections d. Swimming
e. Trauma f. Prolonged exposure to loud noise ANS: A, B, C Otitis media is usually caused by an upper respiratory infection with gramnegative bacteria, such as Proteus, Klebsiella, and Pseudomonas. In addition, allergy, exposure to cigarette smoke, mycoplasma, and several viruses may be factors. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1881 OBJ: 16 TOP: Otitis media KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 34. What factors must the nurse consider when assessing readiness to learn when teaching health promotion practices for the visually and hearing impaired? (Select all that apply.) a. Cultural beliefs b. Values c. Habits d. Income e. Occupation ANS: A, B, C The nurse must consider the patients culture, beliefs, values, and habits, as well as the special needs of the older adult. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1891 OBJ:N/ATOP:Health promotion KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 35. Which of the following are causes of cataracts? (Select all that apply.) a. Long-term use of corticosteroids b. Hypotension c. Congenital from exposure to maternal rubella d. Diabetes mellitus e. Exposure to sand and dust f. Smoking ANS: A, C, D, F
Among the many causes of cataracts are long-term corticosteroid use, maternal rubella, diabetes mellitus, and smoking. PTS: 1 DIF: Cognitive Level: Application REF: Page 1859 OBJ: 9 TOP: Cataracts KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 36. What would a nurse do when the patient arrives in the PACU after a left stapedectomy? (Select all that apply.) a. Turn the patient to his right side b. Change dressing as it becomes soiled c. Turn patient every 2 hours d. Leave the bed flat e. Medicate immediately on the complaint of nausea ANS: A, D, E The bed is left in the flat position and the patient is positioned with the operated side facing up, the patient is not turned, and the dressing is not changed by the nurse. The patient should be medicated immediately on complaint of nausea to prevent vomiting and possible disruption of graft. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1887 OBJ:17TOP:Stapedectomy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 37. What should the nurse do when assisting a blind person to walk in an unfamiliar hospital environment? (Select all that apply.) a. Discourage the use of the cane b. Advise the patient to walk quickly c. Describe the surroundings d. Encourage the patient to ask for verbal cues e. Place patient hand on nurses shoulder or elbow ANS: C, D, E The patient should be given verbal cues about the environment. Allow the patient to hold the nurses shoulder or elbow while the nurse walks in front, and encourage the use of a cane to let the patient examine the boundaries and obstacles.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1851 OBJ:N/ATOP:Assisting blind to walk KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 38. The home health patient complains of tearing and a feeling of dryness in the right eye. The nurse assesses that the eyelid is turned inward and the sclera is red. The nurse documents the presence of a(n) . ANS: entropion An entropion is the abnormal turning in of the eyelid, causing irritation and tearing of the eye. PTS: 1 DIF: Cognitive Level: Application REF: Page 1859 OBJ: 8 TOP: Entropion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 39. The nurse explains that a pneumatic retinopexy is a repair of a retinal detachment using a bubble of to put pressure on the damaged retina. ANS: gas A pneumatic retinopexy uses a bubble of gas to put pressure on the damaged retina. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1866 OBJ:11TOPneumatic retinopexy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 40. The total removal of an eye is a(n) . ANS: enucleation The surgical removal of the eyeball is an enucleation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1869 OBJ: 9 TOP: Enucleation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 41. The surgical incision into the eardrum with either a knife or a heated wire
loop to relieve pressure in the middle ear is a(n) . ANS: myringotomy The opening of the eardrum with a specialized knife or a heated wire loop to relieve pressure in the middle ear is a myringotomy. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1883 OBJ:17TOP:Myringotomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 42. Progressive deafness caused by the ankylosis of the stapes is the condition of . ANS: otosclerosis Progressive deafness related to the ankylosis of the stapes is diagnosed as otosclerosis. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1885 OBJ: 16 TOP: Otosclerosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity OTHER 43. Arrange the parts of the eye from the exterior to the most interior. (Separate letters by a comma and space as follows: A, B, C, D) a. Choroid b. Cornea c. Aqueous humor d. Retina e. Lens f. Iris ANS: B, C, F, E, D, A The cornea is the outermost, followed by the aqueous humor, iris, lens, retina, and the choroid. PTS: 1 DIF: Cognitive Level: Application REF: Page 1840, Figure 52-1 OBJ:2TOP:Eye structure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological
Integrity 44. Place the nursing intervention in appropriate order for the immediate care of a patient with a penetrating wound of the eye. (Separate letters by a comma and space as follows: A, B, C, D) a. Assess eye, do not remove object b. Cover both eyes with an eye shield or cup c. Lay the patient down flat d. Check for the irregularity of the pupil e. Obtain medical attention immediately ANS: C, A, D, B, E The patient should be placed on his back to prevent loss of the aqueous humor, assessment of the eye for the location of the object and whether the pupil is regular, cover the eye to prevent movement, and obtain medical attention immediately. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1870, Safety Alert OBJ:10TOPenetrating wound of the eye KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity Chapter 53: Care of the Patient with a Neurologic Disorder My Nursing Test Banks Chapter 53: Care of the Patient with a Neurologic Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What are the two divisions of the nervous system? a. Somatic and the autonomic b. Cerebellum and the brainstem c. Medulla oblongata and the diencephalon d. Central and the peripheral ANS: D The central and the peripheral are the two divisions of the nervous system. The autonomic and the somatic are the division of the peripheral nervous system. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1896
OBJ:1TOP:Anatomy and physiology KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. What is the cranial nerve that supplies most of the organs in the thoracic and abdominal cavities and also carries motor fibers to glands that produce digestive juices and other secretions? a. Somatic motor nerve b. Visceral sensory nerve c. Abducens nerve d. Vagus nerve ANS: D The vagus nerve extends from the throat, larynx, and organs in the thoracic and abdominal cavities. It is responsible for sensations and will accelerate peristalsis when stimulated. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1901, Table 53-1 OBJ:5TOP:Anatomy and physiology KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible. What is the most appropriate position for the patient? a. Neck placed in a neutral position b. Head raised slightly with hips flexed c. Supine in gravity neutral position d. Turn on right side with head elevated ANS: A Place the neck in a neutral position (not flexed or extended) to promote venous drainage. PTS: 1 DIF: Cognitive Level: Application REF: Page 1915 OBJ:12TOP:Intracranial pressure (ICP) KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4.Which question is likely to elicit the most valid response from the patient
who is being interviewed about a neurologic problem? a. Do you have any sensations of pins and needles in your feet? b. Does the pain radiate from your back into your legs? c. Can you describe the sensations you are having? d. Do you ever have any nausea or dizziness? ANS: C For patients with suspected neurologic conditions, the presence of many symptoms or subjective data may be significant. Offering leading questions is not beneficial and may allow the patient to give misinformation. Questions should be specific about symptoms. PTS: 1 DIF: Cognitive Level: Application REF: Page 1902 OBJ: 8 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. What is the cardinal sign of increased intracranial pressure in a brain injured patient? a. Pupil changes b. Ipsilateral paralysis c. Vomiting d. Decrease in the level of consciousness ANS: D Collection of objective data includes a change in level of consciousness. A change in the level of consciousness is the earliest sign of increased intracranial pressure. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1913 OBJ:12TOP:Intracranial pressure (ICP) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is assessed in four categories: eye response, brainstem reflexes, motor response, and respiration. How are these results reported? a. As a sum of the scores of the four categories b. As part of the Glasgow coma scale c. As individual scores in each category
d. As progressive scores during a 24-hour period ANS: C The FOUR score coma scale assesses the patient in four categories: eye response, brainstem reflexes, motor response, and respiration. The scores are reported as individual scores in each category. It is frequently done in conjunction with the Glasgow coma scale, not part of it. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1994 OBJ:11TOP:FOUR Score Coma Scale KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. As the result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In the nurses documentation, which would best describe the patients inability to assess spatial position of his body? a. Agnosia b. Proprioception c. Apraxia d. Sensation ANS: B Patients may experience a loss of proprioception with a stroke. This may include apraxia and agnosia (a total or partial loss of the ability to recognize familiar objects or people). PTS: 1 DIF: Cognitive Level: Application REF: Page 1919 OBJ: 19 TOP: Stroke KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8.A patient, age 45, is to have a myelogram to confirm the presence of a herniated intervertebral disk. Which nursing action should be planned with respect to this diagnostic test? a. Obtain an allergy history before the test. b. Ambulate the patient when returned to the room after the test. c. Use heated blanket to keep patient warm after procedure. d. Keep NPO for 6 to 8 hours after the test. ANS: A Before the dye is injected, patients must be asked whether they have any
allergies, specifically whether they have had any anaphylactic or hypotensive episodes from other dyes. PTS: 1 DIF: Cognitive Level: Application REF: Page 1907 OBJ:11TOPiagnostic procedures KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 9.A patient has recently suffered a stroke with left-sided weakness and has problems with choking, especially when drinking thin liquids. What nursing interventions would be most helpful in assisting this patient to swallow safely? a. Use a straw b. Tuck chin when swallowing c. Take a sip of liquid with each bite d. Turn head to the left ANS: B The patient should sit at a 90-degree angle with the head up and chin slightly tucked. PTS: 1 DIF: Cognitive Level: Application REF: Page 1917 OBJ: 16 TOP: Stroke KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. What are surgical navigational systems? a. Computerized devices that guide the surgeon b. A set of detailed anatomic maps pinpointing specific areas of the brai c. A written set of progressive processes for the resection of small brain d. The use of radioactive materials to pinpoint small tumors of the brain ANS: A Surgical navigational systems are computerized devices that guide the surgeon and make possible the resection of tumors that were once thought to be inoperable. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1951 OBJ: 30 TOP: Hematoma KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 11.A family member of a patient who has just suffered a tonic-clonic seizure is concerned about the patients deep sleep. What is this behavior called?
a. Convalescent period b. Neural recovery period c. Sombulant period d. Postictal period ANS: D Seizures are followed by a rest period of variable length, called a postictal period. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1920 OBJ: 14 TOP: Seizures KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. How would a nurse record the behavior when a patient with Alzheimer disease attempts to eat using a napkin rather than a fork? a. Apraxia b. Agnosia c. Aphasia d. Dysphagia ANS: B Agnosia is a total or partial loss of the ability to recognize familiar objects or people through sensory stimuli as a result of organic brain damage. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1933 OBJ: 13 TOP: Agnosia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. Which symptom is specific to migraine headaches? a. Tachycardia b. They become worse in the evening c. They involve the entire head d. They are preceded by an aura ANS: D Migraine headaches are unusual in that signs and symptoms occur before the acute attack. PTS: 1 DIF: Cognitive Level: Application REF: Page 1909 OBJ: 9 TOP: Headaches KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
14. The nurse assures an anxious family member of a 92-year-old patient who
is demonstrating signs of dementia that many causes of dementia are reversible and preventable. What is one example? a. Hypotension b. Alzheimer disease c. Diabetes d. Parkinson disease ANS: A Some forms of dementia are reversible. Dementia caused by hypotension, anemia, drug toxicity, metabolic disturbance, and malnutrition can all be corrected to abolish the dementia. PTS: 1 DIF: Cognitive Level: Application REF: Page 1902 OBJ:117TOP:Causes of dementia KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. What is the nurse assessing when asking the patient, Who is the president of the United States? during a level of consciousness assessment? a. Orientation b. Memory c. Calculation d. Fund of knowledge ANS: D Fund of knowledge is tested by questions such as Who is the president? or asking about current events. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1903 OBJ:9TOP:Level of Consciousness KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What Glasgow Coma Scale rating would a patient receive who opens the eyes spontaneously, but has incomprehensible speech and obeys commands for movement? a.8 b. 10
c. 11 d. 12 ANS: D The Glasgow coma scale was developed in 1974, and it consists of three parts of the neurologic assessment: eye opening, best motor response, and best verbal response. This patient gets a 4 for eye opening, a 2 for incomprehensible speech, and a 6 for moving on demand. PTS: 1 DIF: Cognitive Level: Application REF: Page 1903, Table 53-3 OBJ:10TOP:Glasgow coma scale KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. What is the nurse aware of when assessing a person with a craniocerebral injury? a. Most injuries of this type are irreversible b. Open injuries are always more serious than closed injuries c. Signs and symptoms may not occur until several days after the traum d. Trauma to the frontal lobe is more significant than to any other area ANS: C If a patient who has been conscious for several days after head injury loses consciousness or develops neurologic signs and symptoms, a subdural hematoma should be suspected. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1952 OBJ: 19 TOP: Trauma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18. The nurse is caring for a home health patient who had a spinal cord injury at C5 three years ago. The nurse bases the plan of care on the knowledge that the patient will be able to: a. feed self with setup and adaptive equipment. b. transfer self to wheelchair. c. stand erect with full leg braces. d. sit with good balance. ANS: A A cord injury at C5 allows for ability to drive an electric wheelchair with
mobile hand supports and feed self with adaptive equipment. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1950, Table 53-8 OBJ:30TOP:Spinal cord injury KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19.A frantic family member is distressed about the flaccid paralysis of her son following a spinal cord injury several hours ago. What does the nurse know about this condition? a. It is an ominous indicator of permanent paralysis. b. It is possibly a temporary condition and will clear. c. It degenerates into a spastic paralysis. d. It will progress up the cord to cause seizures. ANS: B A period of flaccid paralysis following a cord injury is called areflexia, or spinal shock, and may be temporary. PTS: 1 DIF: Cognitive Level: Application REF: Page 1954 OBJ: 20 TOP: Trauma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20.A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and goose flesh. What should be the primary nursing intervention based on these assessments? a. Place patient in flat position and check temperature b. Administer oxygen and check oxygen saturation c. Place on side and check for leg swelling d. Sit upright and check blood pressure ANS: D These are indicators of autonomic dysreflexia or hyperreflexia. It is a medical emergency. The patient should be placed in an upright position to decrease blood pressure and the blood pressure should be checked. Assessments for impaction, full bladder, or a urine infection can help to evaluate this condition. PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 1954, Box 53-4 OBJ: 20 TOP: Dysreflexia KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity 21. The nurse is aware that the characteristic gait of the person with Parkinson disease is a propulsive gait, which causes the patient to: a. stagger and need support of a walker. b. shuffle with arms flexed. c. fall over to one wide when walking. d. take small steps balanced on the toes. ANS: B The propulsive gait causes the patient to shuffle with his arms flexed and with a loss of postural reflexes. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1927 OBJ:21TOParkinsonism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22. What does the nurse know about the stroke patient who has expressive aphasia? a. Has difficulty comprehending spoken and written communication b. Cannot make any vocal sounds c. Has total loss and comprehension of language d. Can understand the spoken word, but cannot speak ANS: D The patient with expressive aphasia has difficulty articulating words, but can understand the written and spoken word. PTS: 1 DIF: Cognitive Level: Application REF: Page 1940 OBJ: 16 TOP: Aphasia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 23. The nurse is aware that the drug t-PA (Activase), a tissue plasminogen activator, must be given in hours of the onset of symptoms to have maximum benefit. a. 3 hours b. 4 hours c. 6 hours d. 8 hours
ANS: A t-PA must be given within 3 hours of the onset of symptoms to be beneficial. PTS: 1 DIF: Cognitive Level: Application REF: Page 1941 OBJ: 14 TOP: t-PA KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 24. An 83-year-old patient has had a stroke. He is right-handed and has a history of hypertension and little strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse should approach him: a. from the right side. b. from the left side. c. from the center. d. from either side. ANS: B Another perceptual problem is hemianopia, which is characterized by defective vision or blindness in half of the visual field. If the patient has hemianopia, which is common, the patient should be approached from the nonparalyzed side for care. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1942 OBJ: 13 TOP: Hemianopia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage coming from the nose. What is the most appropriate nursing response to this assessment? a. Cleanse nose with a soft cotton-tipped swab b. Gently suction the nasal cavity c. Gently wipe nose with absorbent gauze d. Ask patient to blow his nose ANS: C The patients ear and nose are checked carefully for signs of blood and serous drainage, which indicate that the meninges are torn and spinal fluid is escaping. No attempt should be made to clean out the orifice or to blow the nose. The drainage can be wiped away. The drainage can be tested for the presence of glucose, which would confirm that the fluid is spinal fluid and
not mucus. PTS: 1 DIF: Cognitive Level: Application REF: Page 1953 OBJ: 20 TOP: Trauma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. How would the nurse instruct a patient with Parkinson disease to improve activity level? a. To use a soft mattress to relax the spine b. To walk with a shuffling gait to avoid tripping c. To walk with hands clasped behind back to help balance d. To sit in hard chair with arms for posture control ANS: C The patient with Parkinson disease can improve the activity level by sleeping on a firm mattress without a pillow to prevent spinal curvature, hold hands clasped behind to keep better balance, and keep the arms from hanging stiffly at the side. Walk with a lifting of the feet to avoid tripping and freezing. PTS: 1 DIF: Cognitive Level: Application REF: Page 1931 OBJ:21TOParkinson disease KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 27.What is the basic problem that prompts most of the early signs of Alzheimer disease? a. Changes in mood b. Misplacing things c. Memory loss that disrupts daily life d. Problems with words in speaking ANS: C Memory loss that disrupts daily life is the basic problem that prompts most of the early signs of AD. PTS: 1 DIF: Cognitive Level: Application REF: Page 1930, Box 53-2 OBJ:15TOP:Alzheimer disease KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 28.A patient is in which stage of Alzheimer disease when she demonstrates sundowning?
a. Early stage b. Second stage c. Third stage d. Final stage ANS: B Sundowning is seen in the AD patient in the second stage of the disease. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 1932-1933 OBJ:15TOP:Alzheimer disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. Why are the drugs neostigmine (Prostigmin) and pyridostigmine (Mestinon) helpful to the person with myasthenia gravis? a. Improves speech b. Improves visual disturbances c. Reduces pain d. Promotes nerve impulse transmission ANS: D Prostigmine and Mestinon improve the nerve impulses and alleviate the symptoms. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1935 OBJ:21TOP:Myasthenia gravis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. What should the nurse do when the child arrives on the floor with the diagnosis of bacterial meningitis? a. Arrange for humidified oxygen per mask b. Place the child in respiratory isolation c. Inquire about drug allergy d. Hold NPO until orders arrive ANS: B Persons with bacterial meningitis are placed in respiratory isolation until the pathogen can no longer be cultured, usually 24 hours. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1947
OBJ:18TOP:Bacterial meningitis KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 31. What is the purpose of a drug holiday in the treatment of Parkinson disease? a. Change all drugs b. Allow the natural dopamine levels to rise c. Restart drugs at a lower dosage with favorable results d. Reduce the extrapyramidal symptoms ANS: C A drug holiday is a period of time when all drugs are withdrawn from the person with Parkinson disease. The drugs are then restarted at a lower dose with favorable results. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1929 OBJ: 21 TOP: Drug holiday KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 32. What is the first sign of Bells palsy? a. Inability to wrinkle forehead and pucker lips on affected side b. Sudden pain in nostril on affected side c. Excessive salivation on the affected side d. Excessive mucus running from nostril on affected side ANS: A Unilateral weakness of the facial muscles usually occurs, resulting in a flaccidity of the affected side of the face with inability to wrinkle the forehead, close the eyelid, pucker the lips, smile, frown, whistle, or retract the mouth on that side. The face appears asymmetric. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1945 OBJ: 17 TOP: Bells palsy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 33. Following a myelogram the nurse should include in the postprocedure care assessment for: a. elevation of blood pressure. b. urine retention.
c. sensation in lower extremities. d. slurred speech. ANS: C Postmyelogram care includes the assessment to ensure there is no leakage of CSF, sensation and strength of the lower extremities, or headache. To avoid a headache, the patient should be flat for a few hours. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1908 OBJ: 11 TOP: Myelogram KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 34. Why is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized immediately? a. The infection needs to be treated with IV antibiotics to prevent paral b. The brain may swell quickly causing seizures c. The disease can rapidly progress into respiratory failure d. IV hydration is needed to prevent possible fatal hypotension ANS: C Hospitalization is necessary for GBS patients because the disease progresses very quickly and respiratory failure may occur. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1946 OBJ:18TOP:Guillain-Barre KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 35. Which foods should the person who suffers from migraine headaches avoid? (Select all that apply.) a. Yogurt b. Caffeine c. Beef d. Pears e. Marinated foods f. Milk ANS: A, B, E Some foods may cause or worsen headaches. Foods that may provoke
headaches include vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1909 OBJ: N/A TOP: Headache KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 36. What are the three signs of Cushing response? (Select all that apply.) a. Increased pulse rate b. Increased blood pressure c. Widened pulse pressure d. Bradycardia e. Increased systolic blood pressure f. Uncontrolled thermoregulation ANS: C, D, E A widened pulse pressure, increased systolic blood pressure, and bradycardia are together called Cushing response. It is considered an important diagnostic sign of late-stage brain herniation. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1913 OBJ:19TOP:Increased intracranial pressure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 37. Which of the following techniques are necessary for safely feeding a hemiplegic patient? (Select all that apply.) a. Mixing liquids and solid foods together b. Taking the patients dentures out to prevent choking c. Checking the affected side of mouth for food accumulation d. Offering small bites of food e. Elevating the patient to no more than 30 degrees f. Adding a thickening agent to liquids ANS: C, D, F Important nursing measures include avoiding foods that cause choking, checking the affected side of the mouth for accumulation of food and resultant poor hygiene, not mixing liquids and solid foods, and encouraging the patient to take small bites.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1917 OBJ: 18 TOP: Hemiplegia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 38. What is the reticular activating system (RAS) essential to? (Select all that apply.) a. Concentration b. Wakefulness c. Speech d. Attention e. Memory f. Introspection ANS: A, B, D, F The RAS, located on the brainstem, is essential to wakefulness, attention, concentration, and introspection. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1903 OBJ:1TOP:reticular activating system KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 39.What are the effects of normal aging on the nervous system? (Select all that apply.) a. Small vessel occlusion b. Loss of neurons c. Calcification of cerebrum d. Reduction of cerebral blood flow e. Lipofuscin f. Decrease in oxygen use ANS: B, D, E, F As the person ages, normal age-related changes occur such as loss of neurons, reduction of cerebral blood flow, appearance of lipofuscin, a decrease in oxygen use and brain metabolism, and a decline in velocity of nerve impulses. PTS: 1 DIF: Cognitive Level: Application REF: Page 1901 OBJ:6TOP:Age-related changes KEY:Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity COMPLETION 40. is/are responsible for the transmission of impulses between synapses. ANS: Neurotransmitters Neurotransmitters (acetylcholine, norepinephrine, dopamine, and serotonin) function to conduct transmission between the synapses. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1897 OBJ: 1 TOP: Neurotransmitters KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 41.A is a diagnostic procedure used to identify lesions by observing the flow of radiopaque dye through the subarachnoid space. ANS: myelogram Preparation for this procedure is the same as for lumbar puncture. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1907 OBJ:11TOPiagnostic tests KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 42.The nurse explains that the triad of signs of Parkinson disease is: , and ANS: tremor, rigidity, bradykinesia tremor, bradykinesia, rigidity bradykinesia, tremor, rigidity bradykinesia, rigidity, tremor rigidity, bradykinesia, tremor rigidity, tremor, bradykinesia Tremor, rigidity, and bradykinesia are the triad that make up the signs of Parkinson disease. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1927 OBJ:21TOParkinson disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
43. Involuntary rhythmic movement of the eyes, with oscillations that may be
horizontal, vertical, or mixed movements, is called ANS: nystagmus Nystagmus is a rhythmic movement of the eyes, which may be horizontal, vertical, or mixed in directional movement. The eye movement cannot be controlled by the patient. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1924 OBJ:9TOP:Anatomy and physiology KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 44. The waxy substance that covers the neuron fibers and increases the rate of transmission of impulses is the . ANS: myelin Myelin is the waxy substance that covers the neuron fibers (axons and dendrites) and increases the rate of transmission of impulses. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1897 OBJ: 2 TOP: Myelin KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity OTHER 45. The nurse explains that the two divisions of the autonomic nervous system work to maintain homeostasis. Place in order the autonomic events. (Separate letters by a comma and space as follows: A, B, C, D) a. Parasympathetic nervous system dominates b. Extremely stressful or frightening event c. Blood pressure, heart rate, and adrenaline output decrease d. Sympathetic nervous system dominates e. Heart rate and blood pressure rise, secretion of adrenaline ANS: B, D, E, A, C In the event of a frightening event, the sympathetic nervous system dominates and increases the blood pressure, heart rate, and adrenaline output in the fight or flight mechanism. The body is calmed by the parasympathetic
nervous system dominating and reducing the heart rate, blood pressure, and adrenaline output. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1901 OBJ:1TOP:Autonomic nervous system KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity Chapter 54: Care of the Patient with an Immune Disorder My Nursing Test Banks Chapter 54: Care of the Patient with an Immune Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. Which of the following is an example of immunocompetence? a. A child that is immune to measles because of an inoculation b. A person who has seasonal allergies every fall c. When the symptoms of a common cold disappear in 1 day d. A neonate having a natural immunity from maternal antibodies ANS: C Immunocompetence is demonstrated by the immune system responding appropriately to a foreign stimulus and the bodys integrity is maintained as with cold symptoms that resolve with residual illness. PTS: 1 DIF: Cognitive Level: Application REF: Page 1962 OBJ:1TOP:Immunocompetence KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. An anxious patient enters the emergency room with angioedema of the lips and tongue, dyspnea, urticaria, and wheezing after having eaten a peanut butter sandwich. What should be the nurses first intervention? a. Apply cool compresses to urticaria b. Provide oxygen per non-rebreathing mask c. Cover patient with a warm blanket d. Prepare for venipuncture for the delivery of IV medication ANS: B Provision of oxygen is the initial primary intervention. Anaphylaxis may advance very rapidly and the patient may have to be intubated. Covering the
patient with a warm blanket is not wrong, but not an initial intervention. PTS: 1 DIF: Cognitive Level: Application REF: Page 1971 OBJ:6TOP:Anaphylactic reaction KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. What is the etiology of autoimmune diseases based on? a. Reaction to a superantigen b. Immune system producing no antibodies at all c. T cells destroying B cells d. B and T cells producing autoantibodies ANS: D Autoimmune disorders are failures of the tolerance to self. B and T cells produce autoantibodies that can cause pathophysiologic tissue damage. Autoimmune disorders may be described as an immune attack on the self and result from the failure to distinguish self protein from foreign protein. PTS: 1 DIF: Cognitive Level: Application REF: Page 1974 OBJ:1TOP:Autoimmune disorders KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4.A patient is admitted with a secondary immunodeficiency from chemotherapy. The nursing plan of care should include provisions for: a. infection control. b. supporting self-care. c. nutritional education. d. maintaining high fluid intake. ANS: A Immune deficient persons are at risk for infection and need to be protected aggressively for contagion. PTS: 1 DIF: Cognitive Level: Application REF: Page 1973 OBJ:10TOP:Immunodeficiency diseases KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 5. The nurse takes into consideration that when the antigen and antibody react,
the complement system is activated which: a. toughens the cell wall. b. generates more T cells. c. attracts phagocytes. d. makes the antigen resistant. ANS: C The complement system is a group of plasma proteins that are dormant until there is an antigen-antibody interaction. The proteins destroy the cell membrane and attract phagocytes. PTS: 1 DIF: Cognitive Level: Application REF: Page 1966 OBJ:3TOP:Complement system KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. How does normal aging change the immune system? a. Depresses bone marrow b. T cells become hyperactive c. B cells show deficiencies in activity d. Increase in the size of the thymus ANS: C Normal aging causes deficiencies in both B and T cell activation, but the bone marrow is essentially uncompromised. The thymus decreases in size. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1966 OBJ:N/ATOP:Age-related changes KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 7.What would the nurse recommend for a 94-year-old home health patient with deteriorated cell-mediated immunity? a. Avoiding the influenza vaccine b. Getting pneumonia vaccine c. Having skin tests for all antigens d. Taking large doses of beta-carotene ANS: B As the older adult loses some of the cell-mediated immunity, especially against pneumonia and influenza, it is recommended that they acquire the
immunization. PTS: 1 DIF: Cognitive Level: Application REF: Page 1966 OBJ:3TOP:Age-related changes KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8.A patient who works in a plant nursery and has suffered an allergic reaction to a bee sting is stabilized and prepared for discharge from the clinic. During discussion of prevention and management of further allergic reactions, the nurse identifies a need for additional teaching based on which comment? a. I need to think about a change in my occupation. b. I will learn to administer epinephrine so that I will be prepared if I am c. I should wear a Medic-Alert bracelet indicating my allergy to insect st I will need to take maintenance doses of corticosteroids to prevent rea d. stings. ANS: D The nurses responsibilities in patient education are as follows: Teach the patient preparation and administration of epinephrine subcutaneously. There is no need for the patient to take maintenance doses of corticosteroids because this was a short, rapid reaction. PTS: 1 DIF: Cognitive Level: Application REF: Page 1970 OBJ:5TOP:Allergic reaction KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance 9. What is the substance released by the T cells that stimulates the lymphocytes to attack an inflammation? a. Lymphokine b. Epinephrine c. B cells d. Histamine ANS: A Lymphokines help attract macrophages to the site of the inflammation. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1964 OBJ: 3 TOP: Allergic reaction KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
10. Immediately after the nurse administers an intradermal injection of a
suspected antigen during allergy testing, the patient complains of itching at the site, weakness, and dizziness. Which action by the nurse is most appropriate initially? a. Elevate the arm above the shoulder b. Administer subcutaneous epinephrine
c. Apply a warm compress to area d. Apply a local anti-inflammatory cream to the site ANS: B Injection of subcutaneous epinephrine should be given at the first sign of allergy. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1967 OBJ:7TOP:Anaphylactic reaction treatment KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. Which person is most at risk for a hypersensitivity reaction? a. 26-year-old receiving his second desensitization injection b. 35-year-old starting back on birth control tablets c. The 52-year-old started on a new series of Pyridium for cystitis d. The 84-year-old receiving penicillin for an annually recurring respirat ANS: D The 84-year-old with the deteriorated immune system is a prime candidate for a delayed hypersensitivity reaction. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1960, Box 54-4 OBJ:5TOPelayed hypersensitivity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse recommends to the busy mother of three that the antihistamine fexofenadine (Allegra) would be more beneficial than diphenhydramine (Benadryl) because Allegra: a. is inexpensive. b. contains a stimulant for an energy boost. c. does not dry out the mucous membranes. d. does not induce drowsiness. ANS: D Allegra does not induce drowsiness as does Benadryl. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1969 OBJ:N/ATOP:Antihistamines KEY:Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 13. The patient who had an asthma-like reaction to a desensitization shot was medicated with a subcutaneous injection of epinephrine. What effect should the nurse assure the anxious patient this will have? a. Cause vasodilation b. Produce bronchodilation c. Cause productive coughing d. Reduction of pulse rate ANS: B The drug epinephrine is given in the case of anaphylaxis because it is a quick-acting drug that produces bronchodilation and vasoconstriction, which relieves respiratory distress. The drug can be ordered to be repeated every 20 minutes. The patient may experience an increase in heart rate. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1970 OBJ: 3 TOP: Anaphylaxis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. Health care facilities have reduced the incidence of serious latex reactions by: a. Having local and injectable corticosteroids on hand for employees b. Desensitizing staff who are allergic c. Supplying extra handwashing stations in the halls d. Using only powder-free gloves ANS: D Powder inside gloves can become aerosolized and cause inhalant reactions. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1971 OBJ: 8 TOP: Latex allergic reaction KEY: Nursing Process Step: N/A MSC:NCLEX: Safe, Effective Care Environment 15. What should the nurse include to assess for in the plan of care for a patient undergoing plasmapheresis? a. Hypotension b. Hypersensitivity c. Urticaria d. Flank pain
ANS: A Hypotension occurs during plasmapheresis because of transient volume changes in the blood. PTS: 1 DIF: Cognitive Level: Application REF: Page 1975 OBJ:12TOPlasmapheresis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 16.A patient is undergoing immunotherapy on a perennial basis. With this form of treatment, what should the patient receive? a. Larger doses each week b. Higher concentrations each week c. Increased amounts and concentrations in 6-week cycles d. The same amount and concentration each visit ANS: C Perennial therapy is most widely accepted, because it allows for a higher cumulative dose, which produces a better effect. Perennial therapy usually begins with 0.05 mL of 1:10,000 dilution and increases to 0.5 mL in a 6-week period. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1967 OBJ:N/ATOP:Immunotherapy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 17.What is the term for transplantation of tissue between members of the same species? a. Allograft b. Autograft c. Isograft d. Homograft ANS: A The allograft is the transplantation of tissues between members of the same species, such as a graft for full-thickness burns. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1973 OBJ: N/A TOP: Allograft KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. In which patient should the nurse be most concerned about
immunodeficiency disorder? a. The patient taking desensitization injections (immunotherapy) b. The patient on long-term radiation therapy for cancer c. The overweight patient d. The patient recently diagnosed with lupus erythematosus ANS: B Radiation destroys lymphocytes and depletes the stem cells. Prolonged radiation depresses the bone marrow. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1974 OBJ:N/ATOP:Immunosuppression KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 19.What is the purpose of plasmapheresis in the treatment of rheumatoid arthritis? a. To add corticosteroids to relieve pain b. To remove pathologic substances present in the plasma c. To remove waste products such as urea and albumin d. To add antinuclear antibodies ANS: B Plasmapheresis is the removal of plasma-containing components causing or thought to cause disease. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1974 OBJ:12TOPlasmapheresis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 20.The nurse explains that when the patient received tetanus antitoxin with the antibodies in it, the patient received a type of immunity. a. Active natural b. Passive natural c. Active artificial d. Passive artificial ANS: D When a person receives an inoculation of antibodies from another source, as with tetanus antitoxin, it is considered a passive artificial immunity. PTS: 1 DIF: Cognitive Level: Application REF: Page 1960, Box 54-1
OBJ: 2 TOP: Immunity KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. Because the older adult has decreased production of saliva and gastric secretions, they are at risk for: a. mouth ulcers. b. fissures in corners of the mouth. c. gastrointestinal infections. d. bloating. ANS: C Deficient saliva and gastric secretions make the older adult prone to gastrointestinal infections. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1968 OBJ:N/ATOP:Age-related changes KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 22.What is the major negative effect of cell-mediated immunity? a. Depression of bone marrow b. Rejection of transplanted tissue c. Activation of the T cells d. Stimulation of the B cells ANS: B Cell-mediated immunity has the negative effect of rejection of transplanted tissue. Activation of T cells and stimulation of B cells are the positive basis of the cell-mediated immunity. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1965 OBJ:3TOP:Hypersensitivity KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23.What is B-cell proliferation dependent on? a. Presence of NK (natural killer) cells b. Complement system c. Antigen stimulation d. Lymphokines ANS: C
Antigen stimulation is the sole focus of B-cell proliferation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1964 OBJ:3TOP:B-cell proliferation KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. What timeframe must blood be transfused within once it has been removed from refrigeration? a. 2 hours b. 4 hours c. 6 hours d. 3 hours ANS: B Blood must be administered within 4 hours after removal from refrigeration, and blood components within 6 hours of removal. PTS: 1 DIF: Cognitive Level: Application REF: Page 1972 OBJ:9TOP:Blood products KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 25. The LPN/LVN has arrived at the patients bedside with a unit of packed cells to be connected to an IV that is infusing. When the RN arrives, what is the first thing the nurses must do? a. Check to ensure that the donor and recipient numbers match accordin b. Request the patient to sign the card on the packed cells c. Immediately administer the packed cells d. Check the patients ID bracelet and then administer the packed cells ANS: A Donor and recipient numbers are specific and must be thoroughly checked and the patient identified with an armband. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1972 OBJ:9TOP:Blood transfusion KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 26. The nurse arrives at the bedside of a patient who has had a unit of packed
cells infusing in his right arm for 35 minutes. He is complaining of chills, itching, and shortness of breath. What should be the nurses initial action? a. Cover with a warm blanket b. Take the patients temperature c. Elevate the head of the bed d. Stop the transfusion and continue with saline ANS: D Mild transfusion reaction signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, and cough The initial intervention should be to stop the transfusion and continue with saline. Elevation of the head, taking vital signs, and covering with a warm blanket are not wrong, but are not of primary importance at this time. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1972 OBJ:9TOP:Blood transfusion KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. Which symptom would be classified as a mild transfusion reaction? a. Orthopnea b. Tachycardia c. Hypotension d. Wheezing ANS: A Mild transfusion reaction signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, cough, and orthopnea. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1972 OBJ:9TOP:Blood transfusion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. What should the nurse do because of the increasing strength of the dose in the injections for immunotherapy? a. Observe the patient for at least 20 minutes after administration b. Take the vital signs every 10 minutes for an hour c. Have the patient lie down quietly for an hour
d. Place a warm compress on the area to speed its absorption ANS: A The patient should be observed for 20 minutes after the increased dose of the allergen. If anaphylaxis is going to occur, it will do so within that time frame. PTS: 1 DIF: Cognitive Level: Application REF: Page 1967 OBJ:6TOP:Anaphylaxis reaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 29. If a nurse is sensitive to latex gloves, what potential food sensitivities might the nurse develop? (Select all that apply.) a. Peanuts b. Avocados c. Milk d. Bananas e. Tomatoes f. Potatoes ANS: B, D, E, F A person sensitive to latex may also be sensitive to certain foods, including avocados, kiwi, guava, bananas, water chestnuts, hazelnuts, tomatoes, potatoes, peaches, grapes, and apricots. PTS: 1 DIF: Cognitive Level: Application REF: Page 1971 OBJ:8TOP:Latex allergy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. Which of the following provide the body with innate immunity? (Select all that apply.) a. Skin and mucous membranes b. Lungs c. Heart d. Tears and saliva e. Natural intestinal and vaginal flora f. Stomach acid
ANS: A, D, E, F The innate immune system is composed of the skin and mucous membranes, cilia, stomach acid, tears, saliva, sebaceous glands, and secretions and flora of the intestine and vagina. These organs, tissues, and secretions provide biochemical and physical barriers to disease. PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 1963 Table 54-1 OBJ:2TOP:Natural immunity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31. Which of the following are diseases which result from ones own immune system attacking the body? (Select all that apply.) a. Lupus erythematosus b. Glomerulonephritis c. Polio d. Rheumatoid arthritis e. Thrombocytopenic purpura f. Osteoarthritis ANS: A, B, D, E Autoimmune diseases such as systemic lupus erythematosus, glomerulonephritis, myasthenia gravis, thrombocytopenic purpura, rheumatoid arthritis, and Guillain-Barr syndrome are treated with plasmapheresis. PTS: 1 DIF: Cognitive Level: Application REF: Page 1974 OBJ:11TOP:Autoimmune disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 32. The nurse outlines the functions of the immune system as those actions which: (Select all that apply.) a. Prevention of hemorrhage b. Protection of the bodys internal environment c. Maintenance of hemoglobin level d. Maintenance of homeostasis by removing damaged cells e. Destruction of growth of abnormal cells
ANS: B, D, E The three main functions of the immune system are to protect the bodys internal environment by destroying antigens and pathogens, maintenance of homeostasis by removing damaged cells, and the destruction of abnormal growth in the body. PTS: 1 DIF: Cognitive Level: Application REF: Page 1962 OBJ:N/ATOPurpose of immune system KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. To provide examples of an active acquired immunity, the nurse uses the example of a person who has acquired immunity from measles because that person has had: (Select all that apply.) a. Chickenpox and mumps b. Measles c. An extremely healthy immune system d. An inoculation against measles e. Maternal antibodies against measles ANS: B, D Active or acquired or adaptive immunity occurs from having had disease or having had an immunization against that specific disease. PTS: 1 DIF: Cognitive Level: Application REF: Pages 1963 Table 54-1 OBJ:2TOP:Acquired immunity KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 34. What is humoral immunity based on? (Select all that apply.) a. Production of antibodies by B cells b. T cells are activated by an antigen c. The bodys response to an antigen d. Sensitized T cells destroy the antigen e. Helper T cells activate phagocytosis ANS: A, C, E Both types of immunity are in response to an antigen, In the humoral response helper T cells activate phagocytosis and the production of
antibodies by the B cells. B cells are the main player in humoral response. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1965 OBJ:3TOP:Humoral immunity KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 35. The nurse stresses that when a person produces his own antibodies against a specific antigen, that process of immunity is immunity ANS: active acquired When a persons immune system produces specific antibodies against an antigen, that process is an active acquired immunity. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1964 OBJ:2TOP:Active immunity KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 36.A type IV latex allergy is characterized by . ANS: contact dermatitis Type IV latex allergy is that of a contact dermatitis. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1971 OBJ: 8 TOP: Latex allergy KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 37.The process of immunity through a controlled exposure to an attenuated organism to stimulate the production of antibodies is . ANS: immunization The process of immunity through a controlled exposure to an attenuated organism to stimulate the production of antibodies is immunization. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 1966-1967 OBJ: 2 TOP: Immunization KEY: Nursing Process Step : N/A MSC: NCLEX: Physiological Integrity 38.A transfusion using blood from ones own blood is a(n)
transfusion, which is the best defense against a transfusion reaction. ANS: autologous An autologous transfusion uses blood from ones own body. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1973 OBJ: 9 TOP: Autologous transfusion KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 39. The transfer of tissue between genetically identical individual (twins) is a(n) . ANS: isograft An isograft is the transfer of tissue between genetically identical individual (twins). PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1973 OBJ: N/A TOP: Isograft KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity OTHER 40. The nurse outlines for a patient who has asthma attacks from pollen that the process from exposure to symptoms follows a systematic sequence. Place the physiologic responses of an allergic asthma attack in sequence. (Separate letters by a comma and space as follows: A, B, C, D) a. Release of histamine b. Edema c. Vasodilation d. Activation of mast cells e. Bronchospasm f. Exposure to pollen ANS: F, D, A, C, B, E The mast cells in the lungs are activated by the exposure to pollen. Histamine is released causing vasodilation, edema, and bronchospasm for the asthmatic. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1968 OBJ:5TOP:Sequence of allergic response KEY:Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 41. List the sequence of a plasmapheresis procedure. (Separate letters by a comma and space as follows: A, B, C, D) a. Removal of whole blood in one arm b. Circulation of blood through cell separator c. Remainder of plasma returned through vein in opposite arm d. Separation of plasma and its cellular components e. Replacement of plasma with lactated Ringer f. Removal of undesirable components ANS: A, B, D, F, C, E The whole blood is drawn out of one arm; circulated through a cell separator; plasma is separated with its cellular components; the undesirable components are removed; the remainder of plasma is returned through a vein in the opposite arm; and the lost plasma is replaced with lactated Ringer, normal saline, frozen plasma, or albumin. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1974 OBJ: 12 TOP: Process of plasmapheresis KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity Chapter 55: Care of the Patient with HIV/AIDS My Nursing Test Banks Chapter 55: Care of the Patient with HIV/AIDS Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. When assigned to a newly admitted patient with AIDS, the nurse says, Im pregnant. It is not safe for me or my baby if I am assigned to his case. Which is the most appropriate response by the charge nurse? This patient would not be a risk for your baby if you use standard prec a. direct contact with blood or body fluids. You should ask for a transfer to another unit because contact with this b. you and your baby at risk for AIDS. Wear a mask, gown, and gloves every time you go into his room and u c. plates, and utensils to serve his meals. d. We should recommend that this patient be transferred to an isolation u ANS: A
HIV is transmitted from human to human through infected blood, semen, cervicovaginal secretions, and breast milk. The use of Standard Precautions by all staff members for all patients all the time simplifies this issue. PTS: 1 DIF: Cognitive Level: Application REF: Pages 1996, Box 55-6 OBJ:6TOP:Transmission of AIDS KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 2. The anxious male patient is fearful that he has been exposed to a person with an HIV infection. He states he does not want to go to a laboratory for the ELISA tests because he does not want to be identified. What would be the nurses most helpful response? a. There really is not an option, you will need to get the Western blot tes b. There is an FDA-approved home test called OraQuick. c. The rapid test Reveal can identify all the HIV strains. You can be tested anonymously for ELISA. If you are seronegative, y d. over. ANS: B The OraQuick is a home OTC test approved by the FDA. One seronegative on the ELISA is not evidence because seroconversion may not have taken place. The Western blot test follows if the ELISA is positive. PTS: 1 DIF: Cognitive Level: Application REF: Page 2008 OBJ: 6 TOP: HIV testing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The patient, age 21, has been treated for chlamydia and has a history of recurrent herpes. What should the nurse counsel this patient about? a. Sexual history, risk reduction measures, and testing for HIV b. Getting an appointment at a family planning clinic c. Testing for HIV and what the test results mean d. Abstinence and a monogamous relationship ANS: A Chlamydia is considered a sexually transmitted disease (STD). As such it requires further testing and a sexual history to advise the sexual partners. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2008 OBJ:6TOP:Risk for infection
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 4.A patient has just been diagnosed as HIV-positive. He asks the nurse, Does this mean I have AIDS? Which response would be most informative? a. Most people get AIDS within 3 to 12 weeks after they are infected wit b. Dont worry. You may never get AIDS if you eat properly, exercise, an It varies with every individual, but the average time is 8 to 10 years fr c. is infected, and some go much longer. d. You can expect to develop signs and symptoms of AIDS within 6 mon ANS: C Typical progress of HIV includes a period of relative clinical latency, occurring immediately after the primary infection, which can last for several years. Long-term nonprogressors remain symptom-free for 8 to10 years. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1988 OBJ:4TOProgression of disease KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. Which of the following is a CDC criterion for the progression of HIV infection to AIDS? a. Increase in viral load b. Decreased ratio of CD8 to CD4 c. Increase in white blood cells d. Increased reactivity to skin tests ANS: A AIDS is the end stage of an HIV infection. The CDC has developed criteria for the diagnosis of AIDS, which are: increase in viral load even with pharmacologic interventions, increase in the ratio of CD8 to CD4, decline in the WBCs, and a decreased reactivity to skin tests. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1989 OBJ:7TOP:AIDS diagnostic criteria KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. What should the nurse look for when reviewing a patients chart to determine whether she has progressed from HIV disease to AIDS?
a. CD4+ count below 500, chronic fatigue, night sweats b. HIV-positive test result, CD4+ count below 200, history of opportuni c. Weight loss, persistent generalized lymphadenopathy, chronic diarrhe d. Fever, chills, CD4+ count below 200 ANS: B
Patients who have progressed from HIV disease to AIDS will have the condition in which the CD4+ cell count drops to less than 200 cells/mm3 and have a history of opportunistic diseases. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 1986, Table 55-1 OBJ:9TOProgression of disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7.A male patient is advised to receive HIV antibody testing because of his multiple sexual partners and injectable drug use. What should the nurse inform the patient to ensure understanding? a. The blood is tested with the highly sensitive test called the Western bl The blood is tested with an ELISA; if positive, it is tested again with a b. by a Western blot if the second ELISA is positive. c. A series of HIV tests is performed to confirm if the patient has AIDS. d. If the HIV tests are seronegative, the patient can be assured that he is ANS: B The individuals blood is tested with ELISA or enzyme immunoassay (ELA), antibody tests that detect the presence of HIV antibodies. If the ELA is positive for HIV, then the same blood is tested a second time. If the second ELA is positive, a more specific confirming test such as the Western blot is done. Blood that is reactive or positive in all three steps is reported to be HIV-positive. A seronegative is not an assurance that the individual is free of infection since seroconversion may not have yet occurred. PTS: 1 DIF: Cognitive Level: Application REF: Page 1990, Box 55-2 OBJ:9TOPiagnostic procedures KEY:Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance 8.A 28-year-old married attorney with one child is in the first trimester of her second pregnancy. The patient states that she is at no risk for HIV, so she would not need to be counseled about testing for HIV. Which is the most appropriate response? a. Shes a professional woman in a monogamous relationship. She obviou b. Women are not at great risk. The greatest risk is with gay men. The fastest-growing segment of the population with AIDS is women a c. need to assess her risks. d. We need to review her chart to determine if her first child was infecte ANS: C Increases in AIDS cases in women and heterosexuals and a slowing of cases in the men who have sex with men (MSM) category are a direct reflection of early educational efforts directed at the MSM population, who were believed to be the only population at risk. Women need to be assessed for different manifestations of HIV infection. It is the current recommendation for voluntary HIV testing for all pregnant women. PTS: 1 DIF: Cognitive Level: Application REF: Page 2008 OBJ:6TOP:Risk for infection KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9.A young gay patient being treated for his third sexually transmitted disease does not see why he should use condoms, because they dont work. Which is the most appropriate response? Condoms may not provide 100% protection, but when used correctly every act of sexual intercourse they reduce your risk of getting infecte a. sexually transmitted diseases. You are correct. Condoms dont always work, so your best protection i b. number of partners. Condoms do not provide 100% protection, so you should always discu c. partners their HIV status or ask if they have any STD. Condoms do not provide 100% protection, but when used with a sper d. assured of complete protection against HIV and other STDs. ANS: A
Risk-reducing sexual activities decrease the risk of contact with HIV through the use of barriers. The most commonly used barrier is the male condom. Although not 100% effective, when used correctly and consistently, male condoms are very effective in the prevention of HIV transmission. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2010 OBJ:5TOP:Transmission of disease KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 10.A 21-year-old male who has been an IV heroin user has been experiencing fever, weight loss, and diarrhea and has been diagnosed as having AIDS. At this time, he has a low-grade fever, severe diarrhea, and a productive cough. He is admitted with Pneumocystis jiroveci. What should the nurse do when caring for the patient? a. Use a gown, mask, and gloves when assisting the patient with his ba b. Wear a gown when assisting the patient to use the bedpan c. Use a gown, mask, and gloves to administer oral medications d. Use a mask when taking the patients temperature ANS: A The use of Standard Precautions and body substance isolation has been shown not only to reduce the risk of blood-borne pathogens, but also to reduce the risk of transmission of other disease between the patient and the health care worker. PTS: 1 DIF: Cognitive Level: Application REF: Page 2011 OBJ:16TOP:Transmission of disease KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 11. The nurse should instruct the patient who is diagnosed with AIDS to report signs of Kaposi sarcoma, which include: a. Reddish-purple skin lesions b. Open, bleeding skin lesions c. Blood-tinged sputum d. Watery diarrhea ANS: A
Kaposi sarcoma is a rare cancer of the skin and mucous membranes characterized by blue, red, or purple raised lesions seen mainly in Mediterranean men. Kaposi sarcoma: firm, flat, raised or nodular, hyperpigmented, multicentric lesions on the skin and mucous membranes. PTS: 1 DIF: Cognitive Level: Application REF: Page 1977 OBJ:8TOP:Kaposi sarcoma KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12.A patient states that he feels terrific, but a blood test shows that he is HIVpositive. It is important for the nurse to discuss with him that HIV may remain dormant for several years. What is true of the patient during this time? a. He is not dangerous to anyone. b. He experiences minor symptoms only. c. He experiences decreased immunity. d. He is contagious. ANS: D A prolonged period in which HIV is not readily detectable in the blood follows within a few weeks or months of the initial infection. This titer, or viral load, falls dramatically as the immune system responds and controls the HIV infection, and it may last 10 to 12 years. During this period, there are few clinical symptoms of HIV infection, although an individual is still capable of transmitting HIV to others. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1988 OBJ:15TOProgression of disease KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. To be diagnosed as having AIDS, the patient must be HIV-positive, have a compromised immune system without known immune system disease or recent organ transplant, and present with which of the following? a. Opportunistic infection b. A positive ELISA or Western blot test c. Weight loss, fever, and generalized lymphedema d. CD4+ lymphocyte count less than 200 mm3
ANS: D
The 1993 expanded case definition of AIDS includes all HIV-infected people who have CD4+, Tlymphocyte counts of less than 200 cells/mm3; this includes all people who have one or more of these three clinical conditions: pulmonary tuberculosis, recurrent pneumonia, or invasive cervical cancer, and it retains the 23 clinical conditions listed in the 1987 AIDS case definition. PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 1986, Table 55-1 OBJ:2TOPefinition of AIDS disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. Why should interventions such as promotion of nutrition, exercise, and stress reduction be undertaken by the nurse for patients who have HIV infection? a. They will promote a feeling of well-being in the patient. b. They will improve immune function. c. They will prevent transmission of the virus to others. d. They will increase the patients strength and ability to care for himself ANS: B HIV disease progression may be delayed by promoting a healthy immune system. Useful interventions for HIV-infected patients include the following: nutritional changes that maintain lean body mass, regular exercise, and stress reduction. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2001 OBJ:15TOP:Immune function improvement KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 15.A male patient is concerned about telling others he has HIV infection. What should the nurse stress when discussing his concerns?
a. Care providers and sexual partners should be told about his diagnosis. b. There is no reason to hide his disease. c. Secrecy is a poor idea because it will lower his self-esteem. d. His diagnosis will be obvious to most people with whom he will com ANS: A Nurses have a responsibility to assess each patients risk for HIV infection and counsel those at risk about HIV testing and the behaviors that put them at risk, and about how to reduce or eliminate those risks. The diagnosis needs to be carefully protected and shared only with caregivers who need to know for the purpose of assessment and treatment. PTS: 1 DIF: Cognitive Level: Application REF: Page 2000 OBJ: 13 TOP: Coping KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 16. The HIV patient asks the nurse about what to expect in terms of disease progression. The nurse tells this patient that although the disease can vary greatly among individuals, the usual pattern of progression includes: a. viremia, clinical latency, opportunistic diseases, and death. b. asymptomatic phase, clinical latency, ARC, and AIDS. c. acute retroviral syndrome, early infection, early symptomatic disease, transitional viral syndrome, inactive disease, early symptomatic infect d. opportunistic diseases. ANS: C The progression from HIV to AIDS includes initial exposure, primary HIV infection, asymptomatic HIV infection, early HIV disease, and AIDS. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1980, Figure 55-3 OBJ:4TOProgression of disease KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. While teaching community groups about AIDS, what should the nurse indicate as the most common method of transmission of the HIV virus? a. Sexual contact with an HIV-infected partner b. Perinatal transmission c. Exposure to contaminated blood
d. Nonsexual exposure to saliva and tears ANS: A Modes of transmission have remained constant throughout the course of the HIV pandemic. It is also important for health care providers to remember that transmission of HIV occurs through sexual practices, not sexual preferences. Worldwide, sexual intercourse is by far the most common mode of HIV transmission. PTS: 1 DIF: Cognitive Level: Application REF: Page 2000, Box 55-11 OBJ:7TOP:Transmission of disease KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 18. What do the activated monocytes and macrophages produce in the presence of an inflammatory process? a. Reduction of red cells b. Increase in WBCs c. Neopterin d. Increase in T-helper cells increase natural killer (NK) cells ANS: C Neopterin is produced in the presence of an inflammatory reaction and is increased in HIV disease. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1990, Box 55-2 OBJ: 5 TOP: Neopterin KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 19. For most people who are HIV-positive, marker antibodies are usually present 10 to 12 weeks after exposure. What is the development of these antibodies called? a. Immunocompetence b. Seroconversion c. Opportunistic infection d. Immunodeficiency ANS: B Seroconversion is the development of antibodies from HIV, which takes place approximately 5 days to 3 months after exposure, generally within 1 to
3 weeks. Although the conversion has taken place, the patient is not yet immunodeficient. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1987 OBJ:10TOProgression of disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 20. What should the nurse emphasize when counseling an anxious HIVpositive mother about the care of her HIV-positive infant? The baby will develop AIDS and refer her to a local AIDS support gro a. remain HIV-positive for the rest of its life. Although infants of HIV-infected mothers may test positive for HIV a b. infants are infected with the virus. She has not yet developed AIDS, and that it is possible the baby will n c. many years. If the infant is started on zidovudine (AZT) within the first month afte d. be prevented. ANS: B The decline in pediatric AIDS incidence is associated with the increased compliance with universal counseling and testing of pregnant women and the use of zidovudine by HIV-infected pregnant women and their newborn infants. Infants born to HIV-infected mothers will have positive HIV antibody results as long as 15 to 18 months after birth. This is caused by maternal antibodies that cross the placenta during gestation and remain in the infants circulatory system. PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 1983-1984 OBJ:5TOP:Transmission of disease KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity 21.Why are snacks high in potassium, such as bananas and apricot nectar, recommended? a. Electrolytes are lost through diaphoresis. b. Sodium is lost through frequent diarrhea. c. Potassium will support weight gain. d. Potassium helps fight infection. ANS: C
HIV disease progression may be delayed by promoting a healthy immune system. Nutritional changes that maintain lean body mass, increase weight, and ensure appropriate levels of vitamins and micronutrients are helpful. Eat potassium-rich foods, such as bananas and apricot nectar. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2000, Box 55-6 OBJ: 15 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The depressed patient with AIDS says, I dont understand why I am going to be getting doses of testosterone. What good will that do me now? What should the nurse keep in mind about testosterone when responding? a. It can lower viral load b. It can lighten depression c. It can increase lean body mass d. It can increase appetite ANS: C Testosterone can increase body mass and lean weight. PTS: 1 DIF: Cognitive Level: Application REF: Page 2005 OBJ:16TOP:Transmission of disease KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 23. After what period of time would the home health nurse make a mental health appointment for a patient with an HIV infection after assessing a diminished ability to attend to daily functioning? a. 1 week b. 2 weeks c. 3 weeks d. 1 month ANS: B Patients with HIV infection have a great deal of anxiety and guilt, which may interfere with the daily functions of maintaining relationships and making decisions. When this apathy is assessed for a period of 2 weeks, the nurse should refer the patient for a mental health consult. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2000
OBJ: 13 TOP: Coping KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 24. The HIV-infected patient who has just seroconverted says he just cannot take all those confusing, expensive antiretroviral (ART) medications. He says he still feels fine, anyway. What should the nurse keep in mind when counseling this patient? a. Resumption of the ART later in the disease is just as effective b. Adherence to the ART protocol is essential to the success of the treat c. Cessation of the ART may prevent the emergence of a resistant strain d. Once ART is initiated it cannot be restarted in the same patient ANS: B Compliance and adherence to the ART protocol is essential to its success. Cessation of the medication may stimulate the emergence of a resistant strain of HIV virus. ART can be restarted, but the optimum time to start is soon after seroconversion. PTS: 1 DIF: Cognitive Level: Application REF: Page 2001 OBJ:5TOP:Adherence to ART KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. What medication times should the nurse use in writing out a schedule for taking antiretroviral medication three times a day? a. 8 AM 2 PM 8 PM b. 8AM 4PM 12 AM c. 8AM 5PM 1 AM d. Be given with meals ANS: C Antivirals should be given around the clock to keep the therapeutic level of the ART at a constant level. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1993 OBJ:15TOP:Antiretroviral therapy (ART) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE
26. Which of the following are early signs and symptoms of an HIV
infection? (Select all that apply.) a. Dry mouth b. Weight loss c. Sore throat d. Vaginal dryness e. Nausea f. Dyspnea ANS: B, C, F Signs and symptoms of HIV infection include weight loss, sore throat, and dyspnea. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1980, Box 55-1 OBJ:8TOP:HIV infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 27. Which of the following are methods in which children with AIDS could have contracted their disease? (Select all that apply.) a. During intrauterine life with an HIV-positive mother b. During the birth process of an HIV-positive mother c. From other children who are HIV positive d. From receiving a transfusion contaminated with the HIV virus e. From breastfeeding by an HIV-positive mother ANS: A, B, D, E In the United States, transfusion of infected blood and blood products and transplantation of infected tissues account for 1% of the total adult and adolescent AIDS cases and 2% of the total pediatric AIDS cases. HIV infection can be transmitted from a mother to her infant during pregnancy, at the time of delivery, or after birth, through breastfeeding. In the United States, it is estimated that approximately 30% of infected mothers will transmit HIV to their infants, with approximately 50% to 70% of the transmissions occurring late in utero or intrapartum. In the United States, among children who are less than 13 years old and have AIDS, 93% were infected at birth.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1983 OBJ:5TOP:Transmission of disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. The home health nurse designing a teaching plan for a person with HIV disease that would support weight gain would include information pertaining to (Select all that apply.) a. Limit fluid intake b. Eating high-protein/high-calorie diet c. Drinking nutritional supplements (Boost, Sustacal, etc.) d. Eating several small meals during the day e. Providing referrals to dietitians f. Resistance weight training ANS: B, C, D, E, F Increase protein, calorie, and fat intake. Offer nutritional supplements. Eat several small meals per day instead of three large meals. Provide for referrals. Weigh the patient daily. Weight training maintains muscle tone and improves appetite. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2011 OBJ: 15 TOP: Weight loss KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. Which foods would a nurse recommend for a person with debilitating diarrhea as a result of HIV infection? (Select all that apply.) a. Bananas b. Ensure c. Fresh broccoli d. Cooked fruits and vegetables e. Red meat f. Apricot nectar ANS: A, D, F Avoid dairy products, red meat, margarine, butter, eggs, dried beans, peas, and raw fruits and vegetables. Cooked or canned fruits and vegetables will provide needed vitamins. Eat potassium-rich foods, such as bananas and
apricot nectar. Discontinue foods, nutritional supplements, and medications that may make diarrhea worse (Ensure, antacids, stool softeners). Avoid gasproducing foods. Serve warm, not hot, foods. Plan small, frequent meals. Drink plenty of fluids between meals. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2000, Table 55-6 OBJ: 15 TOP: Weight loss KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. How does the HIV-2 virus compare to the HIV-1 virus? (Select all that apply.) a. It has lower mortality risks in the older adult b. It is less virulent c. It is less infectious in the initial stage of infection d. It predisposes the HIV-infected person to a normal life span e. It develops high viral loads ANS: A, B, C, D Persons who are infected with the HIV-2 are less infectious during the initial stage because the virus is less virulent than HIV-1. These persons tend to live a normal life span and the mortality in the later years is less. PTS: 1 DIF: Cognitive Level: Application REF: Page 1978 OBJ: 7 TOP: HIV-2 KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 31. Which of the following are examples of the AIDS wasting syndrome in a patient with an HIV infection? (Select all that apply.) a. Episodes of vomiting for 20 days b. Appearance of Kaposi sarcoma c. Loss of 10% of body mass d. Marked hair loss e. Episodes of diarrhea for 30 days f. Episodes of hypotension ANS: C, E The AIDS wasting syndrome is due to disturbances in metabolism involving lean body mass. The wasting syndrome is signaled by 10% loss of body weight, 30 days of diarrhea, weakness, and fever. The person who has the
wasting syndrome is considered to have AIDS. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2001 OBJ:4TOP:Wasting syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION 32. is a type of sexual option classified as no risk for a person to become infected with the HIV virus. ANS: Abstinence Abstinence is refraining from sexual contact in which there is exchange of semen, vaginal secretions, or blood. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2000, Box 55-10 OBJ:5TOP:HIV infection prevention KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 33. An organism that can cross from an animal species to humans is a(n) organism. ANS: zoonotic A zoonotic organism is an organism that can cross from an animal species to humans. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1978 OBJ: 1 TOP: Zoonotic KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 34. The nurse explains that an enzyme allows the RNA of the retrovirus to be changed to DNA and incorporated into the hosts genetic material. ANS: reverse transcriptase Reverse transcriptase allows the RNA of the retrovirus to be changed to DNA and incorporated into the hosts genetic material. PTS: 1 DIF: Cognitive Level: Application REF: Page 1984 OBJ:7TOP:Reverse transcriptase
KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 35. The term that describes an immunosuppressed patients inability to react to a skin test is . ANS: anergic Anergic is the term that describes an immunosuppressed patients ability to react to a skin test. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1899 OBJ: 2 TOP: Anergia KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 36. The combination of efforts of the medical team, nutritionist, social workers, and clergy is the necessary approach to the complex needs of the patients with HIV infection. ANS: multidisciplinary The use of many disciplines in a combined approach to a complex medical problem is multidisciplinary. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1999 OBJ: 11 TOP: Multidisciplinary KEY: Nursing Process Step: N/A MSC:NCLEX: Safe, Effective Care Environment OTHER 37. The historical progress of the HIV infection began to be tracked in 1979. Arrange the historical events in sequence of their discovery. (Separate letters by a comma and space as follows: A, B, C, D) a. Infection in heterosexual men and women b. Infection in hemophiliacs c. Infection in injection drug users d. Increased incidence of Kaposi carcinoma in young homosexual men e. Increased incidence of Pneumocystis jiroveci (previously PCP) ANS: E, D, C, B, A The history of the incidence of HIV infection was slow in being recognized. The first observation was an increase in incidence of Pneumocystis jiroveci,
followed by increasing incidence of Kaposi carcinoma in the homosexual population. The infection began to be seen in injection drug users, hemophiliacs, then into the heterosexual population. PTS: 1 DIF: Cognitive Level: Application REF: Page 1977 OBJ:1 | 12TOP:History of incidence of HIV infection KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance Chapter 56: Care of the Patient with Cancer My Nursing Test Banks Chapter 56: Care of the Patient with Cancer Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1.A patient has developed stomatitis from chemotherapy. What should the appropriate intervention for this condition include? a. Instruction in the following of a liquid diet b. Using a commercial mouthwash after each meal c. Cleaning teeth with a cotton swab dipped in hydrogen peroxide d. Using a soft toothbrush ANS: D The use of a soft toothbrush to clean the teeth and rinsing with normal saline or soda will prevent added discomfort and bleeding. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2029 OBJ: 13 TOP: Stomatitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. Which of the following men should be highest priority for referral for a prostate-specific antigen (PSA)? a. 43-year-old Hispanic man b. 45-year-old African American man c. 49-year-old Korean man d. 50-year-old Native American man ANS: B African American men are a high-risk population for prostate cancer. Orientals and Native Americans have a relatively low incidence of prostate cancer. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2020
OBJ: 3 TOP: PSA testing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3.A patient, age 56, has been advised that his prostate-specific antigen (PSA) level is elevated. The physician then performed a digital rectal examination (DRE). What should the next definitive diagnostic test be? a. CA-125 test b. Transrectal ultrasound c. Needle biopsy of the prostate d. MRI ANS: B Men over the age of 50 should be advised to have a prostate-specific antigen (PSA) test and rectal examination once a year. Two other screening methodsDRE and transrectal ultrasonography (TRUS)are used alone and in combination in the early detection of prostate cancer. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2025 OBJ:11TOProstate cancer KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4.How would the nurse explain to the patient who is taking cyclophosphamide (Cytoxan), an alkylating agent, about how the medication works? a. It inhibits DNA and RNA synthesis b. It interferes with DNA replication c. It damages the cell in S phase of replication d. It alters the hormonal environment that promotes cancer growth ANS: B Most chemotherapeutic agents work by interfering with the cells ability to multiply or reproduce. Cytoxan interferes with DNA replication. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2028 OBJ:13TOP:Chemotherapy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. After an elevation of his PSA, the patient has blood drawn for a CA-19-9. When he asks the nurses the purpose of this new test, what is the most
appropriate response? a. It tests for hepatobiliary cancer b. It tests for colorectal cancer c. It tests for bladder cancer d. It tests for lung cancer ANS: A The CA-19-9 is a tumor marker for tumors in the hepatobiliary system. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2025 OBJ: 11 TOP: CA-19-9 KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
6.A patient, age 39, receiving chemotherapy for treatment of her cancer has a white blood cell count of 1600/mm3. This finding requires nursing interventions to provide which of the following? a. Adequate fluid intake b. Protection from falls c. Protection against infection d. Frequent small nutritious snacks ANS: C The nurse needs to protect the patient against pathogens, monitor the patient for signs of infections, and respond aggressively if an infection occurs. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2028 OBJ: 13 TOP: Leukopenia KEY: Nursing Process Step: Planning MSC:NCLEX: Safe, Effective Care Environment 7. What should the home health nurse advise the patient who found a lump in her breast a week ago during breast self-examination? a. Arrange for an examination by her physician b. Wait until her next ovulatory cycle and check the lump again c. Postpone appointment until the lump enlarges d. Apply warm, moist compresses ANS: A Nurses should teach to all patients, both men and women, that any
identifiable problem should be brought to the attention of a physician. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2020 OBJ:3TOP:Self-examination KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. How many minutes of daily exercise does the American Cancer Society recommend as a prevention of cancer? a. 10 minutes b. 15 minutes c. 20 minutes d. 30 minutes ANS: C The ACS recommends 150 minutes of moderate exercise weekly, which comes to around 20 minutes a day. PTS:1DIF:Cognitive Level: Application REF: Page 2020, Health Promotion OBJ: 13 TOP: ACS recommendations KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. Using the TNM staging classification system, what does a tumor staged as T4N3M2 mean? a. No evidence of primary tumor, lymph node involvement, or distant m b. Carcinoma in situ, regional lymph node involvement, and metastasis c. Enlarging tumor, increasing lymph node involvement, and distant me d. Enlarging tumor, no lymph node involvement, or distant metastasis ANS: C TNM cancer staging classification system T4N3M2 means progressive increase in tumor size and involvement, increasing involvement of regional lymph nodes, and distant metastasis present. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2020, Box 56-2 OBJ:10TOP:Cancer staging KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10.A home health patient undergoing radiation therapy says, I feel so useless.
I have no energy, no appetite and I fall asleep whenever I sit down. What is the nurses most therapeutic response? a. Fatigue is part of your illness. Taking several long naps in the daytime Fatigue is an unfortunate side effect of radiation. It will improve when b. treatment. You really shouldnt be fatigued. Let me make an appointment with yo c. this checked out. d. Dont worry about it. You probably deserve the rest! ANS: B Fatigue is a side effect of radiation. Patients should be reassured that energy levels will improve when treatment is finished. PTS: 1 DIF: Cognitive Level: Application REF: Page 2027 OBJ:13TOP:Radiation fatigue KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The nurse instructs a patient who has been smoking for 5 years about the warning signs of cancer. The nurse tells him that one of cancers seven warning signals include: a. nagging cough or hoarseness. b. a sore that does not heal rapidly. c. gallbladder disease. d. hematopoietic changes. ANS: A Cancers seven warning signals include nagging cough or hoarseness. PTS: 1 DIF: Cognitive Level: Application REF: Page 2020, Box 56-1 OBJ:13TOP:Warning signs of cancer KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. Which of the following is a meal that would represent foods that help prevent cancer? a. Broiled steak, baked potato, whole wheat roll, soy milk b. Baked ham, rice and gravy, apples stewed in butter, whole milk c. Fried pork chops, candied sweet potatoes, white rolls and butter, iced
d. Broiled chicken, cabbage with onion and garlic, and soy milk ANS: D Green and yellow vegetables, cruciferous vegetables, whole grain and soy products, reduction of processed meats and red meat are all examples of foods that prevent cancer. PTS:1DIF:Cognitive Level: Knowledge REF: Page 2020, Health Promotion OBJ: 3 TOP: Cancer prevention KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 13. When should the nurse schedule the oral administration of metoclopramide (Reglan)? a. Only at bedtime b. With meals c. 30 minutes before meals d. 30 minutes after meals ANS: C Reglan should be given 30 minutes before meals and at bedtime. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2031 OBJ: 13 TOP: Medications KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 14. What happens during the process of immunosurveillance? a. T cells recognizing and destroying the abnormal cell b. White cells (WBC) destroying the abnormal cell c. Excretion of histamine to interfere with the replication of the abnorm d. B cells attaching to abnormal cell ANS: A The T cells are responsible for immunosurveillance by recognizing an abnormal cell and destroying it. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2021 OBJ:8TOP:Immunosurveillance KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse caring for a patient who is being treated for cancer of the cervix
by a radioactive implant discovers that the applicator with the radioactive material has become dislodged and is lying in the bed between the patients legs. What should the nurse do? a. Using long-handled forceps grasp the applicator and wrap it in a tow b. Help the patient to a chair and cover the applicator with a rubber she c. Reassure the patient by staying at the bedside and call for help d. Notify the charge nurse ANS: D The applicator should not be touched. Reassure the patient and go to report the incident to the charge nurse. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2028 OBJ:13TOP:Internal radiation therapy KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 16. Which of the following people should avoid visiting a patient being treated with internal radiation therapy? a. A 78-year-old using a walker b. An18-year-old woman c. A woman pregnant in the third trimester d. A 24-year-old nursing mother ANS: C Persons under the age of 18 and persons who are pregnant should not be allowed to visit a patient with internal radiation. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2027 OBJ:13TOPsychological support KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Safe, Effective Care Environment 17.A patient, age 63, has terminal cancer of the liver and is cared for by his wife at home. His abdominal pain has become increasingly severe, and he now says it is intense most of the time. The nurse recognizes that teaching regarding pain management has been effective based on which measure implemented by this patient? a. Limiting the use of opiate analgesics to prevent addiction
b.
Using analgesics only when the pain becomes more than he can tolera Taking analgesics around the clock on a regular schedule, using additi c. breakthrough pain d. Resigning himself to the fact that pain is an inevitable consequence of ANS: C Fixed dosage schedules with adequate doses for pain relief provide more constant blood levels and predictable pain relief. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2035 OBJ:16TOPain management KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 18.A female patient, age 59, has lost 10 lb in the first 3 weeks of her chemotherapy and does not eat because nothing tastes good. What would be the appropriate nursing diagnosis for the plan of care? Ineffective health maintenance, related to lack of knowledge of nutriti a. during radiation therapy b. Risk for infection, related to poor nutrition c. Imbalanced nutrition: less than body requirements, related to anorexia d. Ineffective therapeutic regimen management, related to refusal to eat ANS: C Nursing diagnosis includes imbalanced nutrition: less than body requirements, related to anorexia from changes in taste and smell. PTS:1DIF:Cognitive Level: Analysis REF: Page 2030, Nursing Care Plan OBJ: 13 TOP: Chemotherapy KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 19. What measures would the home health nurse, designing nursing interventions for a patient receiving external radiation treatments for a malignancy, recommend to protect the patients skin? a. Applying warm compresses to damaged skin b. Encouraging patient to apply fragrant lotion to skin c. Patting the skin dry after the bath d. Exposing skin to sun for 10 minutes a day
ANS: C Patting the skin dry rather than rubbing is less damaging to the skin. Lotions, sun exposure, and applications of heat or cold are not beneficial. PTS: 1 DIF: Cognitive Level: Application REF: Page 2027 OBJ:13TOP:External radiation therapy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. Which statement is most appropriate for a nurse to tell a patient before insertion of the radioactive implant? Nurses will always be available, but they will spend only short period a. bedside. b. Personal cleanliness is essential, so you will be given a complete bed c. Your diet will be changed to a high-fiber diet to encourage daily bowe Your bed linens will be completely changed each day to minimize rad d. contamination. ANS: A Generally, it is recommended that the nurse spend no more than 10 minutes at a time in the room of a patient with an implant. Baths and linen changes are not given daily. A low-residue diet is the norm to minimize peristalsis and bowel movements that might dislodge the implant. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2027 OBJ:13TOP:Internal radiation therapy KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment 21.A male patient is undergoing external radiation therapy on an outpatient basis for treatment of Hodgkin disease. After 2 weeks of treatment, he tells the nurse that he is so tired he can hardly get out of bed in the morning. Which is an appropriate goal? a. Take two rest periods during the day b. Ambulate in the hall four times a day c. Select two activities for distraction d. Investigate a consultation with a psychiatrist for treatment of depress ANS: A The person undergoing radiation therapy should be assured that lethargy and
fatigue are not uncommon during treatment, and that frequent rest periods are helpful. Periods of rest are very beneficial. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2027 OBJ:13TOP:External radiation therapy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 22.The patient receiving radiation therapy complains of the conspicuous markings on the skin. What can the nurse explain about these markings? a. They are residues of the treatment and can be washed off. b. They are caused by radiation and will fade in time. c. They are indicators of the amount of radiation the patient is receivin d. They are gridlines for treatment and should be left on. ANS: D When external radiation is planned, the specific area on the body is marked to indicate the part at which external radiation will be directed. These markings must not be washed off. PTS: 1 DIF: Cognitive Level: Application REF: Page 2027 OBJ:13TOP:External radiation therapy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. Nursing interventions for the nursing diagnosis of Imbalanced nutrition: less than body requirements would include all these except: a. provide adequate, easily digestible, soft, bland foods. b. give small, frequent, highly nutritional meals. c. allow extra time to eat. d. offer three regular meals of highly nutritious foods. ANS: D A nursing diagnosis of Imbalanced nutrition: less than body requirements will require the nurse to give small, frequent, highly nutritional meals; to allow extra time to eat; and to provide adequate, easily digestible, soft, bland foods. PTS:1DIF:Cognitive Level: Application REF: Page 2030, Nursing Care Plan OBJ: N/A TOP: Nutrition KEY:Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 24.A patient who has malignant cancer secondary to a high-grade lymphoma has been admitted with muscle weakness, tetany, paresthesia, and convulsion. The nurse notices the patient is being treated for tumor lysis syndrome (TLS) and initial treatment has not been successful. What should the nurse tell the family is the next step in treatment? a. Whole blood transfusion b. A bone marrow biopsy c. Immediate radiation treatment d. Dialysis ANS: D A nursing intervention for TLS is to prepare the patient and family for dialysis if other measures are not effective. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2033 OBJ:15TOP:Tumor lysis syndrome KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. Which of the following are thrombocytopenic precautions? a. Requesting an order for aspirin for discomfort b. Trimming toenails close c. Using an electric razor d. Vigorous tooth cleaning ANS: C
The patient should be taught to use an electric shaver. Thrombocytopenia is a reduction in the number of circulating platelets, due to the depression of the bone marrow. When the platelet count is less than 20,000/mm3, spontaneous bleeding can occur. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2030 OBJ:N/ATOP:Thrombocytopenia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 26.The nurse explains to a 43-year-old patient with a benign tumor in her
right breast that a benign tumor differs from a malignant tumor in that benign tumors: a. do not cause damage to adjacent tissue. b. are simply an overgrowth of normal cells. c. do not spread to other tissues and organs. d. frequently recur in the same site. ANS: C A benign tumor differs from a malignant tumor because benign tumors are not recurrent or progressive and are nonmalignant. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2020, Table 56-2 OBJ:8TOP:Benign tumor KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. Why is seeking medical attention when any cancer warning signs occur frequently delayed? a. Difficulty accessing a physician or getting a referral consult. b. Lack of knowledge of the seven warning signs of cancer. c. Fear of the possible diagnosis of cancer and hoping signs will go aw d. Self-examination being complex and difficult to perform. ANS: C Seeking medical attention when any warning signs occur is frequently delayed because people fear the possible diagnosis of cancer and hope the signs and symptoms will just go away. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2037 OBJ:N/ATOP:Cancer identification KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. The nurse knows which of the following to be characteristics of malignant tumors? a. Smooth, well defined; movable when palpated b. Resembles parent tissue; rarely fatal c. Rate of growth varies; rarely contained within a capsule d. Remains localized; slow growth
ANS: C Malignant tumors are rarely contained within a capsule and their rate of growth varies; little resemblance to parent tissue; fatal without treatment; irregular and immobile when palpated. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2020, Table 56-2 OBJ:7TOP:Cancer identification KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. The difference between an excisional biopsy and an incisional biopsy is that an excisional biopsy involves the: a. use of a needle to obtain fluid samples. b. removal of the entire lesion. c. taking a bite from the lesion for study. d. shaving of the superficial layers of the lesion. ANS: B An excisional biopsy involves the excision of the entire lesion. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2023 OBJ:12TOP:Cancer identification KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. What is the function of organizations like The Lost Chord Club, Reach for Recovery, and I Can Cope? a. Arrange for transportation to a clinic b. Provide a small amount of financial support to patients c. Send volunteers to speak with a person facing a lifestyle change d. Arrange for reduced drug costs ANS: C Support groups like The Lost Chord Club, Reach for Recovery, and I Can Cope are available to send volunteers to talk with persons facing lifestyle changes because of cancer. PTS: 1 DIF: Cognitive Level: Application REF: Page 2026 OBJ: N/A TOP: Cancer KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
31. Which of the following characteristics is common in malignant tumors?
a. Usually contained within a capsule b. Divide and multiply in the same manner as normal cells c. Proliferate and respond to treatment d. Progress and destroy surrounding tissues while spreading to distant pa ANS: D Malignant tumors destroy surrounding tissues and may spread to distant parts of the body causing a secondary tumor to grow in that area. Malignant cells divide and multiply but not in the same manner as normal parent cells and are rarely contained within a capsule. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2020, Table 56-2 OBJ:7TOP:Tumor classification KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 32. Which of the following are nursing interventions for the nursing diagnosis of Imbalanced nutrition: less than body requirements? (Select all that apply.) a. Provide adequate, easily digestible, soft, bland foods. b. Give small, frequent, highly nutritional meals. c. Allow extra time to eat. d. Offer three regular meals of highly nutritious foods. ANS: A, B, C A nursing diagnosis of Imbalanced nutrition: less than body requirements will require the nurse to give small, frequent, highly nutritional meals; to allow extra time to eat; and to provide adequate, easily digestible, soft, bland foods. PTS:1DIF:Cognitive Level: Application REF: Page 2030, Nursing Care Plan OBJ: N/A TOP: Nutrition KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. Select the foods that are recommended for prevention of colorectal cancer in men. (Select all that apply.) a. Oranges
b. Ham c. Skinless chicken d. Asparagus e. Cheddar cheese f. Squash ANS: A, C, F Eating plenty of fruits, vegetables, and whole grain foods and limiting intake of high-fat foods will help prevent cancer. PTS:1DIF:Cognitive Level: Comprehension REF: Page 2010, Health Promotion OBJ: 3 TOP: Cancer preventing foods KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 34. The nurse is aware that American men and women have which of the following three sites for cancer in common? (Select all that apply.) a. Lung b. Brain c. Colon d. Liver e. Rectum f. Thyroid ANS: A, C, E The three common cancer sites that American men and women share are cancer of the lung, colon, and rectum. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 2016-2017 OBJ:2TOP:Common cancer sites KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 35. Which of the following are risk factors for cancer? (Select all that apply.) a. Ethnicity b. Environmental irritants c. Alcoholism d. Hereditary factors e. Excessive exercise
f. Exposure to ultraviolet light ANS: B, C, D, F Cancer risk factors include smoking and the use of smokeless tobacco, environmental irritants, alcoholism, hereditary factors, and dietary habits. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2016 OBJ:4TOP:Cancer risk factors KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 36. What would the nurse encourage the patient to look for during selftesticular testing? (Select all that apply.) a. Smooth consistency of testicle b. Stomachache c. Breast enlargement d. Heavy feeling in the scrotum e. Enlarged blood vessels in scrotum f. Hematuria ANS: B, C, D Signs and symptoms of a scrotal tumor include an ache in the groin or stomach, feeling of heaviness in the scrotum, and breast enlargement. PTS: 1 DIF: Cognitive Level: Application REF: Page 2020 OBJ:3TOP:Testicular examination KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 37. What are the signs and symptoms of prostatic enlargement? (Select all that apply.) a. Rotten egg odor to urine b. Hematuria c. Swollen scrotum d. Difficulty starting urine flow e. Strong flow of urine ANS: B, D Indicators of prostatic hypertrophy are hematuria, difficulty starting urine flow, and weak urine stream.
PTS: 1 DIF: Cognitive Level: Application REF: Page 2020 OBJ:3TOProstatic hypertrophy KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 38. How do cancer cells differ from normal cells? (Select all that apply.) a. They replicate in an organized manner. b. They have larger nuclei. c. They have an irregular shape. d. They have a different number of chromosomes. e. They have a different mitosis process. ANS: B, C, D, E Cancer cells are disorderly in replication, have larger nuclei, an irregular shape, a different number of chromosomes, and a different process of mitosis. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 2021 OBJ: 7 TOP: Cancer cells KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 39. The term refers to the process by which a normal cell is transformed into a cancer cell. ANS: carcinogenesis Carcinogenesis is the process by which a normal cell is transformed into a cancer cell. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2016 OBJ:3TOPevelopment of cancer KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 40. Men over age 50 should consider an annual test and rectal examination. ANS: PSA (prostate-specific antigen) PSA prostate-specific antigen Men over age 50 should consult with their physician to consider the benefits
of having a prostate-specific antigen (PSA) test and rectal examination once a year. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2020 OBJ:3TOP:Cancer prevention KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 41. The American Cancer Society recommends a clinical breast examination by a health care professional for women between the age of 20 and 39 years every years. ANS: 3 three Women between the age of 20 to 39 should have a clinical breast examination by health care professionals every 3 years. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2010, Table 56-1 OBJ:3TOP:Breast cancer KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 42.A test screens for occult blood in the stool. ANS: guaiac The guaiac test is a screening test for occult blood in the stool. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2025 OBJ: 1 TOP: Guaiac test KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 43.The nurse remarks that the American Cancer Society (ACS) reports that cancer is the leading cause of death in the United States. ANS: second The ACS reports that cancer is the second leading cause of death in the United States. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2015 OBJ:1TOP:Incidence of cancer KEY:Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance Chapter 57: Professional Roles and Leadership My Nursing Test Banks Chapter 57: Professional Roles and Leadership Cooper and Gosnell: Foundations and Adult Health Nursing, 9th Edition MULTIPLE CHOICE 1. What is the correct term for a concise, one- or two-page summary of educational and work experience, activities and honors, and concrete skills and interests? a. Introduction b. Review c. Rsum d. Composite ANS: C A rsum is a one- or two-page summary of the applicants education and experience. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2042 OBJ: 1 TOP: New graduate KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 2. An employee failed to perform the duties listed in the employment contract. What is the term for this failure? a. Lawsuit b. Termination c. Breach of contract d. Reprimand ANS: C Failure by the nurse or employer to perform contractual duties is known as a breach of contract. A breach of contract may result in a reprimand, termination, or lawsuit. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2042 OBJ: 2 TOP: New graduate KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 3. What is the best way to resolve most disagreements? a. Agreement b. Argument
c. Communication d. Withdrawing ANS: C Most problems can best be resolved by communication at the most basic level. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2044 OBJ: 13 TOP: New graduate KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 4. What is another term for promotion? a. Reward b. Advancement c. Lift d. Bubble ANS: B Advancement may result from additional preparation or additional experience. It may be gained by learning the position more thoroughly and by assuming new and greater responsibilities. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2045 OBJ: 12 TOP: New graduate KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 5. When a rsum reflects too many job changes, the employer may question it. How long should an employee remain at the first place of employment? a. 6 months b. 3 months c. 1 year d. 2 years ANS: C Resigning from a position properly is another skill that the LPN/LVN will need to have. Employers will sometimes question a rsum that reflects frequent job changes; therefore, it is best to remain at the first place of employment at least 1 year. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2045 OBJ: 1 TOP: New graduate KEY: Nursing Process Step: N/A
MSC:NCLEX: N/A 6. Technical and scientific changes have resulted in a multiplicity and complexity of functions placed on nurses, and sometimes job descriptions have not been rewritten. What is true of the role of the LPN/LVN? a. It is constantly enlarging b. It is constantly changing c. It is constantly improving d. It is constantly growing ANS: B The role of the LPN/LVN is constantly changing. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2045 OBJ: 6 TOP: New graduate KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 7. Which organization specifically supports and meets the needs of the LVN/LPN? a. NAPNES b. NLN c. ANA d. NCLEX ANS: A National Association for Practical Nurse Education and Service (NAPNES) is the professional organization that is specifically for LVN/LPNs. The National League for Nursing (NLN) and the American Nurses Association (ANA) are not specific to the LPN. The National Council Licensure Exam (NCLEX) is the test that is taken for licensure. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2047 OBJ: 5 TOP: New graduate KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 8.A nurse may practice in another state if he or she has passed the NCLEXPN examination in the nurses own state and meets the other states educational requirements. What is the process of transferring licensure from one state to another called? a. Auxiliary
b. Co-licensure c. Endorsement d. Qualified licensure ANS: C This licensure transfer from one state to another is called endorsement. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2051 OBJ: 10 TOP: Licensure KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 9. What is the name of the licensing law that defines the title and regulations governing the practice of nursing and states the requirements for licensure? a. State practice act b. Nurse regulation act c. Nurse practice act d. Legislative act ANS: C The nurse practice act defines the title and regulations governing the practice of nursing. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2052 OBJ: 9 TOP: Licensure KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 10. What is the term for the commission of an act that a prudent nurse should not have done, or the omission of an act a prudent nurse should have done, that results in injury or harm to another person? a. Malpractice b. Negligence c. Neglect d. Disregard ANS: B To qualify as negligence, it must be proved that a prudent member of the profession would have acted differently. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 2052 OBJ: 10 TOP: Negligence KEY: Nursing Process Step: N/A MSC:NCLEX: N/A
11. In what setting can the LPN/LVNs management and leadership skills be
developed best? a. Acute care hospital b. Rehabilitation hospital c. Trauma center d. Long-term care facility ANS: D Management and leadership skills of the LPN/LVN can best be developed in long-term care settings with RN supervision. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2053 OBJ: 12 TOP: New graduate KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 12. Which setting provides greater nurse autonomy and continuity of care and is less costly for insurance companies? a. Hospice b. Hospitals c. Home health d. Long-term care ANS: C The advantages of home health are greater nurse autonomy and continuity of care, as well as less cost to insurance. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2053 OBJ: 12 TOP: New graduate KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 13. Which employment setting would likely involve a daytime schedule with weekends off, and would focus on prevention and patient teaching? a. Long-term care b. Physicians office c. Hospice setting d. Adult day care ANS: B Physician offices typically involve a daytime schedule with most weekends off. The setting focuses on prevention and includes opportunities for patient
teaching. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2054 OBJ: 12 TOP: New graduate KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 14. Which health care employment setting would provide the nurse a very good salary, the opportunity to refuse to take an assignment, and more flexibility in the personal schedule but with an uncertainty of work availability? a. Temporary agency b. Long-term care center c. Outpatient clinic d. Adult day care center ANS: A In a temporary agency, the salary is good, and an LPN/LVN has the right to refuse assignments. However, one disadvantage is the uncertainty of work availability. PTS: 1 DIF: Cognitive Level: Application REF: Page 2054 OBJ: 12 TOP: New graduate KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 15. In what employment setting does the nurse give total care to one patient; is totally independent; provides care in the home, hospital, or other facility; is paid directly by the patient; and is legally responsible for his or her own actions? a. Home health nursing b. Private duty nursing c. Patient care nursing d. Agency care nursing ANS: B The private duty nurse gives total care to one patient and is paid directly by the patient or responsible party. The nurse is legally responsible for his or her own actions. PTS: 1 DIF: Cognitive Level: Application REF: Page 2055 OBJ: 12 TOP: New graduate KEY: Nursing Process Step: N/A
MSC:NCLEX: N/A 16.A new graduate who has achieved the goal of getting others to do something that is believed necessary has demonstrated what skill? a. Management b. Leadership c. Influence d. Control ANS: B Leadership is the art of getting others to want to do something that is perceived as necessary. PTS: 1 DIF: Cognitive Level: Application REF: Page 2056 OBJ: 13 TOP: New graduate KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 17. What type of leadership involves a leader who displays little trust or confidence in employees and therefore makes all the decisions? a. Democratic b. Laissez-faire c. Autocratic d. Authoritative ANS: C The autocratic leader displays little trust in employees, and therefore makes all decisions. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2056 OBJ: 14 TOP: Leadership KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 18. What type of leadership uses four different stylesdirecting, coaching, supporting, and delegating? a. Autocratic b. Situational c. Democratic d. Authoritative ANS: B Situational leadership identifies four typical styles for leaders.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2057 OBJ: 14 TOP: Leadership KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 19. What is the physical, emotional, and spiritual exhaustion that can occur among caregivers? a. Excessiveness b. Burnout c. Fatigue d. Weariness ANS: B Physical, emotional, and spiritual exhaustion among caregivers is sometimes called burnout. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2061 OBJ: 22 TOP: Burnout KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 20. Why is it important for new graduates to purchase their own malpractice insurance rather than depend on an institutional policy? a. A private policy will not cover them unless they are on their primary b. A private policy will carry personal liability coverage. c. A private policy will protect them against all lawsuits. d. A private policy will protect them from losing their license. ANS: B The new graduate should purchase private malpractice insurance in addition to that of the institution to ensure that there is personal liability coverage. The private policy will cover the new graduate at any nursing job in which they are employed. No malpractice insurance policy can guarantee that there will not be any lawsuit or loss of license. PTS: 1 DIF: Cognitive Level: Application REF: Page 2061 OBJ: 21 TOP: Malpractice insurance KEY: Nursing Process Step: N/A MSC:NCLEX: N/A MULTIPLE RESPONSE 21. What are considered duties of a team leader? (Select all that apply.) a. Receiving reports on assigned patients
b. Making patient assignments for team members c. Assessing all assigned patients d. Administering medications to all patients e. Conferring with team members ANS: A, B, C, E Receiving reports on assigned patients, making patient assignments, assessing all assigned patients, and conferring with team members are duties of the team leader. Assisting team members with medication administration is a duty of the team leader, not actually administering the medications to all the patients. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2057 OBJ: 15 TOP: Team leading KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 22. Which actions would best aid the new nurse in coping with working the night shift? (Select all that apply.) a. Eat large meals during the night to stay awake b. Use dark shades to block out light when sleeping c. Obtain a prescription for sedatives to aid sleep d. Wear sunglasses on the drive home from work e. Go directly to bed when arriving home from work ANS: B, D Dark shades or room darkening blinds will block the sunshine and allow for darkness when sleeping during the daytime hours. Wear sunglasses on the drive home from work to reduce the melatonin-reducing effect of sunshine. It is best to eat light, balanced meals during the night. Sedatives and alcohol should not be used as an aid to sleep. Allow time to unwind after work before going to bed, and try to follow the same routine daily. PTS: 1 DIF: Cognitive Level: Application REF: Page 2040, Box 57-6 OBJ: 3 TOP: Night shift KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 23.A nursing instructor is preparing her class for the NCLEX-PN examination. Which statements by the students indicate understanding of the testing process? (Select all that apply.)
a. It will be a computerized adaptive test. b. I will have a maximum of 265 questions. c. The maximum time allowed for testing is 5 hours. d. The minimum number of questions on the test is 60. e. My state board of nursing must approve my application to test. ANS: A, C, E The NCLEX-PN examination is a computerized adaptive test. The minimum number of questions for the PN examination is 85, and the maximum number of questions is 205. The maximum time allowed for the test is 5 hours. The state board of nursing must approve the applicant for testing before the authorization to test is issued. PTS: 1 DIF: Cognitive Level: Application REF: Pages 2050-2051 OBJ: 7 TOP: NCLEX exam KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 24. Which questions should the nurse consider before delegating care to another team member? (Select all that apply.) a. Is this the right task? b. Is this the right time? c. Is this the right person? d. Is this the right supervision? e. Is this the right circumstance? ANS: A, C, D, E The five rights of delegation are right task, right circumstance, right person, right direction, and right supervision. Right time is not included in the five rights of delegation. PTS:1DIF:Cognitive Level: Comprehension REF: Page 2050, Coordinated Care Box OBJ: 16 TOP: Delegation KEY:Nursing Process Step: N/AMSC:NCLEX: N/A 25. What data are necessary to compile an effective end-of-shift report? (Select all that apply.) a. Patients mental status b. Status of lung sounds c. All pertinent nursing care
d. The patients favorite TV shows e. Visitors the patient had during the shift ANS: A, B, C The patients mental status, status of lung sounds, and pertinent nursing care performed during the shift should all be included in an end-of-shift report. The patients favorite TV shows and visitors that the patient had during the shift would not normally be included in the end-of-shift report. PTS: 1 DIF: Cognitive Level: Application REF: Page 2060 OBJ: 20 TOP: End-of-shift report KEY: Nursing Process Step: N/A MSC:NCLEX: N/A 26.A manager is concerned that one of the nurses on the unit is experiencing burnout. Which symptoms would support the concerns? (Select all that apply.) a. Fatigue b. Forgetfulness c. Increased energy d. Negative outlook e. Changes in eating habits ANS: A, B, D, E Symptoms of burnout include fatigue, forgetfulness, decreased energy, negative outlook, and changes in eating habits. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2060, Box 57-12 OBJ: 22 TOP: Burnout KEY: Nursing Process Step: N/A MSC:NCLEX: N/A COMPLETION 27. After transcribing each order in a list of orders, the nurse should the order. ANS: check off The nurse should check off each order as it is transcribed to ensure that each order is implemented. PTS: 1 DIF: Cognitive Level: Application REF: Pages 2058-2059 OBJ: 19 TOP: Orders KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment
28. The experienced nurse who assists a novice to learn the skills of the
profession is called a(n) . ANS: mentor The nurse who guides a novice in the skills of the profession is called a mentor. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 2043 OBJ: 11 TOP: Mentoring KEY: Nursing Process Step: N/A MSC:NCLEX: N/A