Chapter 1: Foundations for Medical-Surgical Nursing
MULTIPLE CHOICE : 1. Which type of nursing is the root of all other nursing practice areas? A. Pediatric nursing B. Maternal-child nursing C. Medical-surgical nursing D. Mental health–psychiatric nursing ANS: C Chapter number and title: 1, Foundations for Medical-Surgical Nursing Chapter learning objective: 1. Describing the role and competencies of medical-surgical nursing Chapter page reference: p. 2 Heading: Introduction Integrated Processes: N/A Client Need: N/A Cognitive Level: Knowledge [Remembering] Concept: Professionalism Difficulty: Easy Feedback A B C D
PTS:
Pediatric nursing is only focused on the care of younger persons. Maternal-child nursing focuses on the care of pregnant women and families in the childbearing years. Medical-surgical nursing is the root of all nursing practice as care provided here can be implemented in all other areas of nursing practice. Mental health–psychiatric nursing focuses on emotional and behavioral concerns and disorders. 1
CON: Professionalism
2. Which competency did the Nursing Executive Center of the Advisory Board identify as the greatest academic practice gap for new graduate nurses? A. Knowledge of pharmacology B. Interpretation of assessment data C. Knowledge of pathophysiology D. Decision making ANS: C Chapter number and title: 1, Foundations for Medical-Surgical Nursing Chapter learning objective: 1. Describing the role and competencies of medical-surgical nursing Chapter page reference: p. 3 Heading: Competencies in Medical-Surgical Nursing Integrated Processes: N/A Client Need: N/A
Cognitive Level: Knowledge [Remembering] Concept: Professionalism Difficulty: Easy Feedback A B C D
PTS:
28% of nursing executives identified knowledge of pharmacological implications of medications as the largest academic practice gap. 18% of nursing executives identified interpretation of assessment data as the largest academic practice gap. 34% of nursing executives identified knowledge of pathophysiology of patient conditions as the largest academic practice gap. 20% of nursing executives identified decision making based on the nursing process as the largest academic practice gap. 1
CON: Professionalism
3. In the Nursing Executive Center of the Advisory Board report, what recommendations are made to address the academic practice gap for new graduate nurses? A. Mandatory number of clinical hours B. Increased credits in all entry level courses C. Residency programs D. Additional science prerequisite courses ANS: C Chapter number and title: 1, Foundations for Medical-Surgical Nursing Chapter learning objective: 1. Describing the role and competencies of medical-surgical nursing Chapter page reference: p. 3 Heading: Competencies in Medical-Surgical Nursing Integrated Processes: N/A Client Need: N/A Cognitive Level: Comprehension [Understanding] Concept: Healthcare Systems Difficulty: Moderate Feedback A
B
C
Clinical hours in nursing programs are not a specific recommendation related to the academic practice gap, and clinical hours are more related to state regulations, academic institutional policies, and accreditation standards. Total credits of nursing programs are not a recommendation to address the academic practice gap. Credits are primarily based on state, university, or higher education regulatory bodies recommendations or requirements. Suggested strategies to better prepare the nurse graduate for the realities of practice include the increased use of simulation in nursing education programs, extended transition-to-practice and residency programs, as well as the establishment of academic service partnerships.
D
PTS:
Prerequisite courses for nursing programs were not specifically addressed in relation to the academic practice gap. Decisions related to prerequisite courses are typically determined by school and/or university curriculum committees. 1
CON: Healthcare Systems
4. The medical-surgical nurse wants to determine if a policy change is needed for an identified clinical problem. Which is the nurse’s first action? A. Developing a question B. Disseminating the findings C. Conducting a review of the literature D. Evaluating outcomes of practice change ANS: A Chapter number and title: 1, Foundations for Medical-Surgical Nursing Chapter learning objective: 3. Discussing the incorporation of evidence-based practices into medicalsurgical nursing Chapter page reference: p. 4 Heading: Evidence-Based Nursing Care/Box 1.3 Steps of Evidence-Based Practice Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment/Management of Care Cognitive Level: Comprehension Concept: Evidence-Based Practice Difficulty: Moderate Feedback A B C D
PTS:
The first step of evidence-based practice is to develop a question based on the clinical issue. The last step of evidence-based practice is to disseminate findings. The second step of evidence-based practice is to conduct a review of the literature, or current evidence, available. The fifth step of evidence-based practice is to evaluate the outcomes associated with the practice change. 1
CON: Evidence-Based Practice
5. Which statement regarding the use of the nursing process in clinical practice is accurate? A. “The nursing process is closely related to clinical decision making.” B. “The nursing process is used by all members of the interprofessional team to plan care.” C. “The nursing process has four basic steps: assessment, planning, implementation, and evaluation.” D. “The nursing process is being replaced by the implementation of evidence-based practice.” ANS: A Chapter number and title: 1, Foundations for Medical-Surgical Nursing Chapter learning objective: 1. Describing the role and competencies of medical-surgical nursing
Chapter page reference: pp. 3-4 Heading: Competencies Related to the Nursing Process Integrated Processes: Nursing Process: Diagnosis Client Need: Safe and Effective Care Environment/Management of Care Cognitive Level: Comprehension [Understanding] Concept: Caring Difficulty: Moderate Feedback A
B C D
PTS:
The nursing process is closely related to the nurse’s decision making in the clinical environment because it requires understanding the relationships among physiology, pathophysiology, clinical manifestations, and management of patients. This statement is accurate. The nursing process is not used by all members of the interprofessional team to plan care. The nursing process has five, not four, basic steps: assessment, diagnosis, planning, implementation, and evaluation. The nursing process is not being replaced by the implementation of evidencebased practice. 1
CON: Caring
6. The nurse develops a research question based on observations noted while providing care to patients on the medical-surgical unit. Which step does the nurse implement next during the process of evidence-based practice? A. Search for the best evidence. B. Evaluate the quality of the evidence. C. Integrate the evidence into unit practice. D. Disseminate the evidence to the staff on the unit. ANS: A Chapter number and title: 1, Foundations for Medical-Surgical Nursing Chapter learning objective: 3. Discussing the incorporation of evidence-based practices into medicalsurgical nursing Chapter page reference: p. 4 Heading: Evidence-Based Nursing Care Integrated Processes: N/A Client Need: N/A Cognitive Level: Comprehension [Remembering] Concept: Evidence-Based Practice Difficulty: Easy Feedback A
The first step of evidence-based practice is to develop a research question. Because the nurse has completed this, the next step is to search and collate the best evidence.
7. The nurse is reviewing evidence from a quasi-experimental research study. Which level of evidence should the nurse identify for this research study? 1) Level I 2) Level II 3) Level III 4) Level IV 8. Which level of evidence should the nurse identify when reviewing evidence from a single descriptive research study? 1) Level IV 2) Level V 3) Level VI 4) Level VII 9. Which statement should the nurse make when communicating the “S” in the SBAR approach for effective communication? 1) “The patient presented to the emergency department at 0200 with lower left abdominal pain.” 2) “The patient rated the pain upon admission as a 9 on a 10-point numeric scale.” 3) “The patient has no significant issues in the medical history” 4) “The patient was given a prescribed opioid analgesic at 0300.” 10. The staff nurse is communicating with the change nurse about the change of status of the patient. The nurse would begin her communication with which statement if correctly using the SBAR format? 1) “The patient’s heartrate is 110.” 2) “I think this patient needs to be transferred to the critical care unit.” 3) “The patient is a 68-year-old male patient admitted last night.” 4) “The patient is complaining of chest pain.” 11. Which nursing action exemplifies the Quality and Safety Education for Nursing (QSEN) competency of safety? 1) Advocating for a patient who is experiencing pain 2) Considering the patient’s culture when planning care 3) Evaluating patient learning style prior to implementing discharge instructions 4) Assessing the right drug prior to administering a prescribed patient medication 12. Which type of nursing is the root of all other nursing practice areas? 1) Pediatric nursing 2) Geriatric nursing 3) Medical-surgical nursing 4) Mental health-psychiatric nursing 13. Which did the Nursing Executive Center of The Advisory Board identify as an academic-practice gap for new graduate nurses? 1) Patient advocacy 2) Patient education
3) 4)
Disease pathophysiology Therapeutic communication
14. Which statement regarding the use of the nursing process in clinical practice is accurate? 1) “The nursing process is closely related to clinical decision-making.” 2) “The nursing process is used by all members of the interprofessional team to plan care.” 3) “The nursing process has 4 basic steps: assessment, planning, implementation, evaluation.” 4) “The nursing process is being replaced by the implementation of evidence-based practice.” 15. Which is the basis of nursing care practices and protocols? 1) Assessment 2) Evaluation 3) Diagnosis 4) Research 16. Which is a common theme regarding patient dissatisfaction related to care provided in the hospital setting? 1) Space in hospital rooms 2) Medications received to treat pain 3) Time spent with the health-care team 4) Poor quality food received from dietary 17. The nurse manager is preparing a medical-surgical unit for The Joint Commission (TJC) visit With the nurse manager presenting staff education focusing on TJC benchmarks, which of the following topics would be most appropriate? 1) Implementation of evidence-based practice 2) Implementation of patient-centered care 3) Implementation of medical asepsis practices 4) Implementation of interprofessional care 18. Which aspect of patient-centered care should the nurse manager evaluate prior to The Joint Commission site visit for accreditation? 1) Visitation rights 2) Education level of staff 3) Fall prevention protocol 4) Infection control practices 19. The medical-surgical nurse is providing patient care. Which circumstance would necessitate the nurse verifying the patient’s identification using at least two sources? 1) Prior to delivering a meal tray 2) Prior to passive range of motion 3) Prior to medication administration 4) Prior to documenting in the medical record 20. The nurse is providing care to several patients on a medical-surgical unit. Which situation would necessitate the nurse to use SBAR during the hand-off process?
1) 2) 3) 4)
Wound care Discharge to home Transfer to radiology Medication education
Multiple Response
Identify one or more choices that best complete the statement or answer the question. 21. The staff nurse is teaching a group of student nurses the situations that necessitate hand-off communication. Which student responses indicate the need for further education related to this procedure? Select all that apply. 1) “A hand-off is required prior to administering a medication.” 2) “A hand-off is required during change of shift.” 3) “A hand-off is required for a patient is transferred to the surgical suite.” 4) “A hand-off is required whenever the nurse receives a new patient assignment.” 5) “A hand-off is required prior to family visitation.” 22. Which actions by the nurse enhance patient safety during medication administration? Select all that apply. 1) Answering the call bell while transporting medications for a different patient 2) Identifying the patient using two sources prior to administering the medication 3) Holding a medication if the patient’s diagnosis does not support its use 4) Administering the medication two hours after the scheduled time 5) Having another nurse verify the prescribed dose of insulin the patient is to receive 23. The medical-surgical nurse assumes care for a patient who is receiving continuous cardiopulmonary monitoring. Which actions by the nurse enhance safety for this patient? Select all that apply. 1) Silencing the alarm during family visitation 2) Assessing the alarm parameters at the start of the shift 3) Responding to the alarm in a timely fashion 4) Decreasing the alarm volume to enhance restful sleep 5) Adjusting alarm parameters based on specified practitioner prescription 24. The nurse is planning an interprofessNioUnaRl ScaIreNcGonTfeBre.nCceOfMo r a patient who is approaching discharge from the hospital. Which members of the interprofessional team should the nurse invite to attend? Select all that apply. 1) Physician 2) Pharmacist 3) Unit secretary 4) Social worker 5) Home care aide 25. The nurse manager wants to designate a member of the nursing team as the care coordinator for a patient who will require significant care during the hospitalization. Which skills should this nurse possess in order to assume this role? Select all that apply. 1) Effective clinical reasoning 2) Effective communication skills 3) Effective infection control procedures 4) Effective documentation 5) Effective intravenous skills
Chapter 1: Foundations for Medical-Surgical Nursing Answer Section MULTIPLE CHOICE 1.
ANS: 1 Chapter number and title: 1, Foundations for Medical Surgical Practice Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical nursing Chapter page reference: 003004 Heading: Evidence-Based Nursing Care Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Easy 1
2 3 4
Feedback Systematic reviews of randomized control studies (Level I) are the highest level of evidence because they include data from selected studies that randomly assigned participants to control and experimental groups. The lower the numerical rating of the level of evidence indicates the highest level of evidence; therefore, this type of study provides the strongest evidence to support a practice change. Quasi-experimental studies are considered Level III; therefore, this study does not provide the strongest evidenceNtU o R suSp pIoNrt Ga Tp rBac.tiCceOcMhange. Case-control studies are considered Level IV; therefore, this study does not provide the strongest evidence to support a practice change. Cohort studies are considered Level IV; therefore, this study does not provide the strongest evidence to support a practice change.
PTS: 1 CON: Evidence-Based Practice 2. ANS: 4 Chapter number and title: 1, Foundations of Medical-Surgical Practice Chapter learning objective: Explaining the importance of patient-centered care in the management of medical- surgical patients Chapter page reference: 004-005 Heading: Patient-Centered Care in the Medical-Surgical Setting Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive level: Application [Applying]
Concept: Nursing Roles Difficulty: Moderate 1 2
Feedback Evaluation is a step in the nursing process; however, this is not an action that supports the patient-centered care model. Assessment is a step in the nursing process; however, this is not an action that supports the patient-centered care model.
3 4
Diagnosis is a step in the nursing process; however, this is not an action that supports the patient-centered care model. Compassion is a competency closely associated with patient-centered care; therefore, this action supports the patient-centered model of care.
PTS: 1 CON: Nursing Roles 3. ANS: 3 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Discussing implications to medical-surgical nurses of Quality and Safety Education for Nurses (QSEN) competencies Chapter page reference: 005-006 Heading: Patient Safety Outcomes Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Application [Applying] Concept: Safety Difficulty: Moderate 1 2 3 4
Feedback Safely using alarms is a NPSG identified by TJC. Silencing a cardiorespiratory monitor is not nursing action that supports this NPSG. Patient identification using two separate resources is a NPSG identified by TJC. Identifying a patient using only one source does not support this NPSG. Identification of patient safety risks is a NPSG identified by the TJC. Determining patient safety issues upon admNisUsion R SsIupNpGorTtsBth.isCNOPMSG. Safe use of medication is a NPSG identified by the TJC. Decreasing the amount of pain medication administered does not support this NPSG.
PTS: 1 CON: Safety 4. ANS: 3 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Describing the role and competencies of medical-surgical nursing Chapter page reference: 006-007 Heading: Interprofessional Collaboration and Communication Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment/Management of Care Cognitive level:
Comprehension [Understanding] Concept: Nursing Roles Difficulty: Easy 1 2 3 4
Feedback The nurse does not often assume the interprofessional role of social worker when providing patient care in an acute care setting. The nurse does not often assume the interprofessional role of client advocate role when providing patient care in an acute care setting. The nurse often assumes the interprofessional role of care coordinator when providing patient care in an acute care setting. The nurse does not often assume the interprofessional role of massage therapist when providing patient care in an acute care setting.
PTS: 1 CON: Nursing Roles 5. ANS: 1 Chapter number and title: 1, Foundations of Medical-Surgical Practice Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical nursing Chapter page reference: 003 Heading: Box 1.3 Steps of Evidence-Based Practice Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Analysis [Analyzing] Concept: Evidence-Based Practice Difficulty: Difficult 1 2 3 4
Feedback The first step of evidence-based practice is to develop a question based on the clinical issue. The last step of evidence-based practice is to disseminate findings. The second step of evidence-based practice is to conduct a review of the literature, or current evidence, available. The fifth step of evidence-based practice is to evaluate the outcomes associated with the practice change.
PTS: 1 CON: Evidence-Based Practice 6. ANS: 4 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical nursing Chapter page reference: 004 Heading: Box 1.4 Evaluating Levels of Evidence Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Easy 1
Feedback The lower the numeric value of the evidence the greater the support for a change in practice. Level IV evidence does not carry the lowest level of support
for a practice change. 2
3
4
The lower the numeric value of the evidence the greater the support for a change in practice. Level V evidence does not carry the lowest level of support for a practice change. The lower the numeric value of the evidence the greater the support for a change in practice. Level VI evidence does not carry the lowest level of support for a practice change. The lower the numeric value of the evidence the greater the support for a change in practice. Level VII evidence carries the lowest level of support for a practice change.
PTS: 1 CON: Evidence-Based Practice 7. ANS: 3 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical nursing Chapter page reference: 004 Heading: Box 1.4 Evaluating Levels of Evidence Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Application [Applying] Concept: Evidence-Based Practice Difficulty: Moderate 1 2 3 4
Feedback A systemic review of randomized controlled studies, not a quasiexperimental research study, is identified as Level I. Evidence from at least one study randomized control study, not a quasi-experimental research study, is identified as Level II. A quasi-experimental research study is identified as a Level III. Evidence from case-control or cohort studies, not a quasiexperimental research study, is identified as a Level IV.
PTS: 1 CON: Evidence-Based Practice 8. ANS: 3 Chapter number and title: 1,NURSINGTB.CO Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical nursing Chapter page reference: 004 Heading: Box 1.4 Evaluating Levels of Evidence Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Application [Applying] Concept: Evidence-Based Practice Difficulty: Moderate 1
Feedback Evidence from case-control or cohort studies, not a single descriptive research study, is identified as a Level IV.
2 3 4
Evidence from systemic reviews of descriptive or qualitative studies, not a single descriptive research study, is identified as Level V. Evidence from a single descriptive research study is identified as Level VI. Evidence from expert individual authorities or committees, not a single descriptive research study, is identified as Level VII.
PTS: 1 CON: Evidence-Based Practice 9. ANS: 1 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Describing the role of interprofessional collaboration and teamwork in the provision of safe, quality patient care
Chapter page reference: 005 Heading: Box 1.6 The SBAR Approach for Effective Communication Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Application [Applying] Concept: Communication Difficulty: Moderate 1
2 3 4
10.
Feedback The “S” reflects the patient’s current situation which is communicated by providing a brief statement of the issue. This statement by the nurse exemplifies the current situation. The “A” reflects the patient’s assessment data. This statement by the nurse exemplifies the patent’s assessment data. The “B” reflects the patient’s medical history. This statement by the nurse exemplifies communicating the patient’s history related to the current problem. The “R” reflects specific actions needed to address the situation. This statement by the nurse exemplifies the actions implemented to address current level of pain.
PTS: 1 CON: Communication ANS: 4 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Describing the role of interprofessional collaboration and teamwork in the provision of safe, quality patient care Chapter page reference: 005 Heading: Box 1.6 The SBAR Approach for Effective Communication Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Analysis [Analyzing] Concept: Communication Difficulty: Moderate 1
Feedback This statement is the “A” in the SBAR communication. This is an assessment finding by the staff nurse.
2 3 4
11.
This statement is the “R” in the SBAR communication. This is the recommendation by the staff nurse. This statement is the “B” in the SBAR communication. This is the background information. This statement is the “S” in the SBAR communication. This is the situation information.
PTS: 1 CON: Communication ANS: 4 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Discussing implications to medical-surgical nurses of Quality and Safety Education for Nurses (QSEN) competencies Chapter page reference: 006 Heading: Box 1.8 Quality and Safety Education for Nursing (QSEN) Competencies
Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Application [Applying] Concept: Safety Difficulty: Moderate 1 2 3 4
12.
Feedback Advocating for a patient who is in pain exemplifies the QSEN competency of patientcentered care, not safety. Considering the patient’s cultural background exemplifies the QSEN competency of patient-centered care, not safety. Evaluating the patient’s learning style prior to implementing discharge instructions exemplifies the QSEN competency of patientcentered care, not safety. Assessing the right drug prior to administering a prescribed medication exemplifies the QSEN competency of safety.
PTS: 1 CON: Safety ANS: 3 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Describing the role and competencies of medical-surgical nursing Chapter page reference: 002 Heading: Introduction Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Knowledge [Remembering] Concept: Nursing Difficulty: Easy Feedback 1 Pediatric nursing is not the root of all nursing practice areas. 2 Geriatric nursing is not the root of all nursing practice areas. 3 Medical-surgical nursing is the root of all nursing practice as care provided here can be implemented in all other areas of nursing practice. 4 Mental health-psychiatric nursing is not the root of all nursing practice areas.
13.
PTS: 1 CON: Nursing ANS: 3 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Describing the role and competencies of medical-surgical nursing Chapter page reference: 002-003 Heading: Competencies in MedicalSurgical Nursing Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Knowledge [Remembering] Concept: Critical Thinking Difficulty: Easy 1
Feedback Patient advocacy is not identified as an academic-practice gap for new graduate nurses.
2 3 4
14.
PTS: 1 CON: Critical Thinking ANS: 1 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice” Chapter learning objective: Describing the role and competencies of medical-surgical nursing Chapter page reference: 003 Heading: Competencies Related to the Nursing Process Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Comprehension [Understanding] Concept: Critical Thinking Difficulty: Easy 1 2 3 4
15.
Patient education is not identified as an academic-practice gap for new graduate nurses. Knowledge of pathophysiology of patient conditions is identified as an academicpractice gap for new graduate nurses. Therapeutic communication is not identified as an academic-practice gap for new graduate nurses.
Feedback The nursing process is closely related to the nurse’s decision-making in the clinical environment. This statement is accurate. The nursing process is not used by all members of the interprofessional team to plan care. The nursing process has 5, not 4, basic steps: assessment, diagnosis, planning, implementation, and evaluatioNn. The nursing process is not being replaced by the implementation of evidence-based practice.
PTS: 1 CON: Critical Thinking ANS: 4 Chapter number and title: 1, Foundations for Medical-Surgical Nursing Practice Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical nursing Chapter page reference: 003004 Heading: Evidence-Based Nursing Care Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Knowledge [Remembering]
Concept: Evidence-Based Practice Difficulty: Easy 1 2 3
Feedback Assessment is a step in the nursing process; however, this is not the basis for nursing care practices and protocols. Evaluation is a step in the nursing process; however, this is not the basis for nursing care practices and protocols. Diagnosis is a step in the nursing process; however, this is not the basis for nursing care practices and protocols.
4
16.
PTS: 1 CON: Evidence-Based Practice ANS: 3 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Explaining the importance of patient-centered care in the management of medical- surgical patients Chapter page reference: 004-005 Heading: Patient-Centered Care in the Medical-Surgical Setting Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Knowledge [Remembering] Concept: Communication Difficulty: Easy 1 2 3 4
17.
Evidence that is obtained through research is the basis for nursing care practices and protocols.
Feedback Space in each hospital room is not a common theme of patient dissatisfaction. Medications received for pain management is not a common theme of patient dissatisfaction. A lack of time with members of the health care team is a common theme of patient dissatisfaction. Poor food quality is not a common theme of patient dissatisfaction.
PTS: 1 CON: Communication ANS: 2 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Explaining the importance of patient-centered care in the management of medical- surgical patients Chapter page reference: 004-005 Heading: Patient-Centered Care in the Medical-Surgical Setting Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Application [Applying] Concept: Quality Improvement Difficulty: Moderate 1
Feedback Implementation of evidence-based practice is not the benchmark in which acute care facilities are evaluated against.
2 3 4
18.
Implementation of patient-centered care is the benchmark in which acute care facilities are evaluated against. Implementation of medical asepsis practices is not the benchmark in which acute care facilities are evaluated against. Implementation of interprofessional care is not the benchmark in which acute care facilities are evaluated against.
PTS: 1 ANS: 1
CON: Quality Improvement
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Explaining the importance of patient-centered care in the management of medical- surgical patients Chapter page reference: 004-005 Heading: Patient-Centered Care in the Medical-Surgical Setting Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Application [Applying] Concept: Quality Improvement Difficulty: Moderate 1 2
3 4
19.
Feedback Visitation rights should be evaluated prior to a TJC accreditation site visit as this aspect of patient-centered care is incorporated into the site evaluation. The education level of staff is not evaluated prior to a TJC accreditation visit. This information should be evaluated for a hospital that is attempting to earn Magnet status. While the fall prevention program will be reviewed during a TJC accreditation site visit this is not an aspect of patient-centered care. While infection control practices will be reviewed during a TJC accreditation site visit this is not an aspect of patient-centered care.
PTS: 1 CON: Quality Improvement ANS: 3 Chapter number and title: 1, Foundations of Medical-Surgical Practice Chapter learning objective: Discussing implications to medical-surgical nurses of Quality and Safety Education for Nurses (QSEN) competencies Chapter page reference: 005-006 Heading: Patient Safety Outcomes Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Application [Applying] Concept: Safety Difficulty: Moderate 1
Feedback While the nurse should take care to deliver the meal tray to the correct patient this circumstance does not require verification of patient identity through two sources.
2
3 4
20.
While the nurse should take care to implement passive range of motion on the correct patient this circumstance does not require verification of patient identity through two sources. The nurse should identify a patient using two sources prior to medication administration. While the nurse should take care to document patient care in the correct medical record this circumstance does not require verification of patient identity through two sources.
PTS: 1 CON: Safety ANS: 3 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Describing the role of interprofessional collaboration and teamwork in the provision of safe, quality patient care Chapter page reference: 005-006 Heading: Patient Safety Outcomes Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Application [Applying] Concept: Communication, Safety Difficulty: Moderate 1
2 3
4
Feedback Effective staff communication is essential to safe patient care, especially during handoffs. Implementation of wound care is not an example of a hand-off situation. Effective staff communication is essential to safe patient care, especially during hand- offs. Discharge to home is not an example of a hand-off situation. Effective staff communication is essential to safe patient care, especially during hand- offs. Patient transfer to another unit of the hospital necessitate a change in who is responsible for direct patient care; therefore, this situation would necessitate the need for SBAR during the hand-off process. Effective staff communication is essential to safe patient care, especially during hand- offs. Medication education is not an example of a hand-off situation.
PTS: 1
CON: Communication | Safety
MULTIPLE RESPONSE 21. ANS: 2, 3, 4 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Describing the role of interprofessional collaboration and teamwork in the provision of safe, quality patient care Chapter page reference: 005-006 Heading: Patient Safety Outcomes Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Analysis [Analyzing]
Concept: Communication Difficulty: Difficult 1. 2. 3. 4. 5.
Feedback This is incorrect. Hand-off communication is not required prior to the administration of medication. The nurse would, however, verify the patient’s identity using two sources. This is correct. Hand-off communication is required when patient care is transferred from one provider to another, such as during the change of shift. This is correct. Hand-off communication is required when patient care is transferred from one provider to another, such as when a patient is transferred to the surgical suite. This is correct. Hand-off communication is required when patient care is transferred from one provider to another, such as anytime the nurse receives a new patient assignment. This is incorrect. Hand-off communication is not required prior to family visitation.
PTS: 1 CON: Communication 22. ANS: 2, 3, 5 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Discussing implications to medical-surgical nurses of Quality and Safety Education for Nurses (QSEN) competencies Chapter page reference: 005-006 Heading: Patient Safety Outcomes Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Application [Applying] Concept: Safety Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback This is incorrect. Interruptions should be minimized during the medication administration process; therefore, the nurse should not answer the call bell for another patient while transporting medications for administration. This is correct. Verification of the right patient is one of the rights of medication administration; therefore, the nurse would identify the patient using two sources prior to the administration of medication. This is correct. The nurse should ensure that the rationale for all medications are associated with the patient condition; therefore, this action enhances patient safety during medication administration. This is incorrect. One of the rights of medication administration is the right time, which correlates to 30 minutesNbU efR orSe I orN3G0 T mB in.utCesOaMfter the scheduled time. This nursing action would not enhance patient safety during medication administration. This is correct. Verifying the dose of a high-risk medication, such as insulin, enhances patient safety during medication administration.
PTS: 1 CON: Safety 23. ANS: 2, 3, 5 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Discussing implications to medical-surgical nurses of Quality and Safety Education for Nurses (QSEN) competencies Chapter page reference: 005-006 Heading: Patient Safety Outcomes Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Analysis [Analyzing]
Concept: Safety Difficulty: Difficult
1. 2.
Feedback This is incorrect. Monitor alarms should be audible even during family visitation. Inaudible alarms may impede patient safety. This is correct. The nurse should assess the alarm parameters, comparing to the prescribed settings, at the start of each shift. This action enhanced patient safety.
3. 4. 5.
This is correct. The nurse should respond to all alarms in a timely fashion, which enhances patient safety. This is incorrect. Monitor alarms should be audible at all times, even when the patient is asleep to enhance patient safety. This is correct. The nurse should adjust alarm parameters based on specific practitioner prescriptions. This action enhances safety.
PTS: 1 CON: Safety 24. ANS: 1, 2, 4 Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice Chapter learning objective: Describing the role of interprofessional collaboration and teamwork in the provision of safe, quality patient care Chapter page reference: 006-007 Heading: Interprofessional Collaboration and Communication Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Application [Applying] Concept: Collaboration Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback This is correct. The physician is a member of the interprofessional team and should be invited to participate in the care conference. This is correct. The pharmacist is a member of the interprofessional team and should be invited to participate in the care R conferen.ce. This is incorrect. The unit secretary is not a member of the interprofssional team; therefore, would not require an invitation to attend the care conference. This is correct. The social worker is a member of the interprofessional team; therefore, should be invited to participate in the care conference. This is incorrect. The home care aide, while a member of the interprofessional team, would not benefit from attending a care conference while the patient is hospitalized.
PTS: 1 CON: Collaboration 25. ANS: 1, 2, 4 Chapter number and title: 1, Foundation of Medical-Surgical Nursing Practice Chapter learning objective: Describing the role of interprofessional collaboration and teamwork in the provision of safe, quality patient care Chapter page reference: 006-007
Heading: Interprofessional Collaboration and Communication Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Analysis [Analyzing] Concept: Collaboration Difficulty: Difficult
1.
Feedback This is correct. Effective clinical reasoning is a skill required for the nurse to assume the role of care coordinator.
2. 3.
4. 5.
PTS: 1
This is correct. Effective communication is a skill required for the nurse to assume the role of care coordinator. This is incorrect. Effective infection control procedures are expected to meet the standard of care; however, this skill is not required for the nurse to assume the role of care coordinator. This is correct. Effective documentation, a form of communication, is a skill required for the nurse to assume the role of care coordinator. This is incorrect. Effective intravenous skills are not required for the nurse to assume the role of care coordinator. CON: Collaboration
Chapter 2: Interprofessional Collaboration and Care Coordination Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The home care nurse is planning care for a diabetic patient requiring an extensive dressing change twice a day, assistance with activities of daily living (ADLs), and comprehensive education. Which role is the nurse assuming by coordinating the care this patient requires? 1) Collaborator NURSINGTB.COM 2) Case manager 3) Health educator 4) Health promoter 2. The nurse is discussing follow-up care with a patient who is being discharged. The patient and family cross their arms and state angrily that the team's suggestions are not acceptable. Which response by the nurse is appropriate? 1) “We only want what's best for you.” 2) “We will leave you alone to discuss your options.” 3) “Perhaps you did not understand the recommendations.” 4) “Let's discuss other options that might work well for you and your family.” 3. The nurse is preparing a patient for discharge who will be requiring physical therapy (PT) to rehabilitate after a total knee replacement. After reading the health-care provider’s order for PT, which would be the nurse's initial action? 1) Teach the family the exercises needed for the patient. NURSINGTB.COM
2) 3) 4)
Call home health and schedule a therapist to visit the home for therapy. Set up appointments according to the order with the hospital PT department. Discuss the various types of settings for therapy and have the patient choose the venue.
4. The nurse is caring for a patient with rheumatoid arthritis who expresses the desire to remain active as long as possible. In order for the patient to meet this goal, what should the nurse prepare to do? 1) Tell the patient there is no hope. 2) Ask the patient the reason for the decision. 3) Teach the patient nutrition and joint exercises. 4) Refer the patient to the appropriate professionals.
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5. A nurse is working as the designated leader of a group of health-care providers in a community clinic setting. The team members are working to decrease the number of adolescent pregnancies in the community. They have defined the problem and are now focusing on objectives and considering various viewpoints presented by the group. The nurse is tasked with helping the team to stay focused in order to address the defined problem. Which competency of collaboration does this describe? 1) Trust 2) Mutual respect 3) Communication 4) Decision making 6. The nurse managers in a community hospital have been charged with reviewing job descriptions of unlicensed assistive personnel (UAPs) and have questions about the delegation of certain patient care activities to UAPs by nurses. To which group, organization, or individual would committee members direct their questions to obtain definitive answers about the parameters of nurse delegation to UAPs? 1) The state board of nursing 2) The American Nurses Association 3) The hospital's Chief Nursing Officer 4) The hospital's Chief Executive Officer
2)
7. Which statement is a primary and historical barrier to effective nursephysician collaboration that has persisted over time? 1) The view among the general population that nurses’ contributions to patients’ care is less important to their health and well-being compared to the contribution of physicians The nurses’ and physicians’ perceptions of inequity in their roles, with nurses assuming a subservient role and physicians assuming leadership and superior role in health-care settings NURSINGTB.COM 3) A general lack of education provided in schools for health professionals about the benefits on health-care quality linked 4) A lack of published evidence about the effectiveness of collaborative efforts among and between nurses and physicians to nurse-physician collaboration 8. A patient with Type 1 diabetes mellitus has developed an open sore on the shin and is having trouble meeting daily goals for exercising. The patient is scheduled for discharge in a couple of days. When planning for this patient’s continued care, who will the nurse notify regarding the patient’s needs after discharge? 1) The pharmacy 2) The case manager 3) The physical therapist 4) The occupational therapist NURSINGTB.COM
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9. A patient who is recovering from coronary bypass surgery is placed on a critical pathway for extended care. Which patient statement indicates appropriate understanding of the plan of care? 1) “I cannot alter the critical pathway plan.” 2) “I must be able to meet goals that are set for me.” 3) “My insurance plan can deny payment if I do not meet goals.” 4) “The chosen critical pathway can be altered to meet my needs.” 10. The case manager interviews an older adult patient hospitalized after hip replacement surgery. The patient requires in-patient rehabilitation prior to being discharged home. The case manager works with the hospital nursing staff, the rehabilitation center, the patient’s family members, and other care providers to assist with a smooth transition. Which is the primary goal of the care management model described here? 1) To provide greater peace of mind for the patient and his or her family members
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2) 3) 4)
To track a patient’s progress to ensure that appropriate care is provided until discharge To manage concerns that are related to the patient’s medical care and treatment regimen only To provide a continuum of clinical services in order to help contain costs and improve patient outcomes
11. The patient’s case manager, diabetes educator, and dietician meet to discuss the patient’s needs in preparation for discharge to home. The patient’s primary healthcare provider arrives and states, “I will be making all decisions regarding the patient’s discharge care.” With the primary health-care provider’s decision to lead the team, the dynamic has shifted between which two types of teams? 1) Intradisciplinary to interdisciplinary team 2) Multidisciplinary to intradisciplinary team 3) Interprofessional to interdisciplinary team 4) Interdisciplinary to multidisciplinary team 12. A school-age patient is admitted to the pediatric intensive care unit (PICU), unconscious and with multiple traumatic injuries, after a skateboard accident that included a closed head injury. Many health professionals are involved in the patient’s care and the scene is chaotic. The parents are extremely anxious and want to know what is happening. The case manager asks for an interdisciplinary team meeting to speak with the patient’s parents. Which is the rationale for this meeting? 1) To allow for each specialty to practice independently 2) To share and evaluate information for care planning and implementation, and prevent priority conflicts, redundancy, and omissions in care 3) To all the primary health-care provider to make all the decision regarding the patient’s care 4) To prevent the parents from trying to change the plan of care NURSINGTB.COM 13. The Chief Nursing Officer and Chief Medical Officer in an urban teaching hospital are leading a series of meetings with nurses, physicians, hospital lawyers, and risk managers to review and update hospital privileging procedures and requirements for advanced practice RNs and physicians new to the hospital. This is an example of which type of collaborative team? 1) Intradisciplinary 2) Interdisciplinary 3) Multidisciplinary 4) Complementary 14. A local hospital formed a neurotrauma (NT) team with the following members: acute care nurses, physicians, other care partners (e.g., physical therapists, social workers, case managers, dieticians), and representatives from the NT outpatient clinic. This team is led by a physician who makes treatment decisions based on the treatment plans developed by individual team members who each communicate with NURSINGTB.COM
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the patients, asking the same or similar questions to obtain data needed for their treatment plan. Which type of communication and action is represented in the scenario described? 1) Parallel communication 2) Parallel functioning 3) Information exchange 4) Coordination and consultation 15. The nurse is caring for a patient who is reporting pain of 8/10 on a 1 to 10 numeric pain scale. The nurse administers the prescribed pain medication. When the nurse reevaluates the patient one hour later, the patient is still reporting pain of 8/10. Which action by the nurse is appropriate at this time? 1) Wait for the health-care provider to make rounds to report the problem.
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2) 3) 4)
Report to the health-care provider by telephone. Increase the dosage of the medication. Include in the nursing report that the medication is ineffective.
16. Handoff communication, the transfer of information during transitions in care such as during change-of-shift report, includes an opportunity to ask questions, clarify, and confirm the information between sender and receiver. Which is the main objective for ensuring effective communication during a patient handoff? 1) To avoid lawsuits 2) To ensure patient safety 3) To facilitate quality improvement 4) To make sure all documentation is done 17. The nurse is providing care to a patient diagnosed with end-stage renal disease. When planning a care plan conference for this patient, who does the nurse invite to participate? 1) The oncologist 2) The psychiatrist 3) The hospital CEO 4) The family members 18. Which should be the focus of an educational session for nurses and other members of the interdisciplinary team when addressing high rates of patient readmission to the health system? 1) Medication errors 2) Coordination of care 3) Adverse clinical events 4) Roles of each member providing care 19. Which patient population should the Nn uUrsReSfoIc N u sGoTn Bto.inCcO r eM a se access to care that is coordinated, safe, and focused on the patient’s unique needs across all care settings? 1) Pediatric patients 2) Older adult patients 3) Young adult patients 4) Acute needs patients 20. Which is a basic principle of the Patient Protection and Affordable Care Act of 2010 that the nurse should include in a teaching session for members of the health-care team? 1) Decreased access 2) Decreased cost of care 3) Decreased quality of care 4) Decreased safety Multiple Response Identify one or more choices that best complete the statement or answer the question. NURSINGTB.COM
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21. The hospital’s nurse case manager has been extensively involved with a shooting victim and members of the patient’s family in coordinating care of providers from many disciplines as the patient progressed from the emergency department (ED) to the intensive care unit (ICU), and then onto the medical-surgical unit. After three weeks of hospitalization, the case manager is helping to prepare the patient for discharge to a rehabilitation center where treatment will continue. Which outcomes have been documented in the literature as benefits of such collaboration? Select all that apply. 1) Improved patient outcomes 2) Decreased duplication of health-care services
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3) 4) 5)
Increased overall cost of health-care services Decreased patient morbidity and mortality Decreased level of job satisfaction
22. The case manager assembles a team of health-care professionals, including the patient’s primary health-care provider, physical therapist, and social worker, for the purpose of collaborative discharge planning and decision making. Which type of team did the case manager assemble? Select all that apply. 1) Management 2) Intradisciplinary 3) Interdisciplinary 4) Interprofessional 5) Primary nursing care 23. The nurse is preparing to document care provided to the patient during the day shift. The nurse documents that the patient experienced an increased pain level while ambulating which required an extra dose of pain medication; took a shower; visited with family; and ate a small lunch. Which information is important to include during the oral end-of-shift reporting? Select all that apply. 1) The last antibiotics given 2) The patient’s taking a shower 3) The patient’s visit with family 4) The extra dose of pain medication 5) The patient’s response to ambulation 24. When the nurse receives a telephone order from the health-care provider's office, which guidelines are used to ensure the order is correct? Select all that apply. 1) Ask the prescriber to speak slowly. 2) Read the order back to the prescN riU b eRr. SINGTB.COM 3) Know agency policy for telephone orders. 4) Sign the prescriber’s name and credentials. 5) Ask the prescriber to repeat or spell out medication. 25. When discussing the importance of interprofessional collaboration, which advantages should the nurse include? Select all that apply. 1) Improved team member satisfaction 2) Increased division among team members 3) Increased safety with medication administration 4) Enhanced communication among team members 5) Increased patient satisfaction with discharge transition process
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Chapter 2: Interprofessional Collaboration and Care Coordination Answer Section MULTIPLE CHOICE 1.
ANS: 2 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Exploring the role of the registered nurse in patient centered transitional care programs Chapter page reference: 017 Heading: Case Manager Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Collaboration Difficulty: Easy Feedback 1 Collaboration means a collegial working relationship with other health-care providers to supply patient care. Collaborative practice requires the discussion of diagnoses and management in the delivery of care. 2 Case management involves one or more individuals overseeing the needs and requirements of a particular individual's health. 3 Health promotion activities include disease prevention and healthy lifestyle interventions. Health education would be included in this particular situation, but collaboration is a more inclusiNveUdReS finIitNioGn To fBw.hCatOisMoccurring with these individuals and the care they require. 4 Health promotion activities include disease prevention and healthy lifestyle interventions. Health education would be included in this particular situation, but collaboration is a more inclusive definition of what is occurring with these individuals and the care they require.
PTS: 1 CON: Collaboration 2. ANS: 4 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Defining interprofessional collaboration in the health-care setting Chapter page reference: 010-011 Heading: The Care Transitions Program Integrated Processes: Communication and Documentation Client Need: Psychosocial NURSINGTB.COM
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Integrity Cognitive level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 Telling the patient that the doctor only wants what is best sends the message that the patient does not know what is best, when, in fact, a well-informed patient does know what is best and should be able to make the correct choice. 2 By leaving the room, the nurse and doctor have turned their backs on the patient.
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3 4
The patient may not understand the recommendations, but pointing that out can be seen as demeaning. The patient is the center of the team, and the goal is to facilitate healing. There are always other options to consider to reach that goal. The nurse would discuss other options with the patient, which will most likely increase cooperation by the patient, who will feel in control as the decision is made.
PTS: 1 CON: Communication 3. ANS: 4 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Exploring the role of the registered nurse in patientcentered transitional care programs Chapter page reference: 011 Heading: The Care Transitions Program Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Collaboration Difficulty: Moderate Feedback 1 The therapy that the patient requires must be performed by a professional physical therapist. To teach the family exercises encroaches upon the expertise of the professional who will be performing the service. 2 Scheduling home PT is leaving the patient out of the decision-making process. 3 The nurse would not refer the patient for outp atient th erapy unless the N UR S I N G T B .C O M patient requests that form of therapy. 4 The nurse best exhibits the characteristic that the patient has a right to self- determination by presenting the methods available for PT and answering the patient's questions about each so the patient can make an informed decision. PTS: 1 CON: Collaboration 4. ANS: 4 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Identifying the roles of health-care professionals coordinating care for patients Chapter page reference: 015-019 Heading: Providers Integrated Processes: Nursing Process NURSINGTB.COM
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Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Collaboration Difficulty: Hard Feedback 1 The patient with a chronic disease should not be told there is no hope but should be helped toward reaching desired goals. 2 Asking the patient the reason for the decision is irrelevant to the situation. 3 The nurse can teach some nutrition and exercise but cannot go into the depth that this patient would need.
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4
The number of patients with chronic diseases with health-care needs is increasing rapidly, and nurses and primary health-care providers cannot meet all of these patients’ needs. When a patient expresses the desire to live as normally as possible, the nurse should refer the patient to professionals who can help the patient meet that goal.
PTS: 1 CON: Collaboration 5. ANS: 4 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Defining interprofessional collaboration in the health-care setting Chapter page reference: 013-015 Heading: Interprofessional Collaboration Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Collaboration Difficulty: Easy Feedback 1 Trust occurs when an individual is confident in the actions of another individual. Both mutual respect and trust imply mutual process and outcome and may be expressed verbally or nonverbally. 2 Mutual respect occurs when two or more people show or feel honor or esteem toward one another. 3 Communication is necessary in effective collaboration; it occurs only if the involved parties are committed to understanding each other's professional roles and appreciating each other as individuals. 4 Decision making involves shared responsibility for the outcome. The team must follow specific steps of the decision-making process, beginning with a clear definition of the problem. Team decision making must be directed at the objectives of the effort and requires full consideration and respect for various and diverse viewpoints, and often requires guidance and direction from a group leader. PTS: 1 CON: Collaboration 6. ANS: 1 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Identifying the roles of health-care professionals coordinating care for patients Chapter page reference: 014-015 Heading: Interprofessional NURSINGTB.COM
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Education Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Legal Difficulty: Easy Feedback 1 Parameters for the delegation of patient care tasks by nurses to UAPs are established by each state's board of nursing. 2 This organization does not provide definitive answers regarding tasks that nurses can delegate to UAPs. 3 This individual does not provide definitive answers regarding tasks that nurses can delegate to UAPs.
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4
This individual does not provide definitive answers regarding tasks that nurses can delegate to UAPs.
PTS: 1 CON: Legal 7. ANS: 2 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Defining interprofessional collaboration in the health-care setting Chapter page reference: 013-015 Heading: Interprofessional Collaboration Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Collaboration Difficulty: Easy Feedback 1 Evidence does not suggest that the general population views nurses’ contributions to the care of patients as less important, thus this is not considered a primary barrier to nursephysician collaboration. 2 A primary and historical barrier to effective nurse-physician collaboration has been nurses’ and physicians’ perceptions of inequity in their roles, with nurses assuming a subservient role and medical providers perceiving their role to be superior in the provision of health-care services. 3 Likewise, because health professional students are in fact educated about the benefits of collaborative practice and published evidence has documented the effectiveness of collaboration in improving patient outcomes, these are not barriers to collaboration. 4 In addition, the federal government, as evidenced in particular by the Healthy People initiative, has promoted collaborative efforts among patients, nurses, physicians, other health-care providers, and the larger community to improve the health of the U.S. population. PTS: 1 CON: Collaboration 8. ANS: 2 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Identifying the roles of health-care professionals coordinating care for patients Chapter page reference: 017-018 Heading: Case Manager Integrated Processes: Nursing Process NURSINGTB.COM
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Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Collaboration Difficulty: Moderate Feedback 1 The pharmacy is not needed as part of the team at this time. 2 The patient’s needs and progress have changed. The nurse notifies the case manager to coordinate changes in care needed after discharge. This patient’s exercise program needs to be revamped, and the case manager is the individual to coordinate this change. 3 A physical therapist may be needed, but the nurse would coordinate care best by notifying the case manager.
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4
The occupational therapist mainly deals with the upper body areas needing rehabilitation.
PTS: 1 CON: Collaboration 9. ANS: 4 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Exploring unique patient situations requiring or enhanced by interprofessional collaboration Chapter page reference: 019-020 Heading: Unique Patient Situations Requiring or Enhanced by Interprofessional Collaboration Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Management Difficulty: Difficult Feedback 1 The patient is included in the discussion of meeting goals. 2 The case manager monitors and works with the patient to alter the pathway as needed during the recovery process. 3 It is possible to have variances in a critical pathway that, if documented properly, should be paid for by insurance. 4 Care maps, or critical pathways, are flexible enough to be adjusted and tailored to the patient's needs and wishes. 10.
PTS: 1 CON: ManageNmUent R SINGTB.COM ANS: 4 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Describing models of transitional care Chapter page reference: 010-012 Heading: Evidence-Based Models of Transitional Care Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehensive [Understanding] Concept: Management Difficulty: Easy Feedback 1 Although the involvement of case managers in care typically provides NURSINGTB.COM
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2 3
4
11.
greater peace of mind for patients and family members, this is not the primary goal of this service. Toward this end, case managers not only with help to coordinate care and treatment during hospitalization, but also assist with planning for care following discharge. Their focus includes not only medical care, but issues related to health promotion and disease prevention, the cost of health care received, and planning for the efficient use of resources. Case managers coordinate patient care to help ensure that a continuum of clinical services is provided. The goal of case management is to improve patient outcomes and to help contain costs.
PTS: 1 ANS: 4
CON: Management
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Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Describing models of transitional care Chapter page reference: 010011 Heading: The Transitional Care Model Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Collaboration Difficulty: Easy 1
2
3 4
12.
Feedback Intradisciplinary teams include members of the same profession. Interdisciplinary teams include professionals of varied backgrounds who share in decision making. Multidisciplinary teams include members of varied backgrounds, but treatment decisions are made by one member–usually the primary health-care provider. Intradisciplinary teams include members of the same profession. The term interprofessional team is synonymous with interdisciplinary team. Interdisciplinary teams include professionals of varied backgrounds who share in decision making. Multidisciplinary teams include members of varied backgrounds, but treatment decisions are made by one member–usually the primary health-care provider.
PTS: 1 CON: Collaboration ANS: 2 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Exploring unique patient situations requiring or enhanced by interprofessional NURSINGTB.COM collaboration Chapter page reference: 019-020 Heading: Unique Patient Situations Requiring or Enhanced by Interprofessional Collaboration Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Collaboration NURSINGTB.COM
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Difficulty: Easy Feedback 1 Interdisciplinary collaboration engages each professional’s contribution to joint care planning, implementation, and accomplishment of patient goals, with possibly less redundancy, more efficiency, and fewer care omissions. The parents of a minor child should be involved in all aspects of care and decision making. 2 Interdisciplinary collaboration engages each professional’s contribution to joint care planning, implementation, and accomplishment of patient goals, with possibly less redundancy, more efficiency, and fewer care omissions. The parents of a minor child should be involved in all aspects of care and decision making. 3 Interdisciplinary collaboration engages each professional’s contribution to joint care planning, implementation, and accomplishment of patient goals, with possibly less redundancy, more efficiency, and fewer care omissions. The parents of a minor child should be involved in all aspects of care and decision making.
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4
13.
PTS: 1 CON: Collaboration ANS: 2 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Describing models of transitional care Chapter page reference: 010011 Heading: The Transitional Care Model Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Collaboration Difficulty: Easy 1 2
3 4
14.
Interdisciplinary collaboration engages each professional’s contribution to joint care planning, implementation, and accomplishment of patient goals, with possibly less redundancy, more efficiency, and fewer care omissions. The parents of a minor child should be involved in all aspects of care and decision making.
Feedback Intradisciplinary teams comprise members of the same profession working to achieve a common goal. A team comprising members from different disciplines that is focused on achieving a common goal is an interdisciplinary team. Their varying professional backgrounds helps to ensure that other perspectives are represented as the issue is considered. Multidisciplinary teams are more commonly teams whose members work more autonomously toward the common goal. Complementary is not a type of team, although team members’ efforts can be complementary and provide a broader perspective of issues.
PTS: 1 CON: Collaboration ANS: 1 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Defining interprofessional collaboration in the health-care setting Chapter page reference: 013-014 Heading: Interprofessional Communication Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension NURSINGTB.COM
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[Understanding] Concept: Communication Difficulty: Easy Feedback 1 The type of communication and action used by this health-care team is parallel communication. It is at the lowest level along the continuum of communication and collaboration among health team members and is characterized by each professional communicating with the patient independently, asking the same or similar questions needed to develop their plan of care.
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2
3 4
15.
16.
The next level up on the continuum of communication and collaboration, but not described in this scenario, is parallel functioning. Here, communication is more coordinated, but each professional still develops separate interventions and care plans. In parallel functioning, the exchange of information among team members is more structured and planned, but decision making is unilateral and does not involve much collegiality. While there is an information exchange occurring, this is not the best description of the scenario. The actions of this NT team do not demonstrate coordination and consultation or comanagement and referral, the two highest levels of communication and collaborative action.
PTS: 1 CON: Communication ANS: 2 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Defining interprofessional collaboration in the health-care setting Chapter page reference: 013-014 Heading: Interprofessional Communication Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 Waiting for the physician to arrive co uld cause th e patient to experience NU RS I N G T B. C O M a great deal of pain in the interim. 2 In this case reporting to the physician by telephone is appropriate. 3 The nurse cannot alter the dose of medication. 4 The nurse would address the patient's distress immediately and later include the event in the end-of-shift report to the oncoming nurse. PTS: 1 CON: Communication ANS: 2 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Defining interprofessional collaboration in the health-care setting Chapter page reference: 013-014 Heading: Interprofessional Communication Integrated Processes: Communication and Documentation NURSINGTB.COM
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Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Comprehension [Understanding] Concept: Communication; Safety Difficulty: Easy Feedback 1 Handoff communication may be scrutinized during a lawsuit, but avoiding litigation is not a primary objective. 2 Ineffective communication is the primary cause of sentinel events, making patient safety the primary objective of the handoff communication process. 3 Analysis of handoff communication may be a quality improvement criterion, not a primary objective.
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17.
18.
Handoff communication may be verbal or written.
PTS: 1 CON: Communication | Safety ANS: 4 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Defining interprofessional collaboration in the health-care setting Chapter page reference: 013-014 Heading: Interprofessional Communication Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Management Difficulty: Moderate Feedback 1 The choice of health-care professionals who are invited to attend the conference is based on the needs of the patient. 2 The choice of health-care professionals who are invited to attend the conference is based on the needs of the patient. 3 The choice of health-care professionals who are invited to attend the conference is based on the needs of the patient. 4 The choice of health-care professionals who are invited to attend the conference is based on the needs of the patient. Family members are an important part of the care plan conference, especially for patients who are unable to advocate for themselves. PTS: 1 CON: ManageNmUent R SINGTB.COM ANS: 2 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Discussing the importance of successful transitions for medical-surgical patients Chapter page reference: 009-010 Heading: Overview of Transitional Care Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Management Difficulty: Easy Feedback NURSINGTB.COM
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2
3
4
The safety of the patient is at risk during transitions between care settings, particularly following an acute hospitalization. The patient’s needs may go unmet, and there is the risk for medication errors and adverse clinical events; however, these are not the focus of an education session regarding readmission rates. Hospital readmission rates are often attributed to a lack of coordination of care as patients are discharged to rehabilitation facilities, long-term care agencies, or back to their homes; therefore, this should be the focus of the educational session. The safety of the patient is at risk during transitions between care settings, particularly following an acute hospitalization. The patient’s needs may go unmet, and there is the risk for medication errors and adverse clinical events; however, these are not the focus of an education session regarding readmission rates. The role of each member of the interdisciplinary team should not be the focus of an educational session to decrease hospital readmission rates.
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19.
20.
PTS: 1 CON: Management ANS: 2 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Discussing the importance of successful transitions for medical-surgical patient Chapter page reference: 009 Heading: Introduction Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Management Difficulty: Moderate Feedback 1 The pediatric patient population is not identified as a group where access to coordinated, safe, and focused care is lacking across care settings. 2 Access to care that is coordinated, safe, and focused on the patient’s unique needs across all care settings has eluded many patients, particularly the elderly and chronically ill. 3 The young adult patient population is not identified as a group where access to coordinated, safe, and focused care is lacking across care settings. 4 Patients requiring acute care is not identified as a group where access to coordinated, safe, and focused care is lacking across care settings. PTS: 1 CON: Management ANS: 2 NURSINGTB.COM Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Describing changes in the health-care landscape Chapter page reference: 009-010 Heading: Overview of Transitional Care Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Healthcare System Difficulty: Moderate NURSINGTB.COM
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1 2 3 4
Feedback Increased, not decreased, access is a basic principle of the Patient Protection and Affordable Care Act of 2010. Decreased cost of care is a basic principle of the Patient Protection and Affordable Care Act of 2010. Increased, not decreased, quality of care is a basic principle of the Patient Protection and Affordable Care Act of 2010. Increased, not decreased, safety is a basic principle of the Patient Protection and Affordable Care Act of 2010.
PTS: 1
CON: Healthcare System
MULTIPLE RESPONSE
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21. ANS: 1, 2, 4 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Describing models of transitional care Chapter page reference: 009010 Heading: Overview of Transitional Care Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Management Difficulty: Easy
1.
2.
3. 4.
5.
Feedback This is correct. Research findings suggest that collaboration in health care among patients, family members, caregivers, and communities leads to improved patient outcomes, a reduction in duplicated health-care services, and a decrease in patient morbidity and mortality. This is correct. Research findings suggest that collaboration in health care among patients, family members, caregivers, and communities leads to improved patient outcomes, a reduction in duplicated health-care services, and a decrease in patient morbidity and mortality. This is incorrect. Research findings suggest that collaboration in health care among patients, family members, caregivers, and communities leads to a decreased, not increased, cost of care. This is in correct. Research findings suggest that collaboration in health care among patients, family members, caregivers, and communities leads to improved patient outcomes, a reduction in duplicated health-care services, and a decrease in patient morbidity and mortality. This is incorrect. Collaborative efforts have also been found to contribute to an enhanced sense of autonomy. ThisNiU ncRreSasIe NinGsTenBse.oCf OauMtonomy has been linked to nurses’ greater job satisfaction.
PTS: 1 CON: Management 22. ANS: 3, 4 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Describing models of transitional care Chapter page reference: 010011 Heading: The Transitional Care Model Integrated Processes: Nursing NURSINGTB.COM
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Process Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Collaboration Difficulty: Easy
1. 2. 3.
Feedback This is incorrect. Management teams are executive-level teams that run the day-to-day operations of a corporation. This is incorrect. Intradisciplinary teams include members of the same profession. This is correct. Interdisciplinary teams include professionals of varied backgrounds who share decision making. The terms interprofessional team and interdisciplinary team are synonymous.
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4. 5.
This is correct. Interdisciplinary teams include professionals of varied backgrounds who share decision making. The terms interprofessional team and interdisciplinary team are synonymous. This is incorrect. A primary nursing care team includes a primary nurse and associate nurses who will provide care to a patient during a hospital stay.
PTS: 1 CON: Collaboration 23. ANS: 4, 5 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Defining interprofessional collaboration in the health-care setting Chapter page reference: 013-014 Heading: Interprofessional Communication Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Communication Difficulty: Difficult 1. 2. 3. 4. 5.
Feedback This is incorrect. Antibiotics are reflected on the medication administration record (MAR). This is incorrect. Taking a shower does not need to be reported, only documented. This is incorrect. Visiting with the family need not be mentioned at change of shift but should be documented. This is correct. The nurse would also report any as-needed medications given and when they were last given. NURSINGTB.COM This is correct. In order to provide for the patient’s safety, the nurse would pass on the patient’s response to ambulation so that the oncoming staff can take fall precautions.
PTS: 1 CON: Communication 24. ANS: 1, 2, 3, 5 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Defining interprofessional collaboration in the health-care setting Chapter page reference: 013-014 Heading: Interprofessional Communication Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application NURSINGTB.COM
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[Applying] Concept: Communication Difficulty: Moderate 1.
2.
3.
Feedback This is correct. When receiving a telephone order from a provider, the nurse should ask the prescriber to repeat or spell out the medication, to speak slowly, and read the order back to the prescriber once the prescription is complete. This is correct. When receiving a telephone order from a provider, the nurse should ask the prescriber to repeat or spell out the medication, to speak slowly, and read the order back to the prescriber once the prescription is complete. This is correct. It is also important for the nurse to know the agency’s policy regarding telephone orders.
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4. 5.
This is incorrect. The nurse does not sign the prescriber’s name and credentials; the nurse only transcribed the prescription and the prescriber countersigns it within a time period prescribed by the agency’s policy. This is correct. When receiving a telephone order from a provider, the nurse should ask the prescriber to repeat or spell out the medication, to speak slowly, and read the order back to the prescriber once the prescription is complete.
PTS: 1 CON: Communication 25. ANS: 1, 4, 5 Chapter number and title: 2, Interprofessional Collaboration and Care Coordination Chapter learning objective: Exploring unique patient situations requiring or enhanced by interprofessional collaboration Chapter page reference: 019-020 Heading: Unique Patient Situations Requiring or Enhanced By Interprofessional Collaboration Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Collaboration Difficulty: Moderate 1. 2. 3. 4. 5. PTS: 1
Feedback This is correct. Improved team member satisfaction is an advantage of interprofessional collaboration. This is incorrect. There is a decreased, not increased, division among team members with interprofessional collaboration. CO This is incorrect. There N is UinRcrSeaIsNedGsT afBet. y w ithMthe discharge transition process, not medication administration, with interprofessional collaboration. This is correct. Enhanced communication among team members is an advantage of interprofessional collaboration. This is correct. Increased patient satisfaction with the discharge transition process is an advantage of interprofessional collaboration. CON: Collaboration
Chapter 3: Cultural Considerations Multiple Choice NURSINGTB.COM
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Identify the choice that best completes the statement or answers the question. 1. The nurse is providing care to a Muslim patient who presents to the emergency department (ED) with abdominal pain and vaginal bleeding. The patient’s spouse asks that only a female examines the patient. Which is the most culturally appropriate statement by the nurse in response to this request? 1) “Your spouse will be covered so it will not matter what the gender of the examiner is.” 2) “The male and female providers here both respect privacy.”
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3) 4)
“Your request is unreasonable and cannot be honored at this time.” “Every attempt will be made to honor your request regarding the care of your spouse.”
2. The nurse is caring for a Chinese patient who is one day postoperative for abdominal surgery. The patient’s nonverbal cues indicate pain, but the patient denies the need for pain medication. Which action by the nurse is appropriate? 1) Seeking out a family member to convince the patient to take the medication 2) Consulting the health-care provider about administering medication without the patient’s knowledge 3) Offering the medication again stating that providing comfort is a priority 4) Allowing the patient to suffer in silence 3. The nurse is providing care to an infant who is experiencing colic. The infant’s family immigrated to the United States six months ago. The mother explains that she believes that an herbal remedy, prepared by the village doctor, is the best way to treat the infant’s colic. Which action by the nurse is most appropriate? 1) Ask the mother what the ingredients are in the remedy. 2) Give the mother an alternate remedy for colic. 3) Explain how herbal ingredients may be harmful to the infant. 4) Tell the mother not to use the remedy because there is no way to know what the ingredients’ scientific effect may be. 4. During a sexual history the patient states, “I have always felt like a man trapped in a woman’s body.” Which conclusion about the patient is potentially accurate? 1) Bisexuality 2) Heterosexuality 3) Homosexuality 4) Transgender NURSINGTB.COM 5. The nurse is working with a number of patients at a free clinic. Which population is at the highest risk for low levels of health care? 1) Immigrants 2) Adolescents 3) Older adults 4) Newborns 6. Which treatment program should the nurse include in the plan of care for a homeless client whose Type 1 diabetes mellitus (DM) requires daily insulin injections? 1) Home health care 2) Outpatient clinic 3) Partial hospitalization 4) Inpatient hospital-based care 7. The novice nurse working in an inner-city hospital that serves a diverse patient population states, “I want to NURSINGTB.COM
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learn everything possible about all of the patients.” Which response by the seasoned nurse is appropriate? 1) “I will give you a great book that describes all of the critical factors.” 2) “You should always be nonjudgmental.” 3) “This will come with time as you get to know clients and then encounter problems.” 4) “You need to first understand who you are.” 8. Which acculturation behavior will the nurse observe in a patient who has emigrated from Mexico to the United States? 1) The client buys all needed products from the local store owned by people from Mexico.
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2) 3) 4)
The client lives in a neighborhood that is populated predominantly with people from Mexico. The client speaks Spanish only. The client attends a church service in the neighboring community to meet new people.
9. A male nurse enters the room of a female patient to obtain the patient's vital signs. The patient’s spouse appears uncomfortable with the nurse and moves closer to the patient. Which action by the nurse is most appropriate? 1) Ask a female staff member to obtain the patient’s vital signs. 2) Ask the spouse to leave the patient’s room to obtain the vital signs. 3) Perform the intervention without discussion with the patient or spouse. 4) Explain the procedure to both the patient and the spouse. 10. The nurse is providing care to an adult patient from another country and notices that the patient consults with her mother on all health-care decisions. Which action by the nurse is the most appropriate? 1) Ask the patient why the parent is being consulted for every decision. 2) Accept the behavior of the patient and family member. 3) Ask the patient's mother to leave the room to provide the patient with more privacy. 4) Confront the patient’s mother to state the importance of the patient making her own decisions. 11. When preparing an in-service for staff nurses regarding health disparity, which definition should the nurse include in the presentation? 1) Factors that help explain why some people experience poorer health than others. 2) Describes the health of a person or community along with the many measures that contribute to this health. 3) Achieved when every person haN s tUh R e pIpoNrG tu T n iB ty.toCaOttaMin his or her health potential and no one is disadvantaged. 4) Differences in the incidence, prevalence, mortality rate, and burden of diseases that exist among specific populations. 12. Which of these should the nurse focus on to decrease health disparities among Hispanic patients? 1) Translation services 2) Nutritional education 3) Pediatric immunizations 4) Hypertension prevention 13. Which traditional Chinese medical treatment includes the insertion of needles into precise points along the channel system of flow of the qi? 1) Cupping 2) Moxibustion 3) Acupuncture 4) Skin pinching NURSINGTB.COM
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14. Which traditional Chinese medical treatment involves the use of a heated cup used to treat joint pain? 1) Cupping 2) Moxibustion 3) Acupuncture 4) Skin pinching 15. Which traditional Chinese medical treatment includes the application of heat from different sources to various points which allows medicine to be absorbed through the skin?
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1) 2) 3) 4)
Cupping Moxibustion Acupuncture Skin pinching
16. Which traditional Vietnamese medical treatment is used to treat a headache or sore throat? 1) Cupping 2) Moxibustion 3) Acupuncture 4) Skin pinching 17. A Vietnamese patient with a history of joint and muscle pain presents with large ecchymosis on the hips and legs. Which traditional Vietnamese medical treatment should the nurse inquire about when conducing the assessment? 1) Cao gio 2) Be bao or bar gio 3) Giac 4) Xong 18. Which patient population should the nurse plan care based on individualistic cultural attributes? 1) Canadian 2) Latino 3) Filipino 4) Hindu 19. Which patient population should the nurse plan care based on collectivistic cultural attributes? 1) British NURSINGTB.COM 2) Swedish 3) Norwegi an 4) Vietnam ese 20. When communicating with a patient who is of Vietnamese descent, which action by the nurse is appropriate? 1) Using the patient’s surname with a title 2) Being straightforward with the patient 3) Maintaining direct eye contact with the patient 4) Sharing intimate life details with the patient 21. Which nursing action is appropriate when conducting a cultural assessment for a patient? 1) Stereotyping concepts related to the patient’s culture 2) Evaluating the concepts in isolation from one another 3) Determining how each aspect of the patient’s culture interacts 4) Assuming that the patient believes all aspects of information related to the identified culture NURSINGTB.COM
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Multiple Response Identify one or more choices that best complete the statement or answer the question. 22. Which should the nurse consider when assessing for health disparities within the community? Select all that apply. 1) Age 2) Gender
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3) 4) 5)
Ethnicity Disability Education
23. The nurse is caring for several pediatric patients with numerous cultural backgrounds. Which patients would the nurse anticipate will be encouraged to express themselves? Select all that apply. 1) An Appalachian adolescent 2) A British school-age child 3) An Arab school-age child 4) An Asian-Indian adolescent 5) A Japanese pre-adolescent 24. The nurse is caring for several pediatric patients with numerous cultural backgrounds. Which patients would the nurse anticipate will be discouraged to express themselves? Select all that apply. 1) An Appalachian adolescent 2) A British school-age child 3) An Arab school-age child 4) An Asian-Indian adolescent 5) A Japanese pre-adolescent 25. Which health-care practices are anticipated when providing care to a patient of German descent? Select all that apply. 1) Traditional practices as the first line of defense 2) Self-medicating with over-the-counter drugs 3) Use of liberal pain medication 4) Use of medications ordered from other countries NaUaRn S 5) Mental health issues hold a stigm d aIrN e hGidTdBen.COM 26. Which health-care practices are anticipated when providing care to an Alaskan Native patient? Select all that apply. 1) Traditional practices as the first line of defense 2) Self-medicating with over-the-counter drugs 3) Use of liberal pain medication 4) Use of medications ordered from other countries 5) Mental health issues hold a stigma and are hidden 27. Which questions should the nurse ask when conducting an assessment to determine if the patient has any high-risk cultural behaviors? Select all that apply. 1) “Do you smoke tobacco products?” 2) “How many alcoholic beverages do you drink each day?” 3) “Who makes the health-care decisions within your family?” 4) “Do you use any herbal medications that we should be aware of?” 5) “Are there any foods you would like to include in your diet during hospitalization?”
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Chapter 3: Cultural Considerations Answer Section MULTIPLE CHOICE 1.
ANS: 4 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures Chapter page reference: 030-034 Heading: Individualism versus Collectivism Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Diversity Difficulty: Moderate 1 2
3 4
Feedback The response of covering the client or stating the request is unreasonable shows insensitivity to the patient’s cultural need. Although both male and female staff have professional and ethical responsibilities to respect a patient’s privacy, the nurse must still make efforts to meet the request of the client. The response of covering the patient or stating the request is unreasonable shows insensitivity to the patient’s cultural need. Many cultures have religious bNeUlieRfsStI h aNt G p rTo hBib.itCeO x aMmination by men of the reproductive areas of a female. To provide culturally appropriate care, the nurse must recognize this as a legitimate request and make every attempt to honor this request.
PTS: 1 CON: Diversity 2. ANS: 3 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures Chapter page reference: 030-034 Heading: Individualism versus Collectivism Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity - Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort; Diversity Difficulty: Moderate Feedback NURSINGTB.COM
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1
2
Members of the Chinese culture will typically not complain of pain or physical problems because they are taught self-restraint and the priority of the group over individual needs. Due to this belief, seeking out a family member to convince the patient to take the medication is inappropriate. It is unethical to administer a medication to a patient without his or her consent.
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3
4
Members of the Chinese culture will typically not complain of pain or physical problems because they are taught self-restraint and the priority of the group over individual needs. Many people of this culture will consider refusal of something offered as a gesture of courtesy. The nurse should take these into account and offer the pain medication to the client. The nurse should make every effort to offer the patient pain medication but respect his or her decision.
PTS: 1 CON: Comfort | Diversity 3. ANS: 1 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Discussing elements of cultural assessment Chapter page reference: 026-028 Heading: Overview of Cultural Domains and Their Concepts Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Diversity Difficulty: Moderate Feedback 1 To recognize cultural practices, the nurse must acknowledge that use of old and home remedies is part of caregiving practices. Asking the mother what ingredients are in the herbal remedy allows the nurse to best evaluate what the mother is using, and then a m deat nernmeri.nation of the benefit or detriment to the infant can be made in a nonjudgmental NURSINGTB.COM 2 Telling the mother not to use the remedy, giving an alternative, or making a judgment that any herbal ingredient is harmful does not recognize this cultural practice and shows insensitivity on the part of the nurse. 3 Telling the mother not to use the remedy, giving an alternative, or making a judgment that any herbal ingredient is harmful does not recognize this cultural practice and shows insensitivity on the part of the nurse. 4 Telling the mother not to use the remedy, giving an alternative, or making a judgment that any herbal ingredient is harmful does not recognize this cultural practice and shows insensitivity on the part of the nurse. PTS: 1 CON: Diversity 4. ANS: 4 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Discussing elements of NURSINGTB.COM
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cultural assessment Chapter page reference: 026-028 Heading: Overview of Cultural Domains and Their Concepts Integrated Processes: Nursing Process – Assessment Client Need: Psychosocial Integrity Cognitive level: Comprehension [Understanding] Concept: Diversity Difficulty: Easy Feedback 1 A bisexual individual prefers sexual relationships with both men and women.
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2 3 4
A homosexual individual prefers sexual relationships with individuals of the same gender. A heterosexual individual prefer sexual relationships with individuals of the opposite gender. A transgender individual is someone who identifies with a different gender than one assigned.
PTS: 1 CON: Diversity 5. ANS: 1 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Describing how health disparities impact the health and welfare of society Chapter page reference: 023-025 Heading: Health Disparities and the Need for Cultural Competence Integrated Processes: Nursing Process – Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Diversity Difficulty: Easy Feedback 1 The term “vulnerable population” refers to groups of people in our culture who are at greater risk for diseases and reduced life span due to lack of resources and exposure to more risk factors. People may be made vulnerable by immigration status. 2 While adolescents are often at risk for low levels of health care, this population isn’t at the greatest risk. 3 While older adults are often at risk fo r low lev e ls o f health care, this N U RS I N GT B . C O M population isn’t at the greatest risk. 4 While newborns are often at risk for low levels of health care, this population isn’t at the greatest risk. PTS: 1 CON: Diversity 6. ANS: 2 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Describing how health disparities impact the health and welfare of society Chapter page reference: 023-025 Heading: Health Disparities and the Need for Cultural Competence Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Health Care NURSINGTB.COM
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System Difficulty: Moderate Feedback 1 Because the patient is homeless, home health care would not be the best option in this situation. 2 The outpatient clinic would provide the care the patient requires in the most costeffective manner. 3 There is no indication for inpatient or partial hospitalization at this time. 4 There is no indication for inpatient or partial hospitalization at this time. PTS: 1
CON: Health Care System
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7.
ANS: 4 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Identifying domains, concepts, and terminology essential to cultural assessment Chapter page reference: 025-026 Heading: Culture and Essential Terminology Integrated Processes: Culture and Spirituality Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Diversity Difficulty: Moderate Feedback 1 Reading about culture and remaining nonjudgmental are strategies that can be incorporated after engaging in a self-awareness inventory. 2 Reading about culture and remaining nonjudgmental are strategies that can be incorporated after engaging in a self-awareness inventory. 3 Although experience working with diverse clients will help, it will be more meaningful after engaging in a self-awareness inventory. 4 It is a priority for the nurse to develop an awareness of his or her own perceptions, prejudices, and stereotypes regarding the client populations that are served.
PTS: 1 CON: Diversity 8. ANS: 4 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Identifying domains, concepts, and terminology essential to cultural assessment Chapter page reference: 025-026 NURSINGTB.COM Heading: Culture and Essential Terminology Integrated Processes: Nursing Process – Assessment Client Need: Psychosocial Integrity Cognitive level: Comprehension [Understanding] Concept: Diversity Difficulty: Easy Feedback 1 This behavior is an example of a patient who may feel comfortable only in the Mexican culture. 2 This behavior is an example of a patient who may feel comfortable only in the Mexican culture. NURSINGTB.COM
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3 4
This behavior is an example of a patient who may feel comfortable only in the Mexican culture. Individuals experience acculturation when they begin to adapt or borrow habits of the new culture. The client who attends church in the neighboring community to meet new people is displaying acculturation.
PTS: 1 CON: Diversity 9. ANS: 4 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Describing the importance of culturally competent skills Chapter page reference: 026-028 Heading: Overview of Cultural Domains and Their Concepts Integrated Processes: Nursing Process – Implementation
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Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Diversity Difficulty: Moderate Feedback 1 Asking another staff member to obtain the patient’s vital signs is inappropriate. 2 The patient’s spouse should not be asked to leave the room unless the patient prefers this procedure to be done with privacy. 3 Performing an intervention without first discussing it and asking for permission may be interpreted as assault. 4 The nurse should explain the procedure to both the patient and the spouse prior to touching the patient.
10.
11.
PTS: 1 CON: Diversity ANS: 2 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Describing the importance of culturally competent skills Chapter page reference: 026-028 Heading: Overview of Cultural Domains and Their Concepts Integrated Processes: Nursing Process - Implementation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Diversity Difficulty: Moderate NURSINGTB.COM Feedback 1 This action is inappropriate and do not consider the patient’s cultural or family values. 2 The nurse should accept this behavior as a cultural norm. 3 This action is inappropriate and do not consider the patient’s cultural or family values. 4 This action is inappropriate and do not consider the patient’s cultural or family values. PTS: 1 CON: Diversity ANS: 4 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Describing how health disparities impact the health and welfare of society Chapter page reference: 023-025 Heading: Health Disparities and the Need for Cultural Competence Integrated Processes: Teaching and NURSINGTB.COM
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Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Diversity Difficulty: Moderate Feedback 1 Determinants of health is defined as factors that help explain why some people experience poorer health than others. 2 Health status is described the health of a person or community along with the many measures that contribute to this health. 3 Health equity is achieved when every person has the opportunity to attain his or her health potential and no one is disadvantaged.
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4
12.
PTS: 1 CON: Diversity ANS: 1 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Describing how health disparities impact the health and welfare of society Chapter page reference: 023-025 Heading: Health Disparities and the Need for Cultural Competence Integrated Processes: Nursing Process – Planning Client Need: Psychosocial Integrity Cognitive level: Analysis [Analyzing] Concept: Diversity Difficulty: Difficult 1
2
3
4
13.
Health disparity is defined as the differences in the incidence, prevalence, mortality rate, and burden of disease that exist among specific populations.
Feedback Health-care providers and policymakers need to target vulnerable subgroups of Hispanic seniors and identify areas of linguistic isolation to minimize these disparities; therefore, the nurse should focus on translation services to decrease noted health disparities for Hispanic patients. Nutritional education, pediatric immunizations, and hypertension prevention may all be appropriate; however, this is not the nurse’s focus to decrease health disparities for this population. Nutritional education, pediatric immunizations, and hypertension prevention may all be appropriate; however, this is nNotUthReSnIurNseG’sTfoc B .u sC tOo Mdecrease health disparities for this population. Nutritional education, pediatric immunizations, and hypertension prevention may all be appropriate; however, this is not the nurse’s focus to decrease health disparities for this population.
PTS: 1 CON: Diversity ANS: 3 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures Chapter page reference: 030-034 Heading: Individualism versus Collectivism Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity NURSINGTB.COM
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Cognitive level: Knowledge [Remembering] Concept: Diversity Difficulty: Easy Feedback 1 Cupping is a traditional Chinese medical treatment where a heated cup or glass jar is put on the skin creating a vacuum, which causes the skin to be drawn into the cup. The heat that is generated is used to treat joint pain. 2 Moxibustion is the application of heat from different sources to various points. The localized erythema occurs with the heat from the burning substance and the medicine is absorbed through the skin.
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3 4
14.
15.
Acupuncture includes the insertion of needles into precise points along the channel system of flow of the qi. Skin pinching is traditional Vietnamese, not Chinese, medicine.
PTS: 1 CON: Diversity ANS: 1 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures Chapter page reference: 030-034 Heading: Individualism versus Collectivism Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive level: Knowledge [Remembering] Concept: Diversity Difficulty: Easy Feedback 1 Cupping is a traditional Chinese medical treatment where a heated cup or glass jar is put on the skin creating a vacuum, which causes the skin to be drawn into the cup. The heat that is generated is used to treat joint pain. 2 Moxibustion is the application of heat from different sources to various points. The localized erythema occurs with the heat from the burning substance and the medicine is absorbed through the skin. 3 Acupuncture includes the insertion of needles into precise points along the channel system of flow of the qi. 4 Skin pinching is traditional Vietna m ese, not Chines e, medicine. NU R SI N GT B.C O M PTS: 1 CON: Diversity ANS: 2 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures Chapter page reference: 030-034 Heading: Individualism versus Collectivism Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive level: Knowledge [Remembering] Concept: Diversity Difficulty: Easy Feedback 1 Cupping is a traditional Chinese medical treatment where a heated cup or glass jar is put on the skin creating a vacuum, which causes the skin to be drawn into the cup. The heat that is generated is used to treat joint pain. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2
3 4
Moxibustion is the application of heat from different sources to various points. The localized erythema occurs with the heat from the burning substance and the medicine is absorbed through the skin. Acupuncture includes the insertion of needles into precise points along the channel system of flow of the qi. Skin pinching is traditional Vietnamese, not Chinese, medicine.
PTS: 1
CON: Diversity
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
16.
17.
ANS: 4 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures Chapter page reference: 030-034 Heading: Individualism versus Collectivism Integrated Processes: Culture and Spirituality Client Need: Psychosocial Integrity Cognitive level: Knowledge [Remembering] Concept: Diversity Difficulty: Easy Feedback 1 Cupping is a traditional Chinese, not Vietnamese, medical treatment where a heated cup or glass jar is put on the skin creating a vacuum, which causes the skin to be drawn into the cup. The heat that is generated is used to treat joint pain. 2 Moxibustion is the application of heat from different sources to various points. The localized erythema occurs with the heat from the burning substance and the medicine is absorbed through the skin. This is a traditional Chinese, not Vietnamese, medical practice. 3 Acupuncture includes the insertion of needles into precise points along the channel system of flow of the qi. This is a traditional Chinese, not Vietnamese, medical practice. 4 Skin pinching is traditional Vietnamese medical practice used to treat headache or sore throat. PTS: 1 CON: Diversity NURSINGTB.COM ANS: 3 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures Chapter page reference: 030-034 Heading: Individualism versus Collectivism Integrated Processes: Nursing Process – Assessment Client Need: Psychosocial Integrity Cognitive level: Comprehension [Understanding] Concept: Diversity Difficulty: Easy Feedback 1 Cao gio (literally, “rubbing out the wind”) is used for treating colds, sore throats, flu, sinusitis, and similar ailments. 2 Be bao or bar gio (skin pinching) is a treatment for headache or sore throat. 3 Giac (cup suctioning), another dermabrasive procedure, is used to relieve stress, headaches, and joint and muscle pain. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4
18.
Xong (an herbal preparation) relieves motion sickness or cold-related problems.
PTS: 1 CON: Diversity ANS: 1 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures Chapter page reference: 030-034 Heading: Individualism versus Collectivism
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Integrated Processes: Nursing Process – Planning Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Diversity Difficulty: Moderate Feedback 1 Patients of Canadian descent are likely to have individualistic cultural attributes. 2 Patients of Latino descent are likely to have collectivistic, not individualistic, cultural attributes. 3 Patients of Filipino descent are likely to have collectivistic, not individualistic, cultural attributes. 4 Patients of Hindu descent are likely to have collectivistic, not individualistic, cultural attributes.
19.
20.
PTS: 1 CON: Diversity ANS: 4 Chapter number and title: 3, Cultural Attributes Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures Chapter page reference: 030-034 Heading: Individualism versus Collectivism Integrated Processes: Nursing Process – Planning Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Diversity Difficulty: Moderate NURSINGTB.COM Feedback 1 Patients of British descent are likely to have individualistic, not collectivistic, cultural attributes. 2 Patients of Swedish descent are likely to have individualistic, not collectivistic, cultural attributes. 3 Patients of Norwegian descent are likely to have individualistic, not collectivistic, cultural attributes. 4 Patients of Vietnamese descent are likely to have collectivistic cultural attributes. PTS: 1 CON: Diversity ANS: 1 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures Chapter page reference: 030-034 Heading: Individualism versus Collectivism Integrated Processes: Communication and Documentation Client Need: Psychosocial NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Integrity Cognitive level: Application [Applying] Concept: Communication; Diversity Difficulty: Moderate Feedback 1 Individuals of Vietnamese descent tend to have collectivistic cultural attributes; therefore, communication is formal and using the patient’s surname with a title is a way of gaining trust.
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2 3 4
21.
This is an individualistic, not collectivistic, cultural attribute related to communication. This is an individualistic, not collectivistic, cultural attribute related to communication. This is an individualistic, not collectivistic, cultural attribute related to communication.
PTS: 1 CON: Communication | Diversity ANS: 3 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Discussing elements of cultural assessment Chapter page reference: 026-028 Heading: Overview of Cultural Domains and Their Concepts Integrated Processes: Nursing Process – Assessment Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Diversity; Assessment Difficulty: Moderate Feedback 1 While information related to the patient’s identified culture is a starting point, stereotyping based on culture should be avoided. 2 Concepts monitored during a cultural assessment should not be evaluated in isolation. 3 Concepts should be assessed together because they affect one another. 4 Assumptions should not be made regarding patient care based on the identified culture. PTS: 1
CON: Diversity | Assessment
MULTIPLE RESPONSE
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22. ANS: 1, 2, 3, 4 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Describing how health disparities impact the health and welfare of society Chapter page reference: 023-025 Heading: Health Disparities and the Need for Cultural Competence Integrated Processes: Nursing Process – Assessment Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Diversity NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Difficulty: Moderate
1. 2.
3.
Feedback This is correct. Health disparities can affect population groups based on gender, age, ethnicity, socioeconomic status, geography, sexual orientation, disability, or special needs health-care needs. This is correct. Health disparities can affect population groups based on gender, age, ethnicity, socioeconomic status, geography, sexual orientation, disability, or special needs health-care needs. This is correct. Health disparities can affect population groups based on gender, age, ethnicity, socioeconomic status, geography, sexual orientation, disability, or special needs health-care needs.
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4. 5.
This is correct. Health disparities can affect population groups based on gender, age, ethnicity, socioeconomic status, geography, sexual orientation, disability, or special needs health-care needs. This is incorrect. Education is not a specific consideration when assessing the RN to assess for health disparities within the community.
PTS: 1 CON: Diversity 23. ANS: 1, 2 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures Chapter page reference: 030-034 Heading: Individualism versus Collectivism Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive level: Comprehension [Understanding] Concept: Communication; Diversity Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is correct. The Appalachian culture is considered individualistic; therefore, the nurse would anticipate that this patient will be encourage to express him- or herself. This is correct. The British culture is considered individualistic; therefore, the nurse would anticipate that this patient will be encourage to express him- or herself. This is incorrect. The Arab culture is considered collectivistic; therefore, the nurse would not anticipate this patient toNbeU en ex or herself. R ScoIura N GgeTtoBculture . CprOesMsis himThis is incorrect. The Asian-Indian considered collectivistic; therefore, the nurse would not anticipate this patient to be encourage to express him- or herself. This is incorrect. The Japanese culture is considered collectivistic; therefore, the nurse wouldnot anticipate this patient to be encourage to express him- or herself.
PTS: 1 CON: Communication | Diversity 24. ANS: 3, 4, 5 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures Chapter page reference: 030-034 Heading: Individualism versus Collectivism Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Cognitive level: Comprehension [Understanding] Concept: Communication; Diversity Difficulty: Easy
1. 2. 3.
Feedback This is incorrect. The Appalachian culture is considered individualistic; therefore, the nurse would anticipate that this patient will be encouraged to express him- or herself. This is incorrect. The British culture is considered individualistic; therefore, the nurse would anticipate that this patient will be encouraged to express him- or herself. This is correct. The Arab culture is considered collectivistic; therefore, the nurse would anticipate this patient to be discouraged from expressing himor herself.
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4. 5.
This is correct. The Asian-Indian culture is considered collectivistic; therefore, the nurse would anticipate this patient to be discouraged from expressing him- or herself. This is correct. The Japanese culture is considered collectivistic; therefore, the nurse would anticipate this patient to be discouraged from expressing him- or herself.
PTS: 1 CON: Communication | Diversity 25. ANS: 1, 2, 3 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures Chapter page reference: 030-034 Heading: Individualism versus Collectivism Integrated Processes: Nursing Process – Planning Client Need: Psychosocial Integrity Cognitive level: Comprehension [Understanding] Concept: Diversity Difficulty: Easy 1. 2. 3. 4. 5.
Feedback This is correct. A patient of German descent is likely to have individualistic cultural attributes; therefore, this practice is anticipated. This is correct. A patient of German descent is likely to have individualistic cultural attributes; therefore, this practice is anticipated. This is correct. A patient of German descent is likely to have individualistic cultural attributes; therefore, this practice is anticipated. This is incorrect. cultural attributes.This wNo ul U dR bSeIant N GicTip at B .edCfor O Ma patient with collectivistic This is incorrect. This would be anticipated for a patient with collectivistic cultural attributes.
PTS: 1 CON: Diversity 26. ANS: 4, 5 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures Chapter page reference: 030-034 Heading: Individualism versus Collectivism Integrated Processes: Nursing Process – Planning Client Need: Psychosocial Integrity Cognitive level: Comprehension [Understanding] Concept: Diversity Difficulty: Easy Feedback NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. 2. 3. 4. 5.
PTS: 1
This is incorrect. This would be anticipated for a patient with individualistic cultural attributes. This is incorrect. This would be anticipated for a patient with individualistic cultural attributes. This is incorrect. This would be anticipated for a patient with individualistic cultural attributes. This is correct. An Alaskan Native patient is likely to have collectivistic cultural attributes; therefore, this practice should be anticipated by the nurse. This is correct. An Alaskan Native patient is likely to have collectivistic cultural attributes; therefore, this practice should be anticipated by the nurse. CON: Diversity
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27. ANS: 1, 2 Chapter number and title: 3, Cultural Considerations Chapter learning objective: Identifying domains, concepts, and terminology essential to cultural assessment Chapter page reference: 026-028 Heading: Overview of Cultural Domains and Their Concepts Integrated Processes: Nursing Process – Assessment Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Diversity; Assessment Difficulty: Moderate 1. 2. 3. 4. 5. PTS: 1
Feedback This is correct. Use of tobacco is considered a high-risk behavior that is monitored during the cultural assessment process. This is correct. Use of alcoholic beverages may be a high-risk behavior; therefore, this question is appropriate to include in the domain of the cultural assessment which monitors high-risk behaviors. This is incorrect. This question assesses family roles and organization, not high-risk behaviors. This is incorrect. This question assesses health-care practices, not high-risk behaviors. This is incorrect. This question assesses nutrition, not high-risk behaviors. CON: Diversity | Assessment NURSINGTB.COM
Chapter 4: Ethical Concepts Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is providing care to a client who is considered brain dead. The family has opted to end care and the health-care provider asks the nurse to pull the endotracheal (ET) tube. The nurse is uncomfortable with this request. Which is the reason the nurse is experiencing difficulty with this task? 1) An ethical conflict 2) Personal values 3) Legal issues 4) A cultural conflict 2. The nurse is providing care to an older adult patient with terminal cancer who has NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
opted to discontinue treatment and go home. The patient’s family, however, wants to continue treatment. The nurse agrees to be present while the patient tells the family. Which ethical patient principle is the nurse supporting? 1) Beneficence 2) Autonomy 3) Nonmaleficence 4) Justice
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3. Which statement best describes the American Nurses Association (ANA) Code of Ethics for professional nurses? 1) “It alleviates suffering for those cared for by professional nurses.” 2) “It provides standards for professional nursing practice.” 3) “It reflects legal judgments in professional nursing practice.” 4) “It serves as legal standards for professional nursing practice.” 4. Which statement regarding the American Nurses Association (ANA) Code of Ethics for professional nurses is accurate? 1) “It is used by all health-care professionals.” 2) “It guides nurses in their professional behavior and relationships.” 3) “It forms the basis for possible lawsuits.” 4) “It is the only code of ethics available for nurses." 5. Which professional value is the nurse demonstrating by volunteering time to work in a local free clinic? 1) Human dignity 2) Integrity 3) Altruism 4) Social justice 6. Which action is appropriate when dealing with an ethical dilemma in practice? 1) Relying on nursing judgment 2) Examining all conflicts in the situation 3) Investigating all aspects of the situation 4) Making a decision based on the policy of the agency 7. The hospice nurse is providing care tNo Ua R teS rmIinNaGl pTatBie.ntCwOhMo has asked about guidance and support in ending life. Which should the nurse recognize in regards to making an ethical and moral decision in this circumstance? 1) Euthanasia has legal implications along with moral and ethical ones. 2) Passive euthanasia is an easy decision to arrive at. 3) Active euthanasia is supported in the Code for Nurses. 4) Assisted suicide is illegal in all states. 8. The nurse is providing care to a 3-year-old child whose parents decide to decline further treatment for cancer, which has metastasized. There is a conflict between the child’s parents and the rest of the family. Which should the nurse consider when determining the appropriate action for this patient? 1) The age of the child 2) The beliefs of the child 3) The values of the parents 4) The values of the rest of the family 9. A patient is diagnosed with a sexually transmitted infections (STI) and states to the nurse, “Promise you will not tell anyone about my condition.” Which action should the nurse take, when considering the Health Insurance Portability and Accountability Act (HIPAA) of 1996? NURSINGTB.COM
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1) 2) 3) 4)
Honor the patient’s wishes Respect the patient’s privacy and confidentiality. Communicate only necessary information. Not disclosing any information to anyone.
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10. The nurse is providing care to an older adult patient who has decided to discontinue the prescribed hemodialysis. The patient’s family, however, is not supportive of this decision. When using the theory of principles-based reasoning, which statement from the nurse is appropriate? 1) “The patient understands the decision and the advanced stage of the disease. If the patient quits treatment, the patient will die.” 2) “I need to try to help the family understand the patient’s decision so they can work through this situation together.” 3) “This patient is of sound mind and is capable of making independent decisions regarding health care. It really is the patient’s decision to make.” 4) “This patient’s health is so deteriorated that the treatment is not saving the patient's life. It is prolonging the ultimate outcome, which is death.” 11. The nurse is providing care to an older adult patient who is scheduled for surgery. During the preoperative assessment, the nurse discovers that the patient does not have an adequate understanding of the procedure. Which is the reason for the nurse to take action in this situation? 1) The patient is very old and has multiple health problems. 2) The family needs to agree to the surgery. 3) The nurse witnessed the consent. 4) The patient has a right to informed consent. 12. The nurse is providing care to a patient who states, “My doctor is refusing to treat me because I am noncompliant with his recommendations.” Which is the priority nursing action in this situation? 1) Have the patient contact a consumer agency. 2) Advise the patient to sue the health-care provider. 3) Take the patient’s issue to the hospital ethics committee. 4) Notify the health-care provider of the patient’s complaints. NURSINGTB.COM 13. A patient diagnosed with acquired immune deficiency syndrome (AIDS) is admitted to the acute care floor. Which stance regarding the care for this patient is supported by the American Nurses Association (ANA) Code of Ethics? 1) The nurse is morally obligated to care for the patient unless the risk exceeds responsibility. 2) The nurse has the responsibility to ensure the patient gets adequate medical care. 3) The patient has the right to choose not to disclose his or her condition to staff. 4) The patient is morally bound to disclose every aspect of his or her condition to staff. 14. An adolescent patient diagnosed with leukemia decides to stop chemotherapy treatments. The patient’s parents, however, want the health-care team to continue all treatments. Which action by the nurse is appropriate when providing care to this patient and family? 1) Helping the family by providing information and allowing them to voice their NURSINGTB.COM
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2) 3) 4)
concerns Confronting the parents and telling them not to be “selfish” in their child’s time of need Calling the authorities immediately Obtaining a court order to determine the patient is legally able to make his or her own decisions
15. A patient tells the nurse, “I don’t really like the nurse on the first shift; she treats me bad.” Which action by the nurse is appropriate in order to advocate for this patient? 1) Call the agency patient advocacy department. 2) Confront the nurse when she comes to work. 3) Tell the patient he or she has the right to switch nurses. 4) Call the local authorities.
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16. The nurse is providing care for a postpartum patient who states, “I know my rights and you have to do what I tell you!” Which response by the nurse is appropriate? 1) “I don't mind doing anything within reason, but you have a responsibility to be considerate to the staff as well.” 2) “That statement is not included in your patient rights; don't yell at me.” 3) “Why do you feel angry … did I do something you did not like?” 4) “Do you want me to take the baby to the nursery so you can calm down?” 17. Which is the priority nursing action for the ethical decision-making process? 1) Determine exactly what needs to be decided. 2) Formulate alternatives to solve the issue. 3) Implement an action to achieve the greatest benefit with the least amount of risk. 4) Ascertain if new information is available regarding the issue. 18. Which number of alternative solutions should be included when conducting ethical decision-making? 1) One 2) Two 3) Three 4) Four 19. Which ethical principle is the nurse assessing when asking who benefits from the actions of others? 1) Beneficence 2) Autonomy 3) Justice 4) Fidelity 20. Which ethical principle requires the cTcoBu . n tC a bOleMfor commitments made to self or nNuUrsRe S toIbN e others? 1) Beneficence 2) Autonomy 3) Justice 4) Fidelity Multiple Response Identify one or more choices that best complete the statement or answer the question. 21. Which should the nurse be aware of when preparing to act as a patient advocate in the hospital setting? Select all that apply. 1) The rights of a patient in a long-term care facility 2) The health department's patient rights statement 3) The hospital's patient rights statement 4) State and federal patient rights legislation 5) The unit policy manual 22. According to Provision 2 of the American Nurses Association (ANA) Code of NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Ethics, which member of the health-care team is the nurse’s primary commitment? Select all that apply. 1) Patient 2) Family 3) Physician 4) Community 5) Surgeon
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23. Which are ethical issues for the nurse to consider prior to deciding whether or not to honor the picket line during a strike situation? Select all that apply. 1) The need to support coworkers in their efforts to improve working conditions 2) The need to ensure that clients receive care and are not abandoned 3) The desire to take some time off 4) Loyalty to the nurse’s employer 5) The need for higher pay 24. The nurse is providing care to a pregnant patient with a history of drug use. The patient refuses testing for human immunodeficiency virus (HIV) despite the recommendation of her nurse-midwife. Which actions by the nurse are appropriate in this situation? Select all that apply. 1) Refusing to treat the patient unless she is tested 2) Running the test without the patient’s knowledge 3) Emphasizing the importance of the test to the patient 4) Offering counseling regarding the testing 5) Encouraging the patient to reconsider the decision to be tested throughout the pregnancy 25. A hospice nurse is providing care to a patient diagnosed with ovarian cancer. The patient is concerned that her two daughters are at an increased risk for cancer and asks the nurse for help. Which actions by the nurse are appropriate? Select all that apply. 1) Provide the family with information on hereditary cancer risks. 2) Assure the client that ovarian cancer is not hereditary. 3) Offer to refer the daughters to a genetic counselor. 4) Arrange for the client to have genetic testing. 5) Tell the client that her additional worrying is too stressful. NURSINGTB.COM
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 4: Ethical Concepts Answer Section MULTIPLE CHOICE 1.
ANS: 2 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Addressing ethical dilemmas associated with the care of the acutely ill adult Chapter page reference: 042 Heading: Experimental Therapies Integrated Processes: Caring Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Ethics Difficulty: Easy Feedback 1 The decision is within ethical principles. 2 The nurse is distressed because of personal values, which are in conflict with causing the client's death. 3 Extubating this patient would not be a legal decision. 4 Cultural values are not evidenced in this instance.
PTS: 1 CON: Ethics ANS: 2 2. NURSINGTB.COM Chapter number and title: 4, Ethical Concepts Chapter learning objective: Defining ethical principles Chapter page reference: 037-039 Heading: Ethical Theories Relevant to Nursing Integrated Processes: Caring Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Ethics Difficulty: Easy Feedback 1 Beneficence means “doing good.” NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 3 4
Autonomy refers to the right to make one’s own decisions. The nurse is supporting this principle by supporting the client in his decision. Nonmaleficence is the duty to “do no harm.” Justice is often referred to as fairness.
PTS: 1 CON: Ethics 3. ANS: 2 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Identifying professional standards that guide ethical nursing practice Chapter page reference: 035-037 Heading: Professional Standards for Ethical Practice Integrated Processes: Caring Client Need: Safe and Effective Care Environment – Management of Care
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Cognitive level: Comprehension [Understanding] Concept: Ethics Difficulty: Easy Feedback 1 Codes of ethics provide the atmosphere in which the nurse is able to alleviate suffering. 2 The ANA Code of Ethics is a formal statement of the group’s ideals and values. It is a set of ethical principles that serves as a standard for professional actions. 3 Codes of ethics do not necessarily reflect legal judgments. 4 Codes of ethics usually have higher requirements than legal standards, and they are never lower than the legal standards of the profession. PTS: 1 CON: Ethics 4. ANS: 2 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Identifying professional standards that guide ethical nursing practice Chapter page reference: 035-037 Heading: Professional Standards for Ethical Practice Integrated Processes: Caring Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Ethics Difficulty: Easy Feedback 1 Each profession has its own code of ethics. 2 The ANA Code of Ethics is a guide fo r nurses in th eir work with clients N U RS I N G TB . C O M and other professionals. 3 State laws regarding nursing are the basis of lawsuits, not the Code of Ethics. 4 There is also an International Code of Ethics promulgated by the International Council of Nurses. PTS: 1 CON: Ethics 5. ANS: 4 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Defining ethical principles Chapter page reference: 035-037 Heading: Professional Standards for Ethical Practice Integrated Processes: Caring Client Need: Safe and Effective Care Environment – NURSINGTB.COM
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Management of Care Cognitive level: Comprehension [Understanding] Concept: Ethics Difficulty: Easy Feedback 1 Human dignity is respect for the worth and uniqueness of individuals and populations. 2 Integrity is acting in accordance with an appropriate code of ethics and accepted standards of practice. 3 Altruism is concern for the welfare and well-being of others. 4 Social justice is upholding fairness on a social scale. This value is demonstrated in professional practice when the nurse works to ensure equal treatment under the law and equal access to quality health care.
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PTS: 1 CON: Ethics 6. ANS: 3 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse Chapter page reference: 039-043 Heading: Ethical Dilemmas Integrated Processes: Caring Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Ethics Difficulty: Moderate Feedback 1 Overconfidence can lead to poor decision making. 2 Examining the conflicts surrounding the issue is only one aspect of the situation to consider. 3 To avoid making a premature decision, the nurse plans to investigate all aspects of the dilemma before deciding. 4 Reading the agency policy regarding the matter addresses only one aspect of the situation. PTS: 1 CON: Ethics 7. ANS: 1 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Addressing ethical dilemmas associated with the care NURSINGTB.CO of the acutely ill adult Chapter page reference: 039-043 Heading: Ethical Dilemmas Integrated Processes: Caring Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Ethics; Legal Difficulty: Easy Feedback 1 Determining whether an action is legal is only one aspect of deciding whether it is ethical. Legality and morality are not one and the same. The nurse must know and follow the legal statutes of the profession and boundaries within the state before making any decision. NURSINGTB.COM
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2 3 4
Passive euthanasia involves the withdrawal of extraordinary means of life support and is never an easy decision. Active euthanasia and assisted suicide are in violation of the Code for Nurses. Some states and countries have laws permitting assisted suicide for clients who are severely ill, are near death, and wish to commit suicide.
PTS: 1 CON: Ethics | Legal 8. ANS: 3 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse Chapter page reference: 039-043 Heading: Ethical Dilemmas
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Integrated Processes: Caring Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Ethics Difficulty: Easy Feedback 1 The age of the child is not a relevant factor in the decision making if the child is under 18 years. 2 The child is too young to have values and beliefs. 3 When confronted with a conflict regarding care, one of the first actions by the nurse is to consider the values and beliefs of the parents who are making the decision. 4 The nurse is respectful with the rest of the family but should consider the parents’ decision only. PTS: 1 CON: Ethics 9. ANS: 3 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Identifying professional standards that guide ethical nursing practice Chapter page reference: 037-039 Heading: Ethical Theories Relevant to Nursing Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Ethics Difficulty: Moderate NURSINGTB.COM Feedback 1 Clients must be able to trust that their information is secure and will only be shared with appropriate entities. In this case, the nurse may be required to report information to the state health department. 2 Clients must be able to trust that their information is secure and will only be shared with appropriate entities. In this case, the nurse may be required to report information to the state health department. 3 HIPAA includes standards that protect the confidentiality, integrity, and availability of data as well as standards that define appropriate disclosures of identifiable health information and client rights protection. Nurses are entrusted with sensitive information, which at times must be revealed to other health-care personnel in order to NURSINGTB.COM
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provide appropriate health care. In this case, the nurse may be required to report information to the state health department.
4
10.
Nurses should not make promises to keep necessary information private.
PTS: 1 CON: Ethics ANS: 3 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Describing ethical theories Chapter page reference: 037-039 Heading: Ethical Theories Relevant to Nursing Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care
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Cognitive level: Application [Applying] Concept: Ethics Difficulty: Moderate Feedback 1 The patient’s understanding of his decision and its consequences does not address the patient’s right to make a decision autonomously. 2 Caring theories, or relationship theories, stress courage, generosity, commitment, and the need to nurture and maintain relationships. Caring theories promote the common good or the welfare of the group. Trying to help the family understand the patient’s decision is an example of a caring-based theory in practice. 3 Principles-based theories stress individual rights, such as autonomy. The patient has the ability to make the decision, and it is his right to autonomy to do that. 4 Considering the patient’s condition and the outcome of treatment is an example of consequence-based reasoning, in which the nurse looks at the outcomes of the patient’s decision.
11.
PTS: 1 CON: Ethics ANS: 4 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Addressing ethical dilemmas associated with the care of the acutely ill adult Chapter page reference: 040 Heading: Informed Consent Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] NURSINGTB.COM Concept: Ethics Difficulty: Easy 1 2 3 4
12.
Feedback The patient’s age and health problems are not the reasons for the nurse to take action. The family does not make the decision regarding surgery unless the patient has been declared incompetent by the court. The nurse would want to have the surgery explained for the client’s sake, not because the nurse signed the form. The nurse should notify the surgeon because the patient has the right to informed consent.
PTS: 1 ANS: 3
CON: Ethics NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 4, Ethical Concepts Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse Chapter page reference: 043-044 Heading: Ethics Committees Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Ethics Difficulty: Hard
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
13.
14.
Feedback A consumer agency is not appropriate because this is an ethical matter. The nurse never advises a patient to sue but assists the patient to find help resolving the issue. Acting as a patient advocate and protecting the patient’s rights, the nurse should enlist the help of the hospital ethics committee. The nurse should act on behalf of the patient, and the best way to do that is by taking the issue to the hospital ethics committee, not to the health-care provider.
PTS: 1 CON: Ethics ANS: 1 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Identifying professional standards that guide ethical nursing practice Chapter page reference: 035-037 Heading: Professional Standards for Ethical Practice Integrated Processes: Caring Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Ethics Difficulty: Easy Feedback 1 According to the ANA Code of Ethics, the nurse cannot set aside the moral obligation to care for the patient infected with human immunodeficiency virus (HIV) unless the risk exceeds the responsibility. 2 This does not reflect the stanceN bUyRthSeIANNGATCBo.deCoOf MEthics. 3 This does not reflect the stance by the ANA Code of Ethics. 4 This does not reflect the stance by the ANA Code of Ethics. PTS: 1 CON: Ethics ANS: 1 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse Chapter page reference: 039-043 Heading: Ethical Dilemmas Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Ethics Difficulty: NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Moderate Feedback 1 Parents have the authority to make health-care decisions for their children. Dilemmas arise when parents and children do not agree on whether or not to go forward with a recommended treatment. In most cases, the nurse and other members of the health-care team who have developed a therapeutic alliance with the child and family may be able to help the family come to a joint decision by providing additional information and opportunity to discuss their concerns with each other calmly and openly. In some cases, however, the health-care team may need to seek guidance from the agency’s ethics committee.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 3 4
15.
16.
Confronting the parents is likely to do more harm than good especially in the context of telling the parents they are being selfish in their child’s time of need. There is no need to contact the authorities. It is not appropriate to obtain a court order to determine if the patient is legally able to make his or her own decision in this circumstance.
PTS: 1 CON: Ethics ANS: 1 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse Chapter page reference: 035-037 Heading: Professional Standards for Ethical Practice Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Ethics Difficulty: Moderate Feedback 1 Individual patients who feel their rights have been violated or are endangered have a number of options. Many hospitals and large provider agencies have patient advocates who can help patients navigate the system and intervene to ensure that their rights are maintained. 2 Confronting the nurse is likely to cause a confrontation and is not the best action for the nurse to take at this time. 3 While the patient does have the right to refuse ca re , this is not N URS INGT B .C O M always a realistic solution. 4 There is no need to contact the authorities as there is no evidence that the nurse has been abusive to this patient. PTS: 1 CON: Ethics ANS: 1 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse Chapter page reference: 035-037 Heading: Professional Standards for Ethical Practice Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Concept: Communication; Ethics Difficulty: Moderate Feedback 1 Most hospitals now publish lists of patient responsibilities, emphasizing that health care is a partnership between the patient and caregivers, that other patients have a right to be comfortable too, and that there are consequences if patients don't comply with treatment plans, cooperate with the health-care team, or be considerate of the staff and other patients. 2 This is not an appropriate response by the nurse. 3 This is not an appropriate response by the nurse. 4 This is not an appropriate response by the nurse.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
17.
18.
PTS: 1 CON: Communication | Ethics ANS: 1 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse Chapter page reference: 039-043 Heading: Ethical Dilemmas Integrated Processes: Nursing Process – Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Ethics Difficulty: Hard Feedback 1 The priority action for the ethical decision-making process is assessment. During this step, the nurse determines exactly what needs to be decided. 2 During the planning stage of ethical decision-making, the nurse formulates alternatives to solve the issue. 3 During the implementation stage of ethical decision-making, the nurse implements an action to achieve the greatest benefit with the least amount of risk. 4 During the evaluation stage of ethical decision-making, the nurse ascertains if new information is available regarding the issue to determine if new actions should be implemented. PTS: 1 CON: Ethics ANS: 3 NURSINGTB.COM Chapter number and title: 4, Ethical Concepts Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse Chapter page reference: 039-043 Heading: Ethical Dilemmas Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Knowledge [Remembering] Concept: Ethics Difficulty: Easy Feedback NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
19.
One alternative solution is not the recommended number when implementing ethical decision-making. Two alternative solutions are not the recommended number when implementing ethical decision-making. The nurse should ensure that three alternative solutions are available when implementing ethical decision-making. Four alternative solutions are not the recommended number when implementing ethical decision-making.
PTS: 1 CON: Ethics ANS: 1 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Defining ethical principles Chapter page reference: 037-039
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Heading: Ethical Theories Relevant to Nursing Integrated Processes: Nursing Process – Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Ethics Difficulty: Easy Feedback 1 Beneficence asks the question who benefits from the actions taken by others. 2 Autonomy examines an individual person’s right to make decisions while providing acknowledgement and respect for the person’s choices. 3 Justice examines who will be vulnerable from any actions taken. 4 Fidelity requires the nurse to be accountable for commitments made to others and self.
20.
PTS: 1 CON: Ethics ANS: 4 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Defining ethical principles Chapter page reference: 037-039 Heading: Ethical Theories Relevant to Nursing Integrated Processes: Nursing Process – Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Ethics Difficulty: Easy NURSINGTB.COM 1 Beneficence asks the question who benefits from the actions taken by others. 2 Autonomy examines an individual person’s right to make decisions while providing acknowledgement and respect for the person’s choices. 3 Justice examines who will be vulnerable to any actions taken. 4 Fidelity requires the nurse to be accountable for commitments made to others and self. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1
CON: Ethics
MULTIPLE RESPONSE 21. ANS: 3, 4 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Identifying professional standards that guide ethical nursing practice Chapter page reference: 039-043 Heading: Ethical Dilemmas Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Ethics; Nursing Roles Difficulty: Easy Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. 2. 3. 4.
5.
This is incorrect. The rights of a patient in a long-term care facility are not applicable when providing care in the hospital setting. This is incorrect. The rights of a patient in the health department setting are not applicable when providing care in the hospital setting. This is correct. The hospital’s patient rights statement will assist the nurse to act as a patient advocate in the hospital setting. This is correct. The state and federal patient rights legislation is applicable to patients in the hospital setting; therefore, the nurse should have knowledge of this information when acting as a patient advocate. This is incorrect. The unit’s policy manual will not have a separate policy statement from the hospital regarding the patient’s rights.
PTS: 1 CON: Ethics | Nursing Roles 22. ANS: 1, 2, 4 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Identifying professional standards that guide ethical nursing practice Chapter page reference: 035-037 Heading: Professional Standards for Ethical Practice Integrated Processes: Caring Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Ethics Difficulty: Easy
1. 2. 3. 4. 5.
NURSINGTB.COM This is correct. The patient is the nurse’s primary commitment according to the ANA Code of Ethics. This is correct. The family is the nurse’s primary commitment according to the ANA Code of Ethics. This is incorrect. The physician is not the nurse’s primary commitment according to the ANA Code of Ethics. This is correct. The community is the nurse’s primary commitment according to the ANA Code of Ethics. This is incorrect. The surgeon is not the nurse’s primary commitment according to the ANA Code of Ethics.
PTS: 1 CON: Ethics 23. ANS: 1, 2, 4 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse Chapter page reference: 035-037 Heading: Professional Standards for Ethical NURSINGTB.COM
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Practice Integrated Processes: Caring Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Ethics Difficulty: Easy Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. 2. 3. 4. 5.
This is correct. Strikers may be concerned about patient care as it is related to adequate staffing. This is correct. Strikes may adversely affect patient care and outcomes. This is incorrect. The desire to take time off and the need for higher pay are not ethical issues. This is correct. Nurses may feel allegiance to a hospital where they have worked for years. This is incorrect. The desire to take time off and the need for higher pay are not ethical issues.
PTS: 1 CON: Ethics 24. ANS: 3, 4, 5 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse Chapter page reference: 039-043 Heading: Ethical Dilemmas Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Ethics Difficulty: Moderate 1. 2. 3. 4. 5.
Feedback This is incorrect. Testing for HIV status is not mandatory; therefore, it is unethical to refuse to treat the patient unless she is tested. This is incorrect. It is unethical to test the patient for HIV without her knowledge; patients have the right to refuse treatment. This is correct. SuggestiNngUcRoun S IseNliGngTaBnd. co C OnsMistently encouraging testing are recommended. This is correct. Suggesting counseling and consistently encouraging testing are recommended. This is correct. Suggesting counseling and consistently encouraging testing are recommended.
PTS: 1 CON: Ethics 25. ANS: 1, 3, 4 Chapter number and title: 4, Ethical Concepts Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse Chapter page reference: 039-043 Heading: Ethical Dilemmas Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Ethics Difficulty: NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Moderate 1. 2. 3. 4. 5.
Feedback This is correct. A nurse’s role as educator is crucial to ethical practice. This is incorrect. Inaccurate reassurance or avoidance does not respect the patient’s rights. This is correct. Providing appropriate alternatives and options for the patient and the family are correct responses to the patient's concerns. This is correct. Providing appropriate alternatives and options for the patient and the family are correct responses to the patient's concerns. This is incorrect. Inaccurate reassurance or avoidance does not respect the patient’s rights.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1
CON: Ethics
Chapter 5: Palliative Care and End-of-Life Issues Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A competent older adult patient has a living will that expresses the patient’s desire to avoid resuscitation and heroic life support measures. The patient’s family, however, is not supportive of this directive and plans to contest the living will. Which nursing action is appropriate based on the current situation? 1) Notify the hospital attorney. 2) Contact the Social Services department. 3) Place the document on the patient’s medical record. 4) Explain to the patient that the conflict could invalidate the document. 2. The nurse is providing care for a Catholic patient who has suffered a massive cerebral hemorrhage and is not expected to survive. Which intervention by the nurse is most appropriate? 1) Contact a priest to deliver the Sacrament of the Sick. 2) Make plans for the family to wash the body after death. 3) Contact a rabbi so that the patient can participate in prayer. 4) Discuss the need to cremate the patient, as burial is not accepted in this faith. 3. The nurse is caring for a terminally ill patient and family members. The family has been tearful and sad since the terminal diagnosis was given. WhNicUhRshSoIulNd GbeTtBh e.nCu O rsMe’s focus when planning care? 1) Hopelessness 2) Caregiver role strain 3) Anticipatory grieving 4) Complicated grieving 4. The nurse is providing care to a patient who is diagnosed with terminal lung cancer. The patient is lying in the supine position with noisy wet respirations noted and is not breathing well. The patient has a living will which designates the implementation of comfort measures. Which action by the nurse is appropriate? 1) Withhold all care until the patient dies. 2) Provide the patient with pain medication as ordered. 3) Ask the family what they want to be done for the patient. 4) Reposition the patient to a lateral position, with the head elevated as tolerated. 5. The nurse is caring for a dying child who is being treated with comfort measures only. Which nursing action supports the primary goal for this patient? 1) Assess and medicate, as ordered, for any signs and symptoms of distress. 2) Maintain a busy schedule for child and family members. NURSINGTB.COM
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3) 4)
Keep the child entertained so she does not think about dying. Ensure that a good relationship is maintained with the family.
6. The parents of a child with terminal cancer ask the nurse that the child not be told that he will not recover. The child asks the nurse if he is dying. What should the nurse do at this time? 1) Ignore the child’s question and change the subject. 2) Tell the child he is dying and offer to stay with him. 3) Suggest a meeting with the health-care team and the parents.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4)
Offer to bring in the child life therapist to help explain the situation.
7. An older school-age child is brought to the emergency department (ED) after a car accident. The parents witness and stare at the resuscitation scene unfolding before them. The child is not responding to the resuscitative efforts after 30 minutes. Which is the best communication strategy for the nurse to use in this situation? 1) Ask the parents to leave until the child has stabilized. 2) Ask the parents to stand at the foot of the cart to watch. 3) Discuss with the parents whether they would like resuscitative efforts to be continued at this point. 4) Inform the parents that resuscitative efforts have not been effective and are not beneficial to the child. 8. An adolescent patient with terminal cancer tells the nurse that she does not want to continue treatment, even though her parents are planning for her to participate in a study trial that involves aggressive chemotherapy. Which action by the nurse is the most appropriate? 1) Tell her not to worry, that she knows her parents want the best for her. 2) Tell the patient that the decision is her parents’ and she has to participate in the study. 3) Notify the adolescent that she can make her own decisions no matter what her parents want. 4) Request that the parents and daughter meet together with the healthcare team to discuss options and the implications of various choices. 9. The nurse is providing care for a patient receiving curative care who is experiencing chronic pain due to cancer. Which type of care should the nurse plan for upon discharge for this patient? 1) Home health care NURSINGTB.COM 2) Palliative care 3) Hospice care 4) Rehabilitative care 10. The nurse is assessing the patient for palliative care. When assessing the social domain, which should the nurse include? 1) Financial concerns 2) Pain 3) Depression 4) Spiritual concerns 11. The nurse is assessing the patient for palliative care. When assessing the physical domain, which should the nurse include? 1) Financial concerns 2) Pain 3) Depression 4) Spiritual concerns NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
12. The nurse is assessing the patient for palliative care. When assessing the psychosocial and psychiatric domain, which should the nurse include? 1) Financial concerns 2) Pain 3) Depression 4) Spiritual concerns
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13. The nurse is assessing the patient for palliative care. When assessing the cultural domain, which question should the nurse include? 1) “Do you have any financial concerns regarding your care?” 2) “Are you currently experiencing pain?” 3) “Are you experiencing any depression or anxiety?” 4) “Do you have any specific dietary preferences that affect your care?” 14. The nurse is educating the family of a patient who is receiving hospice care due to a terminal illness. Which medication should the nurse tell the family to administer for this patient if delirium occurs? 1) Morphine 2) Haloperidol 3) Diphenhydramine 4) Docusate 15. The nurse is educating the family of a patient who is receiving hospice care due to a terminal illness. Which medication should the nurse tell the family to administer to treat the patient’s pain? 1) Morphine 2) Haloperidol 3) Diphenhydramine 4) Docusate 16. The nurse is educating the family of a patient who is receiving hospice care due to a terminal illness. Which benzodiazepine medication should the nurse tell the family to administer to treat the patient if hyperactive delirium occurs? 1) Morphine 2) Haloperidol NURSINGTB.COM 3) Diphenhydra mine 4) Lorazepam 17. The nurse is providing care to a patient who is approaching death. Which family member statement regarding the physical and psychological changes associated with death is reflective of the late stage? 1) “A loss of appetite often occurs during this stage.” 2) “Respirations may sound loud and wet during this stage.” 3) “I might notice that he will begin to sleep more during this stage.” 4) “Confusion or disorientation may begin to occur during this stage.” 18. The nurse is providing care to a patient who is approaching death. Which family member statement regarding the physical and psychological changes associated with death is reflective of the middle stage? 1) “A loss of appetite often occurs during this stage.” 2) “Respirations may sound loud and wet during this stage.” 3) “I might notice that he will begin to sleep more during this stage.” 4) “Confusion or disorientation may begin to occur during this stage.” NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
19. Which response by the nurse indicates the use of reflective reasoning when communicating with the family of a patient who is in the process of dying? 1) “I can see this is difficult for you.” 2) “Thank you for taking such good care of your mother.” 3) “Your mother is experiencing quite a bit of pain at the moment.” 4) “A social worker will be able to answer all the questions that you have.” 20. Which concept exemplifies a well-managed death experience for a terminal patient and family members? 1) Allowing the patient to die alone
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2) 3) 4)
Withholding pain medication to decrease addiction Encouraging a lengthy dying process to allow for goodbyes Preparing the patient and the family for the process of dying
21. Which is a team action that nurses can employ as a stress-reducing strategy? 1) Practicing yoga on a daily basis 2) Journaling feelings related to patient care 3) Engaging in aerobic exercise several times per week 4) Sending a bereavement card to the family of a patient who recently passed Multiple Response Identify one or more choices that best complete the statement or answer the question. 22. Which factors can create moral distress for nurses? Select all that apply. 1) Supportive management staff 2) Low stress patient environment 3) High technology patient care situations 4) Cultural differences with the patient population 5) Resource pressures when providing patient care 23. The nurse is providing care to a patient who is diagnosed with terminal lung cancer. Which clinical manifestations indicate imminent death? Select all that apply. 1) Diaphoresis 2) Increased cardiac output 3) Decreased blood pressure 4) Tachycardia followed by bradycNarUdR ia SINGTB.COM 5) An increase in the volume of Korotkoff's sounds 24. The wife of a patient with end-stage chronic obstructive pulmonary disease (COPD) tells the nurse that she wishes her husband were eligible for hospice care but she thinks that hospice is only available for cancer patients and would require a change in health-care providers. Which responses by the nurse are appropriate? Select all that apply. 1) Inform her that hospice care is very expensive. 2) Inform her that a diagnosis of cancer is not required for hospice care. 3) Inform her that all hospice programs provide care 24 hours per day, 7 days per week 4) Inform her that her husband can retain his provider when transitioning to hospice care. 5) Inform her that her husband is not eligible for hospice care with the current diagnosis of COPD. 25. The nurse is providing care to a terminal patient who is experiencing delirium. Which should the nurse assess prior to administering haloperidol to this patient? Select all that apply. 1) Last stool 2) Blood pressure NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3) 4) 5)
Respiratory rate Bladder distention Medication regimen
26. Which statement from the nurse to family members is appropriate to encourage the participation of providing physical care to the patient during the dying process? Select all that apply. 1) “You can bring in pictures of the family to comfort your loved one.” 2) “Apply lip balm to your loves one’s mouth if you feel the lips are dry.”
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3) 4) 5)
“You can massage your loved one’s arms and legs to provide comfort.” “Bring in music that your loved one likes to listen to with headphones.” “Your child can call your loved one if you don’t want to expose him to this process.”
27. A terminal patient has opted to stop treatment. The family, however, believes the patient is no longer competent to make this decision. Which data supports that the patient is capable of making this treatment decision? Select all that apply. 1) The patient is aware of the current date and location. 2) The patient does not want to be a burden on the family. 3) The patient communicates the decision with the health-care team. 4) The patient understands the nature and consequences of treatment. 5) The patient states the benefits and risks associated with the treatment.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 5: Palliative Care and End-of-Life Issues Answer Section MULTIPLE CHOICE 1.
ANS: 3 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life Chapter page reference: 051 Heading: Domain 8: Ethical and Legal Aspects of Care Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Critical Thinking; Legal Difficulty: Moderate 1 2 3 4
Feedback There is no need to notify the hospital attorney at this time. If there are concerns about the authenticity of the document, the Social Services department or the unit supervisor will need to be contacted. This patient is competent; therefore, the wishes of the client take priority. The document should be placed on the patient’s medical record and the health-care provider notified. A lack of support by the family, or a plan to contest, does not invalidate the document NURSINGTB.COM legally.
PTS: 1 CON: Critical Thinking | Legal 2. ANS: 1 Chapter number and title: 5, Palliative Care and End-ofLife Issues Chapter learning objective: Listing the domains of palliative care Chapter page reference: 048 Heading: Domain 5: Spiritual, Religious, and Existential Aspects of Care Integrated Processes: Nursing Process – Implementation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Spirituality Difficulty: Moderate Feedback NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
In the Catholic faith, it is common to receive the Sacrament of the Sick from a priest in order to receive spiritual strength and prepare for death. Making plans for the family to wash the body after death is appropriate for a patient who is Muslim, not Catholic. Contacting a rabbi would be appropriate for a Jewish, not Catholic, patient. Cremation is not preferred over burial in the Catholic faith.
PTS: 1 CON: Spirituality 3. ANS: 3 Chapter number and title: 5, Palliative Care and End-of-Life Issues
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Chapter learning objective: Developing communication and support strategies for family members Chapter page reference: 050-051 Heading: Family Support Integrated Processes: Nursing Process – Planning Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate Feedback 1 There are no assessment findings that indicate complicated grieving or hopelessness. 2 This reaction is typical of family members, so there is no indication that the family is exhibiting caregiver role strain. 3 Grieving prior to the actual loss is termed anticipatory grieving. 4 There are no assessment findings that indicate complicated grieving or hopelessness. PTS: 1 CON: Grief and Loss 4. ANS: 1 Chapter number and title: 5, Palliative Care and End-ofLife Issues Chapter learning objective: Listing the domains of palliative care Chapter page reference: 048050 Heading: Symptom Management Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Grief and NURSINGTB.COM Loss Difficulty: Moderate Feedback 1
2 3
“Comfort measures only” indicates that the patient does not want extraordinary measures to sustain life. This does not mean that nursing care ceases but that nursing care to provide patient comfort is intensified and maintained through the end stages of the patient’s life. The nurse did not note the patient had any verbal or nonverbal signs or symptoms of pain, so medicating the patient for pain is not appropriate. Asking the family what they want to be done is inappropriate when a patient has written a living will. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4
Repositioning the patient from the supine position to a lateral position with the head elevated as tolerated would be the first step to address the patient’s symptoms. The nurse may need to medicate the patient with an anticholinergic agent to dry the secretions if ordered. If not ordered, the patient may need to contact the health-care provider to get an order for this type of medication for comfort measures.
PTS: 1 CON: Grief and Loss 5. ANS: 1 Ans: 1 Chapter number and title: 5, Palliative Care and End-ofLife Issues Chapter learning objective: Listing the domains of palliative care Chapter page reference: 048050 Heading: Symptom Management
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Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate 1 2 3 4
Feedback The major goal for the dying child is to promote comfort and keep the child symptom- free. A dying child does not have the energy to maintain a busy schedule. Keeping the child entertained is good, but the pediatric patient needs to voice her feelings about death and dying. Maintaining a good relationship is important but not a major goal for the child’s care.
PTS: 1 CON: Grief and Loss 6. ANS: 3 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Developing communication and support strategies for family members Chapter page reference: 050-051 Heading: Family Support Integrated Processes: Nursing Process – Implementation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate NURSINGTB.COM Feedback 1 Avoiding the subject is not an option. Changing the subject or ignoring the child is not appropriate. 2 Telling the child he is dying would be going against the parents’ wishes. 3 Offering to set up a meeting with the health-care team to discuss the parents’ fears and concerns about telling their child the truth is the best action by the nurse. 4 The nurse should explain that the parents will talk to the child about this. The child has asked the nurse, but because the child is a minor, the nurse must consult with the parents first. Legally they cannot talk to the child. PTS: 1 CON: Grief and Loss 7. ANS: 4 Chapter number and title: 5, Palliative Care and End-of-Life Issues NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Developing communication and support strategies for family members Chapter page reference: 050-051 Heading: Family Support Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate Feedback 1 This is not an effective communication strategy in this situation. 2 This is not an effective communication strategy in this situation.
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3 4
When asking to withhold therapy such as cardiopulmonary resuscitation, it is helpful to indicate that the therapy is not effective in reversing overwhelming illness or brain damage. Care must be used in how the parents are asked to withdraw therapies. An effective communication strategy is to inform the parents that an intervention was initiated to give the child the best chance of recovery, but it has not been effective and is not beneficial to the child.
PTS: 1 CON: Grief and Loss 8. ANS: 4 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Developing communication and support strategies for family members Chapter page reference: 050-051 Heading: Family Support Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Grief and Loss; Legal Difficulty: Moderate Feedback 1 Telling her not to worry does not address the problem. 2 This is not an accurate statement from the nurse. 3 This is not an accurate statement from the nurse. 4 Adolescents with a serious medical condition are more capable of making treatment decisions than most teenagers.NHUoRwSevIerN, th Determination G eT Pa B .tien C Ot SelfM Act of 1990 limits the legal rights of individuals younger than 18 to make their own health-care decisions. If the adolescent states a desire to withdraw from or refuse treatment, her parents and health-care team should discuss the reasons for her decision and help her understand the implications of her decision and any treatment alternatives that may influence her choice. PTS: 1 CON: Grief and Loss | Legal 9. ANS: 2 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Discussing the meaning of palliative care and hospice care Chapter page reference: 047-052 Heading: Palliative Care Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] NURSINGTB.COM
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Concept: Comfort Difficulty: Moderate Feedback 1 Home health care provides skilled care to patients who are home bound. This is not the best choice for the patient. 2 Palliative care is a specialized form of care that focuses on relief of pain and other symptoms and stress associated with a severe illness. 3 Hospice care focuses on the care of a terminally patient with less than 6 months to live.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4
10.
11.
Rehabilitative care provides rehab services for patients who require strengthening after hospitalization.
PTS: 1 CON: Comfort ANS: 1 Chapter number and title: 5, Palliative Care and End-ofLife Issues Chapter learning objective: Listing the domains of palliative care Chapter page reference: 048 Heading: Domain 4: Social Aspects of Care Integrated Processes: Nursing Process – Assessment Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Assessment Difficulty: Moderate Feedback 1 Assessing the patient’s financial concerns is included when conducting an assessment for the social aspects related to palliative care. 2 Assessing the patient’s pain is included when conducting an assessment for the physical aspects of palliative care. 3 Assessing the patient for depression is included when conducting an assessment for the psychosocial and psychiatric aspects of palliative care. 4 Assessing the patient for spiritual concerns is included when conducting an assessment for the spiritual, religious, and existential aspects of palliative care. PTS: 1 CON: Assessm NeUn tR SINGTB.COM ANS: 2 Chapter number and title: 5, Palliative Care and End-ofLife Issues Chapter learning objective: Listing the domains of palliative care Chapter page reference: 048 Heading: Domain 2: Physical Aspects of Care Integrated Processes: Nursing Process – Assessment Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Assessment Difficulty: Moderate Feedback 1 Assessing the patient’s financial concerns is included when conducting an assessment for the social aspects related to palliative NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
care. 2 3 4
12.
Assessing the patient’s pain is included when conducting an assessment for the physical aspects of palliative care. Assessing the patient for depression is included when conducting an assessment for the psychosocial and psychiatric aspects of palliative care. Assessing the patient for spiritual concerns is included when conducting an assessment for the spiritual, religious, and existential aspects of palliative care.
PTS: 1 CON: Assessment ANS: 3 Chapter number and title: 5, Palliative Care and End-ofLife Issues Chapter learning objective: Listing the domains of palliative care
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Chapter page reference: 048 Heading: Domain 3: Psychological and Psychiatric Aspects of Care Integrated Processes: Nursing Process – Assessment Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Assessment Difficulty: Moderate Feedback 1 Assessing the patient’s financial concerns is included when conducting an assessment for the social aspects related to palliative care. 2 Assessing the patient’s pain is included when conducting an assessment for the physical aspects of palliative care. 3 Assessing the patient for depression is included when conducting an assessment for the psychosocial and psychiatric aspects of palliative care. 4 Assessing the patient for spiritual concerns is included when conducting an assessment for the spiritual, religious, and existential aspects of palliative care.
13.
PTS: 1 CON: Assessment ANS: 4 Chapter number and title: 5, Palliative Care and End-ofLife Issues Chapter learning objective: Listing the domains of palliative care Chapter page reference: 048 Heading: Domain 6: Cultural Aspects of Care Integrated Processes: Nursing Process – Assessment ClientNURSINGTB.COM Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Assessment; Diversity Difficulty: Moderate Feedback 1 Assessing the patient’s financial concerns is included when conducting an assessment for the social aspects related to palliative care. 2 Assessing the patient’s pain is included when conducting an assessment for the physical aspects of palliative care. 3 Assessing the patient for depression or anxiety is included when conducting an assessment for the psychosocial and psychiatric aspects of palliative care. 4 Assessing the patient for dietary preferences that may affect care is included when conducting an assessment for the cultural aspects of palliative care. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
14.
PTS: 1 CON: Assessment | Diversity ANS: 2 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life Chapter page reference: 048-050 Heading: Symptom Management Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
15.
16.
Feedback Morphine is an opiate administered to treat the patient’s pain, not delirium. Haloperidol is a drug that is administered to treat delirium that can occur at the end of life. Diphenhydramine is an anticholinergic agent administered to dry the patient’s secretions, not to treat delirium. Docusate is a stool softener used to treat constipation, not delirium.
PTS: 1 CON: Grief and Loss ANS: 1 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life Chapter page reference: 048-050 Heading: Symptom Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate Feedback 1 Morphine is an opiate administered to treat the pain that patients may experience at the end of life. 2 Haloperidol is a drug that is administered to treat delirium, not pain, that can occur at the end of life. 3 Diphenhydramine is an anticholin er gic agent ad min istered to dry NU R S I N G T B . C O M the patient’s secretions, not to treat pain. 4 Docusate is a stool softener used to treat constipation, not pain. PTS: 1 CON: Grief and Loss ANS: 4 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life Chapter page reference: 048-050 Heading: Symptom Management Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
Feedback Morphine is an opiate administered to treat the pain that patients may experience at the end of life. Docusate is a stool softener used to treat constipation, not delirium. Diphenhydramine is an anticholinergic agent administered to dry the patient’s secretions, not to treat delirium. Lorazepam, a benzodiazepine, is administered for a patient who is experiencing hyperactive delirium at the end of life.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
17.
18.
PTS: 1 CON: Grief and Loss ANS: 2 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life Chapter page reference: 048-050 Heading: Domain 7: Care of the Imminently Dying Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Grief and Loss Difficulty: Hard Feedback 1 A loss of appetite often occurs during the early stage of the physical and psychological changes that occur prior to death. 2 Respirations often sound loud and wet during the late stage of the physical and psychological changes that occur prior to death. 3 Sleeping more often occurs during the early stage of the physical and psychological changes that occur prior to death. 4 Confusion or disorientation often occurs during the middle stage of the physical and psychological changes that occur prior to death. PTS: 1 CON: Grief and Loss ANS: 4 Chapter number and title: 5, Palliative Care and End-of-Life Issues NURSINGTB.COM Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life Chapter page reference: 048-050 Heading: Domain 7: Care of the Imminently Dying Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Grief and Loss Difficulty: Hard Feedback 1 A loss of appetite often occurs during the early stage of the physical and psychological changes that occur prior to death. 2 Respirations often sound loud and wet during the late stage of the physical and psychological changes that occur prior to death. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 4
19.
Sleeping more often occurs during the early stage of the physical and psychological changes that occur prior to death. Confusion or disorientation often occurs during the middle stage of the physical and psychological changes that occur prior to death.
PTS: 1 CON: Grief and Loss ANS: 1 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Developing communication and support strategies for family members Chapter page reference: 050-051 Heading: Family Support
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Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Communication; Grief and Loss Difficulty: Moderate Feedback 1 The use of reflective listening often helps the family process the dying experience. Making a statement such as acknowledging that the experience is difficult is a response by the nurse that exemplified reflective listening. 2 This is not an example of reflective listening. 3 This is not an example of reflective listening. 4 This is not an example of reflective listening.
20.
21.
PTS: 1 CON: Communication | Grief and Loss ANS: 4 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Developing communication and support strategies for family members Chapter page reference: 050-051 Heading: Domain 8: Ethical and Legal Aspects of Care Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive level: Comprehension [Understanding] Concept: Grief and Loss Difficulty: Easy NURSINGTB.COM 1 A well-managed death experience includes a patient who does not die alone but in the presence of loved ones or caretakers. 2 Appropriate symptom management, including pain management, is included in a well- managed death experience. The risk for addiction is not an issue. 3 A prolonged dying experience should be avoided even if the patient is unable to say goodbye to loved ones. 4 A well-managed death experience includes preparing the patient, and family members, for what to expect during the process of dying. PTS: 1 CON: Grief and Loss ANS: 4 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Identifying nursing self-care strategies Chapter page NURSINGTB.COM
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reference: 052-053 Heading: Nurse SelfCare Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive level: Comprehension [Understanding] Concept: Nursing Roles Difficulty: Easy Feedback 1 Yoga is an individual, not team, self-care activity. 2 Journaling feelings is an individual, not team, self-care activity. 3 Engaging in aerobic exercise is an individual, not team, self-care activity.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4
Sending a bereavement card to the family of a patient who has recently passed is a team action nurses can employ as a stressreducing strategy.
PTS: 1
CON: Nursing Roles
MULTIPLE RESPONSE 22. ANS: 3, 4, 5 Chapter number and title: 5, Palliative Care and End-ofLife Issues Chapter learning objective: Explaining moral distress in end-of-life issues Chapter page reference: 052053 Heading: Ethical Implications and Moral Distress Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive level: Comprehension [Understanding] Concept: Grief and Loss Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is incorrect. An unsupportive, not supportive, management staff leads to moral distress for nurses. This is incorrect. A high, not low, stress environment leads to moral distress for nurses. This is correct. High technology patient care situations often lead to moral distress for nurses. This is correct. Cultural differences between the nurse and the patient population often lead to moral distress for nursesN. URSINGTB.COM This is correct. Resource pressures when providing patient care often lead to moral distress for nurses.
PTS: 1 CON: Grief and Loss 23. ANS: 1, 3, 4 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Developing communication and support strategies for family members Chapter page reference: 048-051 Heading: Domain 7: Care of the Imminently Dying Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
[Understanding] Concept: Grief and Loss Difficulty: Easy
1. 2. 3. 4.
Feedback This is correct. Peripheral circulation decreases, leading to diaphoresis; clammy, cool skin; and changes in skin coloring. This is incorrect. Decreased cardiac output results from bradycardia and hypotension. This is correct. The heart rate and blood pressure decrease, resulting in decreased cardiac output, which is a sign of imminent death. This is correct. The heart rate might initially increase as hypoxia develops; then the heart rate and blood pressure decrease, resulting in decreased cardiac output.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5.
This is incorrect. A change in pulse pressure and a decrease in the volume of Korotkoff's sounds indicate imminent death.
PTS: 1 CON: Grief and Loss 24. ANS: 2, 4 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Discussing the meaning of palliative care and hospice care Chapter page reference: 047 Heading: Domain 1: Structure and Process of Care Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Grief and Loss Difficulty: Moderate 1. 2. 3. 4. 5.
Feedback This is incorrect. Hospice care is often less expensive than conventional care in the last six months of life. This is correct. In addition to clients who are diagnosed with cancer, a variety of clients qualify for hospice care. This is incorrect. Hospice teams visit clients intermittently, although they are available 24/7 for support and care. This is correct. Hospice reinforces the client-primary physician relationship by advocating office or home visits. This is incorrect. In add iti N on U RtoS cli I NenGtsT wBh.oCarOe Mdiagnosed with cancer, a variety of clients qualify for hospice care. A diagnosis of end-stage COPD is often a qualifier for hospice care.
PTS: 1 CON: Grief and Loss 25. ANS: 1, 4, 5 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life Chapter page reference: 048-050 Heading: Symptom Management Integrated Processes: Nursing Process – Assessment Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Grief and Loss; Assessment Difficulty: Moderate NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. 2. 3. 4.
Feedback This is correct. The last noted stool should be assessed to determine if constipation may be causing the delirium prior to medicating with the prescribed drug. This is incorrect. The nurse would not assess the patient’s blood pressure to determine the cause of delirium. This is incorrect. The nurse would not assess the patient’s respiratory rate to determine the cause of the delirium. This is correct. Bladder distention is often a cause for delirium; therefore, the nurse should assess for this prior to administering the prescribed drug.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5.
This is correct. Certain medications are known to cause delirium; therefore, the nurse should assess the patient’s medication regimen prior to administering the prescribed drug.
PTS: 1 CON: Grief and Loss | Assessment 26. ANS: 2, 3 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Developing communication and support strategies for family members Chapter page reference: 050-051 Heading: Family Support Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Analysis [Analyzing] Concept: Grief and Loss Difficulty: Hard
1. 2.
3.
4. 5.
Feedback This is incorrect. While bringing pictures is an appropriate suggestion, this does not allow the family to participate in the physical care of the patient during the dying process. This is correct. The lips of a patient who is experiencing the process of dying often become dry; therefore, the application of lip balm is an appropriate suggestion to allow the family to participate in the physical care of this patient. This is correct. A patient who is dying often experiences pain that can be remedied by massage; therefore, suggesting this to the family allows them to participate in the physical care of this patient. This is incorrect. While NbrUinRgiSn gI m usTicBfo.r CthOe Mpatient to listen to is NG appropriate, this addresses the patient’s psychosocial, not physical, needs. This is incorrect. Suggesting that a child call the dying patient is appropriate; however, this addresses the psychosocial, and not physical, needs of the patient and family.
PTS: 1 CON: Grief and Loss 27. ANS: 3, 4, 5 Chapter number and title: 5, Palliative Care and End-of-Life Issues Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life Chapter page reference: 051-052 Heading: Domain 8: Ethical and Legal Aspects of Care Integrated Processes: Nursing Process – Assessment Client Need: Psychosocial Integrity Cognitive level: Comprehension NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
[Understanding] Concept: Grief and Loss Difficulty: Easy
1. 2. 3.
Feedback This is incorrect. While this data supports that the patient is alert and oriented it does not indicate the patient’s decisional capacity. This is incorrect. The patient stating that he or she does not want to be a burden on the family is not data that supports the patient’s decisional capacity. This is correct. Being able to communicate a decision with the health-care team supports the patient’s decisional capacity.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4. 5.
PTS: 1
This is correct. Understanding the nature and the consequences of treatment supports the patient’s decisional capacity. This is correct. Stating the benefits and risks associated with the treatment supports the patient’s decisional capacity. CON: Grief and Loss
Chapter 6: Geriatric Implications for Medical-Surgical Nursing Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is providing care to an older adult patient who is experiencing bradycardia. When educating the patient about this disorder, which age-related cardiovascular change should the nurse include? 1) Stiffened artery walls 2) Increased size of the left atrium 3) Reduced number of pacemaker cells in the SA node 4) Decreased cardiac responsiveness to beta-adrenergic stimuli 2. The nurse is providing care to an oldeNrUadRuSltIp aNtiGenTt Bw.h oCiOs dMiagnosed with congestive heart failure (CHF). When educating the patient about this disorder, which age-related cardiovascular change should the nurse include? 1) Stiffened artery walls 2) Increased size of the left atrium 3) Reduced number of pacemaker cells in the SA node 4) Decreased cardiac responsiveness to beta-adrenergic stimuli 3. The nurse is providing care to an older adult patient who is diagnosed with atrial fibrillation. When educating the patient about this disorder, which age-related cardiovascular change should the nurse include? 1) Stiffened artery walls 2) Increased size of the left atrium 3) Reduced number of pacemaker cells in the SA node 4) Decreased cardiac responsiveness to beta-adrenergic stimuli 4. Which statement should the nurse include when educating older adult patients about dementia? 1) “Dementia causes impaired judgment.” 2) “Dementia causes fluctuations in alertness.” NURSINGTB.COM
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3) 4)
“Symptoms of dementia cause day-night reversal.” “Symptoms of dementia do not last more than one month.”
5. The nurse is providing care to an older adult patient who is diagnosed with an ulcer. Which age-related gastrointestinal change is often the cause for this diagnosis? 1) Slowed gastric emptying 2) Atrophied gastric mucosa 3) Increased secretion of gastrin
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4)
Reduced secretion of intrinsic factor
6. The nurse is providing care to an older adult patient who is diagnosed with osteoporosis. Which age-related cause should the nurse include in the teaching session? 1) Decreased speed of foot movements 2) Decreased absorption of vitamin D 3) Increased intramuscular fat 4) Increased subcutaneous fat 7. The nurse is assessing the older adult patient using the Get-Up-and-Go test. The patient is unable to stand without assistance. Which score should the nurse document? 1) 0 2) 1 3) 3 4) 4 8. Which nursing action is appropriate when conducting an hourly rounding when providing care to older adult patients? 1) Obtaining patient vital signs 2) Assisting the patient to the bathroom 3) Accounting for all personal items in the patient’s room 4) Documenting the amount of intake for the last meal eaten by the patient 9. Which classification should the nurse use when providing care to an adult patient who is 70 years of age? 1) Old 2) Old-old 3) Oldest NURSINGTB.COM old 4) Youngold 10. Which senescence term should the nurse use to describe the hardening of tissue due to fibrous tissue overgrowth that occurs with the aging process? 1) Atrophy 2) Stenosis 3) Sclerosis 4) Calcification 11. Which senescence term should the nurse for a patient who is diagnosed with narrowing of the coronary arteries? 1) Atrophy 2) Stenosis 3) Sclerosis 4) Calcification 12. Which senescence term should the nurse use to describe the wasting away of muscle NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
mass that occurs with the aging process? 1) Atrophy 2) Stenosis 3) Sclerosis 4) Calcification 13. Which senescence term should the nurse use to describe deposits of calcium salt in the blood vessels that often occurs with aging?
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1) 2) 3) 4)
Atrophy Stenosis Sclerosis Calcification
14. Which data collected by the nurse during the health history of an older adult patient increases the risk for heart disease? 1) Dependent edema 2) Diabetes insipidus 3) Cigarette smoking 4) Diminished hearing 15. Which nursing action supports The Joint Commission (TJCs) safety goals for providing home care to an older adult patient? 1) Verifying the patient’s first and last name during each visit 2) Administering all prescribed medications to the patient during scheduled visits 3) Recommending the use of throw rugs on hard wood floors to prevent patient falls 4) Asking family members to smoke in another room when oxygen is in use by the patient 16. Which clinical manifestation should the nurse anticipate when providing care to an older adult patient who is diagnosed with Parkinson disease? 1) Tremors 2) Paralysis 3) Vision impairment 4) Right-sided weakness 17. Which electrolyte imbalance should N thU e nRuSrsIe N mG o nTitBo r.aCn Oo lMd er adult patient for due to impaired renal diluting capacity and concentrating ability? 1) Hypokalemia 2) Hyponatremia 3) Hypocalcemia 4) Hypomagnesemia 18. Which electrolyte imbalance should the nurse monitor an older adult patient for when a diuretic is prescribed? 1) Hypokalemia 2) Hyponatremia 3) Hypocalcemia 4) Hypomagnesemia 19. The nurse is providing care to an older adult patient who is diagnosed with a vitamin B deficiency. The patient tells the nurse, “I feel so tired all the time and my daughter says I look pale.” Based on this data, which should the nurse suspect? 1) Anemia 2) Osteoporosis 3) Atrophic gastritis 4) Gastroesophageal reflux disease (GERD) 20. The nurse educates the older adult patient to increase activity, lose weight, and limit NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
dietary intake of fats and calories. Which disease process is the patient at risk for based on the teaching? 1) Fecal impaction 2) Diabetes insipidus 3) Type 2 diabetes mellitus (DM)
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4)
Gastroesophageal reflux disorder (GERD)
21. Which clinical manifestation does the nurse anticipate when providing care to an older adult patient diagnosed with failure to thrive (FTT)? 1) An increased appetite 2) A high cholesterol level 3) A weight loss of five pounds 4) Skin that loses elasticity with poor turgor Multiple Response Identify one or more choices that best complete the statement or answer the question. 22. Which older adult patient diagnoses should the nurse include information regarding cachexia into the plan of care? Select all that apply. 1) Lung cancer 2) Osteoporosis 3) Gastroesophageal reflux disorder (GERD) 4) Acquired immune deficiency syndrome (AIDS) 5) Chronic obstructive pulmonary disease (COPD) 23. Which priority safety concerns should the nurse assess when providing care to older adult patients? Select all that apply. 1) Falls 2) Neglect 3) Depression 4) Polypharmacy NURSINGTB.COM 5) Poor dietary intake 24. Which items found by a nurse during a home health visit increase the older adult patient’s risk for physical safety issues? Select all that apply. 1) Rugs 2) Electrical cords 3) Nonskid appliance in bathtub 4) Medications stored in a weekly divider 5) Telephone with emergency numbers listed 25. Which changes associated with aging should the nurse identify as possible inhibitors to medication adherence and safety? Select all that apply. 1) Decreased memory 2) Decreased visual acuity 3) Decreased hearing acuity 4) Decreased sense of smell 5) Decreased physical strength
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Chapter 6: Geriatric Implications for Medical-Surgical Nursing Answer Section MULTIPLE CHOICE 1.
ANS: 3 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Discussing age-related physiological changes Chapter page reference: 057-058 Heading: Common Cardiovascular Health Issues Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Feedback 1 Moderate The stiffening of artery walls causes the systolic blood pressure to rise. 2 3 4
Left atrial enlargement causes a fourth heart sound to be auscultated and is also responsible for an increased risk for hypertension and congestive heart failure (CHF). A reduced number of pacemaker cells in the SA node causes the maximum heart rate to decrease with age, leading to bradycardia. Decreased cardiac responsiveness to beta-adrenergic stimuli increases the risk for arrhythmias, atrial fibrillation, and reduced heart rate control when exposed to stressors.
NURSINGTB.COM CON: Perfusion
PTS: 1 2. ANS: 2 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Discussing age-related physiological changes Chapter page reference: 057-058 Heading: Common Cardiovascular Health Issues Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
Feedback The stiffening of artery walls causes the systolic blood pressure to rise. Left atrial enlargement causes a fourth heart sound to be auscultated and is also responsible for an increased risk for hypertension and congestive heart failure (CHF). A reduced number of pacemaker cells in the SA node causes the maximum heart rate to decrease with age, leading to bradycardia. Decreased cardiac responsiveness to beta-adrenergic stimuli increases the risk for arrhythmias, atrial fibrillation, and reduced heart rate control when exposed to stressors.
PTS: 1 3. ANS: 4
CON: Perfusion
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Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Discussing age-related physiological changes Chapter page reference: 057-058 Heading: Common Cardiovascular Health Issues Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate 1 2 3 4
Feedback The stiffening of artery walls causes the systolic blood pressure to rise. Left atrial enlargement causes a fourth heart sound to be auscultated and is also responsible for an increased risk for hypertension and congestive heart failure (CHF). A reduced number of pacemaker cells in the SA node causes the maximum heart rate to decrease with age, leading to bradycardia. Decreased cardiac responsiveness to beta-adrenergic stimuli increases the risk for arrhythmias, atrial fibrillation, and reduced heart rate control when exposed to stressors.
PTS: 1 CON: Perfusion 4. ANS: 1 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Identifying common health-care issues of the elderly Chapter page reference: 059-060 Heading: Dementia NURSINGTB.COM Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Cognition Difficulty: Moderate Feedback 1 Dementia causes impaired judgment; therefore, the nurse should include this statement in the educational session. 2 Delirium, not dementia, caused fluctuation in alertness. 3 Delirium, not dementia, causes day-night reversal. 4 Delirium, not dementia, lasts for no more than one month. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1 CON: Cognition 5. ANS: 3 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Discussing age-related physiological changes Chapter page reference: 062-064 Heading: Common Gastrointestinal Changes Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy
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1 2 3 4
Feedback Slowed gastric emptying causes gastric distention and anorexia. Atrophied gastric mucosa causes gastric distention and anorexia. Increased secretion of gastrin causes an increase in gastric acid which often leads to ulceration. Reduced secretion of intrinsic factor causes impaired vitamin B12 absorption.
PTS: 1 CON: Digestion 6. ANS: 2 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Discussing age-related physiological changes Chapter page reference: 064-065 Heading: Common Musculoskeletal Changes Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 Decreased speed of foot movement increases the patient’s risk for falls. 2 Decreased vitamin D absorption caused the development of osteoporosis. 3 Increased intramuscular fat causes a loss of muscle mass. 4 Increased subcutaneous fat causes a loss of muscle mass. 7.
PTS: 1 CON: Fluid a nNdUERleSctIroNlyGteTBBa .la nCcOe M ANS: 4 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Identifying common health-care issues of the elderly Chapter page reference: 064-065 Heading: Common Musculoskeletal Changes Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Mobility Difficulty: Easy NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
Feedback A score of 0 is assigned for a patient who can rise unassisted or hands free. A score of 1 is assigned for a patient who can rise using arms to push up in one attempt. A score of 3 is assigned for a patient who makes several attempts to push up andsucceeds in standing. This score indicates a higher risk for falls. A score of 4 is assigned for a patient who is unable to stand without assistance. This score indicates a higher risk for falls.
PTS: 1 CON: Mobility 8. ANS: 2 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Analyzing care priorities for geriatric patients Chapter page reference: 067-069
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Heading: Safety Issues Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 Hourly rounding is evidence-based practice that increases patient safety and decreases the risk for patient falls. The 4 P’s of hourly rounding include pain, potty, positioning, and possessions. Obtaining vital signs is not an action included in the 4 P’s of hourly rounding. 2 Hourly rounding is evidence-based practice that increases patient safety and decreases the risk for patient falls. The 4 P’s of hourly rounding include pain, potty, positioning, and possessions. Assisting the patient to the bathroom an action included in the 4 P’s of hourly rounding. 3 Hourly rounding is evidence-based practice that increases patient safety and decreases the risk for patient falls. The 4 P’s of hourly rounding include pain, potty, positioning, and possessions. Accounting for essential, not all, personal items is an action included in the 4 P’s of hourly rounding. Essential items include the call bell, tissues, eye glasses, etc. 4 Hourly rounding is evidence-based practice that increases patient safety and decreases the risk for patient falls. The 4 P’s of hourly rounding include pain, potty, positioning, and possessions. Documenting the amount of intake at the last meal is not an action included in the 4 P’s of hourly rounding. PTS: 1 CON: EvidencNeU-BRa S seId N PrGacTtiBce.COM 9. ANS: 4 Chapter number and title: 6, Geriatric Implications for MedicalSurgical Nursing Chapter learning objective: Defining the demographics of the aging population Chapter page reference: 056 Heading: Demographics Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Knowledge [Remembering] Concept: Communication Difficulty: Easy NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
10.
Feedback A patient age 75 to 85 is classified as old. A patient 85 years of age and older is classified as oldest old or oldold. A patient 85 years of age and older is classified as oldest old or oldold. A patient age 65 to 75 is classified as young-old.
PTS: 1 CON: Communication ANS: 3 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Discussing age-related physiological changes Chapter page reference: 056-057 Heading: Age-Related Changes and Common Health Problems Integrated Processes: Communication and Documentation
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 Atrophy is the term used to describe a wasting away or decrease in the size of an organ. 2 Stenosis is the term used to describe the narrowing or constricting of a passage of orifice. 3 Sclerosis is the term used to describe the hardening of tissue due to fibrous tissue overgrowth. 4 Calcification is the term used to describe abnormal deposits of calcium salts on organs.
11.
12.
PTS: 1 CON: Communication ANS: 2 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Discussing age-related physiological changes Chapter page reference: 056-057 Heading: Age-Related Changes and Common Health Problems Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 Atrophy is the term used to describe a wa stin g a way or decrease in the size of an organ. N URS I N G TB .CO M 2 Stenosis is the term used to describe the narrowing or constricting of a passage of orifice. 3 Sclerosis is the term used to describe the hardening of tissue due to fibrous tissue overgrowth. 4 Calcification is the term used to describe abnormal deposits of calcium salts on organs. PTS: 1 CON: Communication ANS: 1 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Discussing age-related physiological changes Chapter page NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
reference: 056-057 Heading: Age-Related Changes and Common Health Problems Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 Atrophy is the term used to describe a wasting away or decrease in the size of an organ. 2 Stenosis is the term used to describe the narrowing or constricting of a passage of orifice. 3 Sclerosis is the term used to describe the hardening of tissue due to fibrous tissue overgrowth. 4 Calcification is the term used to describe abnormal deposits of calcium salts on organs.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
13.
14.
PTS: 1 CON: Communication ANS: 4 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Discussing age-related physiological changes Chapter page reference: 056-057 Heading: Age-Related Changes and Common Health Problems Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 Atrophy is the term used to describe a wasting away or decrease in the size of an organ. 2 Stenosis is the term used to describe the narrowing or constricting of a passage of orifice. 3 Sclerosis is the term used to describe the hardening of tissue due to fibrous tissue overgrowth. 4 Calcification is the term used to describe abnormal deposits of calcium salts on organs. PTS: 1 CON: Communication ANS: 3 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Identifying common health-care issues of the elderly Chapter page reference: 056-057 NURSINGTB.COM Heading: Age-Related Changes and Common Health Problems Integrated Processes: Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy Feedback 1 Dependent edema is often a clinical manifestation of, not risk factor NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 3 4
15.
for, heart disease. Diabetes mellitus, not insipidus, is a risk factor for heart disease. Cigarette smoking is a risk factor for heart disease. Diminished hearing is an age-related change; however, this is not a risk factor for heart disease.
PTS: 1 CON: Perfusion ANS: 1 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Analyzing care priorities for geriatric patients Chapter page reference: 058 Heading: Safety Alert Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Safety Difficulty: Moderate
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2
3 4
16.
17.
Feedback Correctly identifying the patient is a TJC safety goal when providing home care. The nurse verifies the patient using the first and last name in order to meet this safety goal. Using medications safety is a TJC safety goal when providing home care. The nurse must use communication, teaching, and organizational skills to educate the patient about his or her medications. This includes indications, side effects, and dosing intervals. The nurse helps the patient develop a system for organizing the medications, usually accomplished with a “mediplanner” pill container. Throw rugs are discouraged as these increase the risk for patient falls, according to the TJC safety goals when providing home care. Smoking is prohibited in the home of any patient who is receiving oxygen per the TJC safety goals when providing home care.
PTS: 1 CON: Safety ANS: 1 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Identifying common health-care issues of the elderly Chapter page reference: 061 Heading: Parkinson’s Disease Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Neurologic Regulation Difficulty: Easy NURSINGTB.COM 1 Tremors, rigidity, and gait disturbances are all anticipated when providing care to an older adult patient diagnosed with Parkinson disease. 2 Paralysis is not a clinical manifestation anticipated when providing care to a patient diagnosed with Parkinson disease. 3 Vision impairment is not a clinical manifestation anticipated when providing care to a patient diagnosed with Parkinson disease. 4 Right-sided weakness is not a clinical manifestation anticipated when providing care to a patient diagnosed with Parkinson disease. PTS: 1 CON: Neurologic Regulation ANS: 2 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Identifying common health-care issues of the elderly Chapter NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
page reference: 061-062 Heading: Common Renal Issues Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Easy Feedback 1 Potassium imbalances occur from gastrointestinal losses and diuretics. 2 Sodium imbalances occur due to impaired renal diluting capacity and concentrating ability.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 4
18.
19.
Calcium imbalances are not associated with impaired renal diluting capacity and concentrating ability. Magnesium imbalances are not associated with impaired renal diluting capacity and concentrating ability.
PTS: 1 CON: Fluid and Electrolyte Balance ANS: 1 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Identifying common health-care issues of the elderly Chapter page reference: 061-062 Heading: Common Renal Issues Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Easy Feedback 1 Potassium imbalances occur from gastrointestinal losses and diuretics. 2 Sodium imbalances occur due to impaired renal diluting capacity and concentrating ability. 3 Calcium imbalances are not caused by diuretics. 4 Magnesium imbalances are not caused by diuretics. PTS: 1 CON: Fluid and Electrolyte Balance ANS: 1 NURSINGTB.COM Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Identifying common health-care issues of the elderly Chapter page reference: 062-064 Heading: Common Gastrointestinal Changes Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation Difficulty: Easy Feedback 1 A vitamin B12 deficiency often leads to anemia, which manifests with fatigue and pale skin. 2 Osteoporosis is not a consequence of a vitamin B 12 deficiency nor does it manifest with fatigue and pale skin. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3
4
20.
Atrophic gastritis is a common gastrointestinal issue that can occur with aging; however, it is not a consequence of a vitamin B 12 deficiency nor does it manifest with fatigue and pale skin. GERD is a common gastrointestinal issue that occurs with aging; however, it is not a consequence of a vitamin B12 deficiency nor does it manifest with fatigue and pale skin.
PTS: 1 CON: Hematologic Regulation ANS: 3 Chapter number and title: 6, Geriatric Implications for MedicalSurgical Nursing Chapter learning objective: Identifying common health-care issues of the elderly
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Chapter page reference: 062-064 Heading: Common Gastrointestinal Changes Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Metabolism Difficulty: Easy Feedback 1 This patient is not at risk for fecal impaction based on the current teaching. 2 This patient is not at risk for diabetes insipidus based on the current teaching. 3 This patient is at risk for type 2 DM based on the current teaching. 4 This patient is not at risk for GERD based on the current teaching.
21.
PTS: 1 CON: Metabolism ANS: 4 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Identifying common health-care issues of the elderly Chapter page reference: 063-064 Heading: Nutritional Issues Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Nutrition Difficulty: Moderate NURSINGTB.COM 1 A decreased, not increased, appetite is anticipated when providing care to an older adult patient diagnosed with FTT. 2 A low, not elevated, cholesterol level is anticipated when providing care to an older adult patient diagnosed with FTT. 3 Weight loss that is greater than five percentage of the patient’s weight is anticipated for a patient diagnosed with FTT. 4 Dehydration, manifested with decreased elasticity and turgor of the skin, supports the diagnosis of FTT. PTS: 1
CON: Nutrition
MULTIPLE RESPONSE NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
22. ANS: 1, 4, 5 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Identifying common health-care issues of the elderly Chapter page reference: 063-064 Heading: Nutritional Issues Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Nutrition Difficulty: Moderate
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. 2. 3. 4. 5.
Feedback This is correct. Cachexia is the loss of weight and muscle mass and cannot be reversed nutritionally. It is associated with the diagnosis of cancer. This is incorrect. A diagnosis of osteoporosis is not associated with cachexia. This is incorrect. A diagnosis of GERD is not associated with cachexia. This is correct. Cachexia is the loss of weight and muscle mass and cannot be reversed nutritionally. It is associated with the diagnosis of AIDS. This is correct. Cachexia is the loss of weight and muscle mass and cannot be reversed nutritionally. It is associated with the diagnosis of COPD.
PTS: 1 CON: Nutrition 23. ANS: 1, 2, 4 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Analyzing care priorities for geriatric patients Chapter page reference: 067-069 Heading: Safety Issues Integrated Processes: Nursing Process – Assessment Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Safety Difficulty: Moderate 1. 2. 3. 4. 5.
Feedback This is correct. Falls areNaUp rio R SriItyNsGafTetyB co . CncOeMrn the nurse should assess for when providing care to any older adult patient. This is correct. Neglect is a priority safety concern the nurse should assess for when providing care to any older adult patient. This is incorrect. Depression is not a priority safety concern for older adult patients. This is correct. Polypharmacy is a priority safety concern the nurse should assess for when providing care for any older adult patient. This is incorrect. Poor dietary intake is not a priority safety concern for older adult patients.
PTS: 1 CON: Safety 24. ANS: 1, 2 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Developing support strategies for the elderly Chapter page reference: 067 Heading: Physical Safety Integrated Processes: Nursing Process – Assessment NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Safety Difficulty: Moderate 1.
Feedback This is correct. Rugs increase the risk for falls for older adult patients; therefore, this is a physical safety risk.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2. 3. 4. 5.
This is correct. Electrical cords increase the risk for falls for older adult patients; therefore, this is a physical safety risk. This is incorrect. A nonskid appliance in the bathtub decreases the older adult patient’s risk for falls. This is incorrect. Medications that are stored in a weekly divider decrease the patient’s risk for physical injury. This is incorrect. A telephone with emergency numbers listed decreases the patient’s risk for physical injury.
PTS: 1 CON: Safety 25. ANS: 1, 2, 5 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: Analyzing care priorities for geriatric patients Chapter page reference: 067-068 Heading: Medication Safety Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Safety Difficulty: Moderate
1. 2. 3. 4. 5. PTS: 1
Feedback This is correct. Decreased memory often interferes with the patient’s ability to remember if a medication has been taken, which is a safety risk. This is correct. DecreaseNdUv RisuSaIl aNcui G ty T Bcan . CinOtMerfere with the patient’s ability to read the medication label for administration purposes, which is a safety risk. This is incorrect. While older adult patients do experience a decrease in hearing, this is not a factor in medication adherence and safety. This is incorrect. While older adult patients do experience a decrease in the sense of smell, this is not a factor in medication adherence and safety. This is correct. Decreased physical strength impedes the patient’s ability to safety administer prescribed medications. CON: Safety
Chapter 7: Oxygen Therapy Management Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is providing care to a patient who has a tracheostomy. The loss of which protective mechanismdoes the nurse plan to monitor this patient for during NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
the respiratory assessment process? 1) The ability to cough 2) The filtration and humidification of inspired air 3) A decrease in the oxygen-carrying capacity of the trachea 4) The sneeze reflex initiated by irritants in the nasal passages 2. When conducting a respiratory assessment, the nurse notes a low-pitched sound that is continuous throughout inspiration. Which does this lung sound indicate to the nurse?
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1) 2) 3) 4)
Narrow bronchi Narrow trachea passages Inflamed pleural surfaces Blocked large airway passages
3. The nurse is providing care to a patient admitted with a respiratory disorder. Which laboratory finding would be most significant? 1) Blood pH 7.32 2) Oxygen saturation 96% 3) Serum sodium 140 mg/dL 4) Hemoglobin level 12 mg/dL 4. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) who is prescribed 24% oxygen at 2 L/min. Which is the best method for the nurse to use in order to administer oxygen to this patient? 1) Face mask 2) Venturi mask 3) Nasal cannula 4) Nonrebreather mask 5. The nurse is providing care for a patient admitted with smoke inhalation injury who is developing acute respiratory distress syndrome (ARDS). Which course of action regarding oxygen therapy does the nurse anticipate for this patient? 1) Oxygen via a facial mask 2) Oxygen via a Venturi mask 3) Oxygen via a nasal cannula 4) Oxygen via mechanical ventilatiNo U n RSINGTB.COM 6. The nurse is providing care to a patient, diagnosed with asthma, with a respiratory rate of 28 at rest who is experiencing audible wheezing during inspiration. Which nursing diagnosis should the nurse use when planning care for this patient? 1) Activity Intolerance 2) Impaired Tissue Perfusion 3) Ineffective Airway Clearance 4) Ineffective Breathing Pattern 7. The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease (COPD). The nurse assesses the patient’s breathing rate at 32 breaths per minute. The patient is also experiencing hypertension and fatigue. Which nursing diagnosis is a priority when planning care for this patient? 1) Anxiety 2) Ineffective Coping 3) Ineffective Breathing Pattern 4) Ineffective Airway Clearance 8. The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease (COPD). The patient’s pulse oximetry is 93% on room air with a current respiratory rate of 35 breaths per minute. The most recent chest x-ray indicates a flattened diaphragm with infiltrates. The patient is currently febrile with NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
an increased number of white blood cells (WBCs) noted on the latest complete blood count (CBC). Which prescription does the nurse question for this patient based on the current data? 1) Antibiotic therapy 2) Nonsteroidal anti-inflammatory therapy
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3) 4)
Oxygen therapy via nasal cannula at 3-4 L/min Bronchodilators therapy with adrenergic stimulating drugs
9. The nurse is providing care to an infant diagnosed with respiratory syncytial virus (RSV). The infant is grunting with expiration. Which action by the nurse is appropriate? 1) Limit fluid intake 2) Place the infant in a supine position 3) Perform chest physiotherapy to clear the nasal passages 4) Suction the airway to relieve the current obstruction that is noted 10. Which nursing action determines the accuracy of the detected waveform when monitoring a patient’s oxygen saturation via oximetry? 1) Using a site with adequate perfusion 2) Ensuring the any nail polish is removed 3) Leaving the sensor in place for a minimum of ten seconds 4) Assessing the heart rate and comparing it with the displayed pulse 11. Which did the nurse auscultate when conducting a patient’s respiratory assessment if wheezing is documented? 1) Snoring sounds 2) Gurgling sounds 3) Low-pitched bubbling 4) High-pitched squeaking 12. Which did the nurse auscultate when conducting a patient’s respiratory assessment if rhonchi is documented? 1) Snoring sounds 2) Gurgling sounds NURSINGTB.COM 3) Low-pitched bubbling 4) High-pitched squeaking 13. Which position should the nurse place a patient prior to performing in-line suctioning? 1) Prone 2) Supine 3) Fowler’s 4) Semi-Fowler’s 14. When conducting in-line suctioning, which is the maximum amount of time for each suctioning event? 1) 10 seconds 2) 30 seconds 3) 45 seconds 4) 60 seconds 15. When conducting in-line suctioning on a patient, which amount of time should the nurse allow as a rest period between suction procedures? NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN 1) 2) 3) 4)
5 to 15 seconds 10 to 20 seconds 15 to 25 seconds 20 to 30 seconds
16. The nurse is performing in-line suctioning when the patient experiences a drop in oxygen saturation and bradycardia. Which nursing action is appropriate? 1) Continue suctioning and administer 50% oxygen
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) 3) 4)
Discontinue suctioning and prepare for resuscitation Discontinue suctioning and administer 100% oxygen Continue suctioning and administer prescribed epinephrine
17. The nurse is providing care to a patient who is mechanically ventilated. The highpressure alarm beeps and the nurse notes a mucous plug in the endotracheal (ET) tube. Which action by the nurse is appropriate? 1) Suction, as needed 2) Insert an oral airway 3) Assess for asymmetric chest rise 4) Empty water from the ventilator tubing 18. The nurse is providing care to a patient who is mechanically ventilated. The highpressure alarm beeps and the nurse notes the patient is biting down on the endotracheal (ET) tube. Which action by the nurse is appropriate? 1) Suction, as needed 2) Insert an oral airway 3) Assess for asymmetric chest rise 4) Empty water from the ventilator tubing 19. The nurse is providing care to a patient who is mechanically ventilated. The highpressure alarm beeps and the nurse notes a collection of moisture in the ventilator tubing. Which action by the nurse is appropriate? 1) Empty the water 2) Suction, as needed 3) Insert an oral airway 4) Assess for asymmetric chest rise 20. The nurse is providing education to aNpUatRieSn tIwNhGo iTsBp r.esCcrOibMed oxygen in the home environment. Which statement made by the patient indicates the need for further education? 1) “I will ensure that the oxygen is kept six feet away from the stove.” 2) “I placed a no smoking sign on the door and several places within the house.” 3) “I will store the oxygen on its side, per the instructions provided by the agency.” 4) “I will keep a fire extinguisher in the house and keep it close to where the oxygen is stored.” 21. The nurse is providing education to a patient regarding the use of an incentive spirometer. Which patient statement indicates the need for further education? 1) “I should be in a sitting position when using this device.” 2) “I will use this device 20 times per hour while I am awake each day.” 3) “I will exhale completely prior to placing my lips around the mouthpiece.” 4) “I will hold my breath for 3 seconds after I feel like I cannot inhale any more breath.” 22. The nurse is providing care to a patient who is mechanically ventilated. In order to decrease the risk for aspiration, which action by the nurse is appropriate? 1) Elevate the head of the bed between 30 to 45 degrees 2) Limit each suctioning event to no more than 10 seconds NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3) 4)
Perform chest physiotherapy as prescribed by the practitioner Ensure an NPO status is maintained for the length of the prescribed treatment
23. The nurse is providing care to a patient who is being weaned from mechanical ventilation. Which finding would necessitate the continuation of mechanical ventilation if noted during the assessment process? 1) An FIO2 less than or equal to 0.4–0.5 2) A PEEP less than or equal to 5–8 cm H2 O
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3) 4)
A pH greater than 7.25 during spontaneous ventilation A drop in blood pressure indicating a hypotensive state
24. The nurse is providing care to a patient who is recovering from facial trauma who requires high-flow oxygen therapy. Which method of oxygen delivery should the nurse plan for when providing care? 1) Face tent 2) Nasal cannula 3) Venturi mask 4) Nonrebreather mask 25. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) who requires supplemental oxygen. Which is the anticipated flow rate range by nasal cannula (NC) when providing care for this patient? 1) 1-2 L/min 2) 2-3 L/min 3) 3-4 L/min 4) 4-5 L/min Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. Which independent nursing actions are appropriate to include in the plan of care for a patient who is experiencing an alteration in oxygenation? Select all that apply. 1) Providing suctioning 2) Assisting with positioning NURSINGTB.COM 3) Prescribing bronchodilators 4) Monitoring activity tolerance 5) Encouraging deep breathing exercises 27. Which should the nurse include in the plan of care for a mechanically ventilated patient who is receiving care based on a ventilator bundle? Select all that apply. 1) Elevating the head of the bed 2) Ensuring a sedation vacation each day 3) Conducting a readiness to wean assessment 4) Administering a prescribed peptic ulcer prophylactic regimen 5) Avoiding the use of compression stockings during immobility 28. Which information should the nurse document when monitoring a patient’s oxygen saturation via oximetry? Select all that apply. 1) The SpO2 result 2) The current vital signs 3) The presence of family or visitors at the patient’s bedside 4) The type and amount of oxygen therapy in use 5) The education provided to the patient and family NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
29. The nurse suctions a mechanically ventilated patient using in-line suctioning. Which information should the nurse document in the medical record after the procedure is completed? Select all that apply. 1) The amount of secretions 2) The color of the secretions 3) The consistency of the secretions 4) The patient’s response to the procedure
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5)
The amount of oxygen the patient received during the procedure
30. Which actions by the nurse are considered best practice when providing tracheostomy care? Select all that apply. 1) Asking the family to leave the bedside 2) Suctioning at the start and finish of the procedure 3) Applying appropriate personal protective equipment 4) Inspecting the site of infection, irritation, and skin breakdown 5) Rinsing a disposable inner cannula with sterile water and drying
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 7: Oxygen Therapy Management Answer Section MULTIPLE CHOICE 1.
ANS: 2 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Explaining indications, management, and complications of artificial airways Chapter page reference: 085-092 Heading: Tracheostomy Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 The client can still cough and sneeze, and there is no decrease in the oxygen-carrying capacity of the trachea. 2 When the nasal passages are bypassed, as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming of the nasal passages are also bypassed. 3 The client can still cough and sneeze, and there is no decrease in the oxygen-carrying capacity of the trachea. 4 The client can still cough and sneeze, and there is no decrease in the oxygen-carrying capacity of the trachea. NURSINGTB.COM
PTS: 1 CON: Oxygenation 2. ANS: 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Reviewing concepts of oxygenation Chapter page reference: 084-085 Heading: ETT Management Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
Feedback Wheezing is created by narrow bronchi. Stridor is the sound created by narrow tracheal passages. A low-pitched grating sound is created by inflamed pleural surfaces. The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout inspiration. Rhonchi suggests blockage of large airway passages, which may be cleared with coughing.
PTS: 1 CON: Oxygenation 3. ANS: 1 Chapter number and title: 7, Oxygen Therapy Management
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Reviewing concepts of oxygenation Chapter page reference: 076 Heading: Oxygen Monitoring and Measurement Integrated Processes: Nursing Process – Evaluation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 Normal blood pH is 7.35–7.45. A decreased pH indicates that the client is experiencing acidosis, which indicates an alteration in oxygenation. 2 Oxygen saturation of 96% is within normal limits. 3 The serum sodium does not impact the oxygen capacity of the body. 4 The hemoglobin level affects the amount of oxygen that can be carried in the blood; however, the value is within normal limits. PTS: 1 CON: Oxygenation 4. ANS: 3 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Describing methods of oxygen delivery Chapter page reference: 077 Heading: Nasal Cannula Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] NURSINGTB.COM Concept: Oxygenation Difficulty: Moderate Feedback 1 A face mask is better suited to deliver oxygen at higher percentages and flow rates. 2 A Venturi mask is better suited to deliver oxygen at higher percentages and flow rates. 3 The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2 liters per minute is through nasal cannula. 4 A nonrebreather mask is better suited to deliver oxygen at higher percentages and flow rates. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1 CON: Oxygenation 5. ANS: 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation Chapter page reference: 095-101 Heading: Overview of Mechanical Ventilation Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen therapy alone; therefore, oxygen via face mask is not anticipated.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 3 4
With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen therapy alone; therefore, oxygen via a Venturi mask is not anticipated. With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen therapy alone; therefore, oxygen via nasal cannula is not anticipated. With mechanical ventilation, the FiO 2 (fraction of inspired oxygen– the percentage of oxygen administered) is set at the lowest possible level to maintain a PaO 2 higher than 60 mmHg and oxygen saturation of approximately 90%. It is important to remember that mechanical ventilation does not cure ARDS; it simply supports respiratory function while the underlying problem is identified and treated.
PTS: 1 CON: Oxygenation 6. ANS: 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Reviewing concepts of oxygenation Chapter page reference: 099 Heading: Nursing Diagnoses Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 There is not enough information to determine if this nursing diagnosis is appropriate. 2 There is not enough information to determine if this nursing diagnosis is appropriate. 3 There is not enough information to determ in e if this nursing diagnosis is appropriate. N U R SI N G T B . C O M 4 The patient is experiencing tachypnea and wheezing; therefore, the patient is experiencing an ineffective breathing pattern necessitating the use of this nursing diagnosis when planning care. PTS: 1 CON: Oxygenation 7. ANS: 3 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Reviewing concepts of oxygenation Chapter page reference: 099 Heading: Nursing Diagnoses Integrated Processes: Nursing Process – Diagnosis NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Hard Feedback 1 There is no information to support Anxiety or Ineffective Coping. 2 There is no information to support Anxiety or Ineffective Coping. 3 The patient's respiratory rate of 32 per minute is an indication of an ineffective breathing pattern. The elevated blood pressure and fatigue are indications of a compromised respiratory status. The diagnosis of Ineffective Breathing Pattern would be the priority for the patient at this time. 4 There is no information to support Ineffective Airway Clearance, as there is no mention that the client is coughing.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1 CON: Oxygenation 8. ANS: 3 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Describing methods of oxygen delivery Chapter page reference: 076 Heading: Contraindications to Oxygen Administration Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is an appropriate prescription for this patient. 2 This is an appropriate prescription for this patient. 3 The nurse should be concerned about the order for oxygen to be provided at 3-4 liters/minute. This amount of oxygen is too much for a patient with COPD because the patient's breaths are stimulated by a hypoxic drive and this disease process causes the body to retain carbon dioxide. Providing this much oxygen can result in an increase in carbon dioxide levels, leading to respiratory failure. Oxygen for this patient should be at a lower rate, such as 1-2 liters/minute, with close assessments of the patient's breathing status. 4 This is an appropriate prescription for this patient. PTS: 1
CON: OxygenNatUioRn SINGTB.COM Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Reviewing concepts of oxygenation Chapter page reference: 084-085 Heading: ETT Management Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Oxygenation Difficulty:
9. ANS: 4
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Moderate Feedback 1 Fluids should be increased to thin secretions. 2 Laying the child on his back will not improve the child's ability to breathe. 3 Performing chest physiotherapy is not an appropriate action to assist the child to clear the nasal passages. 4 Grunting is seen with partial airway obstruction caused by increased secretions and edema. The nurse should suction the airway to relieve the obstruction.
10.
PTS: 1 CON: Oxygenation ANS: 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Reviewing concepts of oxygenation Chapter page reference: 076-077 Heading: Oxygen Monitoring and Measurement
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate 1
2 3
4
11.
Feedback While using a site with adequate perfusion is important, this action does not determine the accuracy of the detected waveform when monitoring a patient’s oxygen saturation via oximetry. While ensuring that any nail polish is removed is important, this action does not determine the accuracy of the detected waveform when monitoring a patient’s oxygen saturation via oximetry. While leaving the sensor in place for a minimum of ten seconds is important, this action does not determine the accuracy of the detected waveform when monitoring a patient’s oxygen saturation via oximetry. Assessing the heart rate and comparing it with the displayed pulse is the nursing action that determines the accuracy of the wave form when monitoring a patient’s oxygen saturation via oximetry.
PTS: 1 CON: Oxygenation ANS: 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Reviewing concepts of oxygenation Chapter page reference: NURSINGTB.COM 084-085 Heading: ETT Management Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Snoring sounds indicate rhonchi, caused by airflow obstruction from thick secretions or fluid in the large airways. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 3 4
12.
Gurgling sounds indicate crackles. On inhalation, air comes in contact with secretions in the trachea and large bronchi. Loud, low-pitched bubbling sounds indicate crackles. On inhalation, air comes in contact with secretions in the trachea and large bronchi. Wheezing is characterized as musical, high-pitched squeaking that indicates narrowed passages caused by secretions, bronchospasm, edema, and inflammation.
PTS: 1 CON: Oxygenation ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Reviewing concepts of oxygenation Chapter page reference: 084-085 Heading: ETT Management Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Snoring sounds indicate rhonchi, caused by airflow obstruction from thick secretions or fluid in the large airways. 2 Gurgling sounds indicate crackles. On inhalation, air comes in contact with secretions in the trachea and large bronchi. 3 Loud, low-pitched bubbling sounds indicate crackles. On inhalation, air comes in contact with secretions in the trachea and large bronchi. 4 Wheezing is characterized as musical, high-pitched squeaking that indicates narrowed passages caused by secretions, bronchospasm, edema, and inflammation.
13.
14.
PTS: 1 CON: Oxygenation ANS: 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Explaining indications, management, and complications of artificial airways Chapter page reference: 084-085 Heading: ETT Management Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate NURSINGTB.COM 1 A prone position is not appropriate for a patient who requires in-line suctioning. 2 A supine position is not appropriate for a patient who requires in-line suctioning. 3 A Fowler’s position is not appropriate for a patient who requires inline suctioning. 4 A high-Fowler’s position is appropriate for a patient who requires inline suctioning. Elevating the head of bed will allow for easier ventilation for the patient. PTS: 1 CON: Oxygenation ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Explaining indications, management, and complications of artificial airways Chapter page reference: 084-085 Heading: ETT Management Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Adaptation Cognitive level: Knowledge [Remembering] Concept: Oxygenation Difficulty: Easy Feedback 1 Each suctioning event should last no longer than 10 seconds. Suctioning lasting longer than 10 seconds causes hypoxia, cardiopulmonary compromise, and a vagal response. 2 Each suctioning event should not last 30 seconds as this can cause hypoxia, cardiopulmonary compromise, and a vagal response. 3 Each suctioning event should not last 45 seconds as this can cause hypoxia, cardiopulmonary compromise, and a vagal response.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4
15.
16.
Each suctioning event should not last 60 seconds as this can cause hypoxia, cardiopulmonary compromise, and a vagal response.
PTS: 1 CON: Oxygenation ANS: 2 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Explaining indications, management, and complications of artificial airways Chapter page reference: 084-085 Heading: ETT Management Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Knowledge [Remembering] Concept: Oxygenation Difficulty: Easy Feedback 1 A rest period of 5 to 15 seconds is not adequate between suction procedures. 2 A rest period of 10 to 20 seconds is an appropriate time frame between suction procedures. This time frame decreases the risk for hypoxia, dysrhythmia, and bronchospasm. 3 A rest period of 15 to 25 seconds is not appropriate between suction procedures. 4 A rest period of 20 to 30 seconds is not appropriate between suction procedures. PTS: 1 CON: Oxygenation ANS: 3 Chapter number and title: 7, Oxygen NTUh eRraSp yI M N Ga nTa gBe.mCenOt M Chapter learning objective: Explaining indications, management, and complications of artificial airways Chapter page reference: 084-085 Heading: ETT Management Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate 1
Feedback The nurse should not continue suctioning and administer 50% oxygen if in-lining NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
suctioning causes a drop in oxygen saturation and bradycardia. 2 3 4
17.
While the nurse should discontinue suctioning, it is not necessary to prepare for resuscitation. When in-line suctioning causes a drop in oxygen saturation and bradycardia, the nurse discontinues suctioning and administers 100% oxygen. The nurse should not continue suctioning and administer prescribed epinephrine if in- lining suctioning causes a drop in oxygen saturation and bradycardia.
PTS: 1 CON: Oxygenation ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation Chapter page reference: 097
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Heading: Pressure Support Ventilation Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 A mucous plug often causes a high-pressure alarm when a patient is being mechanically ventilated. The appropriate action by the nurse is to suction the ET tube in order to remove the mucous plug. 2 An oral airway is inserted if the patient is biting on the ET tube, which can cause a high-pressure alarm for a patient who is being mechanically ventilated. 3 Assessing for asymmetric chest rise is an appropriate action if the high-pressure alarm is caused by a pneumothorax, not a mucous plug. 4 Emptying water in the ventilator tubing is an appropriate action if the high-pressure alarm is caused by water collection, not a mucous plug.
18.
PTS: 1 CON: Oxygenation ANS: 2 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation Chapter page reference: 097 Heading: Pressure Support Ventilation Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [ApplyiN ngU] RSINGTB.CO Concept: Oxygenation Difficulty: Moderate Feedback 1 A mucous plug often causes a high-pressure alarm when a patient is being mechanically ventilated. The appropriate action by the nurse is to suction the ET tube in order to remove the mucous plug. 2 An oral airway is inserted if the patient is biting on the ET tube, which can cause a high-pressure alarm for a patient who is being mechanically ventilated. 3 Assessing for asymmetric chest rise is an appropriate action if the high-pressure alarm is caused by a pneumothorax, not when the patient is biting down on the ET tube. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4
19.
Emptying water in the ventilator tubing is an appropriate action if the high-pressure alarm is caused by water collection, not when the patient is biting down on the ET tube.
PTS: 1 CON: Oxygenation ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation Chapter page reference: 097 Heading: Pressure Support Ventilation Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Difficulty: Moderate Feedback 1 Emptying water in the ventilator tubing is an appropriate action if the high-pressure alarm is caused by moisture collection. 2 A mucous plug often causes a high-pressure alarm when a patient is being mechanically ventilated. The appropriate action by the nurse is to suction the ET tube in order to remove the mucous plug. 3 An oral airway is inserted if the patient is biting on the ET tube, which can cause a high-pressure alarm for a patient who is being mechanically ventilated. 4 Assessing for asymmetric chest rise is an appropriate action if the high-pressure alarm is caused by a pneumothorax, not a collection of moisture in the ventilator tubing.
20.
21.
PTS: 1 CON: Oxygenation ANS: 3 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Describing methods of oxygen delivery Chapter page reference: 081-082 Heading: Oxygen Delivery Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Analysis [Analyzing] Concept: Safety Difficulty: Hard Feedback 1 Oxygen should be kept at least 6 feet from so urces of heat, such as the N UR S I N G T B . C O M stove. This statement indicates correct understanding of the information presented. 2 A “no smoking” sign should be placed in the home if oxygen is stored, or in use. This statement indicates correct understanding of the information presented. 3 Oxygen should be stored upright, not on its side. This statement indicates the need for further education. 4 A fire extinguisher should be maintained in the home and stored close to where the oxygen is stored. This statement indicates correct understanding of the information presented. PTS: 1 CON: Safety ANS: 2 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Clarifying indications and nursing implications for the NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
following respiratory care modalities: Incentive Spirometry. Chapter page reference: 093 Heading: Nursing Implications Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Hard Feedback 1 A sitting, or high-Fowler’s, position is recommended when using an incentive spirometer. This statement indicates correct understanding of the information presented.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 3 4
22.
23.
The device should be used 5 to 10 times each hour while awake. This statement indicates the need for further education. The patient exhales completely prior to placing the mouth on the device. This statement indicates correct understanding of the information presented. The patient should hold the breath for three seconds and then exhale completely. This statement indicates correct understanding of the information presented.
PTS: 1 CON: Oxygenation ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation Chapter page reference: 099 Heading: Ventilator-Associated Pneumonia Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Unless contraindicated, any patient who is mechanically ventilated should have the head of the bed elevated at 30 to 45 degrees to decrease the risk for aspiration. 2 While it is important to limit each suctioning event to 10 seconds in length, this is not an action to decrease the risk for aspiration. 3 While chest physiotherapy is often prescribed, this action is not intended to decrease the risk for aspiration. NURSINGTB.COM 4 While many patients who are mechanically ventilated will receive parenteral or enteral nutrition, an NPO status is unnecessary to decrease the risk for aspiration. PTS: 1 CON: Oxygenation ANS: 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation Chapter page reference: 100-101 Heading: Patient Criteria for Weaning Integrated Processes: Nursing Process – Evaluation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Oxygenation Difficulty: Easy 1 2 3 4
Feedback An FIO2 less than or equal to 0.4–0.5 indicates the patient is able to be weaned from mechanical ventilation. A PEEP less than or equal to 5–8 cm H2O indicates the patient is able to be weaned from mechanical ventilation. A pH greater than 7.25 during spontaneous ventilation indicates the patient is able to be weaned from mechanical ventilation. Hemodynamic instability, such as a drop in blood pressure to a hypotensive state, indicates the patient is not a candidate for being weaned from mechanical ventilation.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
24.
PTS: 1 CON: Oxygenation ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Describing methods of oxygen delivery Chapter page reference: 079-080 Heading: High-Flow Delivery Devices Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate 1 2 3 4
25.
Feedback A face-tent is a high-flow delivery device of oxygen that is appropriate for the patient who requires supplemental oxygen if facial trauma is experienced. While a nasal cannula might be appropriate for a patient who needs a low-flow delivery device, this is not appropriate for the patient who requires a high-flow delivery device. A Venturi mask delivers a high-flow of oxygen; however, facial trauma makes this an unrealistic choice. A nonrebreather mask is not an appropriate for the high-flow delivery of oxygen.
PTS: 1 CON: Oxygenation ANS: 1 Chapter number and title: 7,NURSINGTB.COM Oxygen Therapy Management Chapter learning objective: Describing methods of oxygen delivery Chapter page reference: 077 Heading: Nasal Cannula Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Knowledge [Remembering] Concept: Oxygenation Difficulty: Easy Feedback NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1
2 3 4
A low flow rate of 1-2 L/min via NC is anticipated for a patient with COPD. The patient who retains CO2, such as the patient with COPD, will use the lower amount of oxygen (1–2 L/min) so the patient does not lose his or her hypoxic drive to breathe. This flow rate is higher than anticipated when providing care for a patient with COPD who requires supplement oxygen via NC. This flow rate is higher than anticipated when providing care for a patient with COPD who requires supplement oxygen via NC. This flow rate is higher than anticipated when providing care for a patient with COPD who requires supplement oxygen via NC.
PTS: 1
CON: Oxygenation
MULTIPLE RESPONSE
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
26. ANS: 1, 2, 4, 5 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Reviewing concepts of oxygenation Chapter page reference: 074-076 Heading: Overview of Oxygen Therapy Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate 1. 2. 3. 4. 5.
Feedback This is correct. Suctioning is an independent nursing action. This is correct. Repositioning is an independent nursing action. This is incorrect. Prescribing bronchodilators is outside the scope of nursing practice. This is correct. Monitoring activity tolerance is an independent nursing action. This is correct. Encouraging deep breathing exercises is an independent nursing action.
PTS: 1 CON: Oxygenation 27. ANS: 1, 2, 3, 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation Chapter page reference: 099-100 Heading: Nursing Management for a Mechanically NURSINGTB.CO Ventilated Patient Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Evidence-Based Practice Difficulty: Moderate 1.
Feedback This is correct. Elevation of the head of the bed is included in the plan of care for a patient who is receiving care based on a ventilator bundle. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2. 3. 4. 5.
This is correct. A sedation vacation each day is included in the plan of care for a patient who is receiving care based on a ventilator bundle. This is correct. Assessing for readiness to be weaned is included in the plan of care for a patient who is receiving care based on a ventilator bundle. This is correct. Administering the prescribed peptic ulcer prophylactic regimen is included in the plan of care for a patient who is receiving care based on a ventilator bundle. This is incorrect. The patient is placed on deep vein thrombosis prophylaxis, which should include the use of compression stockings during immobility.
PTS: 1 CON: Evidence-Based Practice 28. ANS: 1, 2, 4, 5 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Describing methods of oxygen delivery Chapter page reference: 076-077 Heading: Oxygen Monitoring and Measurement
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Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Communication; Oxygenation Difficulty: Moderate 1. 2. 3.
4. 5.
Feedback This is correct. The SpO2 result is documented in the medical record when monitoring a patient’s oxygen saturation via oximetry. This is correct. The current vital signs are documented in the medical record when monitoring a patient’s oxygen saturation via oximetry. This is incorrect. The presence of family or visitors at the patient’s bedside is not information that is documented in the medical record when monitoring oxygenation saturation via oximetry. This is correct. The type, and amount, of oxygen therapy in use is documented in the medical record when monitoring a patient’s oxygen saturation via oximetry. This is correct. The education provided to the patient and family is documented in the medical record when monitoring a patient’s oxygen saturation via oximetry.
PTS: 1 CON: Communication | Oxygenation 29. ANS: 1, 2, 3, 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation Chapter page reference: 084-085 Heading: ETT Management NURSINGTB.COM Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Communication; Oxygenation Difficulty: Moderate 1. 2. 3. 4.
Feedback This is correct. The amount of secretions collected during in-line suctioning is documented in the patient’s medical record. This is correct. The color of secretions collected during in-line suctioning is documented in the patient’s medical record. This is correct. The consistency of secretions collected during in-line suctioning is documented in the patient’s medical record. This is correct. The patient’s response to the procedure is documented in the medical record. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5.
This is incorrect. The amount of oxygen the patient received during the suctioning procedure is documented on a separate flow sheet, not the medical record.
PTS: 1 CON: Communication | Oxygenation 30. ANS: 3, 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: Explaining indications, management, and complications of artificial airways Chapter page reference: 090-091 Heading: Tracheostomy Care Integrated Processes: Nursing Process – Implementation
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate 1. 2. 3. 4. 5.
PTS: 1
Feedback This is incorrect. The family should be educated about the procedure but there is no need to ask the family to leave the bedside. This is incorrect. The tracheostomy should be suctioned at the start of the procedure and as needed. This is correct. Personal protective equipment is applied to decrease the risk for infection. This is correct. The tracheostomy site is assessed for infection, irritation, and skin breakdown. This is incorrect. A reusable, not disposable, inner cannula is rinsed with sterile water and dried prior to reinsertion. CON: Oxygenation
Chapter 8: Fluid and Electrolyte Management Multiple Choice Identify the choice that best completes the statement or answers the question. NURSINGTB.COM 1. The nurse is providing care to a patient who is diagnosed with multisystem fluid volume deficit. The patient is currently experiencing tachycardia and decreased urine output along with skin that is pale and cool to the touch. The patient has a decreased urine output. Which probable cause to the patient’s symptoms should the nurse include when educating the family? 1) Congestive heart failure 2) Rapidly infused intravenous fluids 3) Natural compensatory mechanisms 4) Pharmacological effects of a diuretic 2. The nurse is providing care to a patient whose serum calcium levels have increased since a surgical procedure performed three days prior. Which intervention should the nurse implement to decrease the risk for the development of hypercalcemia? 1) Monitor vital signs every eight hours 2) Encourage ambulation three times a day 3) Irrigate the Foley catheter one time a day 4) Recommend turning, coughing, and deep breathing every two hours NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3. Which intervention should the nurse implement for a patient whose serum phosphorus level is 2.0 mg/dL? 1) Enforce contact precautions 2) Strain all urine for kidney stones 3) Encourage consumption of milk and yogurt 4) Discourage the consumption of a high-calorie diet
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4. The nurse is providing care to a patient who is prescribed furosemide as part of the treatment for congestive heart failure (CHF). The patient’s serum potassium level is 3.4 mEq/L. Which food should the nurse encourage the patient to eat based on this data? 1) Peas 2) Iced tea 3) Bananas 4) Baked fish 5. A patient is admitted to the emergency department (ED) for dehydration. The patient is 154 lbs. Which urine output indicate the rehydration efforts for this patient have been effective? 1) 20 mL/hr 2) 25 mL/hr 3) 30 mL/hr 4) 35 mL/hr 6. An older adult patient, who appears intermittently confused, is admitted to the hospital after a fall. Based on the current data, which is the patient at an increased risk for developing? 1) Brain attack 2) Dehydration 3) Hemorrhage 4) Kidney damage 7. The nurse is providing care to an older adult patient who is receiving intravenous (IV) fluids at 150 mL/hr. The patient is currently exhibiting crackles in the lungs, shortness of breath, and jugular vein distention. Which complication of IV fluid therapy does the nurse suspect the patient is experiencing? 1) Speed shock NURSINGTB.COM 2) Fluid volume excess 3) Anaphylactic reaction 4) Pulmonary embolism 8. A patient is prescribed 20 mEq of potassium chloride due to excessive vomiting. Which is the rationale for this drug the nurse should provide to the patient? 1) It controls and regulates water balance in the body. 2) It is used in the body to synthesize ingested protein. 3) It is vital in regulating muscle contraction and relaxation. 4) It is needed to maintain skeletal, cardiac, and neuromuscular activity. 9. Which data collected by the nurse during the assessment process places the older adult patient at risk for dehydration? 1) Poor skin turgor 2) Body mass index of 20.5 3) Blood pressure of 140/98 mmHg NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN 4)
Water intake of 2 glasses per day
10. The nurse is reviewing laboratory values for a female patient suspected of having a fluid imbalance. Which laboratory value evaluated by the nurse supports the diagnosis of dehydration? 1) Hematocrit 30% 2) Hematocrit 53% 3) Serum potassium 3.8 mEq/L 4) Serum osmolality 230 mOsm/kg
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
11. The nurse is analyzing the intake and output record for a patient being treated for dehydration. The patient weighs 176 lbs. and had a 24-hour intake of 2,000 mL and urine output of 1,200 mL. Based on this data, which conclusion by the nurse is the most appropriate? 1) Treatment has not been effective. 2) Treatment needs to include a diuretic. 3) Treatment is effective and should continue. 4) Treatment has been effective and should end. 12. The nurse is providing care to a patient who seeks emergency treatment for headache and nausea. The patient works in a mill without air conditioning. The patient states, “I drink water several times each day but I seem to sweat more than I am able to replace.” Which suggestions should the nurse provide to this patient? 1) Drink juices and carbonated sodas. 2) Eat something salty when drinking water. 3) Eat something sweet when drinking water. 4) Double the amount of water being ingested. 13. An older adult patient, who lives in a long-term care facility, presents in the emergency department (ED) due to fever, nausea, and vomiting over the past two days. The patient denies thirst. The urine dipstick indicates a decreased urine specific gravity. Which medical diagnosis should the nurse anticipate when planning care for this patient? 1) Dehydration 2) Hypertension 3) Fluid overload 4) Congestive heart failure 14. The nurse receives shift report on a pediatric medical-surgical unit. The nurse has been assigned four patients for the shift. Which child does the nuNrsUe Rp lSa nItN o G a sTseBss.fCirsOt M b ased on the increased risk for dehydration? 1) A 4-year-old child with a broken leg 2) A 15-month-old child with tachypnea 3) A 16-year-old child with migraine headaches 4) A 10-year-old child with cellulitis of the left leg 15. The nurse is teaching a group of children and their parents about the prevention of heat-related illness during exercise. Which statement by a parent indicates an appropriate understanding of the preventive techniques taught during the teaching session? 1) “My child only needs to hydrate at the end of an exercise session.” 2) “Water is the drink of choice to replenish fluids that are lost during exercise.” 3) “I will have my child stop every 15-20 minutes during the activity for fluids.” 4) “It is important for my child to wear dark clothing while exercising in the heat.” 16. The nurse is providing care to an adult patient admitted with dehydration and hyponatremia. Which medical condition supports the current nursing diagnosis of Electrolyte Imbalance? 1) Osmotic pressure NURSINGTB.COM
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2) 3) 4)
Hydrostatic pressure Isotonic dehydration Hypotonic dehydration
17. The nurse is caring for a patient who is receiving intravenous fluids postoperatively following cardiac surgery. The nurse is aware that this patient is at risk for fluid volume excess. The family asks why the patient is at risk for this condition. Which response by the nurse is the most appropriate? 1) “Fluid volume excess is caused by inactivity.” 2) “Fluid volume excess is caused by the intravenous fluids.”
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3) 4)
“Fluid volume excess is caused by new onset liver failure caused by the surgery.” “Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery.”
18. The nurse is providing care to a patient following hemodialysis. The patient is experiencing tachycardia and decreased urine output along with skin that is pale and cool to the touch. Which goal of hemodialysis does the nurse determine the patient has not met based on the current data? 1) Cardiac decompensation 2) A reduction of extracellular fluid 3) The effects of rapidly infused intravenous fluids 4) The pharmacological effects of a diuretic infused in the dialysate 19. The nurse is caring for a patient with congestive heart failure who is admitted to the medical-surgical unit with acute hypokalemia. Which prescribed medication may have contributed to the patient’s current hypokalemic state? 1) Cortisol 2) Demerol 3) Skelaxin 4) Nonsteroidal anti-inflammatory drugs (NSAIDs) 20. The nurse is caring for a patient with a potassium level of 5.9 mEq/L. The health care provider prescribes both glucose and insulin for the patient. The patient’s spouse asks, “Why is insulin needed?” Which response by the nurse is the most appropriate? 1) “The insulin will help his kidneys excrete the extra potassium.” 2) “The insulin is safer than other medications that can lower potassium levels.” 3) “The insulin lowers his blood sugar levels and this is how the extra potassium is excreted.” 4) “The insulin will cause his extraNpU otRasSsiIumNGtoTmBo.veCiOn tMo his cells, which will lower potassium in the blood.” 21. A patient is admitted to the emergency department (ED) for fluid volume deficit. Which body system should the nurse focus to determine the cause of this imbalance when assessing this patient? 1) Genitourinary 2) Cardiovascular 3) Gastrointestinal 4) Musculoskeletal 22. The nurse is instructing a patient with heart failure about a prescribed sodiumrestricted diet. Which patient statement indicates that additional teaching is required? 1) “I can use as much salt substitute as I want.” 2) “I have to read the labels on foods to find out the sodium content.” 3) “I have to limit the intake of food with baking soda or baking powder.” 4) “I can use spices and lemon juice to add flavor to food when cooking.” 23. The nurse is planning care for the patient with acute renal failure. The nurse plans the patient’s care based on NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
the nursing diagnosis of Excess Fluid Volume. Which assessment data supports this nursing diagnosis? 1) Wheezing in the lungs 2) Generalized weakness 3) Bowel sounds positive in four quadrants 4) Pitting edema in the lower extremities 24. A patient with acute renal failure has jugular vein distention, lower extremity edema, and elevated blood pressure. Based on this data, which nursing diagnosis is the most appropriate?
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1) 2) 3) 4)
Risk for Infection Excess Fluid Volume Ineffective Renal Tissue Perfusion Risk for Altered Cardiac Perfusion
25. The nurse is caring for a patient admitted with hypertension and chronic renal failure who receives hemodialysis three times per week. The nurse is assessing the patient's diet and notes the use of salt substitutes. When teaching the patient to avoid salt substitute, which rationale supports this teaching point? 1) They can potentiate hyperkalemia. 2) They will cause the client to retain fluid. 3) They will increase the risk of AV fistula infection. 4) They will interact with the client's antihypertensive medications. Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. The nurse is providing care to a patient who is exhibiting clinical manifestations of a fluid and electrolyte deficit. Based on this data, which health-care provider prescriptions does the nurse prepare to implement? Select all that apply. 1) Administer diuretics 2) Administer antibiotics 3) Initiate hypodermoclysis 4) Closely monitor patient’s I&O’s 5) Initiate intravenous therapy UgR/dSLI. BNaGseTdBo.n C 27. A patient's serum sodium level is 150Nm thO isMdata, which interventions should the nurse plan for this patient? Select all that apply. 1) Elevate the head of the bed. 2) Instruct on a low-sodium diet. 3) Monitor heart rate and rhythm. 4) Administer diuretics as prescribed. 5) Administer potassium supplement as prescribed. 28. The school nurse is preparing a class session for high school students on ways to maintain fluid balance during the summer months. Which interventions should the nurse recommend Select all that apply. 1) Drink diet soda. 2) Reduce the intake of coffee and tea. 3) Drink more fluids during hot weather. 4) Drink flat cola or ginger ale if vomiting. 5) Exercise during the hours of 10 am and 2 pm. 29. The nurse is concerned that an older adult patient is at risk for developing acute renal failure. Which information in the patient’s history support the nurse’s concern? Select all that apply. 1) Diagnosed with hypotension NURSINGTB.COM
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2) 3) 4) 5)
Recent aortic valve replacement surgery Total hip replacement surgery five years ago Taking medication for type 2 diabetes mellitus Prescribed high doses of intravenous antibiotics
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30. The community nurse visits the home of a young child who is home from school because of sudden onset of nausea, vomiting, and lethargy. The nurse suspects acute renal failure. Which clinical manifestations support the nurse’s suspicions? Select all that apply. 1) Edema 2) Wheezing 3) Hematuria 4) Postural hypotension 5) Elevated blood pressure
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Chapter 8: Fluid and Electrolyte Management Answer Section MULTIPLE CHOICE 1.
ANS: 3 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Reviewing basic concepts related to fluid and electrolyte balance Chapter page reference: 104-105 Heading: Basic Concepts of Fluids Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Easy 1 2 3
4
Feedback The manifestations reported are not indicative of cardiac failure in this client. Rapidly infused intravenous fluids would not cause a decrease in urine output. The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain and heart. A diuretic would cause further fluid loss, and is contraindicated.
PTS: 1 CON: Fluid anNdUERleSctIroNlyGteTBBa.la C ncOe M 2. ANS: 2 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte disorders Chapter page reference: 128-129 Heading: Hypercalcemia Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This intervention is not appropriate to decrease the risk for the development of hypercalcemia. NURSINGTB.COM
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Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching of calcium from the bones into the serum. This intervention is not appropriate to decrease the risk for the development of hypercalcemia. This intervention is not appropriate to decrease the risk for the development of hypercalcemia.
PTS: 1 3. ANS: 3
CON: Fluid and Electrolyte Balance
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Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte disorders Chapter page reference: 129-130 Heading: Hypophosphatemia Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 There is no indication that contact precautions are needed. 2 This intervention is not appropriate for a patient who is experiencing low serum phosphorus levels. 3 A phosphorus level of 2.0 is low, and the client will need additional dietary phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus. 4 There is no indication that the patient requires a high-calorie diet. PTS: 1 CON: Fluid and Electrolyte Balance 4. ANS: 3 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte disorders Chapter page reference: NURSINGTB.COM 120-124 Heading: Potassium Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 Peas are not a potassium-rich food, which is currently needed based on the patient’s serum potassium level. 2 Iced tea is not a potassium-rich food, which is currently needed based on the patient’s serum potassium level. 3 A potassium level of 3.4 is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, the highest in potassium is banana. 4 Baked fish is not a potassium-rich food, which is currently needed based on the patient’s serum potassium level. NURSINGTB.COM
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PTS: 1 CON: Fluid and Electrolyte Balance 5. ANS: 4 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Explaining the significance of osmolality, osmolarity, blood urea nitrogen (BUN), creatinine, and urine specific gravity related to fluid and electrolyte status Chapter page reference: 105109 Heading: Fluid and Electrolyte Regulation Integrated Processes: Nursing Process – Assessment
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Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This is not adequate urine output based on the patient’s current weight. 2 This is not adequate urine output based on the patient’s current weight. 3 This is not adequate urine output based on the patient’s current weight. 4 Expected urine output for an adult patient is 0.5 mL/kg/hr. The patient currently weighs 70 kg; therefore, adequate urine output would be at least 35 mL/hr. PTS: 1 CON: Fluid and Electrolyte Balance 6. ANS: 2 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of dehydration, hypovolemia, and hypervolemia Chapter page reference: 106-108 Heading: Regulatory Mechanisms Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Easy Feedback 1 The risks for kidney damage, brain attack, and bleeding are not N UR S I N G T B . C O M specifically related to aging or fluid and electrolyte issues. 2 During the aging process, the thirst mechanism declines. In a patient with an altered level of consciousness, this can increase the risk of dehydration and high serum osmolality. 3 The risks for kidney damage, brain attack, and bleeding are not specifically related to aging or fluid and electrolyte issues. 4 The risks for kidney damage, brain attack, and bleeding are not specifically related to aging or fluid and electrolyte issues. PTS: 1 CON: Fluid and Electrolyte Balance 7. ANS: 2 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Describing the pathophysiology, clinical NURSINGTB.COM
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presentations, and management of dehydration, hypovolemia, and hypervolemia Chapter page reference: 112-114 Heading: Hypervolemia: Fluid Volume Excess Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Easy Feedback 1 The data does not support this complication.
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2 3 4
Fluid volume excess may occur when older adult patients receive intravenous fluids rapidly. The data does not support this complication. The data does not support this complication.
PTS: 1 CON: Fluid and Electrolyte Balance 8. ANS: 4 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte disorders Chapter page reference: 120 Heading: Hypokalemia – Nursing Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parental Therapies Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 Sodium controls and regulates water balance in the body. 2 Magnesium is used in the body to synthesize ingested protein. 3 Calcium is vital in regulating muscle contraction and relaxation. 4 Potassium is the major cation in intracellular fluids, with only a small amount found in plasma and interstitial fluid. Potassium is a vital electrolyte for skeletal, cardiac, and smooth muscle activity. NURSINGTB.COM PTS: 1 CON: Fluid and Electrolyte Balance 9. ANS: 4 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Discussing changes in fluid and electrolyte balance associated with aging Chapter page reference: 105-109 Heading: Fluid and Electrolyte Regulation Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 Skin turgor is a poor indicator of fluid balance in an older adult patient. 2 A body mass index within normal limits would not contribute to dehydration. A body mass index associated with overweight or obesity could be associated with dehydration, as fat cells contain little or no water. NURSINGTB.COM
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3 4
10.
An elevated blood pressure could indicate fluid volume overload or sodium sensitivity. A poor intake of water could indicate a loss of the thirst response, which occurs as a normal age-related change. Since the patient only ingests two glasses of water each day, this could indicate a reduction in the normal thirst response.
PTS: 1 CON: Fluid and Electrolyte Balance ANS: 2 Chapter number and title: 8, Fluid and Electrolyte Management
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Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of dehydration, hypovolemia, and hypervolemia Chapter page reference: 110 Heading: Laboratory Values Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate 1 2
3 4
11.
Feedback A normal hematocrit value for a female is 37% to 47%. The hematocrit level will decrease in overhydration. The hematocrit measures the volume of whole blood that is composed of RBCs. Because the hematocrit is a measure of the volume of cells in relation to plasma, it is affected by changes in plasma volume. The hematocrit increases with severe dehydration. Serum potassium is not an electrolyte used to determine an alteration in fluid balance. Serum sodium values would be more appropriate. Serum osmolality is a measure of the solute concentration of the blood and is used to evaluate fluid balance. Normal values are 280300 mOsm/kg. An increase in serum osmolality indicates a fluid volume deficit; a decrease reflects fluid volume excess.
PTS: 1 CON: Fluid and Electrolyte Balance ANS: 3 NURSINGTB.COM Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte disorders Chapter page reference: 105109 Heading: Fluid and Electrolyte Regulation Integrated Processes: Nursing Process – Evaluation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Difficult Feedback 1 Treatment has been effective. 2 A diuretic is not needed because the patient is being treated for NURSINGTB.COM
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3
4
12.
dehydration. Urinary output is normally equivalent to the amount of fluids ingested; the usual range is 1,500-2,000 mL in 24 hours, or 40-80 mL in 1 hour (0.5 mL/kg per hour). Patients whose intake substantially exceeds output are at risk for fluid volume excess; however, the patient is dehydrated. The extra fluid intake is being used to improve body fluid balance. The patient's output is 40 mL/hr, which is within the normal range. Treatment has been effective; however, it should continue until the intake and output are more balanced. Ending treatment now could further jeopardize this client's fluid balance.
PTS: 1 ANS: 2
CON: Fluid and Electrolyte Balance
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Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of dehydration, hypovolemia, and hypervolemia Chapter page reference: 114-119 Heading: Sodium Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 Juices and carbonated sodas will not help to replace the loss of sodium. 2 Both salt and water are lost through sweating. When only water is replaced, the individual is at risk for salt depletion. Symptoms include fatigue, weakness, headache, and gastrointestinal symptoms such as loss of appetite and nausea. The client should be instructed to eat something salty when drinking water to help replace the loss of sodium. 3 Eating something sweet will not help replace the loss of sodium. 4 Doubling the amount of water being ingested could lead to hyponatremia and further manifestations.
13.
PTS: 1 CON: Fluid and Electrolyte Balance ANS: 1 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Explaining the significance of osmolality, osmolarity, blood urea nitrogen (BUN), creatinine, and urine specific gravityNreUlaRteSd ItoNflGuiTdBan.dCeO lectrolyte status Chapter page reference: 108-109 Heading: Indicators of Fluid Status Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Easy Feedback
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1
2 3 4
14.
Older adult patients are less able to concentrate their urine, making them susceptible to dehydration. In addition, there is a deficit of the thirst response. However, fever, nausea, and vomiting resulting from these changes are not considered normal. The patient's symptoms of nausea and vomiting suggest decreased intake and increased output through vomiting, placing the client at risk for dehydration. Hypertension does not manifest with the current clinical indicators. Congestive heart failure and fluid overload would present with respiratory difficulty and peripheral edema. Congestive heart failure and fluid overload would present with respiratory difficulty and peripheral edema.
PTS: 1 CON: Fluid and Electrolyte Balance ANS: 2 Chapter number and title: 8, Fluid and Electrolyte Management
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Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of dehydration, hypovolemia, and hypervolemia Chapter page reference: 108 Heading: Insensible Losses Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Difficult Feedback 1 The pediatric patient with a chronic or acute condition that does not directly affect the GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at a lower risk than is a toddler with a condition that increases insensible water loss. 2 The pediatric patient with the greatest risk for dehydration is the child who is under 2 years of age experiencing tachypnea which increases insensible fluid loss. 3 The pediatric patient with a chronic or acute condition that does not directly affect the GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at a lower risk than is a toddler with a condition that increases insensible water loss. 4 The pediatric patient with a chronic or acute condition that does not directly affect the GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at a lower risk than is a toddler with a condition that increases insensible water loss.
15.
PTS: 1 CON: Fluid and Electrolyte Balance ANS: 3 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: DescribinNgUthReSpI atNhoGpThyBs. ioC loOgyM, clinical presentations, and management of dehydration, hypovolemia, and hypervolemia Chapter page reference: 109-112 Heading: Fluid Imbalances Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Difficult Feedback 1 Hydration should occur before and during the activity, not just at the NURSINGTB.COM
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2 3 4
16.
end. A combination of water and sports drinks is best to replace fluids during exercise. During activity, stopping for fluids every 15-20 minutes is recommended. Light-colored, light-weight clothing is best to wear during exercise activities; wearing of dark colors can increase sweating.
PTS: 1 CON: Fluid and Electrolyte Balance ANS: 4 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte disorders Chapter page reference: 116-117 Heading: Hyponatremia Integrated Processes: Nursing Process – Diagnosis
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Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Easy Feedback 1 Osmotic pressure pulls fluid into the capillaries, usually in response to the presence of albumin and other plasma proteins made by the liver. 2 Hydrostatic pressure occurs when extracellular fluid volume excess occurs; the increased fluid volume in the vascular compartment congests the veins. 3 Isotonic dehydration occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion. 4 Hypotonic dehydration occurs when fluid loss is characterized by a proportionately greater loss of sodium than water, causing serum sodium to fall below normal levels.
17.
18.
PTS: 1 CON: Fluid and Electrolyte Balance ANS: 4 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of dehydration, hypovolemia, and hypervolemia Chapter page reference: 112-113 Heading: Hypervolemia: Fluid Volume Excess Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance NURSINGTB.COM Difficulty: Moderate Feedback 1 Fluid volume excess is not caused by inactivity. 2 It is unlikely that the fluid volume excess experienced by the patient is caused by intravenous fluids. 3 Liver failure is not caused by the surgery. 4 Antidiuretic hormone (ADH) and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and stress upon the heart and circulatory system. PTS: 1 CON: Fluid and Electrolyte Balance ANS: 2 Chapter number and title: 8, Fluid and Electrolyte Management NURSINGTB.COM
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Chapter learning objective: Describing the role of endocrine, renal, and respiratory systems in the regulation of fluid and electrolyte balance Chapter page reference: 112-113 Heading: Hypervolemia: Fluid Volume Excess Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Easy Feedback
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1 2 3 4
19.
PTS: 1 CON: Fluid and Electrolyte Balance ANS: 1 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Correlating laboratory data and clinical manifestations related to disorders in: Potassium balance Chapter page reference: 121-122 Heading: Hypokalemia Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Easy 1
2 3 4
20.
Cardiac decompensation would not be an expected outcome of treatment. The patient receiving hemodialysis is expected to have a reduction of extracellular fluid, not a fluid deficit that puts the patient at risk. Diuretics and IV fluids are not administered during hemodialysis. Diuretics and IV fluids are not administered during hemodialysis.
Feedback Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop) diuretics, amphotericin B, and large doses of some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia. N and muscle relaxers would not bring about hySpAoIkDalse,loss mniaarto .cotics, potassium cause NURSINGTB.COM NSAIDs, narcotics, and muscle relaxers would not bring about potassium loss to cause hypokalemia. NSAIDs, narcotics, and muscle relaxers would not bring about potassium loss to cause hypokalemia.
PTS: 1 CON: Fluid and Electrolyte Balance ANS: 4 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte disorders Chapter page reference: 122-124 Heading: Hyperkalemia Integrated Processes: Teaching and Learning NURSINGTB.COM
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Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 Insulin does not promote renal excretion of potassium. 2 Giving insulin to decrease serum potassium levels is not considered a safer method than other medications that can be used. 3 Serum potassium is lowered by entering the cells; this is not controlled by serum glucose.
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21.
22.
Serum potassium levels may be temporarily lowered by administering glucose and insulin, which cause potassium to leave the extracellular fluid and enter cells.
PTS: 1 CON: Fluid and Electrolyte Balance ANS: 3 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of dehydration, hypovolemia, and hypervolemia Chapter page reference: 110-112 Heading: Hypovolemia: Fluid Volume Deficit Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 The patient may demonstrate genitourinary system changes because of the fluid volume deficit; however, this body system does not cause the deficit. 2 The patient may demonstrate cardiovascular system changes because of the fluid volume deficit; however, this body system does not cause the deficit. 3 The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives and/or enemas. 4 The patient may demonstrate musculo sk e letal syste m changes because N URS I NG T B . C O M of the fluid volume deficit; however, this body system does not cause the deficit. PTS: 1 CON: Fluid and Electrolyte Balance ANS: 1 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte disorders Chapter page reference: 114-119 Heading: Sodium Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Analysis [Analyzing] Concept: Fluid and Electrolyte NURSINGTB.COM
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Balance Difficulty: Difficult Feedback 1 Low-sodium salt substitutes are not really sodium-free. They may contain half as much sodium as regular salt. The patient should be instructed to use salt substitutes sparingly because larger amounts often taste bitter instead of salty. 2 Patients should be instructed to read food labels for the amount of sodium in the food item. 3 Baking soda and baking powder contain sodium and should be restricted on a sodium- restricted diet. 4 In place of salt or salt substitutes, the patient should be instructed to use herbs, spices, lemon juice, vinegar, and wine as flavoring when cooking.
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23.
24.
PTS: 1 CON: Fluid and Electrolyte Balance ANS: 4 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Describing the role of endocrine, renal, and respiratory systems in the regulation of fluid and electrolyte balance Chapter page reference: 112-114 Heading: Hypervolemia: Fluid Volume Excess Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Easy Feedback 1 Wheezing in the lungs is an assessment consistent with asthma. 2 Generalized weakness may be due to whatever disease process precipitated the renal failure. 3 Bowel sounds in four quadrants is a normal assessment finding. 4 The patient in acute renal failure will likely be edematous, as the kidneys are not producing urine. PTS: 1 CON: Fluid and Electrolyte Balance ANS: 2 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: ExplaininNgUnRurSsiIngNcGonTsBid.erCatOions M related to patients with fluid disorders
and electrolyte Chapter page reference: 112-114 Heading: Hypervolemia: Fluid Volume Excess Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 The patient is not demonstrating any manifestations that indicate a Risk for Infection. 2 Jugular vein distention, edema, and elevated blood pressure are indications of excessive fluid. The diagnosis Excess Fluid Volume should be selected to guide this patient's care. 3 Oliguria or reduced urine output would be a symptom associated with Ineffective Renal Tissue Perfusion. NURSINGTB.COM
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4
25.
Alterations in heart rate and rhythm would be symptoms associated with Risk for Altered Cardiac Perfusion.
PTS: 1 CON: Fluid and Electrolyte Balance ANS: 1 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte disorders Chapter page reference: 120-124
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Heading: Potassium Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 Many salt substitutes use potassium chloride. Potassium intake is carefully regulated in patients with renal failure, and the use of salt substitutes will worsen hyperkalemia. 2 Increases in weight do need to be reported to the health-care provider as a possible indication of fluid volume excess, but this is not the reason why salt substitute is to be avoided. 3 An AV fistula does need to be protected from injury and infection could be caused by constricting clothing, venipunctures, and other items. 4 The control of hypertension is essential in the management of a client with kidney disease, but salt substitute is not known to interact with antihypertensive medications. PTS: 1
CON: Fluid and Electrolyte Balance
MULTIPLE RESPONSE 26. ANS: 3, 4, 5 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Describing the pathophysiology, clinical rvU o lR e mSiI a presentations, and management of dehydration, hypovolemia, and hypeN NGTB.COM Chapter page reference: 105-109 Heading: Fluid and Electrolyte Regulation Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate 1. 2. 3.
Feedback This is incorrect. Diuretics may be ordered to reduce fluid volume excess. This is incorrect. Antibiotics are not used for fluid and electrolyte imbalance. This is correct. Hypodermoclysis, fluid administered subcutaneously, may be employed as a fluid delivery method, especially among older adults. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4. 5.
This is correct. Monitoring patient’s intake and output is one of several ways to assess the patient’s fluid status. This is correct. Intravenous fluids may be ordered for the patient with a fluid volume deficit if replacement oral fluids cannot be taken in sufficient quantity.
PTS: 1 CON: Fluid and Electrolyte Balance 27. ANS: 2, 4 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Correlating laboratory data and clinical manifestations related to disorders in: Sodium balance
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Chapter page reference: 114-119 Heading: Sodium Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate
1.
2. 3. 4. 5.
Feedback This is incorrect. Elevating the head of the bed would be appropriate if the patient were demonstrating signs of fluid volume overload. This is not known at this time and would not be a routine intervention with an elevated sodium level. This is correct. For an elevated sodium level, the electrolyte will need to be restricted, in the form of a low-sodium diet. This is incorrect. Monitoring of heart rate and rhythm would be more appropriate with a potassium imbalance. This is correct. Diuretics will remove excess fluid being held in the body because of the extra sodium. This is incorrect. A potassium imbalance is not associated with a sodium imbalance. More information is needed before this intervention would be planned or implemented.
PTS: 1 CON: Fluid and Electrolyte Balance 28. ANS: 2, 3, 4 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: ExplaininNgUnRurSsiIngNcGonTsBid.erCatOions M related to patients with fluid disorders and electrolyte Chapter page reference: 105-109 Heading: Fluid and Electrolyte Regulation Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate 1. 2. 3.
Feedback This is incorrect. Diet soda often contains caffeine. This is correct. Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of coffee and tea. This is correct. Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of coffee and tea. NURSINGTB.COM
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4.
5.
PTS: 1
This is correct. Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of coffee and tea. This is incorrect. Exercising between the hours of 10 am and 2 pm, considered the hottest time of the day, should be avoided. CON: Fluid and Electrolyte Balance
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29. ANS: 1, 2, 5 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Describing the role of endocrine, renal, and respiratory systems in the regulation of fluid and electrolyte balance Chapter page reference: 105109 Heading: Fluid and Electrolyte Regulation Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Easy
1.
2.
3.
4. 5.
Feedback This is correct. Older adults develop acute renal failure more frequently because of the higher incidence of serious illnesses, hypotension, major surgeries, diagnostic procedures, and treatment with nephrotoxic drugs. Decreased kidney function associated with aging also puts the older patient at risk for kidney failure. Hypotension, scheduled for aortic valve replacement surgery, and receiving high doses of intravenous antibiotics increase this patient’s risk for developing acute renal failure. This is correct. Older adults develop acute renal failure more frequently because of the higher incidence of serious illnesses, hypotension, major surgeries, diagnostic procedures, and treatment with nephrotoxic drugs. Decreased kidney function associated with aging also puts the older patient at risk for kidney failure. Hypotension, scheduled for aortic valve replacement surgery, and receiving high doses of intravenous antibiotics increase this patient’s risk for developing acute renal failure. This is incorrect. A prevNioUusRhSisItoNryGoTf Bm.a jC o rOsM u rgery and current treatment for type 2 diabetes mellitus are not identified risk factors for the development of acute renal failure. This is incorrect. A previous history of major surgery and current treatment for type 2 diabetes mellitus are not identified risk factors for the development of acute renal failure. This is correct. Older adults develop acute renal failure more frequently because of the higher incidence of serious illnesses, hypotension, major surgeries, diagnostic procedures, and treatment with nephrotoxic drugs. Decreased kidney function associated with aging also puts the older patient at risk for kidney failure. Hypotension, scheduled for aortic valve replacement surgery, and receiving high doses of intravenous antibiotics increase this patient’s NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
risk for developing acute renal failure.
PTS: 1 CON: Fluid and Electrolyte Balance 30. ANS: 1, 3, 5 Chapter number and title: 8, Fluid and Electrolyte Management Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of dehydration, hypovolemia, and hypervolemia Chapter page reference: 112-114 Heading: Hypervolemia: Fluid Volume Excess Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Fluid and Electrolyte Balance Difficulty: Easy
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Feedback 1.
2. 3.
4. 5.
PTS: 1
This is correct. Pediatric manifestations of acute renal failure characteristically begin with a healthy child who suddenly becomes ill with nonspecific symptoms that indicate a significant illness or injury. These symptoms may include any combination of the following: nausea, vomiting, lethargy, edema, gross hematuria, oliguria, and hypertension. This is incorrect. Wheezing is not a manifestation of acute renal failure. This is correct. Pediatric manifestations of acute renal failure characteristically begin with a healthy child who suddenly becomes ill with nonspecific symptoms that indicate a significant illness or injury. These symptoms may include any combination of the following: nausea, vomiting, lethargy, edema, gross hematuria, oliguria, and hypertension. This is incorrect. Postural hypotension is a manifestation of acute renal failure in an older person. This is correct. Pediatric manifestations of acute renal failure characteristically begin with a healthy child who suddenly becomes ill with nonspecific symptoms that indicate a significant illness or injury. These symptoms may include any combination of the following: nausea, vomiting, lethargy, edema, gross hematuria, oliguria, and hypertension. CON: Fluid and Electrolyte Balance
Chapter 9: Acid-Base Balance Multiple Choice Identify the choice that best completes the statement or answers the question. NURSINGTB.COM 1. The nurse is providing care for an adult patient who is admitted to the emergency department (ED) after passing out. The patient has been fasting and currently has ketones in the urine. Which acid-based imbalance should the nurse monitor the patient for based on the current data? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis 2. The nurse is providing care to patient with the following laboratory values: pH – 7.31; PaCO2 – 48 mmHg; and a normal HCO3. Which condition should the nurse plan care for based on the current data? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis 3. The nurse is reviewing the latest arterial blood gas results for a patient with NURSINGTB.COM
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metabolic alkalosis. Which result indicates that the metabolic alkalosis is compensated? 1) pH 7.32 2) HCO3 8 mEq/L 3) PaCO2 48 mmHg 4) PaCO2 18 mmHg 4. Which diagnostic test should the nurse anticipate when providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) to monitor acidbase balance? 1) Pulse oximetry
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2) 3) 4)
Bronchoscopy Sputum studies Arterial blood gases
5. Which patient statement indicates the need for additional education regarding the use of sodium bicarbonate to treat acidosis? 1) “I need to purchase antacids without salt.” 2) “I should use the antacid for at least 2 months.” 3) “I should contact the doctor if I have any gastric discomfort with chest pain.” 4) “I should call the doctor if I get short of breath or start to sweat with this medication.” 6. The patient is receiving sodium bicarbonate intravenously (IV) for correction of acidosis secondary to diabetic coma. The nurse assesses the patient to be lethargic, confused, and breathing rapidly. Which is the nurse's priority response to the current situation? 1) Stop the infusion and notify the provider because the patient is in alkalosis. 2) Increase the rate of the infusion and continue to assess the patient for symptoms of acidosis. 3) Decrease the rate of the infusion and continue to assess the patient for symptoms of alkalosis. 4) Continue the infusion, because the patient is still in acidosis, and notify the provider. 7. The nurse is planning care for an older adult patient with respiratory acidosis. Which intervention should the nurse include in this patient’s plan of care? 1) Maintain adequate hydration. 2) Reduce environmental stimuli. 3) Administer intravenous sodium bicarbonate. 4) Administer prescribed intravenoNusUfR luSidIs N caGreTfuBll. y .COM 8. The results of a patient’s arterial blood gas sample indicate an oxygen level of 72 mmHg. Which should the nurse closely assess when providing care to this patient? 1) Perfusion 2) Cognition 3) Communication 4) Fluid and electrolytes 9. The nurse is caring for a comatose patient with respiratory acidosis. For which intervention will the nurse need to collaborate when caring for this patient? 1) Monitoring vital signs 2) Measuring intake and output 3) Determining recent eating behaviors 4) Identifying current oxygen saturation level 10. The nurse is analyzing the patient's arterial blood gas report, which reveals a pH of 7.15. The patient has just suffered a cardiac arrest. Which consequences of this pH value does the nurse consider for this patient? 1) Decreased cardiac output NURSINGTB.COM
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2) 3) 4)
Decreased potassium levels Increased magnesium levels Decreased free calcium in the ECF
11. The nurse is caring for a patient admitted with renal failure and metabolic acidosis. Which clinical manifestation would indicate to the nurse that planned interventions to relieve the metabolic acidosis have been effective?
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1) 2) 3) 4)
Tachypnea Palpitations Increased deep tendon reflexes Decreased depth of respirations
12. A patient with metabolic acidosis has been admitted to the unit from the emergency department (ED). The patient is experiencing confusion and weakness. Which independent nursing intervention is the priority? 1) Protecting the patient from injury 2) Placing the patient in a high-Fowler's position 3) Administering sodium bicarbonate to the patient 4) Providing the patient with appropriate skin care 13. The nurse is reviewing new orders provided by the health-care provider for a critical care patient with metabolic acidosis. Which prescription should the nurse question? 1) Draw serum potassium levels every two hours. 2) Draw arterial blood gas samples every two hours. 3) Administer one ampule of sodium bicarbonate now. 4) Begin intravenous infusion of 0.9% normal saline. 14. The nurse is providing care to a patient who has been vomiting for several days. The nurse knows that the patient is at risk for metabolic alkalosis because gastric secretions have which characteristic? 1) Gastric secretions are acidic. 2) Gastric secretions are alkaline. 3) Gastric secretions have a foul smell. 4) Gastric secretions are green in color. 15. Which is the priority nursing action wNhUeR n pSrI o vNidGinTgBc. a reCtOo Ma patient who is admitted with metabolic alkalosis? 1) Monitoring oxygen saturation 2) Setting goals for the plan of care 3) Administering prescribed medications 4) Teaching the family about risk factors 16. The nurse is providing care to a patient who is admitted after a morphine overdose. Which acid-base imbalance should the nurse plan this patient’s care to reflect? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis 17. The nurse is providing care for a patient admitted to the unit with respiratory failure and respiratory acidosis. Which data from the nursing history is the probable cause for the patient’s current diagnoses? 1) Aspiration pneumonia NURSINGTB.COM
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2) 3) 4)
A recent trip to South America Recent recovery from a cold virus Use of ibuprofen for the control of pain
18. Which chronic lung condition noted in the patient’s health history supports the current diagnosis of respiratory acidosis? 1) Aspiration 2) Pneumonia 3) Cystic fibrosis
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4)
Hyperthyroidism
19. A patient is admitted to the emergency department for the treatment of a drug overdose causing acute respiratory acidosis. Which substance noted on the toxicology report is the most likely cause for the current diagnosis? 1) PCP 2) Cocaine 3) Marijuana 4) Oxycodone 20. Which clinical manifestation supports the nurse’s plan of care focusing on chronic respiratory acidosis? 1) Irritability 2) Blurred vision 3) Daytime sleepiness 4) Warm, flushed skin 21. The nurse is providing care to a patient who is admitted to the hospital with sudden, severe abdominal pain. Which arterial blood gas supports the patient’s current diagnosis of respiratory alkalosis? 1) pH is 7.35 and PaO2 is 88. 2) pH is 7.30 and HCO3 is 30. 3) pH is 7.47 and PaCO2 is 25. 4) pH is 7.33 and PaCO2 is 36. 22. The client is admitted to the emergency department (ED) with symptoms of a panic attack. Based on this data, the nurse plans care for which health problem? 1) Emesis 2) Memory loss NURSINGTB.COM 3) Hypoventilation 4) Respiratory alkalosis 23. The nurse completes discharge teaching for a patient with an anxiety disorder. Which patient statement indicates correct understanding of information related to respiratory alkalosis? 1) “I will eat more bananas at breakfast.” 2) “I will see my counselor on a regular basis.” 3) “I will not take antacids when I have heartburn.” 4) “I will breathe faster when I am feeling anxious.” 24. The nurse is reviewing the health-care provider orders for a patient who is diagnosed with respiratory alkalosis. Which prescription is appropriate for this patient’s care needs? 1) Draw arterial blood gas analysis. 2) Administer oxygen via face mask. 3) Restrict fluids to two liters per day. 4) Infuse one ampule of sodium bicarbonate. NURSINGTB.COM
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25. The nurse is providing care to a patient who is intubated and receiving mechanical ventilation after a motor vehicle crash. The patient is fighting the ventilator and attempting to remove the endotracheal tube. Which nursing action decreases the patient’s risk for developing respiratory alkalosis? 1) Apply wrist restraints. 2) Administer a prescribed sedative. 3) Teach the patient to take slow, deep breaths. 4) Discuss removing the endotracheal tube with the health-care provider.
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Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. Which risk factors exhibited by the patient presenting in the emergency department (ED) would place the patient at risk for metabolic acidosis? Select all that apply. 1) Pneumonia 2) Abdominal fistulas 3) Acute renal failure 4) Hypovolemic shock 5) Chronic obstructive pulmonary disease 27. A patient recently diagnosed with diabetes mellitus (DM) is hospitalized in diabetic ketoacidosis (DKA) after a religious fast. The patient tells the nurse, “I have fasted during this season every year since I became an adult. I am not going to stop now.” The nurse is not knowledgeable about this particular religion. Which nursing actions would be appropriate? Select all that apply. 1) Request a consult from a diabetes educator. 2) Assess the meaning and context of fasting for this religion. 3) Tell the patient that things are different now because of the new diagnosis. 4) Ask family members of the same religion to discuss fasting with the patient. 5) Encourage the patient to seek medical care if signs of ketoacidosis occur in the future. 28. The nurse is caring for the patient experiencing hypovolemic shock and metabolic acidosis. Which nursing actions are appropriate for this patient? Select all that apply. 1) Limit the intake of fluids. 2) Administer sodium bicarbonate. NURSINGTB.COM 3) Monitor ECG for conduction problems. 4) Keep the bed in the locked and low position. 5) Monitor weight on admission and discharge. 29. The nurse is providing care to a patient who is admitted with manifestations of metabolic alkalosis. Which diagnostic test findings support the admitting diagnosis? Select all that apply. 1) Serum glucose level 142 mg/dL 2) Blood pH 7.47 and bicarbonate 34 mEq/L 3) Intravenous pyelogram shows kidney stones 4) Bilateral lower lobe infiltrates noted on chest x-ray 5) Electrocardiogram changes consistent with hypokalemia 30. Which nursing actions are appropriate when conducting an Allen test? Select all that apply. 1) Rest the patient’s arm on the mattress. 2) Support the patient’s wrist with a rolled towel. 3) Tell the patient to relax the hand and then clench a fist. 4) Ensure that a second nurse is available to assist with the procedure. 5) Press the patient’s radial and ulnar arteries using the index and middle fingers. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 9: Acid-Base Balance Answer Section MULTIPLE CHOICE 1.
2.
ANS: 1 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Comparing and contrasting major acidbase disorders Chapter page reference: 141-143 Heading: Metabolic Acidosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: pH Regulation Difficulty: Easy Feedback 1 The patient who is fasting is at risk for metabolic acidosis. The body recognized fasting as starvation and begins to metabolize its own proteins into ketones, which are metabolic acid. 2 The nurse would not monitor this patient for metabolic alkalosis. 3 The nurse would not monitor this patient for respiratory acidosis. 4 The nurse would not monitor this patient for respiratory alkalosis. PTS: 1 CON: pH Regulation NURSINGTB.COM ANS: 3 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Comparing and contrasting major acidbase disorders Chapter page reference: 140 Heading: Respiratory Acidosis Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: pH Regulation Difficulty: Easy Feedback 1 Uncompensated metabolic acidosis has a decreased pH, normal PaCO2, and normal HCO3. 2 Uncompensated metabolic alkalosis has an increased pH, normal PaCO2, and increased HCO3. 3 If the pH is decreased and the PaCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4
Uncompensated respiratory alkalosis has an increased pH, decreased PaCO 2, and normal HCO3.
PTS: 1 CON: pH Regulation 3. ANS: 3 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Describing the role of the respiratory and renal systems in acid-base balance
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Chapter page reference: 143-145 Heading: Metabolic Alkalosis Integrated Processes: Nursing Process – Evaluation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: pH Regulation Difficulty: Moderate Feedback 1 A normal pH level is 7.35-7.45. A pH of less than 7.35 is acidosis 2 A HCO3 level of 8 mEq/L is low and is most likely associated with metabolic acidosis. In metabolic alkalosis, there is an excess of bicarbonate. 3 To compensate for this imbalance, the rate and depth of respirations decrease, leading to retention of carbon dioxide. The PaCO2 will be elevated. 4 A PaCO2 level of 18 mmHg is low and is seen in respiratory alkalosis. PTS: 1 CON: pH Regulation 4. ANS: 4 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Stating the steps for arterial blood gas interpretation Chapter page reference: 140 Heading: Arterial Blood Gas Results Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: pH NURSINGTB.COM Regulation Difficulty: Moderate Feedback 1 Pulse oximetry is a noninvasive test that evaluates the oxygen saturation level of blood. 2 A bronchoscopy provides visualization of internal respiratory structures. 3 Sputum studies can provide specific information about bacterial organisms. 4 Arterial blood gas analysis is done to assess alterations in acid-base balance caused by respiratory disorders, metabolic disorders, or both. PTS: 1 CON: pH Regulation 5. ANS: 2 Chapter number and title: 9, Acid-Base Balance NURSINGTB.COM
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Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders Chapter page reference: 141-143 Heading: Metabolic Acidosis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: pH Regulation Difficulty: Difficult 1
Feedback The patient should be instructed to use non-sodium antacids to prevent the absorption of excess sodium.
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2 3
4
Bicarbonate antacid should not be used for longer than two weeks. This statement indicates the need for additional teaching. The patient should be instructed to immediately contact the primary health-care provider if gastric discomfort occurs with chest pain or if dyspnea or diaphoresis occurs. The patient should be instructed to immediately contact the primary health-care provider if gastric discomfort occurs with chest pain or if dyspnea or diaphoresis occurs.
PTS: 1 CON: pH Regulation 6. ANS: 4 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders Chapter page reference: 141-143 Heading: Metabolic Acidosis Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: pH Regulation Difficulty: Difficult Feedback 1 The client receiving sodium bicarbonate is prone to alkalosis; monitor for cyanosis, slow respirations, and irregular pulse. The client’s symptoms do not indicate alkalosis so infusion should not be stopped. 2 The infusion should not be increase d or decreas ed without a practitioner order. N U R S I N G T B . C OM 3 The infusion should not be increased or decreased without a practitioner order. 4 The client continues to exhibit signs of acidosis; symptoms of acidosis include lethargy, confusion, CNS depression leading to coma, and a deep, rapid respiration rate that indicates an attempt by the lungs to rid the body of excess acid, and the provider should be notified. PTS: 1 CON: pH Regulation 7. ANS: 1 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders Chapter page reference: 140 Heading: Respiratory Acidosis Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological NURSINGTB.COM
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Adaptation Cognitive level: Application [Applying] Concept: pH Regulation Difficulty: Moderate Feedback 1 In respiratory acidosis, there are a drop in the blood pH, reduced level of oxygen, and retaining of carbon dioxide. The body needs to be well-hydrated so that pulmonary secretions can be removed to improve oxygenation. 2 Reducing environmental stimuli would be appropriate for the patient with respiratory alkalosis. 3 Sodium bicarbonate is indicated in the treatment of metabolic acidosis.
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4
Careful administration of intravenous fluids is important in the older patient with metabolic alkalosis because this population is at risk because of their fragile fluid and electrolyte status.
PTS: 1 CON: pH Regulation 8. ANS: 2 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders Chapter page reference: 133-135 Heading: Acid-Base Balance Overview Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: pH Regulation Difficulty: Difficult Feedback 1 Perfusion is affected by a reduction in circulating fluids. 2 An oxygen level of less than 75 mmHg can be due to hypoventilation. This drop in oxygen will change the patient's level of responsiveness. 3 Although acid-base imbalances can alter communication, there is no direct link between a low oxygen level and changes in communication. 4 With a fluid and electrolyte imbalance, there is another disorder affecting acid-base balance. This might not be affected by oxygen level. PTS: 1 CON: pH RegNulUatRioSn INGTB.COM 9. ANS: 3 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders Chapter page reference: 140 Heading: Respiratory Acidosis Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: pH Regulation Difficulty: Difficult Feedback 1 Monitoring vital signs is an independent nursing action. 2 Measuring intake and output is an independent nursing action. 3 For patients in severe distress, family members may need to be consulted for critical information such as recent eating habits and history of vomiting. NURSINGTB.COM
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4
10.
Identifying current oxygen saturation level is an independent nursing action.
PTS: 1 CON: pH Regulation ANS: 1 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Describing the significance of acid-base balance for normal function Chapter page reference: 133-135 Heading: Acid-Base Balance Overview Integrated Processes: Nursing Process – Planning
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Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: pH Regulation Difficulty: Moderate 1 2
3 4
11.
Feedback The nurse knows that severe acidosis depresses myocardial contractility, which leads to decreased cardiac output. Acid-base imbalances also affect electrolyte balance. In acidosis, potassium is retained as the kidney excretes excess hydrogen ion. Excess hydrogen ions also enter the cells, displacing potassium from the intracellular space to maintain the balance of cations and anions within the cells. The effect of both processes is to increase serum potassium levels. Magnesium levels may fall in acidosis. In acidosis, calcium is released from its bonds with plasma proteins, increasing the amount of ionized (free) calcium in the blood.
PTS: 1 CON: pH Regulation ANS: 4 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Describing the role of the respiratory and renal systems in acid-base balance Chapter page reference: 141-143 Heading: Metabolic Acidosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [UnNdeUrsRtaSndIinNgG] TB.CO Concept: pH Regulation Difficulty: Easy Feedback 1 This finding indicates the patient continues to experience metabolic acidosis. 2 Increased deep tendon reflexes and palpitations are not associated with metabolic acidosis. 3 Increased deep tendon reflexes and palpitations are not associated with metabolic acidosis. 4 The patient with metabolic acidosis will have an increased respiratory rate and depth. Signs that care has been effective would include a decrease in the rate and depth of respirations. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
12.
PTS: 1 CON: pH Regulation ANS: 1 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders Chapter page reference: 141-143 Heading: Metabolic Acidosis Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: pH Regulation Difficulty: Difficult
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1 2 3 4
13.
PTS: 1 CON: pH Regulation ANS: 3 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders Chapter page reference: 141-143 Heading: Metabolic Acidosis Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: pH Regulation Difficulty: Easy 1
2 3
4
14.
Feedback The patient with metabolic acidosis may have symptoms of drowsiness, lethargy, confusion, and weakness. A priority of care would be preventing injury. The high-Fowler's position would not be the safest position for the confused patient. Medication administration requires a practitioner prescription. Skin care would not be a priority on admission.
Feedback As metabolic acidosis is corrected, potassium shifts back into the intracellular space. This shift can lead to hypokalemia and cardiac dysrhythmias. Serum potassium levels should be carefully monitored during treatment Arterial blood gases are used to evaluate treatment and guide additional therapies. Administering bicarbonate to co N UrrRecSt aIcNidGosTisBin.cCreOasMes the risk for hypernatremia, hyperosmolality, and fluid volume excess. This is the order that the nurse should question before providing. Treatment of metabolic acidosis includes correction of fluid balance. An infusion of normal saline would be appropriate.
PTS: 1 CON: pH Regulation ANS: 1 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Comparing and contrasting major acidbase disorders Chapter page reference: 143-145 Heading: Metabolic Alkalosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension NURSINGTB.COM
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[Understanding] Concept: pH Regulation Difficulty: Easy Feedback 1 Metabolic alkalosis due to loss of hydrogen ions usually occurs because of vomiting or gastric suction. Gastric secretions are highly acidic (pH 1-3). When these are lost through vomiting or gastric suction, the alkalinity of body fluids increases. This increased alkalinity results from the loss of acid and from selective retention of bicarbonate by the kidneys as chloride is depleted. 2 Gastric secretions are not alkaline.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 4
15.
16.
The color and odor of gastric secretions have no influence on the development of metabolic acidosis. The color and odor of gastric secretions have no influence on the development of metabolic acidosis.
PTS: 1 CON: pH Regulation ANS: 1 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders Chapter page reference: 143-145 Heading: Metabolic Alkalosis Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: pH Regulation Difficulty: Difficult Feedback 1 The priority for this patient is monitoring oxygen saturation. The depressed respiratory drive that often accompanies metabolic alkalosis can lead to hypoxemia and impaired oxygenation of the tissues. 2 Teaching and goal setting are important aspects of nursing care but are not the priority. 3 Administering medications will be needed as a treatment, but the priority is to discover the cause. 4 Teaching and goal setting are important aspects of nursing care but are not the priority. NURSINGTB.COM PTS: 1 CON: pH Regulation ANS: 3 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Comparing and contrasting major acidbase disorders Chapter page reference: 140 Heading: Respiratory Acidosis Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: pH Regulation Difficulty: Easy Feedback 1 Respiratory alkalosis, metabolic acidosis, and metabolic alkalosis are caused by many NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 3
4
17.
conditions, none of which are related to this patient's morphine overdose. Respiratory alkalosis, metabolic acidosis, and metabolic alkalosis are caused by many conditions, none of which are related to this patient’s morphine overdose. Morphine is a narcotic and generally acts to decrease or suppress respirations; therefore, this patient is probably hypoventilating. The expected acidbase imbalance would be respiratory acidosis. Respiratory alkalosis, metabolic acidosis, and metabolic alkalosis are caused by many conditions, none of which are related to this patient’s morphine overdose.
PTS: 1 ANS: 1
CON: pH Regulation
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Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Comparing and contrasting major acidbase disorders Chapter page reference: 140 Heading: Respiratory Acidosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: pH Regulation Difficulty: Easy Feedback 1 Aspiration of a foreign body and acute pneumonia would put the patient at risk for respiratory acidosis. 2 A recent trip to South America would not constitute a respiratory risk factor for acidosis. 3 Recent recovery from a cold would not likely put the patient at risk for respiratory acidosis. 4 Ibuprofen does not pose a threat to the respiratory health of the patient.
18.
19.
PTS: 1 CON: pH Regulation ANS: 3 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Describing the role of the respiratory and renal systems in acid-base balance Chapter page reference: 140 Heading: Respiratory Acidosis Integrated Processes: Nursing Process – Assessment NURSINGTB.COM Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: pH Regulation Difficulty: Difficult Feedback 1 Pneumonia and aspiration are both acute lung conditions. 2 Pneumonia and aspiration are both acute lung conditions. 3 Chronic lung disease such as asthma and cystic fibrosis puts the patient at risk for respiratory acidosis. 4 Hyperthyroidism is a disorder that results in metabolic acidosis. PTS: 1 CON: pH Regulation ANS: 4 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Describing the role of the respiratory and renal systems in acid-base balance Chapter page reference: 140 NURSINGTB.COM
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Heading: Respiratory Acidosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: pH Regulation Difficulty: Easy Feedback 1 PCP is a hallucinogenic agent.
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2 3 4
20.
21.
Cocaine is a stimulant. Marijuana is not considered as a drug that depresses the central nervous system or respiratory center. Oxycodone is an opiate narcotic. Excessive use or overdose of narcotic substances can lead to respiratory depression and respiratory acidosis.
PTS: 1 CON: pH Regulation ANS: 3 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Comparing and contrasting major acidbase disorders Chapter page reference: 140 Heading: Respiratory Acidosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: pH Regulation Difficulty: Easy Feedback 1 The patient with acute respiratory acidosis may demonstrate warm, flushed skin, irritability, and blurred vision from the acute decline in oxygenation. 2 The patient with acute respiratory acidosis may demonstrate warm, flushed skin, irritability, and blurred vision from the acute decline in oxygenation. 3 The manifestations of acute and chronic respiratory acidosis differ. The patient with chronic respiratory acidosis will demonstrate daytime sleepiness. 4 The patient with acute respiratory a cid o sis may demo nstrate warm, N U RS I N G TB . C O M flushed skin, irritability, and blurred vision from the acute decline in oxygenation. PTS: 1 CON: pH Regulation ANS: 3 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Comparing and contrasting major acidbase disorders Chapter page reference: 140-141 Heading: Respiratory Alkalosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: pH Regulation Difficulty: NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Moderate 1 2 3
4
Feedback This data does not support the current diagnosis. This data does not support the current diagnosis. Acute pain usually causes hyperventilation, which causes the CO2 to drop and the client to experience respiratory alkalosis. The pH would denote alkalosis and would be higher than 7.45. HCO3 would trend downward as the kidneys begin to compensate for the alkalosis by excreting HCO 3. The PaO2 is likely to be normal unless the client has been hyperventilating for a long time and is beginning to tire. This data does not support the current diagnosis.
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22.
23.
PTS: 1 CON: pH Regulation ANS: 4 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Comparing and contrasting major acidbase disorders Chapter page reference: 140-141 Heading: Respiratory Alkalosis Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: pH Regulation Difficulty: Easy Feedback 1 The patient with anxiety does not necessarily have vomiting or memory loss as risk factors. 2 The patient with anxiety does not necessarily have vomiting or memory loss as risk factors. 3 Anxiety and panic attacks will lead to hyperventilation, not hypoventilation. 4 Anxiety disorders increase the risk for the acid-base imbalance respiratory alkalosis, due to hyperventilation that accompanies anxiety and panic attacks. PTS: 1 CON: pH Regulation ANS: 2 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders Chapter page reference: NURSINGTB.COM 140-141 Heading: Respiratory Alkalosis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: pH Regulation Difficulty: Difficult Feedback 1 Eating bananas is more appropriate for the patient at risk for metabolic alkalosis who is on diuretics. 2 The patient understands that reducing anxiety can reduce hyperventilation and respiratory alkalosis. Seeing a counselor can help the patient develop alternative strategies for dealing with anxiety. NURSINGTB.COM
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3 4
24.
Taking too many antacids is associated with metabolic alkalosis. Breathing faster will increase hyperventilation.
PTS: 1 CON: pH Regulation ANS: 1 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders Chapter page reference: 140-141 Heading: Respiratory Alkalosis Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding]
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Concept: pH Regulation Difficulty: Easy Feedback 1 Management of respiratory alkalosis focuses on correcting the imbalance and treating the underlying cause. Arterial blood gases must be ordered prior to beginning medication or oxygen therapy. 2 Oxygen is not anticipated when providing care to a patient experiencing respiratory alkalosis. 3 A fluid restriction is not required in the treatment of respiratory alkalosis. 4 Sodium bicarbonate is used in the treatment of respiratory and metabolic acidosis.
25.
PTS: 1 CON: pH Regulation ANS: 2 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders Chapter page reference: 140-141 Heading: Respiratory Alkalosis Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: pH Regulation Difficulty: Moderate 1 2 3
4
Feedback Applying wrist restraints to a pa anxiety with N UtieRnSt wIhNoGisTdBem.oCnOstrating M an endotracheal tube might exacerbate the patient’s condition. For a patient being mechanically ventilated, the only way to reduce rapid respirations might be to provide a sedative. The patient is being mechanically ventilated, which means there is a problem with maintaining the airway. The patient will not be able to take slow, deep breaths at this time. The reason for the endotracheal tube is to maintain the patient's airway after chest trauma. Removing the tube could lead to a collapse of the airway and a life-threatening situation.
PTS: 1
CON: pH Regulation
MULTIPLE RESPONSE NURSINGTB.COM
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26. ANS: 2, 3, 4 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Comparing and contrasting major acidbase disorders Chapter page reference: 141-143 Heading: Metabolic Acidosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: pH Regulation
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Difficulty: Easy
1. 2.
3.
4.
5.
Feedback This is incorrect. Chronic obstructive pulmonary disease and pneumonia place the patient at risk for respiratory acidosis with the increased retention of carbon dioxide in the blood. This is correct. Metabolic acidosis is rarely a primary disorder. It usually develops during the course of another disease; presence of abdominal fistulas; which can cause excess bicarbonate loss; acute renal failure; and hypovolemic shock. This is correct. Metabolic acidosis is rarely a primary disorder. It usually develops during the course of another disease; presence of abdominal fistulas; which can cause excess bicarbonate loss; acute renal failure; and hypovolemic shock. This is correct. Metabolic acidosis is rarely a primary disorder. It usually develops during the course of another disease; presence of abdominal fistulas; which can cause excess bicarbonate loss; acute renal failure; and hypovolemic shock. This is incorrect. Chronic obstructive pulmonary disease and pneumonia place the patient at risk for respiratory acidosis with the increased retention of carbon dioxide in the blood.
PTS: 1 CON: pH Regulation 27. ANS: 1, 2, 5 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders Chapter page reference: 141-143 Heading: Metabolic Acidosis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological NURSINGTB.CO Adaptation Cognitive level: Application [Applying] Concept: pH Regulation Difficulty: Moderate
1. 2. 3. 4.
Feedback This is correct. The diabetes educator should be contacted to work with the patient on strategies that might allow the fasting to occur in a safe manner. This is correct. Assessing the meaning and context of fasting in the patient’s religion would be educative for the nurse and an appropriate action. This is incorrect. Telling the patient that life is different now does not support religious beliefs. This is incorrect. Asking the family to talk to the patient might help, but the diabetes educator would be able to provide more direct and helpful information for the patient. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5.
This is correct. Stressing the importance of promptly seeking care when signs of ketoacidosis occur helps to promote the patient's health and is appropriate.
PTS: 1 CON: pH Regulation 28. ANS: 2, 3, 4 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders Chapter page reference: 141-143 Heading: Metabolic Acidosis Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation
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Cognitive level: Application [Applying] Concept: pH Regulation Difficulty: Moderate 1. 2. 3. 4. 5.
Feedback This is incorrect. The treatment for hypovolemic shock would include the administration of fluids, not limiting fluids. This is correct. Administering sodium bicarbonate and monitoring ECGs are appropriate for the patient with shock. This is correct. Administering sodium bicarbonate and monitoring ECGs are appropriate for the patient with shock. This is correct. The patient recovering from hypovolemic shock is at risk for injury, so the bed should be kept in the locked and low position. This is incorrect. Patients being treated for hypovolemia will require daily weights, not a weight on admission and then discharge.
PTS: 1 CON: pH Regulation 29. ANS: 2, 5 Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Comparing and contrasting major acidbase disorders Chapter page reference: 143-145 Heading: Metabolic Alkalosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: NURSINGTB.COM Comprehension [Understanding] Concept: pH Regulation Difficulty: Easy 1. 2. 3. 4.
5.
Feedback This is incorrect. Serum glucose level is not used to confirm the diagnosis of metabolic alkalosis. This is correct. In metabolic alkalosis, the blood pH will be greater than 7.45 and the bicarbonate level greater than 28 mEq/L. This is incorrect. The presence of kidney stones is not associated with the development of metabolic alkalosis. This is incorrect. The presence of bilateral lower lobe infiltrates on chest xray would not contribute to the development of metabolic alkalosis. This finding might be the result of metabolic alkalosis if the client's respiratory status is compromised. This is correct. The ECG pattern shows changes similar to those seen with hypokalemia.
PTS: 1 CON: pH Regulation 30. ANS: 1, 2, 5 NURSINGTB.COM
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Chapter number and title: 9, Acid-Base Balance Chapter learning objective: Stating the steps for arterial blood gas interpretation Chapter page reference: 138 Heading: Arterial Blood Gas Assessment Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying]
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Concept: pH Regulation Difficulty: Moderate 1. 2. 3. 4. 5. PTS: 1
Feedback This is correct. Rest the patient’s arm on the mattress or bedside stand and support his wrist with a rolled towel. This is correct. Rest the patient’s arm on the mattress or bedside stand and support his wrist with a rolled towel. This is incorrect. The nurse will tell the patient to first clench the fist, hold the position for a few seconds and then hold the hand in a relaxed position. This is incorrect. A second nurse is not required to perform this test. This is correct. The nurse uses the index and middle fingers to press on the patient’s radial and ulnar arteries. CON: pH Regulation
Chapter 10: Overview of Infusion Therapies Multiple Choice Identify the choice that best completes the statement or answers the question. NURSINGTB.COM 1. The nurse is providing care to a patient who is receiving a blood transfusion. Ten minutes after the infusion is initiated, the patient reports a headache. Upon further assessment the nurse notes that the patient is experiencing dyspnea and feels warm to the touch. Which is the priority nursing action by the nurse? 1) Stop the transfusion. 2) Prepare for a full resuscitation. 3) Notify the health-care provider. 4) Decrease the rate of the transfusion. 2. Which intravenous (IV) fluid should the nurse prepare when a patient requires an isotonic solution? 1) 0.9% normal saline 2) 2.5% dextrose in water 3) 0.33% sodium chloride 4) 5% dextrose in Lactated ringers 3. The nurse adds a medication to an intravenous (IV) fluid container to be hung on the patient’s existing IV line. Which is the first action the nurse takes after adding the medication to the container? NURSINGTB.COM
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1) 2) 3) 4)
Connect the bag to the tubing. Rotate the bag to distribute the medication. Place a completed medication-added label to the bag. Connect the bag to new tubing and flush the air from the tubing.
4. The nurse is initiating intravenous (IV) therapy for an adult patient who requires IV fluid infusion for 2–3 days and might require blood administration. Which would the nurse choose as the best option for IV catheterization?
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1) 2) 3) 4)
Butterfly Huber needle Angiocatheter Implantable venous access device
5. The nurse is assessing an intravenous (IV) insertion site noting redness, warmth, and mild swelling. The patient reports a burning pain along the course of the vein during medication administration. Which term should the nurse use when documenting these findings in the medical record? 1) Phlebitis 2) Infiltration 3) Extravasation 4) Inflammation 6. The nurse is caring for a patient with a medical diagnosis of increased intracranial pressure (ICP). Which intravenous (IV) fluid order would the nurse accept without questioning? 1) Run normal saline at 125 mL/hour. 2) Run half-normal saline at 200 mL/hour. 3) Run 5% dextrose in water at 80 mL/hour. 4) Run 5% dextrose in 0.45% NaCl at 75 mL/hour. 7. The nurse working in the emergency department (ED) is caring for a patient who experienced deep-thickness burns over 40% of the body and is in shock. Which intravenous (IV) prescription does the nurse anticipate for this patient? 1) Nutrient solutions 2) Volume expanders 3) Electrolyte solutions 4) Total parenteral nutritionNURSINGTB.COM 8. Which aspect of intravenous (IV) therapy could the nurse safely delegate to the unlicensed assistive personnel (UAP)? 1) Changing the IV site dressing on the patient's left hand 2) Watching the IV insertion site of the patient who complained of pain at the site 3) Reporting patient’s complaints of pain or leakage from the IV site when bathing the patient 4) Replacing patient’s IV solution when bag runs dry if it is only D5 W, without medications added 9. The nurse is setting up an intravenous (IV) infusion on an electronic infusion pump for a patient recently admitted to the unit. After leaving the room, the pump alarms and reads high pressure. Which is the priority action by the nurse? 1) Resetting the pump to resume infusion 2) Asking the patient if the pump has been tampered with in any way 3) Assessing the IV site and the tubing for kinks or closed roller clamps 4) Discontinuing the patient’s IV access and restarting in a different area 10. The nurse is administering a blood transfusion to an adult patient. The patient reports feeling cold and is shivering 15 minutes after the initiation of the NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
transfusion. The patient’s blood pressure has decreased since the last assessment. Which is the nurse's priority action? 1) Notify the health-care provider. 2) Monitor the blood pressure every five minutes. 3) Stop the blood infusion, and run the normal saline on the other side of the Y tubing.
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4)
Stop the blood infusion, and remove the tubing from the IV catheter, replacing it with normal saline.
11. The nurse is caring for a patient with a central venous catheter used for intermittent medication administration. When flushing the catheter prior to administering the next dose of medication, which initial action by the nurse is the most appropriate? 1) Aspirating the patient’s catheter for blood 2) Positioning the patient in reverse Trendelenburg position 3) Flushing the catheter, using as much force as required in order to clear the line 4) Obtaining a 3 mL syringe and filling it with normal saline for flushing the line 12. When removing a patient’s central line dressing, which action by the nurse is the priority? 1) Applying sterile gloves 2) Inspecting the insertion site for signs of infection 3) Pulling the tape off in the direction of the catheter 4) Pressing the catheter into the skin while removing the tape 13. The nurse is caring for a patient who is to have a peripherally inserted central catheter (PICC) line inserted tomorrow afternoon. The patient’s current peripheral access line is infiltrated, and needs to be restarted. Which site would the nurse avoid using? 1) Radial vein 2) Cephalic vein 3) Median cubital vein 4) Dorsal metacarpal veins 14. Which intravenous (IV) fluid should the nurse prepare when a patient requires a hypertonic solution? 1) 0.9% normal saline NURSINGTB.COM 2) 2.5% dextrose in water 3) 0.33% sodium chloride 4) 5% dextrose in Lactated ringers 15. Which intravenous (IV) fluid should the nurse prepare when a patient requires a hypotonic solution? 1) 0.9% normal saline 2) 5% dextrose in water 3) 0.33% sodium chloride 4) 5% dextrose in Lactated ringers 16. The nurse is providing care to a trauma patient who will require the rapid administration of large volumes of fluid in addition to a blood transfusion. Which gauge should the nurse use when initiating intravenous (IV) access for this patient? 1) 18 2) 20 3) 22 4) 24 NURSINGTB.COM
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17. Which component should the nurse anticipate will be prescribed for a patient with acute blood loss? 1) Platelets 2) Albumin 3) Fresh frozen plasma 4) Packed red blood cells
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18. Which component should the nurse anticipate will be prescribed for a patient with an elevated prothrombin time (PT) and international normalized ratio (INR) who is at an increased risk for bleeding? 1) Platelets 2) Albumin 3) Fresh frozen plasma 4) Packed red blood cells 19. Which component should the nurse anticipate will be prescribed for a patient is not responding to crystalloids for volume expansion? 1) Platelets 2) Albumin 3) Fresh frozen plasma 4) Packed red blood cells 20. Which component should the nurse anticipate will be prescribed for a patient with severe thrombocytopenia? 1) Platelets 2) Albumin 3) Fresh frozen plasma 4) Packed red blood cells Multiple Response Identify one or more choices that best complete the statement or answer the question. 21. The nurse is caring for a patient receiving intravenous (IV) medications. After infusing an IV antibiotic, the nurse assesses the IV site and finds it to be red and edematous, and the patient is reporting pain at the site. Which would the nurse document in NthUe R n uSrsIinNg Gn T o tBes.reCgOa rMd ing the infiltration? Select all that apply. 1) Incident report 2) Actions taken to correct the problem 3) Size and location of erythematous area 4) Health-care provider notification and any orders received 5) Amount of fluid infused per shift on the intake and output record 22. Which patients may benefit from central intravenous (IV) access? Select all that apply. 1) The patient receiving caustic IV therapy. 2) The patient requiring long-term IV therapy. 3) The patient who is afraid of needles and does not want a catheter in the peripheral extremity. 4) The patient requiring numerous IV infusions that are not compatible and cannot be infused together. 5) The unstable patient requiring reliable IV access for administration of medications required. immediately. 23. The nurse is performing venipuncture to initiate intravenous (IV) therapy. Which indicators should the nurse use when choosing the site for IV therapy? Select all that NURSINGTB.COM
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apply. 1) Choosing a straight vein 2) Avoiding a sclerotic vein 3) Looking for sites distal to joints 4) Using the dominant arm, whenever possible 5) Choosing a vein that is visible in addition to palpable
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24. The nurse is providing care to patient who is receiving total parenteral nutrition (TPN). During the shift assessment, the nurse notes that the patient is lethargic and has an elevated temperature and white blood cell count. The nurse suspects the patient is septic. Which actions by the nurse are appropriate in this situation? Select all that apply. 1) Changing the IV tubing 2) Saving the remaining TPN 3) Notifying the health-care provider 4) Recording the lot number of the TPN 5) Replacing the TPN with a normal saline solution 25. The nurse is caring for a patient with a central venous catheter (CVC). Which nursing actions should the nurse implement to prevent an air embolism? Select all that apply. 1) Using Luer-locked connections 2) Frequently checking connections 3) Wearing sterile gloves when accessing any connections 4) Clamping catheters and injection sites when not in use 5) Placing the patient in low-Fowler position to remove the CVC
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Chapter 10: Overview of Infusion Therapies Answer Section MULTIPLE CHOICE 1.
ANS: 1 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Explaining the procedure for safely administering blood products Chapter page reference: 161 Heading: Types of Infusion Reactions Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Medication Difficulty: Moderate 1 2 3 4
Feedback The priority nursing action is to stop the transfusion. If the patient is experiencing a transfusion reaction, this will limit the amount of blood administered. There is no need for resuscitation based on the current data. While the nurse would contact the health-care provider, this is not the priority. Slowing the rate of the transfusion allows for the blood to continue to be administered; therefore, this is not an appropriate nursing action.
PTS: 1 CON: MedicaNtioUnRSINGTB.COM 2. ANS: 1 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Describing the characteristics of common IV solutions Chapter page reference: 147-149 Heading: Solutions Used in Infusion Therapy Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Medication Difficulty: Moderate Feedback 1 An example of an isotonic solution is 0.9% normal saline. 2 An example of a hypotonic solution is 2.5% dextrose in water. 3 An example of a hypotonic solution is 0.33% sodium chloride. 4 An example of a hypertonic solution is 5% dextrose in Lactated ringers. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1 CON: Medication 3. ANS: 2 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Describing the equipment used to provide infusion therapy Chapter page reference: 156-162 Heading: Nursing Management of Infusion Therapy Integrated Processes: Nursing Process – Implementation
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Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Medication Difficulty: Difficult Feedback 1 This is not the first action by the nurse after adding the medication to the IV solution. 2 The bag should be rotated to distribute the medication throughout the fluid, and then a medication label added to the bag. Only after the bag is properly labeled can it be hung. 3 This is not the first action by the nurse after adding the medication to the IV solution. 4 This is not the first action by the nurse after adding the medication to the IV solution. PTS: 1 CON: Medication 4. ANS: 3 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Describing the equipment used to provide infusion therapy Chapter page reference: 155-156 Heading: Equipment Used in Infusion Therapy Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Medication Difficulty: Moderate Feedback 1 A butterfly can be used, if necessary, for IV catheterization, but is best when used for short-term IV infusion, as the NneUedRlSe rIem NaGinTsBin.pClaOceMwithin the vein, and is more likely to infiltrate sooner than is an angiocatheter. 2 A Huber needle is used to access an implantable venous access device, and would not be used for short-term use of a few days. 3 An angiocatheter would be the best choice because the needle is removed and only the catheter remains in place, so it is more likely to last for 2 days without infiltrating. 4 Implantable venous access devices are used when IV fluid needs are anticipated for several months. PTS: 1 CON: Medication 5. ANS: 1 Chapter number and title: 10, Overview of Infusion Therapies NURSINGTB.COM
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Chapter learning objective: Describing the potential complications of infusion therapy and strategies to prevent these complications Chapter page reference: 156-162 Heading: Nursing Management of Infusion Therapy Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Medication Difficulty: Easy 1
Feedback Redness, warmth, edema, and pain that runs along the course of the vein characterize phlebitis.
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2 3 4
An infiltrate is defined as fluid entering the tissues, resulting in swelling, coolness, pallor, and discomfort at the site. This patient’s site is red and warm, not cool and pale, so it is not an infiltrate. Extravasation includes a vesicant drug (one that causes blistering when in the tissues but not in the vascular system), so this is not an extravasation. Inflammation is not a term used for IV therapy.
PTS: 1 CON: Medication 6. ANS: 4 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Describing the characteristics of common IV solutions Chapter page reference: 147-149 Heading: Solutions Used in Infusion Therapy Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapy Cognitive level: Analysis [Analyzing] Concept: Medication Difficulty: Difficult Feedback 1 Normal saline and D5W are isotonic solutions, and so would need to be questioned. 2 Half-normal saline is hypotonic, and so would not be advisable for this patient. saline and D5W are isotonic solutions, and so would need to 3 Normal be questioned. 4 Isotonic and hypotonic fluids should not be administered to clients with increased intracranial pressure, because they increase the risk of cerebral edema. D5 in one-half normal saline is hypertonic, anNdUwRoul S dI be N GaTn Bac.ceCpOtable M IV solution for this patient. PTS: 1 CON: Medication 7. ANS: 2 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Discussing reasons patients require infusion therapy Chapter page reference: 147-149 Heading: Solutions Used in Intravenous Therapy Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Medication NURSINGTB.COM
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Difficulty: Moderate Feedback 1 Long term, this patient might require total parenteral nutrition if he is unable to maintain adequate calorie intake orally, but nutritional solutions would not be a priority concern this early in the patient's course of treatment. 2 Initially, the patient who is in shock will require volume expanders. 3 Once vital signs are stabilized, the primary care provider may order electrolyte solutions. 4 Long term, this patient might require total parenteral nutrition if he is unable to maintain adequate calorie intake orally, but nutritional solutions would not be a priority concern this early in the patient's course of treatment. PTS: 1
CON: Medication
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8.
9.
ANS: 3 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Describing the potential complications of infusion therapy and strategies to prevent these complications Chapter page reference: 156-162 Heading: Nursing Management of Infusion Therapy Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Medication; Legal Difficulty: Moderate Feedback 1 The IV dressing should be changed using sterile technique, and should not be delegated to the UAP. 2 The UAP is not responsible for assessing the site, because the nurse is responsible for all assessments. 3 The UAP can safely be taught to report complaints of pain or leakage from an IV site if it is noted during routine care. 4 Whether medications are added to the IV fluid or not, only the nurse can change the bag, because sterile technique is required, and even a plain solution is considered a medication. PTS: 1 CON: Medication | Legal ANS: 3 Chapter number and title: 10, OverviNe wUR o fSInIfuNsGioTn B T h.eCraOp iMes Chapter learning objective: Describing the potential complications of infusion therapy and strategies to prevent these complications Chapter page reference: 156-162 Heading: Nursing Management of Infusion Therapy Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Medication Difficulty: Moderate Feedback 1 Resetting the pump without performing a thorough assessment could increase the tissue damage if the site is infiltrated. NURSINGTB.COM
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2 3
4
10.
Accusing the patient of tampering with the pump would not be justified. The nurse should assess the IV site because an infiltrated IV, or a site that is proximal to a joint, can impede infusion. If the IV site appears to be within normal limits, the tubing should be checked for any kinks, closed roller clamps, or any other impediment to infusion. The IV site should not be discontinued if it is intact, so it should be assessed before considering moving the site.
PTS: 1 CON: Medication ANS: 4 Chapter number and title: 10, Overview of Infusion Therapies
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Chapter learning objective: Explaining the procedure for safely administering blood products Chapter page reference: 159-161 Heading: Administration of Blood Products Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Medication Difficulty: Moderate Feedback 1 Only after the blood infusion is discontinued would the nurse notify the health-care provider and monitor the patient’s condition. 2 Only after the blood infusion is discontinued would the nurse notify the health-care provider and monitor the patient’s condition. 3 Stopping the blood infusion and running saline through the blood tubing will administer the blood found in the tubing, and could make the transfusion reaction worse. 4 The nurse should completely discontinue the blood infusion, disconnecting the tubing from the IV catheter and placing normal saline or the ordered solution infusing prior to beginning the blood infusion with new tubing.
11.
PTS: 1 CON: Medication ANS: 1 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Comparing peripheral and central venous access including indications, access devices, and potential complications Chapter page reference: 156-162 NURSINGTB.COM Heading: Nursing Management of Infusion Therapy Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapy Cognitive level: Analysis [Analyzing] Concept: Medication Difficulty: Difficult Feedback 1 The catheter should be aspirated for blood prior to flushing the tubing. 2 There would be no need to place the patient in reverse Trendelenburg position, although a left Trendelenburg position may be used if an air embolism is suspected. 3 Excessive pressure should not be used when flushing the catheter, because it can dislodge a clot or cause the catheter to rupture. NURSINGTB.COM
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4
12.
The tubing would be flushed with a 10 mL syringe or larger because small syringes exert too much pressure, which can damage the catheter.
PTS: 1 CON: Medication ANS: 3 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Comparing peripheral and central venous access including indications, access devices, and potential complications Chapter page reference: 152-155Heading: Central Venous Access Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
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Cognitive level: Analysis [Analyzing] Concept: Medication Difficulty: Difficult Feedback 1 Sterile gloves are not used when removing the old dressing. 2 The site is inspected after the old dressing is removed, not while removing the dressing. 3 The tape should be removed in the direction of the catheter to avoid displacing the catheter. 4 The catheter should be held in the nurse’s hand while the tape is removed, not pressed into the patient’s skin.
13.
14.
PTS: 1 CON: Medication ANS: 3 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Comparing peripheral and central venous access including indications, access devices, and potential complications Chapter page reference: 152-155Heading: Central Venous Access Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Medication Difficulty: Easy Feedback 1 There is no need to avoid this site w hen restarting the peripheral access line. NU R S I N G T B . C O M 2 There is no need to avoid this site when restarting the peripheral access line. 3 The median cubital vein is often used for PICC lines, so the nurse should attempt to avoid this site in order to maintain it for the central line. 4 There is no need to avoid this site when restarting the peripheral access line. PTS: 1 CON: Medication ANS: 4 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Describing the characteristics of common IV solutions Chapter page reference: 147-149 Heading: Solutions Used in Infusion Therapy Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] NURSINGTB.COM
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Concept: Medication Difficulty: Moderate Feedback 1 An example of an isotonic solution is 0.9% normal saline. 2 An example of a hypotonic solution is 2.5% dextrose in water. 3 An example of a hypotonic solution is 0.33% sodium chloride. 4 An example of a hypertonic solution is 5% dextrose in Lactated ringers. PTS: 1
CON: Medication
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15.
16.
17.
ANS: 3 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Describing the characteristics of common IV solutions Chapter page reference: 147-149 Heading: Solutions Used in Infusion Therapy Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Medication Difficulty: Moderate Feedback 1 An example of an isotonic solution is 0.9% normal saline. 2 An example of an isotonic solution is 5% dextrose in water. 3 An example of a hypotonic solution is 0.33% sodium chloride. 4 An example of a hypertonic solution is 5% dextrose in Lactated ringers. PTS: 1 CON: Medication ANS: 1 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Describing the equipment used to provide infusion therapy Chapter page reference: 150-152 Heading: Peripheral Venous Access Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] NURSINGTB.COM Concept: Medication Difficulty: Easy Feedback 1 An 18 gauge is appropriate to initiate IV access for a patient who requires both rapid administration of large volumes of fluid and a blood transfusion. 2 While a 20-gauge catheter is appropriate for blood transfusion, this is not appropriate for the rapid administration of large volumes. 3 This catheter is not appropriate for this patient. 4 This catheter is not appropriate for this patient. PTS: 1 CON: Medication ANS: 4 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Explaining the procedure for safely administering blood products Chapter page reference: 159-161 NURSINGTB.COM
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Heading: Administration of Blood Products Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Medication Difficulty: Easy Feedback 1 Platelets are administered for patients who are bleeding due to thrombocytopenia or platelet abnormalities.
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2 3 4
18.
19.
Albumin is administered for volume expansion when crystalloid solutions are not adequate. Fresh frozen plasma is anticipated for a patient with a deficiency of plasma coagulation factors. Packed red blood cells are anticipated for a patient with acute or chronic blood loss and for patients diagnosed with anemia.
PTS: 1 CON: Medication ANS: 3 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Explaining the procedure for safely administering blood products Chapter page reference: 159-161 Heading: Administration of Blood Products Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Medication Difficulty: Easy Feedback 1 Platelets are administered for patients who are bleeding due to thrombocytopenia or platelet abnormalities. 2 Albumin is administered for volume expansion when crystalloid solutions are not adequate. 3 F r e s h f rozen plasma is anticipated for a patient with a deficiency of fplasma a c t ocoagulation rs . NURSINGTB.COM 4 Packed red blood cells are anticipated for a patient with acute or chronic blood loss and for patients diagnosed with anemia. PTS: 1 CON: Medication ANS: 2 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Explaining the procedure for safely administering blood products Chapter page reference: 159-161 Heading: Administration of Blood Products Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: NURSINGTB.COM
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Medication Difficulty: Easy Feedback 1 Platelets are administered for patients who are bleeding due to thrombocytopenia or platelet abnormalities. 2 Albumin is administered for volume expansion when crystalloid solutions are not adequate. 3 Fresh frozen plasma is anticipated for a patient with a deficiency of plasma coagulation factors. 4 Packed red blood cells are anticipated for a patient with acute or chronic blood loss and for patients diagnosed with anemia.
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20.
PTS: 1 CON: Medication ANS: 1 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Explaining the procedure for safely administering blood products Chapter page reference: 159-161 Heading: Administration of Blood Products Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Medication Difficulty: Easy Feedback 1 Platelets are administered for patients who are bleeding due to thrombocytopenia or platelet abnormalities. 2 Albumin is administered for volume expansion when crystalloid solutions are not adequate. 3 Fresh frozen plasma is anticipated for a patient with a deficiency of plasma coagulation factors. 4 Packed red blood cells are anticipated for a patient with acute or chronic blood loss and for patients diagnosed with anemia. PTS: 1
CON: Medication
MULTIPLE RESPONSE
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21. ANS: 2, 3 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Describing the potential complications of infusion therapy and strategies to prevent these complications Chapter page reference: 156-157 Heading: Phlebitis and Infiltration Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Communication; Medication Difficulty: Moderate Feedback NURSINGTB.COM
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1. 2. 3. 4.
5.
This is incorrect. The nurse would complete an incident report any time an IV infiltrates; however, this should not be included in the nursing notes. This is correct. Actions taken, such as discontinuation of the IV, should also be documented in the nursing notes. This is correct. The size of the erythematous area should be measured, marked, and documented in the nursing notes for continuity of care. This is incorrect. Although the health-care provider might be notified, orders received would be written on the health-care provider order sheet and not documented in the nursing record. This is incorrect. Intake from IV fluid would be documented on the intake and output record, not in the nursing notes.
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PTS: 1 CON: Communication | Medication 22. ANS: 1, 2, 4, 5 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Comparing peripheral and central venous access including indications, access devices, and potential complications Chapter page reference: 152-155Heading: Central Venous Access Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Medication Difficulty: Easy
1.
2. 3. 4.
5.
Feedback This is correct. Central venous access can be very useful for patients requiring long-term IV therapy because the catheter can remain in place for extended periods, and IV sites do not have to be changed every few days. This is correct. Caustic medications are less likely to cause phlebitis when administered into the large central veins as opposed to the smaller peripheral veins. This is incorrect. Because of the potential complications from central venous access, it would not be an option considered because of patient preference if short-term IV therapy is required. This is correct. In the critical care areas where patients may receive numerous continuous IV medication drips that might not all be compatible infusing through the same site, a multiple- port central venous access device can provide the best option. This is correct. Patients NwU hoRaSreIuNnsGtaTb Ble .anCdOrMequire rapid administration of medications require reliable IV access that might not be available with peripheral IV lines, and central venous access may be the best option.
PTS: 1 CON: Medication 23. ANS: 1, 2, 3 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Comparing peripheral and central venous access including indications, access devices, and potential complications Chapter page reference: 150-152 Heading: Peripheral Venous Access Integrated Processes: Nursing Process – Implementation NURSINGTB.COM
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Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Medication Difficulty: Moderate 1. 2. 3.
Feedback This is correct. Straight veins provide space for the catheter to be inserted easily. This is correct. Sclerotic veins make it difficult to obtain and maintain IV therapy. This is correct. The site should be sufficiently distal to the wrist or elbow joint to avoid bending or kinking of the IV catheter.
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4. 5.
This is incorrect. It is best, when possible, to use the patient’s non dominant arm, because movement might be somewhat limited, so the patient should be allowed to use the dominant arm. This is incorrect. Some patients, especially dark-skinned people, might not have easily visible veins, so the veins should be palpable even if not visible.
PTS: 1 CON: Medication 24. ANS: 1, 2, 3, 4 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Describing the special precautions required to safely administer parenteral nutrition Chapter page reference: 161-162 Heading: Administration of Total Parenteral Nutrition Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Medication Difficulty: Moderate 1. 2. 3. 4. 5.
Feedback This is correct. This is an appropriate action by the nurse. This is correct. This is an appropriate action by the nurse. This is correct. This is an appropriate action by the nurse. This is correct. This is an appropriate action by the nurse. This is incorrect. The fluNidUsRh ou S IldNbGe TreBpl.acCedO w Mith a 5% or 10% dextrose solution, not normal saline, because the patient has adjusted to a high sugar intake via the TPN, and eliminating all sugar infused could result in hypoglycemia.
PTS: 1 CON: Medication 25. ANS: 1, 2, 4 Chapter number and title: 10, Overview of Infusion Therapies Chapter learning objective: Describing the potential complications of infusion therapy and strategies to prevent these complications Chapter page reference: 157 Heading: Central Line Complications Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: NURSINGTB.COM
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Medication Difficulty: Difficult 1. 2. 3. 4. 5.
Feedback This is correct. The nurse should use Luer-lock connections to prevent an air embolism. This is correct. The nurse should frequently check all connections. This is incorrect. Wearing sterile gloves when accessing any connections will not prevent an air embolism. This is correct. Clamping catheters and injection sites when not in use will help to prevent an air embolism. This is incorrect. The patient should be placed in the supine position for removal of the CVC.
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PTS: 1
CON: Medication
Chapter 11: Pain Management Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which action by the nurse is the most appropriate when initiating guided imagery with a patient as a method to control pain? 1) Suggesting a place where the patient will find peace 2) Guiding the patient toward a most beautiful or peaceful place 3) Asking the patient to use progressive muscle relaxation exercises 4) Asking the patient to take slow, full diaphragmatic/abdominal breaths 2. A patient, who rates abdominal pain as a 10 on a 1 to 10 numeric scale is experiencing nausea, vomiting, and restlessness. Which conclusion is appropriate by the nurse based on the current data? 1) Acute pain 2) Chronic pain 3) End-of-life pain 4) Fibromyalgia pain 3. The nurse is caring for a patient who is experiencing acute chest pain that is rated as a 9 on a 0 to 10 pain scale. Based on this data, which medication does the nurse plan to administer? 1) Morphine NURSINGTB.COM 2) Ibuprofen 3) Naproxen 4) Acetaminop hen 4. The nurse is teaching a class on the perception of pain. What will the nurse teach as being the second step in processing pain stimuli? 1) Thalamus 2) Limbic system 3) Cerebral cortex 4) Reticular system 5. Which nursing action will provide the patient with the most pain relief after abdominal surgery? 1) Offer pain relief before the patient complains of pain. 2) Assess the pain level every 4 hours around the clock. 3) Wait until the patient can describe the pain specifically. 4) Allow the patient to “sleep off” the anesthesia, and then offer pain medication. NURSINGTB.COM
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6. The patient with a sprained ankle is complaining of pain in the injured area. Which term will the nurse use when documenting this patient’s pain? 1) Somatic pain 2) Visceral pain 3) Neuropathic pain 4) Physiological pain 7. Which term should the nurse use to document the maximum amount of pain is able to tolerate?
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1) 2) 3) 4)
Allodynia Hyperalgesia Pain tolerance Pain threshold
8. The nurse is using a nonpharmacologic method to manage a patient’s pain, and applies a unit that applies low- voltage electrical stimulation directly over the pain area. When documenting this intervention, which term is the most appropriate for the nurse to use? 1) TENS unit 2) Nerve block 3) Functional restoration 4) Cutaneous stimulation 9. The patient has pain in the lower back that radiates down the leg as the result of a herniated disk compressing the sciatic nerve that began 4 months ago. When documenting this patient’s pain, which term will the nurse use? 1) Acute somatic pain 2) Acute visceral pain 3) Acute neuropathic pain 4) Chronic neuropathic pain 10. Which type of pain syndrome should the nurse assess when providing care to a female patient? 1) Back pain 2) Interstitial cystitis 3) Cluster headaches 4) Visceral pain from the heart NURSINGTB.COM 11. The nurse is providing care to a postoperative patient who is getting out of bed for the first time since surgery. When conducting the pain assessment, the patient states, “It hurts, but I do not want to take any more drugs. I do not want to end up addicted.” Which response by the nurse is most appropriate? 1) “Don’t worry about getting addicted. I will make sure you don’t get addicted.” 2) “If you don’t take the pain medication on a regular schedule, you won’t get addicted.” 3) “People who have real pain are unlikely to become addicted to analgesics provided to treat the pain.” 4) “You are wise to be concerned; it is probably time to stop taking narcotics if you can manage the pain in other ways.” 12. The nurse is providing care to a patient who had an abdominal nevus removed who is reporting intense pain. Which action by the nurse is appropriate? 1) Administer the stronger analgesic ordered by the primary care provider. 2) Administer a nonnarcotic analgesic because the patient had minor surgery. 3) Notify the health-care provider that the patient's pain is excessive for the minor surgery performed. 4) Attempt to divert the patient without administering an analgesic NURSINGTB.COM
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because the surgery was so minor. 13. A nurse overhears another nurse say, “That patient is asking for pain medication again. He is constantly on the call bell, always reporting how severe his pain is, and I think he is just drug-seeking. I am going to make him wait the full 4 hours before I give this medication again.” Which action by the nurse is the most appropriate in this situation? 1) Informing the charge nurse of what was overheard 2) Reprimanding the nurse and completing an incident or variance report
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3) 4)
Ignoring the situation because the patient is not this nurse’s responsibility Reminding the nurse, in private, that the sensation of pain is whatever the patient says it is
14. The hospice nurse is making a home visit to a patient with terminal cancer. The patient reports poor pain control when the spouse says, “I am giving such big doses of medication, I am afraid she is going to overdose if I give her more.” Which response by the nurse is the most appropriate? 1) “You are not giving adequate pain relief, and she is in severe pain as a result.” 2) “You are wise to be concerned. These are very strong medications you’re administering.” 3) “Let's talk about the medication you’re giving and warning signs to be concerned about.” 4) “You are not giving enough pain medication, so she is in severe pain. You need to give more.” 15. The nurse finds a postoperative patient perspiring with fist clenched upon entering the room. The nurse administers routine medication and provides care. The patient is pleasant and cooperative. Which action by the nurse is appropriate? 1) Asking the patient if pain is being experienced 2) Instructing the patient to use the call bell if he experiences pain 3) Informing the patient that he looks uncomfortable and asking him to describe his pain 4) Documenting “no complaints of pain offered” and assessing that the patient is comfortable 16. The nurse is caring for a patient who is experiencing acute pain. Which action by the patient, noted by the nurse during the assessment, is considered an associated symptom of pain? 1) Crying 2) Vomiting 3) Grimacing 4) Changing position NURSINGTB.COM 17. The nurse is obtaining a pain history. The patient reports pain in the right ear. Which response by the nurse is the most appropriate? 1) “Is the pain minor?” 2) “Do you have anything else that hurts?” 3) “I will note that in the record. Is there anything else I should know?” 4) “Tell me more about the pain and what you do for it when it hurts.” 18. Which data collected by the nurse is nonessential when conducting a patient pain history? 1) Intensity, quality, and patterns 2) Significant other’s assessment of the pain 3) Precipitating factors, alleviating factors, and associated symptoms 4) Effects on activities of daily living, coping resources, and affective responses NURSINGTB.COM
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19. When caring for an older adult patient who does not speak English, which assessment tool is the most appropriate for the nurse to use to assess this patient’s pain? 1) An interpreter. 2) The patient’s affect. 3) The patient’s vital signs. 4) The FACES rating scale. 20. The pain management team individualizes the analgesic regimen by guiding the adjustment of medication, dose, time intervals, and route of administration. When discussing this method of treating pain, which term is the most appropriate for the nurse to use? 1) Analgesia 2) Equianalgesia
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3) 4)
Polypharmacy Dose-reduction pharmacology
21. Which is the reason for the nurse to administer ibuprofen, over acetaminophen, when providing patient pain management? 1) Analgesic effects 2) Antipyretic effects 3) Anti-inflammatory effects 4) Antipyretic and anti-inflammatory effects 22. The patient reports difficulty sleeping related to anxiety. Which nonpharmacologic pain management intervention might the nurse consider performing in order to relax the patient? 1) Massage 2) Distraction 3) Acupressure 4) Acupuncture 23. The nurse administered an oral analgesic to a patient complaining of a mild-tomoderate headache. Which activity would the nurse consider to help relieve the patient’s discomfort until the analgesic takes effect? 1) Crossword puzzles 2) Slow rhythmic breathing 3) Reading or watching TV 4) Video or computer games Multiple Response Identify one or more choices that best complete thNeUsRtatSemIeNn Gt oTrBan.sCweOrMthe question. 24. The nurse is creating a pain management plan using the three-step approach for a patient with intractable pain. Which interventions should the nurse include in this plan? Select all that apply. 1) Administer an opioid analgesic first. 2) Administer a nonopioid analgesic first. 3) Administer a mild opioid analgesic last. 4) Administer analgesics upon patient request. 5) Administer a combination nonopioid-opioid second. 25. The nurse is working on the orthopedic unit, and is caring for a patient who reports back pain. Which responses by the nurse would be appropriate when caring for this patient? Select all that apply. 1) “Does anything other than your back hurt?” 2) “I'm sorry you're hurting. I want to make you feel better.” 3) “Why don't you try another position until it's time for more pain medication?” 4) “You had medication for your pain at 4 p.m., so I can't give you any more until 8 p.m.” 5) “People with back pain experience very different symptoms. Tell NURSINGTB.COM
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me more about your back pain.” 26. According to the World Health Organization Three-Step Approach, if the nurse is caring for a patient reporting mild pain that persists after using full doses of step 1 medications, which medications can the nurse administer? Select all that apply. 1) Codeine 2) Fentanyl 3) Morphine 4) Hydrocodone with ibuprofen
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5)
Oxycodone with acetaminophen
27. The nurse administers a nonsteroidal anti-inflammatory drug (NSAID) to a patient who is experiencing chronic pain. When teaching the patient about this medication, which effects will the nurse include in the session? Select all that apply. 1) Sedating effects 2) Analgesic effects 3) Anesthetic effects 4) Antipyretic effects 5) Anti-inflammatory effects
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Chapter 11: Pain Management Answer Section MULTIPLE CHOICE 1.
ANS: 4 Chapter number and title: 11, Pain Management Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients with pain Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Feedback Moderate 1 The nurse should never suggest a peaceful place, but should allow the patient to choose 2 3 4
the place where he finds peace. The nurse should never suggest a peaceful place, but should allow the patient to choose the place where he finds peace. After deep breathing, the patient may be asked to use progressive muscle relaxation exercises, and then the nurse will guide the patient toward a peaceful place. The nurse begins by helping the patient to relax using slow breaths.
NURSINGTB.COM CON: Comfort
PTS: 1 2. ANS: 1 Chapter number and title: 11, Pain Management Chapter learning objective: Defining types of pain Chapter page reference: 174-177 Heading: Comprehensive Assessment Strategies for Acute and Chronic Pain Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Comfort NURSINGTB.COM
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Difficulty: Easy 1 2 3 4
Feedback Acute pain is pain of varying severity, location, and etiology that lasts fewer than 6 months. Acute pain is often manifested by nausea, vomiting, and restlessness. Chronic pain lasts longer than 6 months and persists beyond the expected period of healing. End-of-life pain is pain that is associated with the process of dying. Fibromyalgia pain is widespread muscular and joint pain.
PTS: 1 CON: Comfort 3. ANS: 1 Chapter number and title: 11, Pain Management
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Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients with pain Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 Acute pain is often treated with an opioid such as morphine. Morphine is often used to treat chest pain that is associated with a myocardial infarction. 2 Acetaminophen, ibuprofen, and naproxen are more appropriate for other types of pain, not acute chest pain. 3 Acetaminophen, ibuprofen, and naproxen are more appropriate for other types of pain, not acute chest pain. 4 Acetaminophen, ibuprofen, and naproxen are more appropriate for other types of pain, not acute chest pain. PTS: 1 CON: Comfort 4. ANS: 3 Chapter number and title: 11, Pain Management Chapter learning objective: Explaining the pathophysiologic processes that underlie the pain process Chapter page reference: 169-172 Heading: Processing Pain NURSINGTB.COM Messages Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 The thalamus is the main relay station for sensory information. 2 The transmission of pain moves through the limbic system after the thalamus. 3 The cerebral cortex is the second step in processing pain stimuli. 4 Transmission of pain impulses occurs in the reticular system after traveling though the thalamus as the main relay station. PTS: 1
CON: Comfort NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5.
ANS: 1 Chapter number and title: 11, Pain Management Chapter learning objective: Developing a comprehensive plan of nursing care for patients with pain Chapter page reference: 177-179 Heading: Nursing Management of Pain Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate
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1 2
3 4
6.
Feedback Anticipating a patient’s pain will ensure a more manageable pain experience than waiting until the patient complains of pain. If the patient is asleep, she should not be awakened simply to assess the pain every 4 hours unless there are other significant nonverbal signs during sleep that indicate that the patient is in pain. These can include grimacing, moaning, thrashing, or guarding of a surgical site. Pain management needs to be implemented prior to the patient's describing specific postoperative pain, or “sleeping off” anesthesia. Pain management needs to be implemented prior to the patient's describing specific postoperative pain, or “sleeping off” anesthesia.
PTS: 1 CON: Comfort ANS: 1 Chapter number and title: 11, Pain Management Chapter learning objective: Defining types of pain Chapter page reference: 166-169 Heading: Definitions of Pain Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate 1 2 3 4
NURSINGTB.COM Somatic pain originates in the skin, muscles, bone, or connective tissue, and would best describe this client’s pain. Visceral pain tends to be poorly located, resulting from activation of pain receptors in the organs and/or hollow viscera. Neuropathic pain results from damaged or malfunctioning nerves. Somatic pain is a subclassification of physiological pain, so it would be less specific to call it physiological as opposed to somatic.
PTS: 1 CON: Comfort 7. ANS: 3 Chapter number and title: 11, Pain Management Chapter learning objective: Defining types of pain Chapter page reference: 172-174 Heading: Factors Shaping the Pain Experience Integrated Processes: Communication and NURSINGTB.COM
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Documentation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 Allodynia is pain produced by nonpainful stimuli, such as the touch of wind to the area. 2 Hyperalgesia, or hyperpathia, denotes a heightened response to painful stimuli. 3 Pain tolerance is the maximum amount of pain a client can tolerate.
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4
Pain threshold is the lowest amount of stimuli needed for a person to label a sensation as pain.
PTS: 1 CON: Comfort 8. ANS: 1 Chapter number and title: 11, Pain Management Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients with pain Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 The unit described is a TENS unit, or transcutaneous electrical nerve stimulator, which is a form of cutaneous stimulation. 2 Nerve block is a pharmacologic treatment injecting an analgesic or steroid into the site of pain. 3 Functional restoration is a form of social therapy. 4 TENS would be the specific name of this treatment, whereas cutaneous stimulation would be a more general term. 9.
PTS: 1 CON: ComforNt URSINGTB.COM ANS: 3 Chapter number and title: 11, Pain Management Chapter learning objective: Defining types of pain Chapter page reference: 166-169 Heading: Definitions of Pain Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 The terminology is not used to document this patient’s pain. NURSINGTB.COM
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2 3 4
10.
The terminology is not used to document this patient’s pain. The pain is considered acute because it has lasted less than 6 months. It is neuropathic pain because it is caused by damage to the sciatic nerve. The terminology is not used to document this patient’s pain.
PTS: 1 CON: Comfort ANS: 2 Chapter number and title: 11, Pain Management Chapter learning objective: Describing components that comprise a comprehensive pain assessment Chapter page reference: 174-177 Heading: Comprehensive Assessment Strategies for Acute and Chronic Pain Integrated Processes: Nursing Process – Assessment
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Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 Back pain syndrome is more common in male, not female, patients. 2 Interstitial cystitis is more common in female patients; therefore, the nurse should assess for this. 3 Cluster headache syndrome is more common in male, not female, patients. 4 Visceral pain syndrome is more common in male, not female, patients.
11.
PTS: 1 CON: Comfort ANS: 3 Chapter number and title: 11, Pain Management Chapter learning objective: Developing patient educational strategies to promote self-care and improved patient outcomes Chapter page reference: 177179 Heading: Nursing Management of Pain Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate 1 2 3
4
12.
NURSINGTB.COM This statement is inappropriate. This statement is inappropriate. Many patients worry about becoming addicted to narcotic analgesics if they are required for more than a few days. It is important for the nurse to reassure the patient by providing truthful information. This statement is inappropriate.
PTS: 1 CON: Comfort ANS: 1 Chapter number and title: 11, Pain Management Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
with pain Chapter page reference: 177179 Heading: Nursing Management of Pain Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate 1
Feedback Pain perception is what the patient says it is, and the nurse should medicate the patient based on the patient’s description of the pain, not what the nurse anticipates. If the patient reports severe pain, the nurse should administer strong analgesics.
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2 3 4
13.
PTS: 1 CON: Comfort ANS: 4 Chapter number and title: 11, Pain Management Chapter learning objective: Developing patient educational strategies to promote self-care and improved patient outcomes Chapter page reference: 177179 Heading: Nursing Management of Pain Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Communication Difficulty: Moderate 1 2 3 4
14.
Patients who have minor surgery can still experience severe pain, and administering weaker analgesics when the patient reports severe pain would not be responsible practice. There is no need to notify the health-care provider unless the nurse’s assessment indicates there is something unusual occurring. Diverting the patient most likely will not be effective alone, although diversion might be possible after administering the analgesic.
Feedback Informing the charge nurse would only be necessary if the nurse who was overheard did not respond constructively to the nurse’s correction. This is not an appropriate respNonUseR by S IthNeGnTurBse.. COM It is every nurse’s responsibility to speak up and advocate for the client when situations arise that place the client at risk of incorrect treatment. The nurse would address the situation privately, and not in front of others at the nurses’ station.
PTS: 1 CON: Communication ANS: 3 Chapter number and title: 11, Pain Management Chapter learning objective: Developing patient educational strategies to promote selfcare and improved patient outcomes Chapter page reference: 177179 Heading: Nursing Management of Pain NURSINGTB.COM
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Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort; Communication Difficulty: Moderate 1 2
Feedback This response is likely to make the spouse feel guilty and does not provide information to provide the best care possible. Telling the patient’s spouse that his or her concern is warranted is untrue.
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3
4
15.
PTS: 1 CON: Comfort | Communication ANS: 3 Chapter number and title: 11, Pain Management Chapter learning objective: Developing a comprehensive plan of nursing care for patients with pain Chapter page reference: 177-179 Heading: Nursing Management of Pain Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate 1
2 3 4
16.
It is not unusual for a family caregiver to withhold medication out of fear of overdosing the cancer patient. It is important for the nurse to inform the caregiver that his feelings are not unusual, and then provide him with the information he needs to make an informed and appropriate decision that will make the client more comfortable. This response is likely to make the spouse feel guilty and does not provide information to provide the best care possible.
Feedback Some patients might feel that admitting to pain is a sign of weakness, and might not bring it up unless the nurse specifically refers to the patient’s apparent discomfort and asks him to describe his pain and indicates the patient's apparent discomfort. Instructing the patient to use the call bell puts the responsibility for pain assessment on the patient instead of on the nurse. It is the nurse’s responsibility to assess for pain and not wait for the patient to mention it. The patient’s body language indicates the likelihood of pain.
PTS: 1 CON: Comfort ANS: 2 Chapter number and title: 11, Pain Management Chapter learning objective: Describing components that comprise a comprehensive pain assessment Chapter page reference: 166-169 Heading: Definitions of Pain Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Comfort NURSINGTB.COM
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Difficulty: Easy Feedback 1 Changing position, crying, and grimacing are manners of expressing pain. 2 Symptoms that are often associated with pain include nausea, vomiting, and dizziness. 3 Changing position, crying, and grimacing are manners of expressing pain. 4 Changing position, crying, and grimacing are manners of expressing pain.
17.
PTS: 1 CON: Comfort ANS: 4 Chapter number and title: 11, Pain Management
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Describing components that comprise a comprehensive pain assessment Chapter page reference: 174-177 Heading: Comprehensive Assessment Strategies for Acute and Chronic Pain Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate 1 2 3 4
18.
Feedback This is a closed question and will not allow the nurse to gather the information needed regarding the patient’s pain. This is a closed question and will not allow the nurse to gather the information needed regarding the patient’s pain. This is a closed question and will not allow the nurse to gather the information needed regarding the patient’s pain. When the patient reports pain, the nurse should seek more information. When assessing pain, the nurse should assess all aspects of the pain, including character, onset, location, duration, exacerbation, relief, and radiation.
PTS: 1 CON: Comfort ANS: 2 Chapter number and title: 11, Pain Management Chapter learning objective: Describing components that comprise a comprehensive pain assessment Chapter page reference: 174-177 NURSINGTB.COM Heading: Comprehensive Assessment Strategies for Acute and Chronic Pain Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Assessment; Comfort Difficulty: Easy 1 2
Feedback The nurse should determine all of the other factors in order to put a plan of care in place that will help the patient address and treat the pain effectively. During a pain history, it is the patient’s description of the pain that is most important, not the significant other’s. NURSINGTB.COM
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3 4
19.
The nurse should determine all of the other factors in order to put a plan of care in place that will help the patient address and treat the pain effectively. The nurse should determine all of the other factors in order to put a plan of care in place that will help the patient address and treat the pain effectively.
PTS: 1 CON: Assessment | Comfort ANS: 4 Chapter number and title: 11, Pain Management Chapter learning objective: Describing components that comprise a comprehensive pain assessment Chapter page reference: 196-199 Heading: Managing Pain in Special Populations Integrated Processes: Nursing Process – Assessment
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Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Comfort Difficulty: Easy 1
2 3 4
20.
Feedback If an interpreter is available the nurse can ask the interpreter to discuss the pain in more detail, but the FACES rating scale will help the nurse to respond to the patient’s pain appropriately and quickly without waiting for an interpreter. Affect and vital signs might not be accurate indicators of the patient’s discomfort. Affect and vital signs might not be accurate indicators of the patient’s discomfort An interpreter might not always be readily available, so the FACES rating scale can be used because it is not necessary to use language.
PTS: 1 CON: Comfort ANS: 2 Chapter number and title: 11, Pain Management Chapter learning objective: Defining types of pain Chapter page reference: 166-169 Heading: Definitions of Pain Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Comfort NURSINGTB.COM Difficulty: Easy Feedback 1 Analgesia is a classification of medication used for pain control. 2 The term equianalgesia refers to the relative potency of various opioid analgesics compared to a standard dose of parenteral morphine (gold standard opioid). This tool helps professionals individualize the analgesic regimen by guiding the adjustment of medication, dose, time interval, and route of administration. 3 Polypharmacy is a generic term for multiple medication administration, often used with elders who are on many medications. 4 Dose-reduction pharmacology is not terminology associated with pain management. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
21.
PTS: 1 CON: Comfort ANS: 3 Chapter number and title: 11, Pain Management Chapter learning objective: Examining pain management strategies Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Comfort Difficulty: Easy Feedback 1 Both ibuprofen and acetaminophen provide analgesic effects. 2 Both ibuprofen and acetaminophen provide antipyretic effects.
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23.
Ibuprofen is administered over acetaminophen when antiinflammatory properties are desired for pain management. While ibuprofen is administered for its anti-inflammatory properties both acetaminophen and ibuprofen have antipyretic properties.
PTS: 1 CON: Comfort ANS: 1 Chapter number and title: 11, Pain Management Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients with pain Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Comfort Difficulty: Easy Feedback 1 Massage is used for relaxation, and can be effective in helping the client who is anxious. 2 Distraction, acupressure, and acupuncture are not used for relaxation, although they can be effective in helping the patient cope with pain. 3 Distraction, acupressure, and acupuncture are not used for relaxation, although they can be effective in helping the patient cope with pain. 4 Distraction, acupressure, and acup u ncture a re n ot u se d for relaxation, NU R S I N G T B . C O M although they can be effective in helping the patient cope with pain. PTS: 1 CON: Comfort ANS: 2 Chapter number and title: 11, Pain Management Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients with pain Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Basic NURSINGTB.COM
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Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback 1 Reading, watching TV, video games, and crossword puzzles might exacerbate the symptoms because the patient with a headache is often more comfortable in a dark, low-stimuli environment. 2 Slow rhythmic breathing would be an effective distraction technique for a patient with a headache. 3 Reading, watching TV, video games, and crossword puzzles might exacerbate the symptoms because the patient with a headache is often more comfortable in a dark, low-stimuli environment.
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Reading, watching TV, video games, and crossword puzzles might exacerbate the symptoms because the patient with a headache is often more comfortable in a dark, low-stimuli environment.
PTS: 1
CON: Comfort
MULTIPLE RESPONSE 24. ANS: 2, 3, 5 Chapter number and title: 11, Pain Management Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients with pain Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parental Therapies Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback This is incorrect. An opioid analgesic is not the first choice when using the three-step approach in pain management. This is correct. The first step in the three-step approach to pain management involves administering a nonopioNidUdRruSgIfiNrsG t. TB.COM This is correct. If the patient is still experiencing pain, the mild opioid should be replaced with a stronger opioid in step 3. This is incorrect. Pain-relieving drugs should be given “by the clock” (every 3-6 hours) rather than on demand to maintain freedom from pain. This is correct. If pain is not adequately controlled with this mild intervention, patients should advance to step 2 and receive a mild opioid in combination with the same or a new nonopioid drugs.
PTS: 1 CON: Comfort 25. ANS: 1, 2, 5 Chapter number and title: 11, Pain Management Chapter learning objective: Developing a comprehensive plan of nursing care for patients with pain Chapter page reference: 177-179 Heading: Nursing Management of Pain Integrated Processes: Nursing Process – NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Comfort Difficulty: Moderate Feedback
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1.
2.
3. 4. 5.
This is correct. The nurse should inform the patient that it is the job of the nurse to work to make the patient feel better, seek more information about the type of pain the patient is experiencing, and question any other discomforts the patient may be experiencing. This is correct. The nurse should inform the patient that it is the job of the nurse to work to make the patient feel better, seek more information about the type of pain the patient is experiencing, and question any other discomforts the patient may be experiencing. This is incorrect. Allowing the patient to remain in pain would not be prudent practice, and would be lacking in caring. This is incorrect. Allowing the patient to remain in pain would not be prudent practice, and would be lacking in caring. This is correct. The nurse should inform the patient that it is the job of the nurse to work to make the patient feel better, seek more information about the type of pain the patient is experiencing, and question any other discomforts the patient may be experiencing.
PTS: 1 CON: Comfort 26. ANS: 1, 4, 5 Chapter number and title: 11, Pain Management Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based interventions into a plan of care for patients with pain Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: NURSINGTB.COM Comfort Difficulty: Moderate 1. 2. 3. 4.
Feedback This is correct. If the pain persists or the pain is moderate, the second step is a weak opioid, or a combination of opioid and nonopioid medicine can be used. Codeine is a weak opioid. This is incorrect. Fentanyl is a strong opioid that is not administered until step 3. This is incorrect. Morphine is a strong opioid that is not administered until step 3. This is correct. If the pain persists or the pain is moderate, the second step is a weak opioid, or a combination of opioid and nonopioid medicine can be used. Hydrocodone with ibuprofen is an opioid/nonopioid medicine. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5.
This is correct. If the pain persists or the pain is moderate, the second step is a weak opioid, or a combination of opioid and nonopioid medicine can be used. Oxycodone with acetaminophen is an opioid/nonopioid medicine.
PTS: 1 CON: Comfort 27. ANS: 2, 4, 5 Chapter number and title: 11, Pain Management Chapter learning objective: Developing patient educational strategies to promote self-care and improved patient outcomes Chapter page reference: 179-196 Heading: Pain Management Options Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying]
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Concept: Comfort Difficulty: Moderate 1. 2. 3.
4. 5. PTS: 1
Feedback This is incorrect. These medications do not have sedating or anesthetic effects in most patients, although some patients might report being able to fall asleep more easily once pain is reduced. This is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) have antiinflammatory, analgesic, and antipyretic effects. This is incorrect. These medications do not have sedating or anesthetic effects in most patients, although some patients might report being able to fall asleep more easily once pain is reduced. This is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) have antiinflammatory, analgesic, and antipyretic effects. This is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) have antiinflammatory, analgesic, and antipyretic effects. CON: Comfort
Chapter 12: Complementary and Alternative Care Initiatives Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which is a guiding principle when usNinUgRthSe IRNecGipTieBnt./PCraOctMitioner Partnership in the delivery of complementary and alternative medicine to a patient? 1) Defining health as harmonious and balanced 2) Believing that qi permeates and bonds all living things 3) Establishing a relationship because building trust instills hope 4) Emphasizing a healthy lifestyle for a proactive approach to wellness 2. Which is a guiding principle when using the Wellness Model of Care in the delivery of complementary and alternative medicine to a patient? 1) Defining health as harmonious and balanced 2) Believing that qi permeates and bonds all living things 3) Establishing a relationship because building trust instills hope 4) Emphasizing a healthy lifestyle for a proactive approach to wellness 3. Which is a guiding principle when using the Energy Paradigm in the delivery of complementary and alternative medicine to a patient? 1) Defining health as harmonious and balanced 2) Encouraging self-awareness regarding body changes 3) Establishing a relationship because building trust instills hope 4) Emphasizing a healthy lifestyle for a proactive approach to wellness NURSINGTB.COM
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4. The nurse should offer the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan of care for patients with which emotional or psychological disorder? 1) Neuropathy 2) Fibromyalgia
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3) 4)
Chronic fatigue Carpal tunnel syndrome
5. The nurse should offer the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan of care for patients with which pain disorder? 1) Insomnia 2) Menopause 3) Fibromyalgia 4) Chronic fatigue 6. Which patient statement indicates the need for further education regarding the benefits of using Energy Healing Therapies in the plan of care? 1) “It promotes relaxation.” 2) “It helps to reduce stress.” 3) “It will decrease my stamina.” 4) “It will relieve musculoskeletal discomfort.” 7. Which gastrointestinal (GI) issue might benefit from the nurse educating the patient about the use of herbal medicine? 1) Reflux 2) Flatulence 3) Constipation 4) Hemorrhoids 8. A patient is interested in exploring the use of a complementary and alternative medicine (CAM) health-care provider. Which patient statement indicates the need for further education regarding questions that should be asked of any CAM provider? NURSINGTB.COM 1) “I will ask the provider if he or she accepts my insurance plan.” 2) “None of these providers are licensed so I need to be very careful.” 3) “I will ask the provider to provide education regarding any side effects.” 4) “Sessions may be required several times per month, so I will ask about frequency of visits.” 9. A nurse is interested in implementing complementary and alternative medicine (CAM) into practice. Which research barrier may inhibit this from occurring? 1) Detailed standardization for interpretation of systematic reviews 2) Large number of patients involved in clinical trials 3) Generic treatment plans 4) Reluctant funding 10. A patient asks for reliable information from the Internet regarding complementary and alternative medicine (CAM). Which URL should the nurse provide to this patient? 1) www.google.com 2) www.webmd.com 3) www.cdc.gov 4) www.fda.gov NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
11. Which term should the nurse use when referring to the dominant health-care system within the United States during a training session with other health-care providers regarding complementary and alternative medicine (CAM)? 1) Eastern medicine 2) Conventional medicine
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3) 4)
Folklore medicine practices Old-world traditional medicine
12. When teaching about the use of complementary and alternative medicine (CAM), which patient statement indicates to the nurse the need for additional education? 1) “The goals of care for CAM and conventional medicine are very different.” 2) “The term alternative is used when the treatment is outside of conventional methods.” 3) “The term complementary refers to CAM practices that are paired with conventional medicine.” 4) “The top ten reasons adult seek CAM include things such as pain, anxiety, depression, and headaches.” 13. Which nursing action indicates a holistic approach to patient care? 1) Refusing a patient assignment because of differing religious beliefs 2) Telling the patient’s family that spiritual beliefs should be kept to themselves 3) Asking the patient to limit responses to information that is pertinent to today’s visit 4) Providing housing information for a family who seeks care for their child’s ear infection 14. Which therapy should the nurse document as a specific category for complementary and alternative medicine (CAM)? 1) Naturopathy 2) Acupuncture 3) Therapeutic touch 4) Dietary supplements 15. Which patient diagnosis would contraindicate the use of massage at a complementary and alternative medicine (CAM) NURSINGTB.COM therapy? 1) Depression 2) Osteoporosis 3) Fibromyalgia 4) Tumor sites 16. Which patient prescription would contraindicate the use of massage therapy in the nursing plan of care? 1) Insulin 2) Warfarin 3) Propranolol 4) Acetaminophen 17. Which patient condition would cause the nurse to assess for physical limitations and mobility restrictions prior to including mind/body therapies in the plan of care? 1) Cataracts NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN 2) 3) 4)
Pregnancy Previous back surgery Controlled hypertension
18. Which patient condition supports the use of an energy healing therapy with anecdotal evidence? 1) Asthma 2) Depression 3) Bipolar disorder 4) Anorexia nervosa 19. Which term should the nurse use to describe the healing properties associated with botanicals?
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1) 2) 3) 4)
Natural Artificial Alternative Complementary
20. The nurse is preparing to administer a prescribed herbal product with a traditional antibiotic. Which should the nurse consult prior to administering these prescribed therapies? 1) The charge nurse for the shift. 2) The pharmacologist for the unit. 3) A physician’s desk reference (PDR). 4) A reputable Internet site regarding complementary and alternative medicine (CAM). Multiple Response Identify one or more choices that best complete the statement or answer the question. 21. Which top ten diagnoses for adult patients should the nurse include complementary and alternative therapies when planning care? Select all that apply. 1) Cancer 2) Anxiety 3) Arthritis 4) Insomnia 5) Dyspepsia 22. Which are the benefits for a patient diagnosed with heart disease, when the nurse includes Mind/Body therapies in the plan of care? Select all that apply. NURSINGTB.COM 1) Decreased fatigue 2) Decreased headache 3) Decreased heart rate 4) Decreased blood pressure 5) Decreased body temperature 23. The nurse plans to include the use of Mind/Body therapies for patients with which diagnoses in order to facilitate communication and social interaction? Select all that apply. 1) Autism 2) Anxiety 3) Depression 4) Sleep disorders 5) Alzheimer disease 24. The nurse plans to include the use of Mind/Body therapies for patients with which diagnoses in order to facilitate relaxation? Select all that apply. 1) Autism 2) Anxiety NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN 3) 4) 5)
Depression Sleep disorders Alzheimer disease
25. Which are general benefits the nurse would include in a teaching session for a patient who is considering the use of Manipulative and Body-Based therapies? Select all that apply. 1) Alleviates pain 2) Relieves insomnia
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3) 4) 5)
Decreases heart rate Facilitates mental clarity Increases range of motion
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Chapter 12: Complementary and Alternative Care Initiatives Answer Section MULTIPLE CHOICE 1.
ANS: 3 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Defining complementary and alternative medicine Chapter page reference: 202-203 Heading: Introduction Integrated Processes: Nursing Process – Planning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Promoting Health Difficulty: Easy 1 2 3 4
Feedback This is a guiding principle when using the Energy Paradigm for the implementation of complementary and alternative medicine. This is a guiding principle when using the Energy Paradigm for the implementation of complementary and alternative medicine. This is a guiding principle when using the Recipient/Practitioner Partnership for the implementation of complementary and alternative medicine. This is the guiding principle when using the Wellness Model of Care for the implementation of the complementary and alternative medicine.
NURSINGTB.COM CON: Promoting Health
PTS: 1 2. ANS: 4 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Defining complementary and alternative medicine Chapter page reference: 202-203 Heading: Introduction Integrated Processes: Nursing Process – Planning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Promoting Health Difficulty: Easy Feedback NURSINGTB.COM
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1 2 3 4
This is a guiding principle when using the Energy Paradigm for the implementation of complementary and alternative medicine. This is a guiding principle when using the Energy Paradigm for the implementation of complementary and alternative medicine. This is a guiding principle when using the Recipient/Practitioner Partnership for the implementation of complementary and alternative medicine. This is the guiding principle when using the Wellness Model of Care for the implementation of complementary and alternative medicine.
PTS: 1
CON: Promoting Health
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3.
ANS: 1 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Defining complementary and alternative medicine Chapter page reference: 202-203 Heading: Introduction Integrated Processes: Nursing Process – Planning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Promoting Health Difficulty: Easy 1 2 3 4
Feedback This is a guiding principle when using the Energy Paradigm for the implementation of complementary and alternative medicine. This is the guiding principle when using the Wellness Model of Care for the implementation of complementary and alternative medicine. This is a guiding principle when using the Recipient/Practitioner Partnership for the implementation of complementary and alternative medicine. This is the guiding principle when using the Wellness Model of Care for the implementation of complementary and alternative medicine.
PTS: 1 CON: Promoting Health 4. ANS: 3 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Differentiating the classifications of complementary and alternative medicine NURSINGTB.COM Chapter page reference: 203-209 Heading: Classification of CAM Integrated Processes: Nursing Process – Planning Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Nursing Difficulty: Moderate Feedback 1 Neuropathy is a pain, not emotional or psychological, disorder that might be treated with the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan of care. NURSINGTB.COM
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2
3
4
Fibromyalgia is a pain, not emotional or psychological, disorder that might be treated with the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan of care. Chronic fatigue is an emotional or psychological disorder that might be treated with the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan of care. Carpal tunnel syndrome is a pain, not emotional or psychological, disorder that might be treated with the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan of care.
PTS: 1 CON: Nursing 5. ANS: 3 Chapter number and title: 12, Complementary and Alternative Care Initiatives
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Chapter learning objective: Differentiating the classifications of complementary and alternative medicine Chapter page reference: 203-209 Heading: Classification of CAM Integrated Processes: Nursing Process – Planning Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Nursing Difficulty: Moderate Feedback 1 Insomnia is an emotional or psychological, not pain, disorder that might be treated with the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan of care. 2 Menopause is an emotional or psychological, not pain, disorder that might be treated with the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan of care. 3 Fibromyalgia is a pain disorder that might be treated with the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan of care. 4 Chronic fatigue is an emotional or psychological, not pain, disorder that might be treated with the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan of care. PTS: 1 CON: Nursing 6. ANS: 3 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Differentiating the classifications of complementary and alternative medicine NURSINGTB.COM Chapter page reference: 208 Heading: Box 12.6 Benefits of Energy Healing Therapies Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Analysis [Analyzing] Concept: Promoting Health Difficulty: Difficult Feedback 1 Energy Healing Therapies are known to promote relaxation. This statement indicates correct understanding of the information presented. 2 Energy Healing Therapies are known to reduce stress. This statement indicates correct understanding of the information presented. NURSINGTB.COM
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3 4
Energy Healing Therapies are known to increase, not decrease, stamina. This statement indicates the need for further education. Energy Healing Therapies are known to relieve musculoskeletal discomfort. This statement indicates correct understanding of the information presented.
PTS: 1 CON: Promoting Health 7. ANS: 3 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Differentiating the classifications of complementary and alternative medicine Chapter page reference: 208-209 Heading: Herbal Medicine and Botanicals Integrated Processes: Nursing Process – Planning
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Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Bowel Elimination Difficulty: Easy Feedback 1 The treatment of reflux is not a GI issue that is supported by evidence to benefit from herbal medicines. 2 The treatment of flatulence is not a GI issue that is supported by evidence to benefit from herbal medicines. 3 Evidence supports the use of herbal medicines in the treatment of constipation. 4 The treatment of hemorrhoids is not a GI issue that is supported by evidence to benefit from herbal medicines. PTS: 1 CON: Bowel Elimination 8. ANS: 2 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Discussing the nursing implications of complementary and alternative medicine Chapter page reference: 209-211 Heading: Nursing Implications: Assessment, Education, and Research Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Analysis [Analyzing] Concept: Promoting Health Difficulty: Difficult NURSINGTB.COM 1 The patient should be encouraged to ask the provider if he or she accepts the patient’s health insurance plan. 2 Many CAM providers are licensed; therefore, this statement indicates the need for further education by the nurse. 3 The patient should be sure that he or she is educated regarding any possible side effects associated with the CAM treatment. 4 Many CAM treatments require follow-up visits; therefore, this statement indicates appropriate understanding of the information presented. PTS: 1 CON: Promoting Health 9. ANS: 4 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Discussing the nursing implications of complementary and NURSINGTB.COM
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alternative medicine Chapter page reference: 209-211 Heading: Nursing Implications: Assessment, Education, and Research Integrated Processes: Caring Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Easy Feedback 1 Inadequate, not detailed, standardization for interpretation of systematic reviews is a research barrier for the implementation of CAM into practice.
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2 3 4
10.
11.
A limited, not large, number of patients involved in clinical trials is a research barrier for the implementation of CAM into practice. Personalized, not generic, treatment plans is a research barrier for the implementation of CAM into practice. Funding for research is an issue for the implementation of CAM into practice.
PTS: 1 CON: Evidence-Based Practice ANS: 4 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Discussing the nursing implications of complementary and alternative medicine Chapter page reference: 209-211 Heading: Nursing Implications: Assessment, Education, and Research Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Promoting Health Difficulty: Moderate Feedback 1 A google search will not yield reliable information from the Internet regarding CAM. 2 WebMD is not a reliable source for information on the Internet regarding CAM. 3 While the CDC is a reputable Internet resource, it is not known as a reliable resource regarding CAM. 4 The FDA is a reputable Internet resource regarding CAM. This is the URL the nurse should provide to this patient. NURSINGTB.COM PTS: 1 CON: Promoting Health ANS: 2 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Defining complementary and alternative medicine Chapter page reference: 202-203 Heading: Introduction Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Health Care System Difficulty: Moderate NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
12.
Feedback Western, not eastern, medicine is another term for the traditional health-care system within the United States. Conventional medicine is another term for the traditional health-care system within the United States. Folklore medicine practices refers to CAM, not the traditional health-care system within the United States. Old-world traditional medicine refers to CAM, not the traditional health-care system within the United States.
PTS: 1 ANS: 1
CON: Health Care System
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Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Defining complementary and alternative medicine Chapter page reference: 202-203 Heading: Introduction Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Health Care System Difficulty: Difficult Feedback 1 The goals of care for CAM and conventional medicine are quite similar. This statement indicates the need for further education. 2 The term alternative in CAM refers to treatment that is outside of the conventional methods. 3 The term complementary in CAM refers to practices that are paired with conventional medicine. 4 Pain, anxiety, depression, and headaches are included in the top 10 reasons adult patients seeks CAM.
13.
PTS: 1 CON: Health Care System ANS: 4 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Defining complementary and alternative medicine Chapter page reference: 202-203 Heading: Introduction NURSINGTB.COM Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Nursing Difficulty: Moderate 1 2 3 4
Feedback Refusing a patient assignment due to differing religious beliefs does not indicate a holistic approach to patient care. Telling a patient’s family that their spiritual beliefs should be kept to themselves does not indicates a holistic approach to patient care. Asking the patient to limit responses to information that is pertinent to today’s visit does not indicates a holistic approach to patient care. Providing information to a family about housing, when they seek care for their child’s NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
ear infection indicates a holistic approach to patient care.
14.
PTS: 1 CON: Nursing ANS: 4 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Differentiating the classifications of complementary and alternative medicine Chapter page reference: 203-209 Heading: Classification of CAM Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care
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Cognitive level: Application [Applying] Concept: Critical Thinking Difficulty: Moderate Feedback 1 Naturopathy is a type of Whole medical systems/Alternative medical systems therapy but not a category of CAM. 2 Acupuncture is a type of Whole medical systems/Alternative medical systems therapy but not a category of CAM. 3 Therapeutic touch is a type of healing energy touch therapy but not a category of CAM. 4 Dietary supplements a specific therapy that is also a category of CAM.
15.
16.
PTS: 1 CON: Critical Thinking ANS: 4 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Differentiating the classifications of complementary and alternative medicine Chapter page reference: 206 Heading: Massage Therapy Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Critical Thinking Difficulty: Moderate Feedback 1 Depression is not a patient diagnosis that contraindicates the use of massage therapy. 2 Osteoporosis is not a patient diagn o sis tha t con tra ind icates the use of NU R S I N G T B . C O M massage therapy. 3 Fibromyalgia is not a patient diagnosis that contraindicates the use of massage therapy. 4 The use of massage therapy over tumor sites is contraindicated. PTS: 1 CON: Critical Thinking ANS: 2 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Discussing the nursing implications of complementary and alternative medicine Chapter page reference: 207 Heading: Safety Alert Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Medication Difficulty: Moderate NURSINGTB.COM
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1 2 3 4
Feedback The use of insulin by the patient does not contraindicate the use of massage therapy in the nursing plan of care. The use of warfarin, an anticoagulant agent, contraindicates the use of massage therapy in the nursing plan of care due to the increased risk for bleeding. The use of propranolol by the patient does not contraindicate the use of massage therapy in the nursing plan of care. The use of acetaminophen by the patient does not contraindicate the use of massage therapy in the nursing plan of care.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
17.
PTS: 1 CON: Medication ANS: 2 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Discussing the nursing implications of complementary and alternative medicine Chapter page reference: 207 Heading: Safety Alert Integrated Processes: Nursing Process – Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Assessment Feedback Difficulty: 1 Glaucoma, not cataracts, is a patient diagnosis which would necessitate the need for the Moderate nurse to assess for physical limitations and mobility restrictions prior to the 2
3
4
implementation of mind/body therapies. Pregnancy is a patient diagnosis which would necessitate the need for the nurse to assess for physical limitations and mobility restrictions prior to the implementation of mind/body therapies. Recent back surgery, not previous back surgery, is a patient diagnosis which would necessitate the need for the nurse to assess for physical limitations and mobility restrictions prior to the implementation of mind/body therapies. Uncontrolled, not controlled, hypertension is a patient diagnosis which would necessitate the need for the nurse to assess for physical limitations and mobility restrictions prior to the implementation of mind/body therapies.
NURSINGTB.COM CON: Assessment
18.
PTS: 1 ANS: 1 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Differentiating the classifications of complementary and alternative medicine Chapter page reference: 207-208 Heading: Energy Healing Therapy Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Knowledge [Remembering] Concept: Evidence-Based Practice Difficulty: Easy Feedback NURSINGTB.COM
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1 2 3 4
The use of energy healing therapies is supported by anecdotal evidence for patients diagnosed with asthma. This condition does not support the use of energy healing therapies by anecdotal evidence. This condition does not support the use of energy healing therapies by anecdotal evidence. This condition does not support the use of energy healing therapies by anecdotal evidence.
PTS: 1
CON: Evidence-Based Practice
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19.
20.
ANS: 1 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Differentiating the classifications of complementary and alternative medicine Chapter page reference: 208-209 Heading: Herbal Medicine and Botanicals Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Communication Difficulty: Easy Feedback 1 Natural is a term that is often used to describe the healing properties associated with botanicals. 2 This is not the term that is used to describe the healing properties associated with botanicals. 3 This is not the term that is used to describe the healing properties associated with botanicals. 4 This is not the term that is used to describe the healing properties associated with botanicals. PTS: 1 CON: Communication ANS: 2 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Discussing the nursing implications of complementary and alternative medicine Chapter page NURSINGTB.COM reference: 209 Heading: Safety Alert Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Medication; Safety Difficulty: Difficult Feedback 1 The charge nurse for the shift may not be the best resource for the nurse to consult prior to administering this combination of prescribed therapies. 2 The nurse should consult with the provider, pharmacist, or herbalist prior to administering any herbal product with a prescribed drug. 3 While a PDR is an appropriate reference for prescribed drugs, this resource many not have information regarding the prescribed herbal NURSINGTB.COM
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product. 4
A reputable Internet site for CAM may not have the specific information needed regarding the prescribed drug the nurse needs to administer with the herbal product.
PTS: 1
CON: Medication | Safety
MULTIPLE RESPONSE 21. ANS: 2, 3, 4, 5 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Defining complementary and alternative medicine
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Chapter page reference: 202-203 Heading: Introduction Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Knowledge [Remembering] Concept: Nursing Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is incorrect. Cancer is not a top ten diagnosis for adult patients regarding the use of complementary and alternative therapies. This is correct. Anxiety is a top ten diagnosis for adult patients for the use of complementary and alternative medicine. This is correct. Arthritis is a top ten diagnosis for adult patients for the use of complementary and alternative medicine. This is correct. Insomnia is a top ten diagnosis for adult patients for the use of complementary and alternative medicine. This is correct. Dyspepsia, or stomach upset, is a top ten diagnosis for adult patients for the use of complementary and alternative medicine.
PTS: 1 CON: Nursing 22. ANS: 3, 4, 5 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Differentiating the classifications of complementary and alternative medicine Chapter page reference: NURSINGTB.COM 203-209 Heading: Classification of CAM Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate 1.
Feedback This is incorrect. Decreased fatigue is a benefit when including Mind/Body therapies in the plan of care for a patient diagnosed with an emotional or psychological disorder, not heart disease. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2.
3. 4. 5.
This is incorrect. Decreased incidence of headache is a benefit when including Mind/Body therapies in the plan of care for a patient diagnosed with an emotional or psychological disorder, not heart disease. This is correct. A decrease in the heart rate is a benefit of including Mind/Body therapies in the plan of care for a patient who is diagnosed with heart disease. This is correct. A decrease in the blood pressure is a benefit of including Mind/Body therapies in the plan of care for a patient who is diagnosed with heart disease. This is correct. A decrease in body temperature is a benefit of including Mind/Body therapies in the plan of care for a patient who is diagnosed with heart disease.
PTS: 1 CON: Perfusion 23. ANS: 1, 5 Chapter number and title: 12, Complementary and Alternative Care Initiatives
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Chapter learning objective: Differentiating the classifications of complementary and alternative medicine Chapter page reference: 203-209 Heading: Classifications of CAM Integrated Processes: Nursing Process – Planning Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Communication Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback This is correct. Mind/Body therapies are helpful to facilitate communication and social interaction for patients diagnosed with autism. This is incorrect. While Mind/Body therapies are helpful to patients with anxiety, they do not facilitate communication and social interaction for these patients. This is incorrect. While Mind/Body therapies are helpful to patients with depression, they do not facilitate communication and social interaction for these patients. This is incorrect. While Mind/Body therapies are helpful to patients with sleep disorders, they do not facilitate communication and social interaction for these patients. This is correct. Mind/Body therapies are helpful to facilitate communication and social interaction for patients diagnosed with Alzheimer disease.
PTS: 1 CON: Communication 24. ANS: 2, 3, 4 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Differentiating the classifications of complementary and NURSINGTB.COM alternative medicine Chapter page reference: 203-209 Heading: Classifications of CAM Integrated Processes: Nursing Process – Planning Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Communication Difficulty: Moderate
1. 2.
Feedback This is incorrect. Mind/Body therapies are helpful to facilitate communication and social interaction, not relaxation, for patients diagnosed with autism. This is correct. Mind/Body therapies are helpful to facilitate relaxation for patients diagnosed with anxiety. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3. 4. 5.
This is correct. Mind/Body therapies are helpful to facilitate relaxation for patients diagnosed with depression. This is correct. Mind/Body therapies are helpful to facilitate relaxation for patients diagnosed with sleep disorders. This is incorrect. Mind/Body therapies are helpful to facilitate communication and social interaction, not relaxation, for patients diagnosed with Alzheimer disease.
PTS: 1 CON: Communication 25. ANS: 2, 4, 5 Chapter number and title: 12, Complementary and Alternative Care Initiatives Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
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Chapter page reference: 205-206 Heading: Mind/Body Therapies Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Promoting Health Difficulty: Moderate
1. 2. 3. 4. 5. PTS: 1
Feedback This is incorrect. Pain reduction is not a general benefit for the use of Manipulative and Body- Based therapies. This is correct. Relief of insomnia is a general benefit for the use of Manipulative and Body- Based therapies. This is incorrect. A reduction in heart rate is not a general benefit for the use of Manipulative and Body-Based therapies. This is a cardiovascular benefit. This is correct. The facilitation of mental clarity is a general benefit for the use of Manipulative and Body-Based therapies. This is correct. An increase in range of motion is a general benefit for the use of Manipulative and Body-Based therapies. CON: Promoting Health
Chapter 13: Overview of Cancer Care NURSINGTB.COM Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is caring for a patient with leukemia. Which treatment should the nurse expect to be prescribed? 1) Chemotherapy 2) IV fluid therapy 3) Diuretic therapy 4) Electrolyte replacement therapy 2. The nurse is caring for an adolescent Asian patient with a strong family history of breast cancer. What should the nurse teach the patient regarding cancer prevention? 1) Perform monthly breast self-examination. 2) Teach the side effects of cancer treatment. 3) Talk to family members who have the disease. 4) Discuss cancer fears with the health-care provider. 3. A patient with anemia caused by chemotherapy is prescribed synthetic erythropoietin. When teaching the patient about the therapeutic effect of this NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
treatment, which is appropriate for the nurse to include? 1) Increase in platelets 2) Decrease in lymph fluid 3) Increase in red blood cells 4) Decrease in white blood cells 4. A nurse is caring for a patient with cancer. The nurse teaches the patient about which potentially undesirable cellular alterations that can occur during the cell cycle? 1) Dysphagia
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2) 3) 4)
Adaptation Hyperplasia Differentiation
5. During a treatment meeting on an oncology unit, the nurse learns that a patient is scheduled for chemotherapy before surgery. What are the purposes for this patient to receive chemotherapy at this specific time? 1) Shrink the tumor 2) Improve wound healing 3) Eradicate all cancer cells 4) Allow the immune system to kill cancer cells 6. The nurse has completed a seminar teaching a group in the community about ways to reduce cancer risks. The nurse returns a month later to evaluate the effectiveness of the seminar. Which statements made by members of the group indicate retention and application of the material presented by the nurse to reduce the risk of developing cancer? 1) “I stopped using tanning booths.” 2) “I have reduced my intake of fiber.” 3) “I have increased the amount of lean red meat in my diet.” 4) “I began drinking two glasses of red wine a day with dinner.” 7. The nurse is preparing a seminar that discusses the risk and incidence of cancer and culture. What information is considered culturally correct when teaching about the risk of developing cancer? 1) Hispanics have an increased risk of cervical, stomach, and liver cancer. 2) African-Americans are more likely to develop cancer than any other ethnic group. 3) The incidence and mortality rate of all type of cancers are lowest in the Caucasian population. 4) African-Americans are less likelNy UtoRdSevIeN loGp TcaBnc.eCr tOhaMn any other ethnic or racial group in the United States. 8. A patient being treated with chemotherapy for cancer complains of fatigue, pallor, progressive weakness, exertional dyspnea, headache, and tachycardia. Which diagnosis should the nurse use as the priority when planning this patient’s care? 1) Powerlessness 2) Ineffective Coping 3) Activity Intolerance 4) Imbalanced Nutrition, Less than Body Requirements 9. The nurse accompanies the health-care provider into the patient’s room and listens as the diagnosis of cancer is shared with the patient and family. Once the health-care provider leaves the room, the nurse notes that the patient and family are teary-eyed regarding the diagnosis. What is the nurse’s most appropriate intervention at this time? 1) Provide emotional support in coping with the diagnosis. 2) Help the patient and family remain realistic about prognosis. 3) Provide teaching about the treatment options for this form of cancer. 4) Arrange for the patient to complete a medical power of attorney form. NURSINGTB.COM
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10. A patient being treated for cancer has a tumor designation of Stage IV, T4, N3, M1. What does this staging indicate to the nurse? 1) The tumor is small in size. 2) There is one single tumor to treat. 3) The tumor will respond to chemotherapy. 4) The tumor has metastasized with lymph node involvement.
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11. During an assessment, the nurse notes that a patient receiving radiation treatments for breast cancer has excoriated skin. What is the priority nursing diagnosis? 1) Risk for Infection 2) Activity Intolerance 3) Excess Fluid Volume 4) Ineffective Breathing Pattern 12. A patient has just been told that a colectomy and ileostomy are needed to treat a new diagnosis of colon cancer. Which nursing diagnosis should the nurse use to plan this patient’s preoperative nursing care? 1) Knowledge Deficit 2) Anticipatory Grieving 3) Risk for Disuse Syndrome 4) Risk for Perioperative–Positioning Injury 13. The nurse is teaching a patient scheduled for a colonoscopy on pre- and postprocedure care. Which statement by the patient indicates the need for further teaching? 1) “It might be quite painful.” 2) “The procedure will only take about one hour.” 3) “The physician might take tissue samples for further analysis.” 4) “I will likely have medications that will make me drowsy during the test.” 14. A patient receiving radiation therapy as treatment for colorectal cancer is experiencing nausea and vomiting. What should the nurse encourage the patient to do? 1) Use a commercial mouthwash before eating a meal. 2) Eat spicy or well-seasoned foods instead of bland foods. 3) Delay the intake of a meal until N thUreRe to S IfoNuGr ho T Bur.s CafOteMr treatment. 4) Avoid all food and liquid until nausea and vomiting stop. 15. A patient with terminal colon cancer is refusing all food and fluids. The patient has a living will that states no artificial nutrition is to be provided; however, the family is asking for a gastrostomy tube. What should the nurse do? 1) Take the case to the hospital’s ethics committee. 2) Honor the family’s wishes and have them sign a consent form. 3) Honor the patient’s refusal and help the family come to terms with the situation. 4) Talk to the physician so he or she can move forward with the family’s wishes. 16. A patient is receiving chemotherapy for the treatment of leukemia. While providing care for this patient, which clinical manifestations would indicate tumor lysis syndrome? 1) Thrombocytopenia 2) Respiratory distress 3) Upper-extremity edema 4) Altered levels of consciousness 17. The nurse is caring for a patient who had a bone marrow transplant for the NURSINGTB.COM
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treatment of leukemia several weeks ago. The patient requires protective isolation. Which statement by the patient’s family indicates understanding of this type of isolation? 1) “It will be important to restrict all visitors.” 2) “We will encourage oral hygiene twice a day.” 3) “You will have to administer all medications by IM injection.” 4) “We will encourage meticulous hand washing among all visitors.”
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18. The nurse is assisting the health-care provider with a bone marrow aspiration and biopsy on a patient who has leukemia. The patient also has thrombocytopenia. Upon completing of the test, which intervention is a priority for the nurse? 1) Make certain the patient understands the purpose of the test. 2) Hold pressure on the wound for approximately five minutes. 3) Label and refrigerate the specimen obtained by the physician. 4) Dispose of the equipment used, and clean the area properly. 19. The nurse is caring for a patient with leukemia who is experiencing neutropenia as a result of chemotherapy. Which action should the nurse include in the plan of care for this patient? 1) Restrict fluid intake 2) Replace hand hygiene with gloves 3) Restrict visitors with communicable illnesses. 4) Insert an indwelling urinary catheter to prevent skin breakdown 20. A nurse is caring for a patient with leukemia who is neutropenic. Which intervention will the nurse implement to ensure this patient’s safety? 1) Place patient in reverse isolation 2) Place patient in standard precaution isolation 3) Administer a prophylactic gram-negative antibiotic 4) Administer neutrophil colony-stimulating factor (N-CSF) as ordered 21. A nurse is planning care for a patient with leukemia. The nurse chooses “Risk for Bleeding” as the nursing diagnosis. Which interventions support this nursing diagnosis? 1) Educate patient in use of soft toothbrush for oral care 2) Use non-electric razor when providing grooming for patient 3) Apply pressure to arterial punctuNrU e R sitSesIfN o rG5 TmBin.uC t eO s M 4) Encourage patient to breathe deeply and huff cough frequently 22. The nurse is caring for a patient who is undergoing diagnostic tests to rule out lung cancer. The patient asks the nurse why a computed tomography (CT) scan was ordered. What is the best response by the nurse? 1) “The doctor prefers this test.” 2) “Why are you concerned about this test?” 3) “It is more specific in diagnosing your condition.” 4) “To rule out the possibility that your problems are caused by pneumonia.” 23. A patient is scheduled to undergo a prostate biopsy. The patient asks the nurse what is expected immediately following the procedure. Which response by the nurse is the most appropriate? 1) ‘Your sexual partners will need to be notified.” 2) “You will need to avoid strenuous activity for 24 hours.” 3) “You will not have any restrictions following the biopsy.” 4) “You will likely experience discomfort for 24-48 hours after the procedure.” Multiple Response Identify one or more choices that best complete the statement or answer the question. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
24. The nurse is caring for a thin, older adult patient who is diagnosed with cancer and is receiving aggressive chemotherapy. The patient is experiencing severe side effects from the therapy and has lost 10 pounds in the past week. What should the nurse teach the patient to do? Select all that apply. 1) Keep a food diary and record intake. 2) Purchase fast foods and prepared foods.
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3) 4) 5)
Eat small frequent meals high in calories. Drink liquid supplements to increase intake of nutrients. Eat cold foods rather than hot foods, because they are better tolerated.
25. A nurse is caring for a patient who is diagnosed with skin cancer. Which nursing interventions will reduce the growth of cancer cells and support normal cell function? Select all that apply. 1) Increasing calorie intake 2) Encouraging mobility and exercise 3) Encouraging increased rest and sleep 4) Assessing normal functioning of organ systems 5) Reducing oxygen supply to retard growth of cancer cells 26. The nurse instructs a group of community members on the difference between benign and malignant neoplasms. Which participant statements indicate that teaching has been effective? Select all that apply. 1) “Malignant tumors can grow back.” 2) “Benign tumors stay in one area.” 3) “Benign tumors grow slowly.” 4) “Malignant tumors are easy to remove.” 5) “Malignant tumors push other tissue out of the way.” 27. The nurse is preparing to perform a health assessment on an adult patient who has a family history of cancer. Which questions should the nurse ask the patient to assess for the early warning signs of cancer? Select all that apply. 1) “Have you noticed a change in your appetite?” 2) “Have you noticed any cuts that have not healed?” 3) “Have you had any changes in bowel or bladder habits?” IaNllGowTiBn g.? C” OM 4) “Have you experienced any probNleUmRsSsw 5) “Do you have a cough that is not associated with seasonal allergies?’ 28. The nurse is caring for a patient who is diagnosed with cancer. Which diagnostic tests may be helpful to assist with treatment options? Select all that apply. 1) MRI 2) Urinalysis 3) Stool analysis 4) Tumor markers 5) Physical assessment 29. The nurse instructs a group of community members about ways to reduce the development of cancer. Which participant statements indicate that teaching has been effective? Select all that apply. 1) “I need to cut down on my smoking.” 2) “I need to get my home tested for radon.” 3) “I need to keep my children away from smokers.” 4) ‘Sunscreen should be applied before spending time outdoors.” 5) “I should eat at least two servings of fruits or vegetables each day.” 30. The nurse is providing discharge instructions to a patient being treated for NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
cancer. For which symptoms should the patient be instructed to call for help at home? Select all that apply. 1) Desire to end life 2) Difficulty breathing 3) New onset of bleeding 4) Improved sense of well-being 5) Significant increase in vomiting
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Chapter 13: Overview of Cancer Care Answer Section MULTIPLE CHOICE 1.
ANS: 1 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Identifying treatment options for oncology patients Chapter page reference: 231-239 Heading: Treatment Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Feedback Easy 1 The patient with an alteration in cell growth has cancer and will most likely be treated 2 3 4
with chemotherapy and antibiotics. Diuretic therapy, IV fluids, and electrolyte replacement are not typically used to treat cancer, although they may be used if complications develop. Diuretic therapy, IV fluids, and electrolyte replacement are not typically used to treat cancer, although they may be used if complications develop. Diuretic therapy, IV fluids, and electrolyte replacement are not typically used to treat cancer, although they may be used if complications develop.
NURSINGTB.COM CON: Cellular Regulation
PTS: 1 2. ANS: 1 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient Chapter page reference: 226-229 Heading: Prevention Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Promoting Health Difficulty: Moderate Feedback 1 In families with a disease, the nurse should inform patients about breast self- examination. 2 Teaching the side effects of cancer treatment would be appropriate if the patient was diagnosed with breast cancer. 3 Talking to family members who have the disease will not help with NURSINGTB.COM
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early detection or prevention. 4
The patient can discuss cancer fears with the nurse; however, this action will not help prevent the development of the disease.
PTS: 1 3. ANS: 3
CON: Promoting Health
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Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Developing teaching and support strategies for the oncology patient and family Chapter page reference: 231-239 Heading: Treatment Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Medication Difficulty: Moderate Feedback 1 Erythropoietin will not stimulate or decrease the production of platelets, white blood cells, or lymph fluid. 2 Erythropoietin will not stimulate or decrease the production of platelets, white blood cells, or lymph fluid. 3 Erythropoietin is a hormone produced in the body to stimulate production of red blood cells; synthetic forms are available for administration to cancer patients or others with significantly low red blood cell counts. 4 Erythropoietin will not stimulate or decrease the production of platelets, white blood cells, or lymph fluid. PTS: 1 CON: Medication 4. ANS: 3 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Explaining the pathophysiology of cancer cells Chapter page reference: NURSINGTB.COM 215-217 Heading: Pathophysiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Dysphagia and adaptation are not a part of the cell cycle. 2 Dysphagia and adaptation are not a part of the cell cycle. 3 Potentially undesirable cellular alterations that can occur during the cell cycle include hyperplasia and anaplasia. Hyperplasia is an increase in the number or density of normal cells. 4 Differentiation is a normal process occurring over many cell cycles that allows cells to specialize in certain tasks. NURSINGTB.COM
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PTS: 1 CON: Cellular Regulation 5. ANS: 1 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Identifying treatment options for oncology patients Chapter page reference: 231-239 Heading: Treatment Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding]
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Concept: Cellular Regulation Difficulty: Easy Feedback 1 Chemotherapy before surgery is used to shrink the tumor. 2 Chemotherapy is not used to improve wound healing. 3 It is impossible to eradicate all cancer cells with chemotherapy. 4 The use of chemotherapy before surgery will not allow the immune system to kill the cancer cells. PTS: 1 CON: Cellular Regulation 6. ANS: 1 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient Chapter page reference: 226-229 Heading: Prevention Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Analysis [Analyzing] Concept: Promoting Health Difficulty: Difficult Feedback 1 Use of tanning booths increases the risk of skin cancer, so discontinuing use would indicate understanding. 2 Increased fiber intake reduces the risk of colon cancer. 3 Increasing the amount of lean red m ea t and d rink in g two glasses of NUR S I N GTB .C O M red wine daily are not actions that reduce cancer risk. 4 Increasing the amount of lean red meat and drinking two glasses of red wine daily are not actions that reduce cancer risk. PTS: 1 CON: Promoting Health 7. ANS: 2 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Discussing the epidemiology of cancer Chapter page reference: 214-215 Heading: Epidemiology Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation; Diversity Difficulty: Easy NURSINGTB.COM
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1 2 3 4
Feedback There is no specific information about the Hispanic population. African-American clients are more likely to develop cancer than any other ethnic group. Mortality rates for cancer are the lowest in the Asian/Pacific Islander population. African-Americans are more likely to develop cancer than any other ethnic or racial group in the United States.
PTS: 1
CON: Cellular Regulation | Diversity
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8.
ANS: 3 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Analyzing nursing care for the oncology patient Chapter page reference: 239-245 Heading: Nursing Management Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Powerlessness is the lack of control over current situations, but this is not the patient’s current problem. Her needs/symptoms are physical, and according to Maslow’s theory must be met prior to emotional needs. Although the patient might be having coping issues, the physical symptoms are her greatest complaints; therefore, coping is not the top priority in planning her care. Again, physiological needs must be met prior to selfactualization needs. 2 Powerlessness is the lack of control over current situations, but this is not the patient’s current problem. Her needs/symptoms are physical, and according to Maslow’s theory must be met prior to emotional needs. Although the patient might be having coping issues, the physical symptoms are her greatest complaints; therefore, coping is not the top priority in planning her care. Again, physiological needs must be met prior to self- actualization needs. 3 The symptoms (fatigue, pallor, progressive weakness, exertional dyspnea, headache, and tachycardia) are caused by aplastic anemia from bone marrow suppression, which is a side effect of the chemothN erU a pRy SdrIu N g sG. DTeBcr.eaCsOedMred blood cells cause less oxygen to be delivered to body tissues, resulting in tissue hypoxia. Tachycardia is a compensation mechanism to speed up the delivery of oxygen that is available in the fewer number of cells that are present. Tissue hypoxia will result in muscle fatigue, and the symptoms that are related to aplastic anemia will decrease endurance and ability to perform activities. 4 Nutrition is not the cause of the symptoms, which are related to tissue hypoxia.
PTS: 1 CON: Cellular Regulation 9. ANS: 1 Chapter number and title: 13, Overview of Cancer Care NURSINGTB.COM
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Chapter learning objective: Developing teaching and support strategies for the oncology patient and family Chapter page reference: 239-245 Heading: Nursing Management Integrated Processes: Nursing Process – Implementation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate Feedback 1 When a patient and family receive a new diagnosis of cancer, it tends to evoke many emotions, including fear, grief, and anger. The patient and family require emotional support at this time, and other actions can be initiated when they have time to learn to accept and cope with the diagnosis.
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2 3 4
10.
11.
This is not an opportune time to teach, set goals, or make decisions regarding power of attorney. This is not an opportune time to teach, set goals, or make decisions regarding power of attorney. This is not an opportune time to teach, set goals, or make decisions regarding power of attorney.
PTS: 1 CON: Cellular Regulation ANS: 4 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Explaining the pathophysiology of cancer cells Chapter page reference: 217 Heading: Staging Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Easy Feedback 1 T refers to the depth of invasion. A 4 indicates a large, not small, tumor. 2 There is no way to determine the number of tumors based on this designation. 3 The staging system is not used to determine tumor response to chemotherapy. 4 Stage IV indicates metastasis. N refers to the absence or presence and extent of lymph node involvement. A 3 indicates a significant number of lymph nodes are involved. NURSINGTB.COM PTS: 1 CON: Cellular Regulation ANS: 1 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Analyzing nursing care for the oncology patient Chapter page reference: 239-245 Heading: Nursing Management Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate Feedback NURSINGTB.COM
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1 2 3 4
12.
Radiation causes skin excoriation. With the excoriation, the patient is at risk for infection due to skin breakdown. Depending on the assessment, the patient may or may not have activity intolerance. The patient who receives radiation is more at risk for fluid volume deficit. There is no evidence of respiratory difficulties in this patient.
PTS: 1 CON: Cellular Regulation ANS: 2 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Developing teaching and support strategies for the oncology patient and family Chapter page reference: 239-245 Heading: Nursing Management
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Integrated Processes: Nursing Process – Diagnosis Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Now is not the time to begin instructions, because the patient will most likely be unable to learn or concentrate on what the nurse is teaching. 2 The patient and family will require support to deal with their emotional response to learning the patient has cancer and will undergo body image-changing surgery. 3 Disuse syndrome and injury from positioning may be factors after surgery. 4 Disuse syndrome and injury from positioning may be factors after surgery.
13.
14.
PTS: 1 CON: Cellular Regulation ANS: 1 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient Chapter page reference: 229-231 Heading: Diagnosing Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Reduction in Risk Potential Cognitive level: Analysis [Analyzing] Concept: Cellular Regulation Difficulty: Difficult NURSINGTB.COM 1 The colonoscopy is not a painful examination. 2 It usually takes about an hour. 3 Tissue samples are often taken during colonoscopies. 4 The client will be given conscious sedation, which causes drowsiness. PTS: 1 CON: Cellular Regulation ANS: 3 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Developing teaching and support strategies for the oncology patient and family Chapter page reference: 239-245 Heading: Nursing Management Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Using a mouthwash and eating spicy foods are not recommended interventions for nausea and vomiting. 2 Using a mouthwash and eating spicy foods are not recommended interventions for nausea and vomiting. 3 Nausea and vomiting are not uncommon in a client receiving radiation, and the patient may benefit from delaying meals for a few hours after treatment, allowing the primary effects to subside somewhat.
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4
15.
16.
Avoiding all food and liquid could put the patient at risk for dehydration.
PTS: 1 CON: Cellular Regulation ANS: 3 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Developing teaching and support strategies for the oncology patient and family Chapter page reference: 239-245 Heading: Nursing Management Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Legal; Cellular Regulation Difficulty: Moderate Feedback 1 An ethics committee is usually considered when there is an ethical dilemma and more input is needed to make a decision. In this case, the patient has made a decision and it should be honored. 2 Patients, not their families, should make decisions about their own health care and treatment. 3 A nurse is morally obligated to withhold food and fluids if it is determined to be more harmful to administer them than to withhold them. The nurse must also honor competent patients’ refusal of food and fluids. This position is supported by the ANA’s Code of Ethics for Nurses, through the nurse’s role as a patient advocate and through the moral principle of autonomy. 4 The physician may or may not be in vo lv ed, but wo uld not disregard N URS I N G T B . C O M the patient’s refusal. PTS: 1 CON: Legal | Cellular Regulation ANS: 4 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Identifying treatment options for oncology patients Chapter page reference: 217-226 Heading: Clinical Presentation Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate NURSINGTB.COM
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1 2 3 4
17.
Feedback Thrombocytopenia occurs with a hematological emergency. Space-occupying lesions can cause respiratory distress and upperextremity edema. Space-occupying lesions can cause respiratory distress and upperextremity edema. Tumor lysis causes a metabolic emergency. Because of electrolyte imbalance, the signs can be oliguria and altered levels of consciousness.
PTS: 1 CON: Cellular Regulation ANS: 4 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Identifying treatment options for oncology patients
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Chapter page reference: 231-239 Heading: Treatment Integrated Processes: Nursing Process – Evaluation Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Analysis [Analyzing] Concept: Cellular Regulation; Infection Difficulty: Difficult Feedback 1 Restrict only visitors with colds, flu, or infection. 2 Oral hygiene should be encouraged after every meal. 3 Medications by injection should be avoided. 4 A patient on protective isolation will be at an increased risk for infection. It will be important to encourage meticulous hand washing among all people who come in contact with the patient.
18.
19.
PTS: 1 CON: Cellular Regulation | Infection ANS: 2 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Analyzing nursing care for the oncology patient Chapter page reference: 231-239 Heading: Treatment Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Safety NURSINGTB.COM Difficulty: Moderate Feedback 1 An explanation of the test is performed before the procedure is begun. 2 The most important task for the nurse is to prevent bleeding after the biopsy. Holding pressure on the wound for five minutes is effective. 3 Dealing with the specimen is accomplished by a third party or after the nurse stabilizes the patient. 4 Cleaning the area is completed after the patient is stable and the specimen is sent to the laboratory. PTS: 1 CON: Safety ANS: 3 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Analyzing nursing care for the oncology patient Chapter page reference: 231-239 Heading: Treatment Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] NURSINGTB.COM
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Concept: Safety Difficulty: Moderate 1
Feedback Fluid intake should be encouraged.
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2 3 4
20.
21.
Gloves may be appropriate but should never replace hand hygiene. In the neutropenic patient, visitors with communicable infections should be restricted. Invasive procedures such as indwelling catheters should be avoided.
PTS: 1 CON: Safety ANS: 1 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Analyzing nursing care for the oncology patient Chapter page reference: 231-239 Heading: Treatment Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 A patient who is neutropenic has a decrease in the level of white blood cells (WBCs) and is susceptible to infection and/or disease. To ensure the safety of the patient with neutropenia, the nurse will place the patient in reverse isolation. 2 Standard precautions should be used for all patients and this does not ensure safety of the neutropenic patient. 3 Administer a broad-spectrum antibiotic as ordered. 4 Administer granulocyte colony-stimulating factor (G-CSF) as ordered. PTS: 1 CON: Safety NURSINGTB.COM ANS: 1 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Analyzing nursing care for the oncology patient Chapter page reference: 239-245 Heading: Nursing Management Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Safety Difficulty: Moderate 1
Feedback The patient at risk for bleeding has specific interventions to which the nurse should adhere. The nurse should educate the patient in the use of a soft toothbrush. NURSINGTB.COM
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2 3 4
22.
An electric razor is preferred when providing grooming for a patient who is at risk for bleeding. The nurse should also limit the use of parenteral injections and apply 15–20 minutes of pressure to any arterial puncture sites. The nurse should discourage the patient to forcefully cough to prevent further bleeding.
PTS: 1 CON: Safety ANS: 3 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient
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Chapter page reference: 229-231 Heading: Diagnosing Cancer Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Health-care provider preference is not a factor for why the CT was ordered. 2 The patient’s question is valid and should not be minimized by asking why the patient is having concerns about the test. 3 Computed tomography (CT) is used to evaluate and localize tumors, particularly tumors in the lung parenchyma and pleura. 4 A chest x-ray can be used to diagnose pneumonia.
23.
PTS: 1 CON: Cellular Regulation ANS: 4 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient Chapter page reference: 229-231 Heading: Diagnosing Cancer Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Cellular NURSINGTB.COM Regulation Difficulty: Moderate Feedback 1 There is no need to notify sexual partners following the procedure. 2 Strenuous activity is avoided only for about four hours. 3 The patient must restrict activity for only a short period after the procedure. 4 The patient may experience discomfort for one to two days after the procedure. PTS: 1
CON: Cellular Regulation
MULTIPLE RESPONSE 24. ANS: 1, 3, 4, 5 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Developing teaching and support strategies for the NURSINGTB.COM
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oncology patient and family Chapter page reference: 239-245 Heading: Nursing Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Nutrition Difficulty: Moderate Feedback
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1.
2.
3.
4.
5.
This is correct. The goal of nutritional teaching is to help the patient increase caloric and nutrient intake through the use of liquid supplements, small frequent meals, and a food diary that will help the nurse evaluate strengths and weaknesses of the current plan. This is incorrect. Fast foods and prepared foods tend to be high in fat and sodium and are not the best choice because they do not contain adequate healthy nutrients. Instead, involving the family in preparing meals or in enrolling in Meals on Wheels may be better options for easy ways of obtaining meals. This is correct. The goal of nutritional teaching is to help the patient increase caloric and nutrient intake through the use of liquid supplements, small frequent meals, and a food diary that will help the nurse evaluate strengths and weaknesses of the current plan. This is correct. The goal of nutritional teaching is to help the patient increase caloric and nutrient intake through the use of liquid supplements, small frequent meals, and a food diary that will help the nurse evaluate strengths and weaknesses of the current plan. This is correct. The patient receiving chemotherapy may tolerate cold foods better than hot foods.
PTS: 1 CON: Nutrition 25. ANS: 1, 3, 4 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Analyzing nursing care for the oncology patient Chapter page reference: 239-245 Heading: Nursing Management Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] NURSINGTB.COM Concept: Cellular Regulation Difficulty: Easy 1.
2. 3. 4.
Feedback This is correct. Cancer cells grow faster than normal cells, so they use more nutrients for growth, resulting in wasting, which can only be counteracted by increasing the caloric intake of the patient. This is incorrect. While patients should not be inactive, they should be taught to reduce activity to reduce weight loss and provide more energy to the healthy cells. This is correct. Increased rest and sleep give the patient’s body more energy to fight the cancer cells. This is correct. Because cancer cells can grow in any area of the body, it is important for the nurse to assess normal functioning of all organ systems. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5.
This is incorrect. Decreasing oxygen supply will retard cancer cell growth but it will also retard normal cell health.
PTS: 1 CON: Cellular Regulation 26. ANS: 1, 2, 3, 4 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Developing teaching and support strategies for the oncology patient and family Chapter page reference: 217 Heading: Types of Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation
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Cognitive level: Analysis [Analyzing] Concept: Cellular Regulation Difficulty: Difficult 1. 2. 3. 4. 5.
Feedback This is correct. Malignant tumors are more difficult to remove. They invade neighboring tissue and can return once removed. This is correct. Benign tumors are slow-growing and stay in one area. This is correct. Benign tumors are slow-growing and stay in one area. This is incorrect. Benign, not malignant, tumors are easy to remove. This is incorrect. Benign, not malignant, tumors push other tissue out of the way.
PTS: 1 CON: Cellular Regulation 27. ANS: 2, 3, 4, 5 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient Chapter page reference: 217-266 Heading: Clinical Presentation Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Application] Concept: Cellular Regulation Difficulty: Moderate
1. 2.
3.
NURSINGTB.COM This is incorrect. Changes in appetite or cough that is associated with seasonal allergies are not associated with the early warning signs of cancer. This is correct. Nurses should assess all patients, especially those with a history of cancer, for early warning signs of cancer. The early warning signs include change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a nagging cough or hoarseness. This is correct. Nurses should assess all patients, especially those with a history of cancer, for early warning signs of cancer. The early warning signs include change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a nagging cough or hoarseness.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4.
5.
PTS: 1
This is correct. Nurses should assess all patients, especially those with a history of cancer, for early warning signs of cancer. The early warning signs include change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a nagging cough or hoarseness. This is correct. Nurses should assess all patients, especially those with a history of cancer, for early warning signs of cancer. The early warning signs include change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a nagging cough or hoarseness. CON: Cellular Regulation
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28. ANS: 1, 2, 4 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient Chapter page reference: 229-231 Heading: Diagnosing Cancer Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Easy Feedback 1.
2.
3. 4.
5.
This is correct. Many diagnostic tests are helpful in determining treatment for cancer. An MRI, urinalysis, and tumor markers are all diagnostic tests that may be used to determine treatment for cancer. This is correct. Many diagnostic tests are helpful in determining treatment for cancer. An MRI, urinalysis, and tumor markers are all diagnostic tests that may be used to determine treatment for cancer. This is incorrect. A stool analysis is not a diagnostic test listed to determine treatment for cancer. This is correct. Many diagnostic tests are helpful in determining treatment for cancer. An MRI, urinalysis, and tumor markers are all diagnostic tests that may be used to determine treatment for cancer. This is incorrect. A physical assessment may be useful to determine how a patient is responding to treatment, but it is not considered a diagnostic test.
NURSINGTB.COM PTS: 1 CON: Cellular Regulation 29. ANS: 2, 3, 4 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient Chapter page reference: 226-229 Heading: Prevention Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Cellular Regulation Difficulty: Difficult 1. 2.
Feedback This is incorrect. All smoking should be discouraged. This is correct. The home should be tested for radon, which is a known cancer-causing substance. NURSINGTB.COM
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3. 4. 5. PTS: 1
This is correct. Children should be protected from exposure to tobacco smoke. This is correct. Sunscreen should be used by those who spend time outside regularly for work or recreation. This is incorrect. Efforts to reduce the development of cancer include eating five servings of fruits and vegetables each day. CON: Cellular Regulation
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30. ANS: 1, 2, 3, 5 Chapter number and title: 13, Overview of Cancer Care Chapter learning objective: Developing teaching and support strategies for the oncology patient and family Chapter page reference: 239-245 Heading: Nursing Management Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate 1. 2.
3. 4. 5.
PTS: 1
Feedback This is correct. The patient should be instructed to call for help with any difficulty breathing, significant increase in vomiting, a desire to end life, or a new onset of bleeding. This is correct. The patient should be instructed to call for help with any difficulty breathing, significant increase in vomiting, a desire to end life, or a new onset of bleeding. This is correct. The patient should be instructed to call for help with any difficulty breathing, significant increase in vomiting, a desire to end life, or a new onset of bleeding. This is incorrect. An increased sense of well-being would be a desired effect of treatment for cancer. This is correct. The patient should be instructed to call for help with any difficulty breathing, significant increase in vomiting, a desire to end life, or a new onset of bleeding. CON: Cellular Regulation
Chapter 14: Overview of Shock and SeN psUisRSINGTB.COM Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is preparing an educational session on sepsis. Which should the nurse include as a major risk factor for the development of this health problem? 1) Immunosuppression 2) Elevated temperature 3) Pneumococcal bacteria 4) Leukocytosis on the complete blood count 2. The nurse identifies the nursing diagnosis of Ineffective Peripheral Tissue Perfusion as being appropriate for a patient with septicemia. Which intervention will address this patient’s health problem? NURSINGTB.COM
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1) 2) 3) 4)
Monitor for cyanosis. Monitor heart rate every hour. Assess temperature every four hours. Monitor pupil reactions every eight hours.
3. An older adult patient is recovering in the intensive care unit (ICU) from septicemia. Which intervention will help prevent further infection for this patient? 1) Provide oral and skin care 2) Implement sterile wound care 3) Encourage turn, cough, and deep breathe every shift.
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4)
Place the Foley drainage on the bed at the patient’s feet
4. A patient is prescribed epinephrine for the prevention of anaphylactic shock. The patient states, “I thought shock was about heart failure.” Which response by the nurse is most appropriate? 1) “There are many kinds of shock that also include infection, nervous system damage, and loss of blood.” 2) “Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood.” 3) “There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure.” 4) “Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure.” 5. An older adult patient is experiencing hypovolemic shock. Which is the priority intervention for this patient? 1) Assessing the cause of bleeding 2) Providing replacement of volume 3) Establishing invasive cardiac monitoring 4) Administering analgesics for control of pain 6. The nurse has just completed the assessment of a patient admitted with a gunshot wound to the femoral artery. Which is the priority nursing diagnosis for this patient? 1) Ineffective Coping 2) Deficient Fluid Volume 3) Decreased Cardiac Output 4) Ineffective Airway Clearance 7. The nurse is administering albumin 5N%UtRo aS pIaNtieGnTt iBn .shCoOckM. Which nursing action is appropriate when assessing this patient? 1) Auscultate breath sounds for crackles 2) Auscultate breath sounds for hyperresonance 3) Auscultate breath sounds for inspiratory stridor 4) Auscultate for an absence of breath sounds in the lower lobes 8.
The nurse explains the purpose of an infusion of albumin 5% to a patient recovering from hypovolemic shock. Which statement indicates that the patient understands the instructions? 1) “It is a protein that pulls water into my blood vessels.” 2) “It is a protein that causes my kidneys to conserve fluid.” 3) “It is a super-concentrated salt solution that helps me conserve body fluid.” 4) “It is a liquid that has electrolytes in it to pull water into my blood vessels.” 9. A patient being treated for hypovolemic shock is prescribed a low dose of dopamine. Which outcome does the nurse anticipate for this patient? 1) Increased cardiac output 2) Stabilization of fluid loss NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN 3) 4)
Urinary output of at least 30 mL/hour Vasoconstriction and increased blood pressure
10. A nurse is caring for a patient who was involved in a motor vehicle accident who has lost approximately 1,500 mL of blood. Based on this data, which type of shock is the patient experiencing? 1) Hypovolemic 2) Cardiogenic 3) Distributive
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4)
Obstructive
11. A nurse working in the intensive care unit (ICU) is caring for a patient in refractory stage of shock. When planning care, which does the nurse anticipate? 1) A subtle change in heart rate 2) A change from aerobic to anaerobic metabolism 3) The development of hyperglycemia 4) The development of cardiac dysrhythmias 12. The nurse is preparing to administer diphenhydramine to a patient who is experiencing a severe allergic reaction to peanuts. Which information about the drug should the nurse provide to the patient? 1) “This is the medication of choice to treat airway obstruction.” 2) “This medication will help relieve your itching and runny nose.” 3) “This medication will prevent you from going into anaphylactic shock.” 4) “This medication will take a while to be effective but will control your symptoms for several hours.” 13. The nurse is conducting medication teaching for a patient who is prescribed an epi-pen. Which statements made by the patient indicates the need for additional instruction? 1) “I will carry an epi-pen with me at all times.” 2) “I will check the expiration date on my epi-pen regularly.” 3) “I should hold the epi-pen in place for 10 seconds after injection.” 4) “I should use the epi-pen to inject the drug into my abdominal wall.” 14. The nurse is providing care to a patient who is admitted to the emergency department with symptoms of a myocardial infarction (MI). Which is the primary purpose of the interventions administered to this patient? 1) Providing pain relief NURSINGTB.COM 2) Preventing extension of damage 3) Preventing cardiogenic shock 4) Reducing blood pressure 15. The nurse is providing care for a patient receiving treatment for cardiogenic shock. Which assessment finding indicates that the compensatory mechanism of vasoconstriction has occurred in this patient? 1) Increased heart rate 2) Increased injection fraction 3) Decreased urine output 4) Decreased temperature 16. The nurse is providing care to a patient who is admitted with cardiogenic shock. The nurse administers the prescribed atropine with no results. Which prescription does the nurse anticipate from the health-care provider based on this data? 1) A beta blocker 2) Transcutaneous pacing 3) Cardiac defibrillation NURSINGTB.COM
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4)
A preload reducer
17. The nurse is providing care to a patient diagnosed with hypovolemic shock. Which nursing action is appropriate for this patient during the initial compensatory phase? 1) Placing a cool blanket over the patient 2) Raising the patient’s head to a 30-degree angle 3) Positioning the patient in the left-lateral recumbent position 4) Turning the patient’s head to one side if no neck injury is suspected
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18. During the initial stage of shock, which clinical manifestation should the nurse monitor for when assessing the patient? 1) Lethargy 2) Hypotension 3) Respiratory alkalosis 4) Subtle changes in heart rate 19. The nurse is providing care to a patient admitted to the emergency department (ED) with a gunshot wound and profound blood loss. Which order does the nurse anticipate for this patient? 1) Normal saline 2) Dextrose in water 3) Packed red blood cells 4) Albumin 20. A patient develops hypovolemic shock secondary to pancreatitis. Which action by the nurse is most appropriate? 1) Starting an 18-gauge intravenous catheter in the patient’s nondominant hand 2) Ordering a type and cross-match of packed red blood cells 3) Preparing to assist with central line placement 4) Inserting a nasogastric tube 21. The nurse is providing care to a patient admitted with a spinal cord injury. The patient is bradycardic, hypotensive, and has cold and clammy skin. Which is the priority nursing action for this patient? 1) Starting two large intravenous catheters 2) Notifying the Rapid Response Team 3) Calling the patient’s physician tN oU reR p oSrtIthNeGcT h aBn g.eC s OM 4) Placing oxygen on the patient 22. A patient in neurogenic shock is receiving rapid intravenous fluids. Which assessment finding indicates the need for additional nursing interventions? 1) The patient’s mean arterial pressure (MAP) is 60 mmHg. 2) The patient is unconscious. 3) The patient has received two liters of infused fluid. 4) The patient is perspiring heavily. 23. Which is the highest priority nursing action when providing care to a patient with shock? 1) Starting two large intravenous catheters 2) Recognizing early clinical manifestations 3) Administering high-flow oxygen 4) Calling for help immediately Multiple Response Identify one or more choices that best complete the statement or answer the question. NURSINGTB.COM
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24. Which will the nurse closely monitor due to the pathophysiology associated with early shock? Select all that apply. 1) Bowel sounds 2) Level of consciousness 3) Urine output 4) Peripheral pulses
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5)
Heart rate
25. Which assessment findings would indicate to the nurse that a patient is exhibiting early symptoms of shock? Select all that apply. 1) Pallor 2) Increased bowel sounds 3) Restlessness 4) Decreased blood glucose 5) Increased respiratory rate 26. A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with early septic shock from the emergency department (ED). The nurse will recognize which symptoms associated with this condition? Select all that apply. 1) Shallow respirations 2) Normal blood pressure 3) Warm and flushed skin 4) Lethargic mental status 5) Decreased urine output 6) Rapid and deep respirations 27. A patient is admitted to the intensive care unit with a systemic infection. Which manifestations will the nurse most likely assess in this patient? Select all that apply. 1) Pain 2) Fever 3) Edema 4) Anorexia 5) Tachycardia NURSINGTB.COM 28. A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with late septic shock from the emergency department (ED). The nurse will recognize which symptoms associated with this condition? Select all that apply. 1) Shallow respirations 2) Lethargic mental status 3) Decreased urine output 4) Normal blood pressure 5) Warm and flushed skin 6) Rapid and deep respirations 29. The nurse is concerned that a patient is demonstrating early signs of hypovolemic shock. Which assessment findings support the nurse’s concern? Select all that apply. 1) Rapid weak pulse 2) Normal respirations 3) Normal blood pressure 4) Slight increase in pulse 5) Prolonged capillary refill time 30. A patient is receiving intravenous nitroprusside (Nipride) for shock. Which adverse reactions will the nurse assess this patient for when administering the NURSINGTB.COM
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infusion? Select all that apply. 1) Confusion 2) Tachycardia 3) Disorientation 4) Muscle spasms
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5)
Gastrointestinal bleeding
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Chapter 14: Overview of Shock and Sepsis Answer Section MULTIPLE CHOICE 1.
ANS: 1 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Discussing the pathophysiology of shock Chapter page reference: 266-271 Heading: Sepsis/Septic Shock Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate 1 2 3
4
Feedback Immunosuppression is a risk factor for the development of sepsis. An elevated temperature is a manifestation of sepsis. Sepsis is most often the result of gram-positive infections from Staphylococcus and Streptococcus bacteria but may also follow gram-negative bacterial infections such as Pseudomonas, Escherichia coli, and Klebsiella. Leukocytosis occurs with sepsis if the patient is able to mount an immune response.
PTS: 1 CON: InfectioNn URSINGTB.COM 2. ANS: 1 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Analyzing the nursing management of selected shock states Chapter page reference: 266-271 Heading: Sepsis/Septic Shock Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Infection; Perfusion Difficulty: Difficult Feedback 1 A change in skin color will alert the nurse immediately of decreased tissue perfusion. 2 Assessing temperature and monitoring heart rate and pupil reaction are important when assessing a patient with septicemia; however, these interventions do not address the identified nursing diagnosis. NURSINGTB.COM
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3
4
Assessing temperature and monitoring heart rate and pupil reaction are important when assessing a patient with septicemia; however, these interventions do not address the identified nursing diagnosis. Assessing temperature and monitoring heart rate and pupil reaction are important when assessing a patient with septicemia; however, these interventions do not address the identified nursing diagnosis.
PTS: 1
CON: Infection | Perfusion
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3.
ANS: 1 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Analyzing the nursing management of selected shock states Chapter page reference: 266-271 Heading: Sepsis/Septic Shock Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Good oral and skin care will prevent breakdown and prevent entry by bacteria. 2 There is no evidence that this patient has a wound. 3 In order to prevent skin breakdown and promote respiratory function, the patient is turned at least every two hours. 4 The Foley drainage bag is always kept below the level of the patient’s bladder to prevent reflux.
PTS: 1 CON: Infection 4. ANS: 1 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Identifying hypovolemic, cardiogenic, and obstructive, and distributive shock Chapter page reference: 264-266 Heading: Anaphylactic Shock Integrated Processes: Communication and NURSINGTB.COM Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Inflammation; Perfusion Difficulty: Moderate Feedback 1 Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord suggests neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent infection may indicate septic shock; and a history of allergies with a sudden onset of symptoms may suggest anaphylactic shock. 2 Kidney failure is not a type of shock. 3 Respiratory failure is not a type of shock. 4 Liver failure is not a type of shock. PTS: 1 5. ANS: 3
CON: Inflammation | Perfusion NURSINGTB.COM
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Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Describing the medical management of selected shock states Chapter page reference: 253-257 Heading: Hypovolemic Shock Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Difficult
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1 2 3
4
Feedback Assessing the cause of bleeding would also occur after establishing invasive cardiac monitoring. Replacement of volume would occur after invasive cardiac monitoring is established. With aging, there is a decrease in cardiac sympathetic activity. Older patients can have secondary volume depletion because of diuretics or malnutrition, and if prescribed a beta blocker, tachycardia may not occur as an early sign of hypovolemic shock. The older patient will require early invasive monitoring in order to avoid excessive or inadequate volume restoration. This should be done early in the treatment phase. Pain would be a consideration but would not be attended to as a first priority.
PTS: 1 CON: Perfusion 6. ANS: 3 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Analyzing the nursing management of selected shock states Chapter page reference: 253-257 Heading: Hypovolemic Shock Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Difficult Feedback 1 There is not enough information to determine whether the patient is experiencing ineffective coping. NURSINGTB.COM 2 The patient will most likely have deficient fluid volume; however, cardiac output is the first priority at this time. 3 The patient sustained a gunshot wound to the femoral artery, which would lead to significant bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a priority for the patient is Decreased Cardiac Output because of low blood volume. 4 There is not enough information to determine whether the patient has ineffective airway clearance. PTS: 1 CON: Perfusion 7. ANS: 1 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Analyzing the nursing management of NURSINGTB.COM
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selected shock states Chapter page reference: 253-257 Heading: Hypovolemic Shock Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 Because albumin 5% is a volume expander and pulls fluid into the vascular space, circulatory overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard with pulmonary congestion
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2 3 4
Hyperresonance is assessed by percussion, not auscultation. Stridor is auscultated with airway obstruction, not pulmonary edema. An absence of breath sounds is heard with a pneumothorax, not with pulmonary edema.
PTS: 1 CON: Fluid and Electrolyte Balance 8. ANS: 1 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Analyzing the nursing management of selected shock states Chapter page reference: 253-257 Heading: Hypovolemic Shock Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Fluid and Electrolyte Balance Difficulty: Difficult Feedback 1 Colloids are proteins or other large molecules that stay suspended in the blood for long periods because they are too large to easily cross membranes. They draw water molecules from the cells and tissues into the blood vessels through their ability to increase plasma oncotic pressure. 2 Albumin 5% does not act on the kidneys. 3 Albumin 5% is not a concentrated saline solution. 4 Crystalloids are intravenous (IV) solutions that contain electrolytes, not proteins, in concentrations resembling those of plasma. They are used to replace lost fluids and promote urine output. NURSINGTB.COM PTS: 1 CON: Fluid and Electrolyte Balance 9. ANS: 3 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Describing the medical management of selected shock states Chapter page reference: 253-257 Heading: Hypovolemic Shock Integrated Processes: Nursing Process – Evaluation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy Feedback NURSINGTB.COM
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1 2 3 4
10.
Increased cardiac output occurs with high, not low, doses of dopamine when beta1- adrenergic receptors are stimulated. Dopamine does not prevent or stabilize fluid loss. At low doses, dopamine stimulates dopaminergic receptors, especially in the kidneys, leading to vasodilation and an increased blood flow through the kidneys. Vasoconstriction and increased blood pressure occur with high, not low, doses of dopamine when alpha-adrenergic receptors are stimulated.
PTS: 1 CON: Perfusion ANS: 1 Chapter number and title: 14, Overview of Shock and Sepsis
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Chapter learning objective: Chapter page reference: 247-248 Heading: Classifications of Shock Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy Feedback 1 Blood loss causes hypovolemic shock. 2 Blood loss does not cause cardiogenic shock. 3 Blood loss does not cause distributive shock. 4 Blood loss does not cause obstructive shock.
11.
12.
PTS: 1 CON: Perfusion ANS: 2 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Describing the stages of shock Chapter page reference: 248-250 Heading: Stages of Shock Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Perfusion NURSINGTB.COM Difficulty: Easy Feedback 1 A subtle change in heart rate is anticipated during the initial stage of shock. 2 In the refractory stage of shock, there is a change from aerobic to anaerobic metabolism due to cellular hypoxia from decreased perfusion. 3 Hyperglycemia develops during the compensatory stage of shock. 4 Cardiac dysrhythmias develop during the progressive stage of shock. PTS: 1 CON: Perfusion ANS: 2 Chapter number and title: 14, Overview of Shock and Sepsis NURSINGTB.COM
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Chapter learning objective: Describing the medical management of selected shock states Chapter page reference: 264-266 Heading: Anaphylactic Shock Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate Feedback 1 While antihistamines may help to prevent airway obstruction if administered quickly after exposure to an allergen this classification is not the medication of choice for treating airway obstruction. 2 Antihistamines help to relieve histamine-related symptoms such as itching, flushing, hives, and rhinorrhea.
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3 4
13.
14.
Antihistamines do not prevent anaphylactic shock; they are used to relieve the histamine-related symptoms associated with an allergic reaction. This description is more applicable to the action of corticosteroids.
PTS: 1 CON: Inflammation ANS: 4 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Describing the medical management of selected shock states Chapter page reference: 264-266 Heading: Anaphylactic Shock Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Medication Difficulty: Difficult Feedback 1 Epi-pens do expire, so the patient should have a plan for checking the date regularly. This statement indicates appropriate understanding of the information presented. 2 Epi-pens do expire, so the patient should have a plan for checking the date regularly. This statement indicates appropriate understanding of the information presented. 3 The pen is held firmly in place for 10 seconds after injection. This statement indicates appropriate understanding of the information presented. 4 The pen is placed against the thigh, not the abdomen, for injection. This statement indicates the need for additional instruction. NURSINGTB.COM PTS: 1 CON: Medication ANS: 3 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Describing the medical management of selected shock states Chapter page reference: 257-261 Heading: Cardiogenic Shock Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy Feedback NURSINGTB.COM
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1 2 3
4
Pain relief is important for this patient, but that is not the primary purpose of the interventions used when treating a patient experiencing an MI. Interventions are performed to prevent further damage, but this is not the primary rationale for their use when treating a patient experiencing an MI. Cardiogenic shock is the cause of death for many persons who have a myocardial infarction. Interventions are designed to reduce the risk of cardiogenic shock when treating a patient experiencing an MI. Interventions would be implemented to reduce elevated blood pressure, but this is not the primary concern in myocardial infarction when treating a patient experiencing an MI.
PTS: 1
CON: Perfusion
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15.
16.
ANS: 3 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Cardiogenic shock Chapter page reference: 257-261 Heading: Cardiogenic Shock Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy Feedback 1 Tachycardia is the result of compensation for decreased cardiac output due to decreased stroke volume. 2 Vasoconstriction does not result in an increase of ejection fraction. 3 Vasoconstriction results in diminished renal blood flow and urine production. 4 Vasoconstriction does not affect the patient’s core temperature; however, vasoconstriction results in shunting of blood away from the skin, causing the skin to be cold and clammy. PTS: 1 CON: Perfusion ANS: 2 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Describing the medical management of selected shock states Chapter page reference: NURSINGTB.COM 257-261 Heading: Cardiogenic Shock Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy Feedback 1 A beta blocker would not increase the heart rate for a patient who is experiencing cardiogenic shock. NURSINGTB.COM
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2
3 4
17.
Atropine is administered as treatment for bradycardia that can occur as a result of cardiogenic shock. If the patient is not responsive to atropine, pacing is likely necessary. Defibrillation is not performed for the bradycardia associated with cardiogenic shock. A preload reducer is not indicated in the treatment of bradycardia.
PTS: 1 CON: Perfusion ANS: 4 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Analyzing the nursing management of selected shock states Chapter page reference: 253-257 Heading: Hypovolemic Shock Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying]
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Concept: Safety Difficulty: Moderate Feedback 1 The patient should be kept warm and comfortable. 2 The head should lie flat. 3 The patient should be supine. 4 Turing the patient’s head to one side protects the airway in case of vomiting.
18.
19.
PTS: 1 CON: Safety ANS: 4 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Describing the assessment of and monitoring techniques indicated for shock Chapter page reference: 248-250 Heading: Stages of Shock Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 Lethargy is anticipated during the progressive, not initial, stage of shock. 2 Hypotension is anticipated during the progressive, not initial, stage of shock. 3 Respiratory alkalosis is anticipated during the compensatory, not initial, stage of shock. 4 Subtle or no clinical manifestations are anticipated when providing care to a patient in the initial stage of shock. NURSINGTB.COM PTS: 1 CON: Perfusion ANS: 3 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Describing the medical management of selected shock states Chapter page reference: 253-257 Heading: Hypovolemic Shock Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: NURSINGTB.COM
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Easy 1 2 3 4
20.
Feedback Crystalloids such as normal saline can be given for volume expansion, but are not of the greatest benefit to the patient. Dextrose in water is seldom administered as a volume expander. Replacement of lost fluid with packed red blood cells increases oxygen-carrying capacity. This is the best choice for blood loss from trauma such as gunshot wounds. Albumin is a volume expander but is not the best choice for this situation.
PTS: 1 CON: Perfusion ANS: 3 Chapter number and title: 14, Overview of Shock and Sepsis
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Chapter learning objective: Describing the medical management of selected shock states Chapter page reference: 253-257 Heading: Hypovolemic Shock Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 A single medium-gauge IV catheter is not sufficient for volume expansion required for a patient experiencing hypovolemic shock. 2 The hypovolemia associated with pancreatitis is not a blood loss hypovolemia. It is also outside of the scope of nursing practice to order laboratory and diagnostic testing. 3 Rapid volume expansion requires the use of large veins, preferably a central line. 4 While a nasogastric tube may be indicated for this patient, it will not be used to increase fluid intake.
21.
22.
PTS: 1 CON: Perfusion ANS: 2 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Analyzing the nursing management of selected shock states Chapter page reference: 263-264 Heading: Neurogenic Shock Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [AnalyzingN] URSINGTB.COM Concept: Perfusion Difficulty: Difficult Feedback 1 This is an appropriate action but is not the priority action. 2 The nurse should call for help from the Rapid Response Team. 3 The nurse should eventually notify the physician, but this is not the priority action. 4 Oxygen therapy is indicated but is not the primary intervention. PTS: 1 CON: Perfusion ANS: 1 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Analyzing the nursing management of selected shock states Chapter page reference: 263-264 NURSINGTB.COM
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Heading: Neurogenic Shock Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy Feedback 1 The MAP should be at least 65 mmHg. This finding indicates the need for further intervention.
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2 3 4
23.
Unconsciousness may result from the mechanism of injury and is not indicative of the need for further intervention. Large amounts of fluid may be required. The presence of perspiration is not related to the adequacy of fluid resuscitation.
PTS: 1 CON: Perfusion ANS: 2 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Analyzing the nursing management of selected shock states Chapter page reference: 247-250 Heading: Overview of Shock Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Difficult Feedback 1 While starting two large intravenous catheters is an important nursing action this is not the priority action. 2 Early recognition of the clinical manifestations of shock can save the patient’s life and is the priority action. 3 While oxygen is often administered in the treatment of shock this is not the priority nursing action. 4 While the nurse may need additional help this is not the priority nursing action. NURSINGTB.COM PTS: 1 CON: Perfusion
MULTIPLE RESPONSE 24. ANS: 1, 3, 4 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Describing the stages of shock Chapter page reference: 247-250 Heading: Overview of Shock Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Difficult NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. 2. 3.
Feedback This is correct. Compensatory changes in early shock can result in hypoperfusion of the gut; therefore, the nurse must closely assess bowel sounds. This is incorrect. While the nurse will assess mental status, the brain is usually protected by compensatory mechanisms in early shock; therefore, this is not an area of priority assessment. This is correct. The shunting that occurs in early shock may cause hypoperfusion of the kidneys leading to decreased urine output; therefore, the nurse must closely monitor intake versus output.
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4.
5.
This is correct. The body shunts blood away from the peripheral tissues in an effort to keep vital organs perfused; therefore, the nurse will monitor for decreased peripheral pulses when assessing for early clinical manifestations of shock. This is incorrect. The body tries to protect the heart and does so in early shock by shunting blood to it; therefore, this is not an area of priority assessment.
PTS: 1 CON: Perfusion 25. ANS: 1, 3, 5 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Describing the stages of shock Chapter page reference: 247-250 Heading: Overview of Shock Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is correct. Pallor of the skin, lips, oral mucosa, nail beds, and conjunctiva may occur in early shock. This is incorrect. Bowel motility decreases, resulting in a decrease in bowel sounds. This is correct. Slight decreases in perfusion of the brain may result in restlessness. This is incorrect. Blood glucose typically rises slightly as a response to the stress of shock. This is correct. A compeNnsa U RtoSryImNeGchTa ni B .smCfOo rM decreased tissue oxygenation is the attempt to obtain additional oxygen through more rapid respirations.
PTS: 1 CON: Perfusion 26. ANS: 2, 3, 6 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Distributive Shock – Sepsis/Septic Shock Chapter page reference: 266-271 Heading: Sepsis/Septic Shock Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological NURSINGTB.COM
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Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection; Perfusion Difficulty: Easy 1. 2. 3. 4.
Feedback This is incorrect. Shallow respirations, a lethargic mental status, and decreased urine output are late-phase manifestations of septic shock. This is correct. Early-phase manifestations include normal blood pressure, rapid and deep respirations, and warm or flushed skin. This is correct. Early-phase manifestations include normal blood pressure, rapid and deep respirations, and warm or flushed skin. This is incorrect. Shallow respirations, a lethargic mental status, and decreased urine output are late-phase manifestations of septic shock.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5. 6.
This is incorrect. Shallow respirations, a lethargic mental status, and decreased urine output are late-phase manifestations of septic shock. This is correct. Early-phase manifestations include normal blood pressure, rapid and deep respirations, and warm or flushed skin.
PTS: 1 CON: Infection | Perfusion 27. ANS: 2, 4, 5 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Describing the assessment of and monitoring techniques indicated for shock Chapter page reference: 266-271 Heading: Sepsis/Septic Shock Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy 1. 2. 3. 4. 5.
Feedback This is incorrect. Edema and pain are symptoms of a local infection. This is correct. Fever, tachycardia, and anorexia are the most common symptoms of a systemic infection. This is incorrect. Edema and pain are symptoms of a local infection. This is correct. Fever, tachycardia, and anorexia are the most common symptoms of a systemic infection. This is correct. Fever, taNchUyRcaSrdIiaN, aGnTd Ban.ore C xi O Ma are the most common symptoms of a systemic infection.
PTS: 1 CON: Infection 28. ANS: 1, 2, 3 Feedback 1. This is correct. Late-phase manifestations include shallow respirations, lethargic mental status, and decreased urine output. 2. This is correct. Late-phase manifestations include shallow respirations, lethargic mental status, and decreased urine output. 3. This is correct. Late-phase manifestations include shallow respirations, lethargic mental status, and decreased urine output. 4. This is incorrect. Early-phase manifestations include normal blood pressure, rapid and deep respirations, and warm or flushed skin. 5. This is incorrect. Early-phase manifestations include normal blood pressure, rapid and deep respirations, and warm or flushed skin. 6. This is incorrect. Early-phase manifestations include normal blood pressure, rapid and deep respirations, and warm or flushed skin. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Distributive shock – Sepsis/Septic Shock Chapter page reference: 266-271 Heading: Sepsis/Septic Shock Integrated Processes: Nursing Process – Assessment
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Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection; Perfusion Difficulty: Easy PTS: 1 CON: Infection | Perfusion 29. ANS: 3, 4, 5 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Hypovolemic shock Chapter page reference: 253-257 Heading: Hypovolemic Shock Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy 1. 2. 3.
4.
5.
Feedback This is incorrect. A weak rapid pulse is a characteristic of the irreversible stage of hypovolemic shock. This is incorrect. Normal respirations are not anticipated for a patient demonstrating early signs of hypovolemic shock. This is correct. Manifestations of early hypovolemic shock include a slight increase in pulse, normal respirations, prolonged capillary refill time, and normal blood pressure. This is correct. ManifestNatUioRnsSoIf NeaGrlTy Bhy.pC ovOoM lemic shock include a slight increase in pulse, normal respirations, prolonged capillary refill time, and normal blood pressure. This is correct. Manifestations of early hypovolemic shock include a slight increase in pulse, normal respirations, prolonged capillary refill time, and normal blood pressure.
PTS: 1 CON: Perfusion 30. ANS: 1, 2, 3, 4 Chapter number and title: 14, Overview of Shock and Sepsis Chapter learning objective: Describing the medical management of selected shock states Chapter page reference: 257-261 Heading: Cardiogenic Shock NURSINGTB.COM
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Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate 1.
2.
Feedback This is correct. Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia are adverse reactions that the nurse should report immediately to the health-care provider. This is correct. Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia are adverse reactions that the nurse should report immediately to the health-care provider.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3.
4.
5.
PTS: 1
This is correct. Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia are adverse reactions that the nurse should report immediately to the health-care provider. This is correct. Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia are adverse reactions that the nurse should report immediately to the health-care provider. This is incorrect. Gastrointestinal bleeding is not an adverse effect of this medication. CON: Perfusion
Chapter 15: Priorities for the Preoperative Patient Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse administers the preoperative medication to the patient one hour before elective surgery, and thendiscovers the preoperative consent is not signed. Which action by the nurse is the most appropriate? 1) Have the patient sign the consent quickly, before the medication begins taking effect. 2) Have a family member or medical power of attorney sign the consent. 3) Send the patient to the holding area without a signed consent. 4) Notify the health-care provider that surgery will need to be canceled. NURSINGTB.COM 2. The nurse is completing the preoperative checklist on the night shift in preparation for the patient’s surgery, scheduled for 0800. Which tasks could the nurse complete at this time? 1) Documenting the time of last voiding 2) Checking the medical record for the history, physical, and signed informed consent 3) Administering preoperative medication 4) Removing the prosthesis 3. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed amiodarone? 1) Obtaining a baseline ECG 2) Monitoring blood pressure 3) Assessing for hyperglycemia 4) Tapering the drug two days prior to surgery 4. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed NURSINGTB.COM
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warfarin? 1) Obtaining a baseline ECG 2) Monitoring blood pressure 3) Assessing for hyperglycemia 4) Tapering the drug two days prior to surgery 5. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed metoprolol? 1) Obtaining a baseline ECG 2) Monitoring blood pressure
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3) 4)
Assessing for hyperglycemia Tapering the drug two days prior to surgery
6. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed dexamethoasone? 1) Obtaining a baseline ECG 2) Monitoring blood pressure 3) Assessing for hyperglycemia 4) Tapering the drug two days prior to surgery 7. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed phenobarbital? 1) Obtaining a baseline ECG 2) Monitoring blood pressure 3) Maintaining the drug during the perioperative period 4) Assessing blood glucose levels closely during the perioperative period 8. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed insulin? 1) Obtaining a baseline ECG 2) Monitoring blood pressure 3) Holding the drug during the perioperative period 4) Assessing blood glucose levels closely during the perioperative period 9. Which should the nurse teach the patient regarding NPO status prior to a surgical procedure? 1) Nothing by mouth for 12 hours prior to surgery 2) Nothing solid by mouth for six hNoU u rRs S p rIioNr tGo TsuBrg.eCryOM 3) No clear liquids by mouth for four hours prior to the surgery 4) No clear liquids by mouth for two hours prior to the surgery 10. Which is the priority nursing action when providing patient care during the preoperative phase of care? 1) Ensuring NPO status 2) Monitoring vital signs 3) Obtaining informed consent 4) Completing a preoperative checklist 11. The nurse is reviewing the medical records for patients who are scheduled for surgery the next day. Which patient may not provide consent to receive blood products? 1) A Hispanic Catholic patient. 2) An African-American Baptist patient. 3) A Caucasian Jehovah’s Witness patient. 4) A Native American patient with no religious affiliation. NURSINGTB.COM
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12. Which identifier should the nurse use during the initial time-out to determine the right patient? 1) Date of birth 2) Maiden name 3) Medical record number 4) Photo placed in the medical record 13. Which information should the nurse collect during the health history that is conducted during the preoperative period? 1) Caretaker after discharge
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2) 3) 4)
Oral intake over the last day Date of last sexual encounter Previous response to anesthesia
14. The nurse is preparing a patient, diagnosed with asthma, for surgery. Which should the nurse include in the plan of care for this patient? 1) Monitoring blood pressure every hour 2) Assessing bowel sounds twice per shift 3) Monitoring pulse oximetry continuously 4) Assessing deep tendon reflexes every hour 15. Which is the priority action by the nurse when a patient discloses a medication allergy during the health history prior to a surgical procedure? 1) Asking the patient to describe the reaction that occurs 2) Documenting the information on the patient’s medical record 3) Placing an alert bracelet on the patient prior to leaving the unit 4) Verifying the information with the patient’s family members at the bedside 16. Which parameter for NPO status is appropriate when providing care to a pediatric patient in the preoperative period? 1) Ensuring nothing by mouth for six hours prior to the surgical procedure 2) Ensuring no solid foods by mouth for six hours prior to the surgical procedure 3) Allowing formula to be included in the child’s intake for up to six hours prior to the surgical procedure 4) Allowing breast milk to be included in the child’s intake for up to six hours prior to the surgical procedure NURSINGTB.COM 17. Which risk factor should the nurse include in the preoperative plan of care for a patient who smokes? 1) Angina pain 2) Gastrointestinal upset 3) Cognitive impairment 4) Respiratory depression 18. Which laboratory test should the nurse include in the plan of care for a patient who may require a blood transfusion during the surgical procedure? 1) Urinalysis 2) Type and crossmatch 3) Basic metabolic panel 4) Arterial blood gas analysis 19. Which gauge catheter should the nurse use when initiating intravenous (IV) access for a preoperative patient? 1) 18 2) 20 3) 22 4) 24 Multiple Response NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Identify one or more choices that best complete the statement or answer the question. 20. Which should the nurse ask the patient to verify during the initial time-out, the “pause for cause”? 1) “What is the name of your surgeon?”
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2) 3) 4) 5)
“Which procedure are you having done today?” “Is the information on your identification band correct?” “Which side of the body is your procedure going to be completed on?” “Have you signed your informed consent for the scheduled procedure?”
21. A patient is informed that a surgical procedure is to be scheduled in two weeks. Which teaching points should the nurse focus to prepare the patient for the surgery? Select all that apply. 1) Maintaining a patent airway 2) Deep breathing and coughing 3) Caring for the surgical incision 4) Managing constipation 5) Managing pain 22. The nurse is preparing a patient for emergency surgery to repair liver and colon lacerations caused by a motor vehicle crash. Which information about this type of surgery will the nurse use to guide the patient's care? Select all that apply. 1) An organ is going to be removed. 2) This is an emergency surgery. 3) The patient will be hospitalized longer. 4) The patient is at risk for blood loss. 5) The patient is at risk for hypothermia. 23. The nurse is preparing an older adult patient for surgery. Which topics should the nurse focus on when preparing this patient’s preoperative teaching? Select all that apply. 1) Level of hearing 2) Transportation needs of the patient after discharge 3) Teaching on deep breathing andNcU o uRgS h iI n gNGTB.COM 4) Plans for discharge care 5) Actions to prevent pressure ulcers 24. When providing preoperative teaching for the patient who is scheduled for coronary artery bypass surgery in the morning, the nurse would include which topics? Select all that apply. 1) Location of incisions 2) Discharge information 3) Postoperative drains to expect 4) Postoperative pain management 5) Coughing and deep breathing exercises 25. The nurse performs preoperative teaching for a patient requiring a surgical intervention. Which actions by the patient indicate appropriate understanding of the information provided? Select all that apply. 1) Demonstrating how to turn and get out of bed 2) Having no anxiety about the impending surgery 3) Demonstrating proper performance of leg exercises 4) Demonstrating proper coughing and deep breathing NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5)
Asking questions about and voicing understanding of information provided
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 15: Priorities for the Preoperative Patient Answer Section MULTIPLE CHOICE 1.
ANS: 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Discussing the essentials of the surgical experience Chapter page reference: 274-279 Heading: Informed Consent Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Legal; Perioperative Difficulty: Moderate Feedback 1 The nurse cannot have the patient sign the consent once the preoperative medication has been administered, because it affects the patient’s ability to reason. 2 Emergency surgery, in some facilities, may be performed if a family member or medical power of attorney signs the consent when the patient is unable to do so, but elective surgery requires the patient’s signature if she is capable of making a reasoned decision. 3 The nurse cannot send the patient to the holding area without a signed consent form. 4 The nurse will notify the healtNh -UcaRreSpIroNvGidTerB, w.hCoOwMill need to cancel surgery until the preoperative medication is excreted and no longer affecting the patient’s ability to make informed decisions, at which time the consent can be signed.
PTS: 1 CON: Legal | Perioperative 2. ANS: 2 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Discussing the essentials of the surgical experience Chapter page reference: 274 Heading: Introduction Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: NURSINGTB.COM
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Moderate Feedback 1 The nurse on day shift preparing to send the patient to surgery would document time of last voiding and administration of preoperative medication. 2 The nurse on night shift could check the medical record to ensure that a history andphysical have been completed, and that the consent for surgery is signed. 3 The nurse on day shift preparing to send the patient to surgery would document time of last voiding and administration of preoperative medication. 4 Many patients prefer to wait until just before going to surgery before removing dentures, contact lenses, and other prostheses.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1 CON: Perioperative 3. ANS: 1 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The prescribed drug is an antiarrhythmic; therefore, the most appropriate nursing action is to obtain a baseline ECG. 2 This nursing action is appropriate for a patient who is prescribed an antihypertensive drug. 3 This nursing action is appropriate for a patient who is prescribed a corticosteroid drug. 4 The nursing action is appropriate for a patient who is prescribed an anticoagulant drug. PTS: 1 CON: Perioperative 4. ANS: 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: NURSINGTB.COM 280-284Heading: Patient Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 This nursing action is appropriate for a patient who is prescribed an antiarrhythmic. 2 This nursing action is appropriate for a patient who is prescribed an antihypertensive drug. 3 This nursing action is appropriate for a patient who is prescribed a corticosteroid drug. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4
The prescribed drug is an anticoagulant; therefore, the most appropriate nursing action is to teach the patient to taper the drug for 48 hours prior to the surgical procedure.
PTS: 1 CON: Perioperative 5. ANS: 2 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative
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Difficulty: Moderate Feedback 1 This nursing action is appropriate for a patient who is prescribed an antiarrhythmic. 2 The prescribed drug is an antihypertensive; therefore, the most appropriate nursing action is to monitor the patient’s blood pressure. 3 This nursing action is appropriate for a patient who is prescribed a corticosteroid drug. 4 The nursing action is appropriate for a patient who is prescribed an anticoagulant drug. PTS: 1 CON: Perioperative 6. ANS: 3 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 This nursing action is appropriate for a patient who is prescribed an antiarrhythmic. 2 This nursing action is appropriate for a patient who is prescribed an antihypertensive drug. 3 The prescribed drug is a corticosteroid; therefore, the most appropriate nursing action is to assess the patient for hypergNlyUcRemSia. I NGTB.COM 4 The nursing action is appropriate for a patient who is prescribed an anticoagulant drug. PTS: 1 CON: Perioperative 7. ANS: 3 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
Feedback This nursing action is appropriate for a patient who is prescribed an antiarrhythmic. This nursing action is appropriate for a patient who is prescribed an antihypertensive drug. The prescribed drug is a medication used to control seizures; therefore, this drug should be maintained during the perioperative period. The nursing action is appropriate for a patient who is prescribed insulin for diabetes management.
PTS: 1
CON: Perioperative
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
8.
ANS: 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 This nursing action is appropriate for a patient who is prescribed an antiarrhythmic. 2 This nursing action is appropriate for a patient who is prescribed an antihypertensive drug. 3 This nursing action is inappropriate as insulin should be administered throughout the perioperative period. 4 The prescribed drug is administered to control the patient’s blood glucose level; therefore, the nurse should monitor the patient’s blood glucose level closely during the perioperative period.
PTS: 1 CON: Perioperative 9. ANS: 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: NURSINGTB.COM 280-284Heading: Patient Assessment Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 This is not the guideline regarding NPO status prior to a surgical procedure. 2 This is not the guideline regarding NPO status prior to a surgical procedure. 3 This is not the guideline regarding NPO status prior to a surgical procedure. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4
10.
The guidelines for NPO status prior to a surgical procedure is nothing solid by mouth for eight hours prior to the procedure and no clear liquids by mouth for two hours prior to the procedure. NPO status is meant to decrease the patient’s risk for aspiration.
PTS: 1 CON: Perioperative ANS: 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: 274 Heading: Introduction Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Perioperative
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Difficulty: Difficult Feedback 1 While ensuring NPO status is important, this is not the priority nursing action. 2 While monitoring vital signs is important, this is not the priority nursing action. 3 The health-care provider, not the nurse, is responsible for obtaining informed consent. 4 The priority nursing action during the preoperative period is to complete the preoperative checklist prior to the patient being transferred to the surgical suite.
11.
12.
PTS: 1 CON: Perioperative ANS: 3 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Analyzing the nursing role in the preoperative process Chapter page reference: 274-279 Heading: Informed Consent Integrated Processes: Nursing Process – Assessment Client Need: Psychosocial Integrity Cognitive level: Comprehension [Understanding] Concept: Perioperative; Diversity Difficulty: Easy Feedback 1 This patient is likely to provide consent to receive blood products. 2 This patient is likely to provide consent to receive blood products. 3 A patient who is a Jehovah’s Witness is not likely to provide consent to receive blood products during the perioperative period. 4 This patient is likely to providNe U coRnsSeI n tNtoGrTecBei.v Ce bOloMod products. PTS: 1 CON: Perioperative | Diversity ANS: 1 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: 279-280 Heading: Time Outs/Cause for Pause Integrated Processes: Nursing Process – Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Legal; Perioperative Difficulty: Moderate Feedback NURSINGTB.COM
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1 2
3
4
Date of birth is an identifier the nurse should use to determine the right patient during the initial time-out conducted during the preoperative period. The patient’s first and last name, not maiden name, are identifiers the nurse should use to determine the right patient during the initial time-out conducted during the preoperative period. The patient’s social security number, not medical record number, is an identifier the nurse should use to determine the right patient during the initial timeout conducted during the preoperative period. A photo placed on the patient’s identification band, not medical record, is an identifier the nurse should use to determine the right patient during the initial time-out conducted during the preoperative period.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
13.
14.
15.
PTS: 1 CON: Legal | Perioperative ANS: 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process – Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Perioperative; Assessment Difficulty: Easy Feedback 1 While the support system and living conditions should be assessed it is unnecessary to determine a specific caregiver after discharge. 2 Last oral intake, not intake over the previous day, is information collected. 3 The date of the patient’s last sexual encounter is not needed. 4 The patient’s previous response to anesthesia should be determined at this time. PTS: 1 CON: Perioperative | Assessment ANS: 3 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: 280-284 Heading: Patient Assessment NURSINGTB.COM Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative; Oxygenation Difficulty: Moderate Feedback 1 This parameter is not required when planning this patient’s care. 2 This parameter is not required when planning this patient’s care. 3 A patient diagnosed with asthma, who is scheduled for surgery, may have difficulty being weaned from the mechanical ventilator. This patient would require continuous pulse oximetry and arterial blood gas analysis in the plan of care. 4 This parameter is not required when planning this patient’s care. PTS: 1 ANS: 3
CON: Perioperative | Oxygenation NURSINGTB.COM
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Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Perioperative Difficulty: Difficult
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1 2 3 4
16.
17.
Feedback While it is important to determine the type of reaction the patient experiences, this is not the priority nursing action. While it is important to document the information in the patient’s medical record, this is not the priority nursing action. The nurse should immediately place an alert bracelet on the patient and communicate this information with the surgical team. It is not necessary to verify the information with the patient’s family members at the bedside.
PTS: 1 CON: Perioperative ANS: 3 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Perioperative; Nutrition Difficulty: Easy Feedback 1 This parameter is not appropriate for the pediatric patient. 2 This parameter is not appropriate for the pediatric patient. Solid foods are allowed up to up eight hours prior to surgeryN. URSINGTB.COM 3 The pediatric patient can have formula for up to six hours prior to surgery. 4 This parameter is not appropriate for the pediatric patient. Breast milk is allowed for up to four hours prior to surgery. PTS: 1 CON: Perioperative | Nutrition ANS: 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Analyzing the nursing role in the preoperative process Chapter page reference: 280-284 Heading: Patient Assessment Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative; Oxygenation Difficulty: Moderate Feedback NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
A patient who smokes is not at a greater risk for angina pain during the perioperative period. A patient who smokes is not at a greater risk for gastrointestinal upset during the perioperative period. A patient who smokes is not at a greater risk for cognitive impairment during the perioperative period. A patient who smokes is at a greater risk for respiratory depression during the perioperative period.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
18.
19.
PTS: 1 CON: Perioperative | Oxygenation ANS: 2 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: 284-286 Heading: Patient Preparation for Surgical Experience Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 A urinalysis is not anticipated for a patient who may require a blood transfusion during a surgical procedure. 2 A type and crossmatch is anticipated for a patient who may require a blood transfusion during a surgical procedure. This will allow for type specific blood to be available for the patient if a transfusion is required. 3 A basic metabolic panel is not anticipated for a patient who may require a blood transfusion during a surgical procedure. 4 An arterial blood gas analysis is not anticipated for a patient who may require a blood transfusion during a surgical procedure. PTS: 1 CON: Perioperative ANS: 1 NURSINGTB.COM Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Identifying the vital preoperative preparation for the patient Chapter page reference: 284-286 Heading: Patient Preparation for Surgical Experience Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Knowledge [Remembering] Concept: Perioperative; Fluid and Electrolyte Maintenance Difficulty: Easy Feedback 1 An 18-gauge catheter is used when initiating IV access for a perioperative patient as this is the gauge preferred for the administration of blood products. NURSINGTB.COM
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2 3 4
This is not an appropriate gauge for the nurse to use when initiating IV access for a perioperative patient. This is not an appropriate gauge for the nurse to use when initiating IV access for a perioperative patient. This is not an appropriate gauge for the nurse to use when initiating IV access for a perioperative patient.
PTS: 1
CON: Perioperative | Fluid and Electrolyte Balance
MULTIPLE RESPONSE
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
20. ANS: 1, 2, 3, 4 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Explaining the priority assessments for the surgical patient Chapter page reference: 279-280 Heading: Time-Outs/Pause for Cause Integrated Processes: Nursing Process – Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate 1. 2. 3. 4. 5.
Feedback This is correct. This question is included in the initial time-out, the “pause for cause.” This is correct. This question is included in the initial time-out, the “pause for cause.” This is correct. This question is included in the initial time-out, the “pause for cause.” This is correct. This question is included in the initial time-out, the “pause for cause.” This is incorrect. This question is not included in the initial time-out. This information is included in the preoperative checklist.
PTS: 1 CON: Perioperative 21. ANS: 2, 3, 4, 5 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Developing teaching and support strategies for the surgical patient and his or her family Chapter page reference: 284-286 NURSINGTB.COM Heading: Patient Preparation for the Surgical Experience Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. 2.
3.
4.
5.
PTS: 1
This is incorrect. Maintaining a patent airway is a nursing action that is performed during the postoperative phase of surgical care. This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain. This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain. This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain. This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain. CON: Perioperative
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
22. ANS: 2, 3, 4, 5 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Developing teaching and support strategies for the surgical patient and his or her family Chapter page reference: 284-286 Heading: Patient Preparation for the Surgical Experience Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback This is incorrect. The suffix -ectomy indicates removal of an organ. The patient is having surgery to repair lacerations. No organ is identified for removal. This is correct. Emergency surgery is performed when a condition is lifethreatening. This is correct. Surgery to control internal hemorrhage from lacerations is an example of emergency surgery. An open procedure usually requires a longer hospital stay. This is correct. Open procedures place the patient at a higher risk for blood loss. This is correct. If there is a large surgical opening, the patient cannot be adequately covered and will be exposed to cold surgical suite air, and can develop hypothermia.
PTS: 1 CON: Perioperative 23. ANS: 1, 3, 4, 5 Chapter number and title: 15, Priorities for the Preoperative Patient NURSINGTB.COM Chapter learning objective: Developing teaching and support strategies for the surgical patient and his or her family Chapter page reference: 284-286 Heading: Patient Preparation for the Surgical Experience Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. 2. 3. 4.
5.
PTS: 1
Feedback This is correct. For the older patient, make sure the patient can hear the information to be presented or provide information through alternative means. This is incorrect. Transportation needs of the patient after discharge would not be part of the preoperative teaching plan. This is correct. Older adults are at greater risk for pneumonia and other postoperative complications and should have teaching related to deep breathing and coughing. This is correct. The older patient is going to need assistance once discharged and should have the necessary medical equipment such as walkers and raised toilet seats, assistance with transportation, or extended care. This is correct. The older patient is at risk for pressure ulcer formation because of poor nutritional status, diabetes, cardiovascular illness, or history of steroid use. CON: Perioperative
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
24. ANS: 1, 3, 4, 5 Feedback 1. This is correct. The location of incisions is included in the preoperative teaching session. 2. This is incorrect. Discharge information is not included in the preoperative teaching session. 3. This is correct. Drains to expect after the surgical procedure is information included in the preoperative teaching session. This is correct. Postoperative pain management is information included in 4. the preoperative teaching session. 5. This is correct. Coughing and deep breathing exercises is information included in the preoperative teaching session. Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: Developing teaching and support strategies for the surgical patient and his or her family Chapter page reference: 284-286 Heading: Patient Preparation for the Surgical Experience Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate PTS: 1 CON: Perioperative 25. ANS: 1, 3, 4, 5 Chapter number and title: 15, Priorities for the Preoperative Patient Chapter learning objective: DevelopiNngUtReaScI hiNngGaTnBd.suCpOpoMrt strategies for the surgical patient and his or her family Chapter page reference: 284-286 Heading: Patient Preparation for the Surgical Experience Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Perioperative Difficulty: Difficult NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. 2. 3. 4. 5. PTS: 1
Feedback This is incorrect. The nurse evaluates the patient’s understanding through the questions asked and the return demonstration of skills performed. This is incorrect. Although preoperative teaching can help to reduce anxiety, it is unlikely to completely eliminate fear. This is correct. The nurse evaluates the patient’s understanding through the questions asked and the return demonstration of skills performed. This is correct. The nurse evaluates the patient’s understanding through the questions asked and the return demonstration of skills performed. This is correct. The nurse evaluates the patient’s understanding through the questions asked and the return demonstration of skills performed. CON: Perioperative
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 16: Priorities for the Intraoperative Patient Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The patient is transferred to the operating table. Which dimension of the operative period is the patient currently experiencing? 1) Postoperative period 2) Preoperative period 3) Perioperative period 4) Intraoperative period 2. The nurse is performing a surgical hand scrub, and holds the hands in which position when rinsing? 1) Straight out from the elbows 2) Lower than the elbows 3) Higher than the elbows 4) Irrelevant as long as the hands are well scrubbed 3. Which personal protective equipment should the scrub nurse don to decrease the likelihood of a splash injury during a surgical procedure? 1) Gloves NURSINGTB.COM 2) Gown 3) Mask 4) Eyewe ar 4. Which classification should the nurse document, according to the American Society of Anesthesiologists, for a patient who is diagnosed with a mild systemic disease? 1) 2 2) 3 3) 4 4) 5 5. Which classification should the nurse document, according to the American Society of Anesthesiologists, for a patient who is diagnosed with a severe systemic disease? 1) 2 2) 3 3) 4 4) 5 6. Which classification should the nurse document, according to the American Society of Anesthesiologists, for a patient who is diagnosed with a severe systemic disease that is a threat to life? NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1) 2 2) 3 3) 4 4) 5
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
7. Which classification should the nurse document, according to the American Society of Anesthesiologists, for a patient who is not expected to survive without the planned surgical procedure? 1) 2 2) 3 3) 4 4) 5 8. Which American Society of Anesthesiologists’ classification should the circulating nurse document for a patient who is brain-dead and having organs procured for donation? 1) 3 2) 4 3) 5 4) 6 9. Which term should the nurse document for a patient who is having surgery for the removal of female reproductive organs? 1) Episiotomy 2) Hysterectomy 3) Amniocentesis 4) Cholecystectomy 10. Which term should the nurse document for a patient who is having surgery for the removal of the gallbladder? 1) Episiotomy 2) Hysterectomy 3) Amniocentesis 4) Cholecystectomy NURSINGTB.COM 11. The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure. When documenting the administration of propofol, which terminology should the nurse use? 1) A narcotic analgesic 2) An intravenous anesthetic 3) A depolarizing muscle relaxant 4) A nondepolarizing muscle relaxant 12. The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure. When documenting the administration of morphine sulfate, which terminology should the nurse use? 1) A narcotic analgesic 2) An intravenous anesthetic 3) A depolarizing muscle relaxant 4) A nondepolarizing muscle relaxant 13. The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
When documenting the administration of cisatracurium, which terminology should the nurse use? 1) A narcotic analgesic 2) An intravenous anesthetic 3) A depolarizing muscle relaxant 4) A nondepolarizing muscle relaxant 14. The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure. When documenting the administration of succinylcholine, which terminology should the nurse use? 1) A narcotic analgesic 2) An intravenous anesthetic
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3) 4)
A depolarizing muscle relaxant A nondepolarizing muscle relaxant
15. Which drug should the nurse prepare for the anesthesiologist to reverse the effects of cisatracurium during a surgical procedure? 1) Fentanyl 2) Atropine 3) Neostigmine 4) Glycopyrrolate 16. Which action should the circulating nurse anticipate during the induction of general anesthesia? 1) Securing the patient’s airway 2) Administering oxygen to the patient by face mask 3) Maintaining the patient using balanced anesthesia 4) Suctioning the patient to decrease incidence of aspiration 17. Which action should the circulating nurse anticipate when the patient is intubated with the administration of general anesthesia? 1) Securing the patient’s airway 2) Administering oxygen to the patient by face mask 3) Maintaining the patient using balanced anesthesia 4) Suctioning the patient to decrease incidence of aspiration 18. Which action by the circulating nurse is appropriate when providing care to a patient during the maintenance phase of general anesthesia? 1) Securing the patient’s airway 2) Administering oxygen to the patNieU ntRbSy IfaNceGmTaBsk.COM 3) Suctioning the patient to decrease incidence of aspiration 4) Documenting drugs for administered for balanced anesthesia 19. Which action should the circulating nurse anticipate during the emergence phase of general anesthesia? 1) Securing the patient’s airway 2) Administering oxygen to the patient by face mask 3) Maintaining the patient using balanced anesthesia 4) Suctioning the patient to decrease incidence of aspiration Completion Complete each statement. 20.
Place the steps the nurse will take to don sterile gloves using the close procedure. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1. With the dominant hand, pick up the opposite glove with the thumb and index
finger, handling it through the sleeve. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2. Open the sterile glove wrapper while the hands are still covered by the sleeves. 3. Use the nondominant hand to grasp the cuff of the glove through the gown cuff, and
firmly anchor it. 4. Extend the fingers into the glove as you pull the glove up over the cuff. 5. Place the fingers of the gloved hand under the cuff of the remaining glove. Multiple Response
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Identify one or more choices that best complete the statement or answer the question. 21. Which individuals should the nurse emphasize when discussing providers who take part in providing patient care during the intraoperative period of the surgical process? Select all that apply. 1) Surgeon 2) Postoperative nurse 3) Circulating nurse 4) Anesthesiologist 5) Social worker 22. Which of these items would the perioperative nurse identify as part of the intraoperative documentation? Select all that apply. 1) Pain assessment 2) Start and stop times of anesthesia 3) Medication review 4) Antibiotic infusion times 5) Start and stop times of the procedure 23. Which is included in the scope of practice for the circulating registered nurse (RN)? Select all that apply. 1) Obtaining informed consent 2) Conducting the initial assessment 3) Assisting the CRNA with patient monitoring 4) Labeling patient samples and sending for analysis 5) Documenting information pertinent the surgical procedure 24. The nurse works in a facility whose policy requires an antiseptic hand rub instead of a surgical scrub when performing surgical hand asepsis. WN h icUhRaSreIkNn oGwTn Bad.vCanOtaMges of the hand rub over the scrub? Select all that apply. 1) Less harmful to the skin 2) Does not require the use of a brush 3) Contains ingredients that help to protect the skin 4) Takes longer to perform 5) Contains alcohol, which could dry the skin 25. Which members of the surgical team are considered sterile? Select all that apply. 1) Surgeon 2) Scrub nurse 3) Anesthesiologist 4) Circulating nurse 5) Surgical assistant 26. Which actions by the nurse are appropriate when preparing a patient for a surgical procedure that requires supine positioning? Select all that apply. 1) Placing the patient on his or her back 2) Supporting the patient’s head in a headrest 3) Placing the patient’s feet on a padded footboard NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4) 5)
Placing the patient’s arms at the sides with palms down Lowering the foot of the bed flexing the patient’s knees
27. Which actions by the nurse are appropriate when preparing a patient for a surgical procedure that requires Fowler’s positioning? Select all that apply. 1) Placing the patient in a lateral position
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2) 3) 4) 5)
Supporting the patient’s head in a headrest Placing the patient’s feet on a padded footboard Placing the patient’s arms at the sides with palms down Lowering the foot of the bed flexing the patient’s knees
28. Which patient populations are at risk for complications due to positioning that is required during surgical procedures? Select all that apply. 1) Pediatric patients 2) Older adult patients 3) Young adult patients 4) Patients diagnosed with bipolar disorder 5) Patients diagnosed with diabetes mellitus
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 16: Priorities for the Intraoperative Patient Answer Section MULTIPLE CHOICE 1.
ANS: 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Explaining priority assessments and procedures in the OR Chapter page reference: 290-291 Heading: Overview of the Surgical Experience Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Knowledge [Remembering] Concept: Perioperative Feedback Difficulty: Easy phase begins with the admission of the patient to the postanesthesia 1 The postoperative 2 3 4
care unit, and ends when healing is complete. The preoperative phase begins when surgery is planned, and ends when the patient is transferred to the operating table. The perioperative period covers all three time periods, from planning surgery until healing is complete. The intraoperative phase begins when the patient is transferred to the operating table, and ends when the patient is admitted to the recovery room.
NURSINGTB.COM CON: Perioperative
PTS: 1 2. ANS: 3 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Explaining priority assessments and procedures in the OR Chapter page reference: 293-295 Heading: Priority Assessments and Procedures Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3
4
This is not an appropriate nursing action during the surgical scrub. This is not an appropriate nursing action during the surgical scrub. The hands should be held higher than the elbows so the water drains down to the elbows and prevents contamination of the clean hands by water running from above the scrubbed area. This is not an appropriate nursing action during the surgical scrub.
PTS: 1 CON: Perioperative 3. ANS: 4 Chapter number and title: 16, Priorities for the Intraoperative Patient
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Chapter learning objective: Explaining priority assessments and procedures in the OR Chapter page reference: 293-295 Heading: Priority Assessments and Procedures Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Perioperative; Infection Difficulty: Moderate Feedback 1 Gloves do not decrease the risk for a splash injury during a surgical procedure. 2 Gowns do not decrease the risk for a splash injury during a surgical procedure. 3 Masks do not decrease the risk for a splash injury during a surgical procedure. 4 Eyewear is worn by the scrub nurse to decrease the risk for a splash injury during a surgical procedure. PTS: 1 CON: Perioperative | Infection 4. ANS: 1 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Communication; Perioperative NURSINGTB.COM Difficulty: Moderate Feedback 1 This is the appropriate classification for a patient with mild systemic disease. 2 This is the appropriate classification for a patient with severe systemic disease. 3 This is the appropriate classification for a patient with severe systemic disease that is a constant threat to life. 4 This is the appropriate classification for a moribund patient who is not expected to survive without the operation.
5.
PTS: 1 ANS: 2
CON: Communication | Perioperative NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Communication; Perioperative Difficulty: Moderate Feedback 1 This is the appropriate classification for a patient with mild systemic disease. 2 This is the appropriate classification for a patient with severe systemic disease.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 4
This is the appropriate classification for a patient with severe systemic disease that is a constant threat to life. This is the appropriate classification for a moribund patient who is not expected to survive without the operation.
PTS: 1 CON: Communication | Perioperative 6. ANS: 3 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Communication; Perioperative Difficulty: Moderate Feedback 1 This is the appropriate classification for a patient with mild systemic disease. 2 This is the appropriate classification for a patient with severe systemic disease. 3 This is the appropriate classification for a patient with severe systemic disease that is a constant threat to life. 4 This is the appropriate classification for a moribund patient who is not expected to survive without the operation. PTS: 1 CON: CommuNnic U at R Sio nI |NPGerTioBp er . ati C Ov Me 7. ANS: 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Communication; Perioperative Difficulty: Moderate Feedback 1 This is the appropriate classification for a patient with mild systemic disease. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 3 4
This is the appropriate classification for a patient with severe systemic disease. This is the appropriate classification for a patient with severe systemic disease that is a constant threat to life. This is the appropriate classification for a moribund patient who is not expected to survive without the operation.
PTS: 1 CON: Communication | Perioperative 8. ANS: 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia
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Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Communication; Perioperative Difficulty: Moderate Feedback 1 This is the appropriate classification for a patient with severe systemic disease. 2 This is the appropriate classification for a patient with severe systemic disease that is a constant threat to life. 3 This is the appropriate classification for a moribund patient who is not expected to survive without the operation. 4 This is an appropriate classification for a patient who is brain-dead whose organs are being removed for donation. PTS: 1 CON: Communication | Perioperative 9. ANS: 2 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Explaining priority assessments and procedures in the OR Chapter page reference: 290-291 Heading: Overview of the Surgical Experience Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Communication; Perioperative Difficulty: Moderate NURSINGTB.COM Feedback 1 An episiotomy is an incision made to the vagina during childbirth; otomy is the suffix that indicates an incision. 2 A hysterectomy is the removal of the female reproductive organs; ectomy is the suffix that indicates the removal of organs. 3 An amniocentesis is the removal of amniotic fluid during pregnancy for analysis; - centesis is the suffix that indicates puncture. 4 A cholecystectomy is the removal of the gallbladder; -ectomy is the suffix that indicates the removal of organs.
10.
PTS: 1 CON: Communication | Perioperative ANS: 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Explaining priority assessments and procedures in the OR Chapter page reference: 290-291 Heading: Overview of the Surgical Experience Integrated Processes: Communication and Documentation NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Communication; Perioperative Difficulty: Moderate Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
11.
12.
An episiotomy is an incision made to the vagina during childbirth; otomy is the suffix that indicates an incision. A hysterectomy is the removal of the female reproductive organs; ectomy is the suffix that indicates the removal of organs. An amniocentesis is the removal of amniotic fluid during pregnancy for analysis; centesis is the suffix that indicates puncture. A cholecystectomy is the removal of the gallbladder; -ectomy is the suffix that indicates the removal of organs.
PTS: 1 CON: Communication | Perioperative ANS: 2 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perioperative; Medication Difficulty: Moderate Feedback 1 Morphine sulfate is a narcotic analgesic. 2 Propofol is an intravenous anesthetic. 3 Succinylcholine is a depolarizing muscle relaxant. 4 Cisatracurium is a nondepolariz NUin gR m S us I NclGe re T la B xa . CntO. M PTS: 1 CON: Perioperative | Medication ANS: 1 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perioperative; Medication Difficulty: Moderate Feedback 1 Morphine sulfate is a narcotic analgesic. 2 Propofol is an intravenous anesthetic. 3 Succinylcholine is a depolarizing muscle relaxant. NURSINGTB.COM
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4
13.
Cisatracurium is a nondepolarizing muscle relaxant.
PTS: 1 CON: Perioperative | Medication ANS: 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perioperative; Medication Difficulty: Moderate Feedback 1 Morphine sulfate is a narcotic analgesic. 2 Propofol is an intravenous anesthetic. 3 Succinylcholine is a depolarizing muscle relaxant. 4 Cisatracurium is a nondepolarizing muscle relaxant.
14.
15.
PTS: 1 CON: Perioperative | Medication ANS: 3 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perioperative; Medication Difficulty: Moderate Feedback 1 Morphine sulfate is a narcotic ana lg es ic. U R S I N GTB.COM 2 Propofol is an intravenous Nanesthetic. 3 Succinylcholine is a depolarizing muscle relaxant. 4 Cisatracurium is a nondepolarizing muscle relaxant. PTS: 1 CON: Perioperative | Medication ANS: 3 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Discussing types of anesthesia utilized in the OR Chapter page reference: 295-301 Heading: Anesthesia Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perioperative; Medication Difficulty: Moderate NURSINGTB.COM
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1 2 3 4
Feedback Fentanyl is a narcotic analgesic administered for pain. Atropine is an anticholinergic agent that reverses muscle relaxants, not depolarizing neuromuscular agents. Neostigmine is a cholinergic agent that reverses the effects of cisatracurium, a depolarizing neuromuscular agent. Glycopyrrolate is an anticholinergic agent that reverses muscle relaxants, not depolarizing neuromuscular agents.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
16.
17.
PTS: 1 CON: Perioperative | Medication ANS: 2 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Analyzing the importance of airway management in the OR Chapter page reference: 301-303 Heading: Airway Management Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The patient’s airway is secured during the intubation phase of general anesthesia. 2 Oxygen is administered to the patient by face mask during the induction of general anesthesia. 3 The patient is maintained with balanced anesthesia during maintenance phase of general anesthesia. 4 The patient is suctioned to decrease the incidence of aspiration during emergence phase of general anesthesia. PTS: 1 CON: Perioperative ANS: 1 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: NURSINGTB.CO Analyzing the importance of airway management in the OR Chapter page reference: 301-303 Heading: Airway Management Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The patient’s airway is secured during the intubation phase of general anesthesia. 2 Oxygen is administered to the patient by face mask during the induction of general anesthesia. 3 The patient is maintained with balanced anesthesia during maintenance of general anesthesia. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4
18.
The patient is suctioned to decrease the incidence of aspiration during emergence phase of general anesthesia.
PTS: 1 CON: Perioperative ANS: 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Analyzing the importance of airway management in the OR Chapter page reference: 301-303 Heading: Airway Management Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The patient’s airway is secured during the intubation phase of general anesthesia. 2 Oxygen is administered to the patient by face mask during the induction of general anesthesia. 3 The patient is suctioned to decrease the incidence of aspiration during emergence phase of general anesthesia. 4 The circulating nurse will document the drugs that are administered to maintain balanced anesthesia during the maintenance phase of general anesthesia.
19.
PTS: 1 CON: Perioperative ANS: 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Analyzing the importance of airway management in the OR Chapter page reference: 301-303 Heading: Airway Management Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The patient’s airway is secured during the intubatio n phase of general anesthesia. N U R S IN G T B . C O M 2 Oxygen is administered to the patient by face mask during the induction of general anesthesia. 3 The patient is given drugs for balanced anesthesia during maintenance of general anesthesia. 4 The patient is suctioned to decrease the incidence of aspiration during emergence phase of general anesthesia. PTS: 1
CON: Perioperative
COMPLETION 20.
AN S: 213 54 NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Explaining priority assessments and procedures in the OR Chapter page reference: 290-291 Heading: Overview of the Surgical Experience Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Feedback: The first step of the process is to open the sterile glove wrapper while the hands are covered by the sleeves of the gown. Next, with the dominant hand, pick up the opposite glove with the thumb and index finger, handling it through the sleeve. The third step is to use the nondominant hand to grasp the cuff of the glove through the gown cuff, and firmly anchor it. The fourth step is to place the fingers of the gloved hand under the cuff of the remaining glove. Finally, the nurse will extend the fingers into the glove and pull the glove up over the cuff. PTS: 1
CON: Perioperative
MULTIPLE RESPONSE 21. ANS: 1, 3, 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Identifying the roles and responsibilities of operating room (OR) team members Chapter page reference: 291-293 Heading: Overview of the Surgical Team Members Integrated Processes: Caring Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Knowledge [Remembering] Concept: Perioperative Difficulty: Easy 1. 2. 3. 4. 5.
Feedback This is correct. The surgNeoUnRpSerIfoNrmGsTthBe.pCroOceMdure. This is incorrect. The postoperative nurse will provide care to the patient after the surgery is completed. This is correct. The circulating nurse is a perioperative registered nurse who cares for the patient during the surgical procedure. This is correct. The anesthesiologist provides the anesthesia during the surgery and continually monitors the patient’s physiologic status. This is incorrect. The social worker will not be in attendance during the procedure but may become involved in the patient’s care during the preoperative and postoperative phases.
PTS: 1 CON: Perioperative 22. ANS: 2, 4, 5 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Explaining priority assessments and NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
procedures in the OR Chapter page reference: 293-295 Heading: Priority Assessments and Procedures Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Communication; Perioperative Difficulty: Easy 1.
Feedback This is incorrect. The pain assessment and medication review are documented during both the preoperative and postoperative assessments.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2. 3. 4.
5.
This is correct. Intraoperative documentation is to include documentation about specific times, such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop times of the procedure. This is incorrect. The pain assessment and medication review are documented during both the preoperative and postoperative assessments. This is correct. Intraoperative documentation is to include documentation about specific times, such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop times of the procedure. This is correct. Intraoperative documentation is to include documentation about specific times, such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop times of the procedure.
PTS: 1 CON: Communication | Perioperative 23. ANS: 2, 3, 4, 5 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Identifying the roles and responsibilities of operating room (OR) team members Chapter page reference: 291-293 Heading: Overview of Surgical Team Members Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Perioperative Difficulty: Easy 1. 2. 3. 4. 5.
NURSINGTB.COM This is incorrect. The surgical provider obtained the informed consent during the preoperative period. This is correct. The circulating RN conducts the initial assessment when the patient is received to the surgical suite. This is correct. The circulating RN assists the anesthesia provider with patient monitoring. This is correct. The circulating RN labels patient samples and sends them for analysis. This is correct. The circulating RN documents information pertinent to the surgical procedure.
PTS: 1 CON: Perioperative 24. ANS: 1, 2, 3 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Explaining priority assessments and procedures in the OR Chapter page reference: 293-295 Heading: Priority Assessments and NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Procedures Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Comprehension [Understanding] Concept: Perioperative Difficulty: Easy Feedback
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1.
2.
3.
4. 5.
This is correct. The antiseptic rub was implemented because it is less harmful to the skin, does not require the use of a brush, and contains ingredients that actually protect the skin. As a result, the nurse is less likely to develop abrasions or dermatitis when using a hand rub instead of the older method of scrubbing the hands using a brush and caustic soaps. This is correct. The antiseptic rub was implemented because it is less harmful to the skin, does not require the use of a brush, and contains ingredients that actually protect the skin. As a result, the nurse is less likely to develop abrasions or dermatitis when using a hand rub instead of the older method of scrubbing the hands using a brush and caustic soaps. This is correct. The antiseptic rub was implemented because it is less harmful to the skin, does not require the use of a brush, and contains ingredients that actually protect the skin. As a result, the nurse is less likely to develop abrasions or dermatitis when using a hand rub instead of the older method of scrubbing the hands using a brush and caustic soaps. This is incorrect. The antiseptic hand rub is faster, not longer, to perform. This is incorrect. The antiseptic hand rub does not contain any drying agents, such as alcohol.
PTS: 1 CON: Perioperative 25. ANS: 1, 2, 5 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Identifying the roles and responsibilities of operating room (OR) team members Chapter page reference: 291-293 Heading: Overview of Surgical Team Members Integrated Processes: Caring Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Comprehension [Understanding] NURSINGTB.COM Concept: Perioperative Difficulty: Easy 1. 2. 3. 4. 5.
Feedback This is correct. The surgeon is considered sterile during a surgical procedure. This is correct. The scrub nurse is considered sterile during a surgical procedure. This is incorrect. The anesthesiologist is not considered sterile during the surgical procedure. This is incorrect. The circulating nurse is not considered sterile during the surgical procedure. This is correct. The surgical assistant is considered sterile during a surgical procedure. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1 CON: Perioperative 26. ANS: 1, 4 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Developing support strategies for the surgical patient and his or her family Chapter page reference: 303-307 Heading: Positioning the Patient in the OR Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. 2. 3. 4. 5.
This is correct. This is an appropriate nursing action when using the supine position during a surgical procedure. This is incorrect. This nursing action is appropriate for Fowler’s position during a surgical procedure. This is incorrect. This nursing action is appropriate for Fowler’s position during a surgical procedure. This is correct. This is an appropriate nursing action when using the supine position during a surgical procedure. This is incorrect. This nursing action is appropriate for Fowler’s position during a surgical procedure.
PTS: 1 CON: Perioperative 27. ANS: 2, 3, 5 Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Developing support strategies for the surgical patient and his or her family Chapter page reference: 303-307 Heading: Positioning the Patient in the OR Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate 1. 2. 3. 4. 5.
Feedback This is incorrect. The la ter N UalRpSosIitNioGn TisBsi.deC-lOy Ming and would not be used if the surgical procedure required the patient to be positioned in Fowler’s position. This is correct. This nursing action is appropriate for Fowler’s position during a surgical procedure. This is correct. This nursing action is appropriate for Fowler’s position during a surgical procedure. This is incorrect. This is an appropriate nursing action when using the supine position during a surgical procedure. This is correct. This nursing action is appropriate for Fowler’s position during a surgical procedure.
PTS: 1 CON: Perioperative 28. ANS: 1, 2, 5
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 16, Priorities for the Intraoperative Patient Chapter learning objective: Examining risks and complications for the surgical patient Chapter page reference: 303-307 Heading: Positioning the Patient in the OR Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Perioperative Difficulty: Easy Feedback
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. 2. 3. 4. 5.
PTS: 1
This is correct. Pediatric patients are at an increased risk for complications during surgical procedures due to required positioning. This is correct. Older adult patients are at an increased risk for complications during surgical procedures due to required positioning. This is incorrect. A young adult patient is not at risk for complications due to positioning during surgical procedures. This is incorrect. A patient diagnosed with bipolar disorder is not at risk for complications due to positioning during surgical procedures. This is correct. Any patient diagnosed with a disease process affecting circulation, such as diabetes mellitus, is at an increased risk for complications during surgical procedures due to required positioning. CON: Perioperative
Chapter 17: Priorities for the Postoperative Patient Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which laboratory test should the postanesthesia care nurse monitor closely for a patient who is prescribed warfarin in the treatment of atrial fibrillation? NURSINGTB.COM 1) Serum glucose 2) Serum potassium 3) Prothrombin (PT) time 4) Blood urea nitrogen (BUN) 2. The nurse is assessing a patient’s postoperative wound and finds it has separated from the suture line with extrusion of the bowel through the opening. When documenting this finding, which term will the nurse use? 1) Wound infection 2) Wound dehiscence 3) Wound evisceration 4) Wound tunneling 3. The nurse is caring for a patient with a drain connected to a portable drainage suction device shaped like a grenade made of plastic. Which term will the nurse use when describing this system during end-of-shift report? 1) Closed wound drainage system 2) Hemovac 3) Jackson-Pratt 4) Reinfusion drain NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4. The patient arrives at the surgeon’s office one week after surgery to have the sutures removed. Which classification would the nurse use when documenting care for this patient? 1) Preoperative 2) Postoperative 3) Perioperative 4) Intraoperative
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5. Upon receiving the patient from the postanesthesia care unit, which nursing action is the priority? 1) Apply clean linens to the bed 2) Assemble required equipment, such as suction, IV pole, or oxygen equipment 3) Assess the patient 4) Notify the family of the patient’s return to the room 6. In the ongoing postoperative period, the nurse independently determines, within the protocols of the hospital, the need for which provision of care? 1) Type of diet 2) Activity level 3) Assessment intervals 4) Intravenous solutions 7. The postoperative patient displays sudden chest pain, shortness of breath, cyanosis, tachycardia, and low blood pressure. The nurse suspects which postoperative complication? 1) Pneumonia 2) Atelectasis 3) Hypovolemia 4) Pulmonary embolism 8. Which laboratory test should the postanesthesia care nurse monitor for a patient who is having difficulty regaining consciousness after a surgical procedure? 1) Serum glucose 2) Serum potassium 3) Prothrombin (PT) time 4) Blood urea nitrogen (BUN) NURSINGTB.COM 9. Which is the priority laboratory test that the postanesthesia care nurse should monitor closely for an older adult patient with renal disease who retained fluid during a surgical procedure? 1) Serum glucose 2) Serum potassium 3) Prothrombin (PT) time 4) Blood urea nitrogen (BUN) 10. The postanesthesia care nurse is providing care to a patient with fluid volume overload who is experiencing cardiac dysrhythmias. Which laboratory test should the nurse monitor for this patient? 1) Serum glucose 2) Serum potassium 3) Prothrombin (PT) time 4) Blood urea nitrogen (BUN) 11. The medical-surgical nurse is providing care to a postoperative patient who is experiencing an elevated temperature. Which laboratory value should the nurse monitor to gather more information? NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1) 2) 3) 4)
Platelet count Serum glucose Red blood cell (RBC) count White blood cell (WBC) count
12. Which nursing action is appropriate when providing care to a patient who is difficult to arouse in the postanesthesia care unit (PACU)? 1) Monitor breath sounds
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) 3) 4)
Administer prescribed heparin Hold prescribed opioid analgesics Assess for malignant hyperthermia
13. Which nursing action is appropriate when providing care to a patient who is exhibiting low oxygen saturation levels in the postanesthesia care unit (PACU). 1) Monitor breath sounds 2) Administer prescribed heparin 3) Hold prescribed opioid analgesics 4) Assess for malignant hyperthermia 14. Which nursing action is appropriate when providing care to a patient who is exhibiting symptoms of a venous thromboembolism (VTE)? 1) Monitor breath sounds 2) Administer prescribed heparin 3) Hold prescribed opioid analgesics 4) Assess for malignant hyperthermia 15. The postanesthesia care unit (PACU) nurse is providing care for a patient who is exhibiting hypothermia. Which nursing action is appropriate? 1) Monitor breath sounds 2) Check serum glucose level 3) Hold prescribed opioid analgesics 4) Provide warm blankets or warming devices 16. The nurse is providing care to a postoperative patient who is experiencing pain. The patient rates the pain at a 4 on a 1 to 10 numeric pain assessmeNntUsRcaSleI. N WGh iTchBp.reCscOriMbed medication should the nurse administer to this patient? 1) Fentanyl 2) Morphine 3) Ibuprofen 4) Hydromorphone 17. Which patient finding would indicate the need for further monitoring rather than discharge home after an outpatient surgical procedure? 1) Pain management with opioid analgesics 2) Lethargy that resolves after several hours 3) Inability to void without fluid retention 4) Persistent nausea without vomiting 18. Which is the priority initial assessment for a patient who is admitted to the postanesthesia care unit (PACU)? 1) Heart rate 2) Temperature 3) Respirations 4) Blood pressure 19. How many providers from the operating room (OR) should participate in the NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
hand-off communication that occurs with the postanesthesia care (PACU) nurse prior to patient transfer? 1) One 2) Two 3) Three 4) Four
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
20. The nurse is providing care to a patient in the postanesthesia care unit (PACU) who lost a large amount of blood during a surgical procedure. Which assessment finding should the nurse monitor this patient for based on the current data? 1) Bradypnea 2) Tachycardia 3) Hypothermia 4) Hypertension Multiple Response Identify one or more choices that best complete the statement or answer the question. 21. The postoperative nurse is planning care for a patient recovering from major thoracic surgery. Which nursing diagnoses should the nurse select to plan for this patient’s immediate care needs? Select all that apply. 1) Risk for Impaired Gas Exchange 2) Risk for Decreased Cardiac Output 3) Risk for Ineffective Airway Clearance 4) Risk for Imbalanced Nutrition: Less than Body Requirements 5) Risk for Imbalanced Fluid Volume 22. Which tasks can the nurse assign to the unlicensed assistive personnel (UAP) who is assisting with providing care to postoperative patients on a medical–surgical unit? Select all that apply. 1) Documenting the assessment completed by the nurse 2) Giving the patient pain medication as ordered by the health-care provider 3) Assisting with patient exercises t cUom p lIeteNeGx TerBci. seCs OM 4) Reporting when a patient canno N RS 5) Conducting discharge teaching 23. Which information should the postanesthesia care unit (PACU) nurse include in the hand-off that occurs with the medical-surgical nurse who will assume care? Select all that apply. 1) Fluid intake and blood loss 2) Placement of intravenous (IV) lines 3) Patient identification using one identifier 4) Information regarding the surgical procedure 5) Over-the-counter (OTC) medications taken at home 24. Which nursing actions are appropriate during Phase I of the postoperative period? Select all that apply. 1) Providing discharge instructions 2) Assessing vital signs per protocol 3) Monitoring electrocardiogram continuously 4) Providing ongoing care until a bed is available 5) Preparing for transfer to the medical-surgical unit 25. Which are appropriate nurse-to-patient ratios in the postanesthesia care unit (PACU)? Select all that apply. 1) 1:1 NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) 1:2 3) 1:3 4) 1:4 5) 1:5
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 17: Priorities for the Postoperative Patient Answer Section MULTIPLE CHOICE 1.
ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 Serum glucose is monitored for a patient who is having difficulty regaining consciousness in the postoperative period. 2 Serum potassium is monitored for patients who experienced abnormal fluid or blood losses and for patients who may have been overhydrated. 3 A PT time is monitored closely for any patient who is prescribed warfarin. Warfarin is often stopped for several days prior to a surgical procedure. However, this patient will continue to be at an increased risk for bleeding. 4 A BUN is monitored for any patient who may have experienced abnormal fluid or blood losses during surgery. ANBUURNSsIhoNuGldTaBls. o C b eOmMonitored for older adult patients and for those with renal disease.
PTS: 1 CON: Perioperative 2. ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 315 Heading: Potential Complications Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Difficulty: Moderate Feedback 1 Wound infection is inflammation, redness, and/or drainage from the wound. 2 Wound dehiscence is separation of the suture line without visible organs or tissues. 3 Wound evisceration is separation of the wound with internal organs and tissues visible through the opening. 4 Wound tunneling is small channels within the wound. PTS: 1 CON: Perioperative 3. ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative; Communication Difficulty: Moderate 1 2 3 4
Feedback All of these drains are nonspecifically known as closed wound drainage systems. A Hemovac is a flat disk. The drain described, shaped like a grenade, is a Jackson-Pratt. A reinfusion drain allows collection of blood from the wound for readministration.
PTS: 1 CON: Perioperative | Communication 4. ANS: 2 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Discussing the significance of the postoperative period Chapter page reference: 310-312 Heading: Introduction Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative; Communication NURSINGTB.COM Difficulty: Moderate Feedback 1 The preoperative phase begins when surgery is planned, and ends when the patient is transferred to the operating table. 2 The patient is in the postoperative phase. The postoperative phase begins with the admission of the patient to the postanesthesia care unit, and ends when healing is complete. 3 The perioperative period covers all three time periods, from planning surgery until healing is complete. 4 The intraoperative phase begins when the patient is transferred to the operating table, and ends when the patient is admitted to the recovery room. PTS: 1
CON: Perioperative | Communication NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN 5.
ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process – Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Perioperative Difficulty: Difficult
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
Feedback Clean linens should be applied to the bed as soon as the patient leaves for surgery or upon notification that the patient will be coming to the unit. Equipment should be gathered in advance and set up to be ready when the patient returns. The priority action for the nurse is to perform a thorough assessment of the patient’s condition. Only after assessing the patient would the nurse notify family members.
PTS: 1 CON: Perioperative 6. ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 315-317 Heading: Nursing Interventions Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative; Nursing Difficulty: Moderate Feedback 1 Activity level, intravenous solutions, and type of diet are ordered by the health-care provider. 2 Activity level, intravenous solutions, and type of diet are ordered by the health-care provider. NURSINGTB.COM 3 The nurse will determine the frequency of patient assessments required, within the protocols established by the facility. The minimum frequency is determined by the facility, but more frequent assessment may be determined by the patient’s condition, and is the decision of the nurse. 4 Activity level, intravenous solutions, and type of diet are ordered by the health-care provider. PTS: 1 CON: Perioperative | Nursing 7. ANS: 4 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 315 Heading: Potential Complications Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Adaptation Cognitive level: Comprehension [Understanding] Concept: Perioperative; Oxygenation Difficulty: Easy Feedback 1 The patient with pneumonia is likely to have a fever, but usually will not display sharp chest pain. 2 Atelectasis can cause respiratory distress, but will not cause chest pain. 3 Hypovolemia does not produce chest pain either, and will usually be displayed by tachycardia, decreased urine output, and drop in blood pressure.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4
The patient is displaying signs of pulmonary emboli, which will cause sudden chest pain and difficulty breathing.
PTS: 1 CON: Perioperative | Oxygenation 8. ANS: 1 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 Serum glucose is monitored for a patient who is having difficult regaining consciousness in the postoperative period. 2 Serum potassium is monitored for patients who experienced abnormal fluid or blood losses and for patients who may have been overhydrated. 3 A PT time is monitored closely for any patient who is prescribed warfarin. Warfarin is often stopped for several days prior to a surgical procedure. However, this patient will continue to be at an increased risk for bleeding. 4 A BUN is monitored for any patient who may have experienced abnormal fluid or blood losses during surgery. A BUN should also be monitored for older adult patients and for those with renal diseasNe.URSINGTB.COM PTS: 1 CON: Perioperative 9. ANS: 4 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perioperative NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Difficulty: Difficult Feedback 1 Serum glucose is monitored for a patient who is having difficult regaining consciousness in the postoperative period. 2 Serum potassium is monitored for patients who experienced abnormal fluid or blood losses and for patients who may have been overhydrated. 3 A PT time is monitored closely for any patient who is prescribed warfarin. Warfarin is often stopped for several days prior to a surgical procedure. However, this patient will continue to be at an increased risk for bleeding. 4 A BUN is monitored for any patient who may have experienced abnormal fluid or blood losses during surgery. A BUN should also be monitored for older adult patients and for those with renal disease.
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
10.
PTS: 1 CON: Perioperative ANS: 2 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Difficult Feedback 1 Serum glucose is monitored for a patient who is having difficult regaining consciousness in the postoperative period. 2 Serum potassium is monitored for patients who experienced abnormal fluid or blood losses and for patients who may have been overhydrated. Patients who experience either hyperkalemia, or hypokalemia, may exhibit cardiac dysrhythmias. 3 A PT time is monitored closely for any patient who is prescribed warfarin. Warfarin is often stopped for several days prior to a surgical procedure. However, this patient will continue to be at an increased risk for bleeding. 4 A BUN is monitored for any patient who may have experienced abnormal fluid or blood losses during surgery. A BUN should also be monitored for older adult patients and for those with renal disease. PTS: 1
CON: PeriopeNraUtive R SINGTB.COM Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perioperative; Infection Difficulty:
11. ANS: 4
NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Moderate Feedback 1 The nurse would monitor a platelet count for a patient who is experiencing bleeding in the postoperative period. 2 A serum glucose level is monitored for a patient with diabetes mellitus. 3 An RBC count is monitored for a patient who experienced significant blood loss during a surgical procedure in order to determine if anemia has occurred. 4 An elevated temperature often indicates the patient is experiencing an infection. An increased WBC count would support this diagnosis.
12.
PTS: 1 CON: Perioperative | Infection ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate postoperative period
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter page reference: 315 Heading: Potential Complications Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 The nurse would monitor breath sounds for a patient experiencing inadequate oxygenation. 2 The nurse would administer a prescribed anticoagulant, such as heparin, for a patient who is experiencing venous thromboembolism (VTE). 3 A patient who is difficult to arouse should have prescribed analgesics held until the patient stabilizes. 4 The nurse would assess a patient for malignant hyperthermia for a patient who is experiencing an increased temperature in the PACU.
13.
14.
PTS: 1 CON: Perioperative ANS: 1 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 315-317 Heading: Nursing Interventions Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [ApplyiN ngU] RSINGTB.CO Concept: Perioperative Difficulty: Moderate Feedback 1 The nurse would monitor breath sounds for a patient experiencing inadequate oxygenation. 2 The nurse would administer a prescribed anticoagulant, such as heparin, for a patient who is experiencing venous thromboembolism (VTE). 3 A patient who is difficult to arouse should have prescribed analgesics held until the patient stabilizes. 4 The nurse would assess a patient for malignant hyperthermia for a patient who is experiencing an increased temperature in the PACU. PTS: 1 ANS: 2
CON: Perioperative NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate postoperative period Chapter page reference: 315 Heading: Potential Complications Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Difficulty: Moderate Feedback 1 The nurse would monitor breath sounds for a patient experiencing inadequate oxygenation. 2 The nurse would administer a prescribed anticoagulant, such as heparin, for a patient who is experiencing venous thromboembolism (VTE). 3 A patient who is difficult to arouse should have prescribed analgesics held until the patient stabilizes. 4 The nurse would assess a patient for malignant hyperthermia for a patient who is experiencing an increased temperature in the PACU.
15.
16.
PTS: 1 CON: Perioperative ANS: 4 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 315 Heading: Potential Complications Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 T h e n u r s e w ould monitor breath sounds for a patient experiencing ox yg e na t io n . inadequate NURSINGTB.COM 2 The nurse would monitor serum glucose levels for a patient who exhibited confusion. 3 A patient who is difficult to arouse should have prescribed analgesics held until the patient stabilizes. 4 The nurse would provide warm blankets or warming devices for a patient with hypothermia. PTS: 1 CON: Perioperative ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate postoperative period Chapter page reference: 314-315 Heading: Pain Management Integrated Processes: Nursing Process – Implementation NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perioperative; Comfort Difficulty: Moderate Feedback 1 Fentanyl is an opioid analgesic that is reserved for severe pain in the postoperative period. 2 Morphine is an opioid analgesic that is reserved for severe pain in the postoperative period.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 4
17.
18.
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is appropriate for mild pain in the postoperative period. Hydromorphone is an opioid analgesic that is reserved for severe pain in the postoperative period.
PTS: 1 CON: Perioperative | Comfort ANS: 4 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate Feedback 1 Effective pain management with opioid analgesics does not indicate the need for further monitoring. This patient can be discharged home. 2 Lethargy that resolves does not indicate the need for further monitoring. This patient can be discharged home. 3 An inability to void postsurgery, without a history of urinary retention, does not require further monitoring. This patient can be discharged home. 4 Persistent nausea, without vomiting, would indicate the need for further monitoring. This patient is not stable enough N Ufor R SdIisNchGarTgeBh.oCmOe.M PTS: 1 CON: Perioperative ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 315-317 Heading: Nursing Interventions Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perioperative; Assessment Difficulty: Difficult Feedback NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1
2
3
While heart rate is an important parameter in the nursing assessment, this is not the priority. The ABCs should guide priority during the initial nursing assessment for the patient admitted to the PACU. While temperature is an important parameter in the nursing assessment, this is not the priority. The ABCs should guide priority during the initial nursing assessment for the patient admitted to the PACU. Respirations is the priority initial assessment for a patient who is admitted to the PACU. The ABCs should guide priority during the initial nursing assessment for the patient admitted to the PACU.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4
20.
While blood pressure is an important parameter in the nursing assessment, this is not the priority. The ABCs should guide priority during the initial nursing assessment for the patient admitted to the PACU.
PTS: 1 CON: Perioperative | Assessment 19. ANS: 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Discussing the significance of the postoperative period Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Knowledge [Remembering] Concept: Communication; Perioperative Difficulty: Easy Feedback 1 This is not the appropriate number of OR providers who should participate in the hand- off communication with the PACU nurse. 2 This is not the appropriate number of OR providers who should participate in the handoff communication with the PACU nurse. 3 Three members of the OR team (anesthesia, surgical provider, and OR nurse) should participate in the hand-off communication with the PACU nurse. 4 This is not the appropriate number of OR providers who should participate in the hand- off communication with the PACU nurse. NURSINGTB.COM CON: Communication | Perioperative PTS: 1 ANS: 2 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Explaining the priority assessments for the postsurgical patient Chapter page reference: 315-317 Heading: Nursing Interventions Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehensive [Understanding] Concept: Perioperative; Perfusion Difficulty: Easy Feedback 1 Bradypnea is not an assessment finding that occurs with blood loss. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 3 4
Tachycardia is an anticipated assessment finding for a patient who loses a significant amount of blood during a surgical procedure. Hypothermia is not an assessment finding that occurs with blood loss. Hypotension, not hypertension, is an assessment finding that occurs with blood loss.
PTS: 1
CON: Perioperative | Perfusion
MULTIPLE RESPONSE 21. ANS: 1, 2, 5
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate postoperative period Chapter page reference: 315-317 Heading: Nursing Interventions Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perioperative Difficulty: Difficult 1.
2.
3. 4. 5.
Feedback This is correct. Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. This is correct. Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. This is incorrect. The Risk for Ineffective Airway Clearance might be appropriate later as the patient recovers from surgery. This is incorrect. There is no Risk for Imbalanced Nutrition: Less than Body Requirements during the immediate postoperative phase. This is correct. Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired GN asUERxcShIanNgG e bTeBca.u C seOo M f anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status.
PTS: 1 CON: Perioperative 22. ANS: 2, 3, 4 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate postoperative period Chapter page reference: 315-317 Heading: Nursing Interventions Integrated Processes: Nursing Process – Implementation NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Perioperative Difficulty: Moderate 1. 2. 3. 4.
Feedback This is incorrect. The nurse performs and documents the patient assessment, not the UAP. This is incorrect. The UAP cannot pass medications. This is correct. The UAP can assist the patient with exercises and report any problems the patient has when performing exercises. This is correct. The UAP can assist the patient with exercises and report any problems the patient has when performing exercises.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5.
This is incorrect. The UAP cannot conduct discharge teaching.
PTS: 1 CON: Perioperative 23. ANS: 1, 2, 4 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate postoperative period Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Communication; Perioperative Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback This is correct. Fluid intake and blood loss is included in the hand-off communication process between the PACU and medical-surgical nurses. This is correct. Information regarding the placement of IV lines is included in the hand-off communication process between the PACU and medical-surgical nurses. This is incorrect. Patient identification during the hand-off process should include two patient identifiers, not one. This is correct. Information regarding the surgical procedure is included in the hand-off communication process between the PACU and medical-surgical nurses. This is incorrect. ImportNanUt RmSedIicNatGioTn sB t.akCenO by M the patient at home, not OTC medications, should be included in the hand-off process.
PTS: 1 CON: Communication | Perioperative 24. ANS: 2, 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate postoperative period Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Perioperative Difficulty: Moderate
1. 2. 3. 4.
Feedback This is incorrect. This is not an appropriate nursing action during Phase I of the postoperative period. This is correct. Assessing vital signs per protocol is an appropriate nursing action during Phase I of the postoperative period. This is correct. Monitoring the electrocardiogram continuously is an appropriate nursing action during Phase I of the postoperative period. This is incorrect. Providing ongoing care until a bed is available is not an appropriate nursing action during Phase I of the postoperative period.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5.
This is incorrect. Preparing for transfer to the medical-surgical unit is not an appropriate nursing action during Phase I of the postoperative period.
PTS: 1 CON: Perioperative 25. ANS: 1, 2, 3 Chapter number and title: 17, Priorities for the Postoperative Patient Chapter learning objective: Discussing the significance of the postoperative period Chapter page reference: 312-314 Heading: Patient Care in the Post-Anesthesia Care Unit (PACU) Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Knowledge [Remembering] Concept: Perioperative Difficulty: Easy 1. 2. 3. 4. 5. PTS: 1
Feedback This is correct. This is an appropriate nurse to patient ratio in the PACU. This is correct. This is an appropriate nurse to patient ratio in the PACU. This is correct. This is an appropriate nurse to patient ratio in the PACU if one patient is awaiting transfer to another unit or awaiting discharge home. This is incorrect. This is not an appropriate nurse to patient ratio in the PACU. This is incorrect. This is not an appropriate nurse to patient ratio in the PACU. CON: Perioperative NURSINGTB.COM
Chapter 18: Assessment of Immune Function Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which physiological barriers protect the patient’s body against microorganisms? 1) A surgical incision 2) Occasional smoking 3) Alcoholic beverages 4) Adequate urinary output NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2. A nurse working in the emergency department (ED) is providing care for a group of patients. Which patient demonstrates a decline in immune response that typically occurs with the aging process? 1) An 88-year-old with pneumonia who has a temperature of 99.5°F. 2) A 56-year-old who has 8 mm induration at the site of a PPD skin test 72 hours earlier. 3) A 58-year-old who reports redness and itching due to a rash from contact with poison ivy. 4) A 70-year-old who has swelling and redness at the incision from an open appendectomy.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3. The nurse is providing care to a patient who has an increased number of lymphocytes. Which explanation should the nurse provide to the patient regarding this abnormality? 1) “An elevated neutrophil count indicates your body is battling a parasitic infection.” 2) “An elevated neutrophil count indicates your body is battling a bacterial infection.” 3) “An elevated neutrophil count indicates your body is experiencing an allergic reaction.” 4) “An elevated neutrophil count indicates your body is experiencing an adaptive immune response.” 4. Which scenario should the nurse provide as one in which active immunity is acquired when educating a group within the community? 1) Having measles as a child 2) Receiving an injection of gamma globulin 3) Becoming ill with tetanus and receiving tetanus toxoid 4) Receiving a rabies shot after being bitten by a rabid dog 5. The nurse is providing care to a patient with a compromised immune system. Which independent nursing intervention is appropriate for the nurse to include in the patient’s plan of care? 1) Recommending gene transfer therapy 2) Administering corticosteroids, per order 3) Prescribing prophylactic antibiotic therapy 4) Educating on the importance of a nutritious diet 6. A nurse is caring for a patient with who is experiencing leukocytosis. When providing care to this patient,which action by the nurse is the most appropriate? 1) Assess for source of infection 2) Assess for bleeding and bruising 3) Place the patient in reverse isolaN tiU o nRpSreIcaNuGt ioTnBs .COM 4) Instruct the patient on the use of an electric razor and soft toothbrush 7. Which question should the nurse to ask during a health history with an adolescent patient, accompanied by a parent, to determine immune status? 1) “Is your child sexually active?” 2) “Is your child planning to go to college?” 3) “Does your child smoke tobacco products?” 4) “Are your child’s immunizations up-to-date?” 8. Which nursing action is appropriate when assessing a patient’s tonsils during a physical examination? 1) Asking the patient to cough several times 2) Asking the patient to open the mouth and say “ah” 3) Palpating the soft tissue of the face near the patient’s nose 4) Palpating the left upper quadrant of the patient’s abdomen 9. Which type of immunoglobulin (Ig) is produced during an allergic reaction? 1) IgA NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) 3) 4)
IgD IgE IgM
10. Which nutritional deficiency often impacts a patient’s ability to mount an immune response? 1) Proteins 2) Calcium 3) Potassium
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4)
Carbohydrates
11. The nurse is providing care to a patient who experienced an allergic reaction. Which leukocyte does the nurse anticipate will be elevated? 1) Basophils 2) Monocytes 3) Eosinophils 4) Neutrophils 12. The nurse is teaching a new mother the immune benefits of breastfeeding her newborn. Which immunoglobulin (Ig) should the nurse include as one that is passed from mother to newborn by breast milk? 1) IgA 2) IgD 3) IgE 4) IgG 13. The nurse is providing care to a patient who has a decreased neutrophil count and elevated hepatic enzymes. Which data in the patient’s health history supports this laboratory data indicating an increased risk for infection? 1) Anorexia nervosa 2) Acute renal failure 3) Pulmonary disease 4) Cirrhosis of the liver 14. The nurse is providing care to patient who is at an increased risk for infection due to poor dietary intake, a decreased white blood cell count, and diminished neutrophil activity. Which information in the patient’s health history supports the current daNtaU? RSINGTB.COM 1) Anorexia nervosa 2) Acute renal failure 3) Pulmonary disease 4) Cirrhosis of the liver 15. The nurse is providing care to a patient who had the spleen removed after a car accident. Which type of infection is this patient at an increased risk for experiencing? 1) Viral 2) Fungal 3) Parasitic 4) Bacterial 16. Which laboratory test should the nurse anticipate for a patient who reports chronic inflammation? 1) Varicella titer 2) Type and crossmatch 3) Erythrocyte sedimentation rate (ESR) 4) Complete blood count (CBC), with differential NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
17. The nurse is teaching a group of patients about first-line defense against infection. Which patient statement indicates the need for further education? 1) “The skin is a first-line defense against infection.” 2) “A sneeze is a mechanical first-line defense against infection.” 3) “My saliva is a biochemical first-line defense against infection.” 4) “A cut with pus is a mechanical first-line defense against infection.”
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
18. The nurse is conducting a health history for a patient who is at risk for infection. Which question is appropriate when collecting data related to the current problem? 1) “Do you smoke cigarettes?” 2) “Are your immunizations current and up-to-date?” 3) “What type of reaction do you have with an allergy flair?” 4) “Did you have your spleen removed after your car accident?” 19. The nurse is conducting a health history for a patient who is at risk for infection. Which question is appropriate when collecting data related to the patient’s social history? 1) “Do you smoke cigarettes?” 2) “Are your immunizations current and up-to-date?” 3) “What type of reaction do you have with an allergy flair?” 4) “Did you have your spleen removed after your car accident?” 20. The nurse is conducting a health history for a patient who is at risk for infection. Which question is appropriate when collecting data related to the patient’s past medical history? 1) “Do you smoke cigarettes?” 2) “Are your immunizations current and up-to-date?” 3) “What type of reaction do you have with an allergy flair?” 4) “Did you have your spleen removed after your car accident?” Multiple Response Identify one or more choices that best complete the statement or answer the question. 21. A patient receives the yellow fever vaccine before traveling to the Amazon Basin and asks the nurse how the vaccine provides protection. Which rNesUpoRnSseIs Nb yGtTh eBn.u C rseOiMs the most appropriate? Select all that apply. 1) “The body's immune system eats away at the protective sheath that covers the nerves.” 2) “A response from yellow fever-specific T cells is activated. B cells secrete yellow fever antibodies.” 3) “In the lymph nodes, part of the lymphoid system, the macrophages present yellow fever antigens to T cells and B cells.” 4) “The initial weak infection is eliminated and the patient is left with a supply of memory T and B cells for future protection against yellow fever.” 5) “Human macrophages engulf the weakened vaccine virus as if it is dangerous and antigens stimulate the immune system to attack it.” 22. The nurse is conducting a physical assessment for a patient with a compromised immune system. Which actions by the nurse are appropriate? Select all that apply. 1) Assessing general appearance NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) 3) 4) 5)
Recommending increased fluid intake Checking joint range of motion (ROM), including that of the spine Inspecting the mucous membranes of the nose and mouth for color and condition Palpating the cervical lymph nodes for evidence of lymphadenopathy or tenderness
23. Which locations should the nurse include when discussing the storage and production of lymphocytes during an education session for novice nurses? Select all that apply. 1) Liver 2) Spleen 3) Thymus 4) Lymph nodes
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5)
Bone marrow
24. The nurse is assessing a patient’s immune system. Which findings increase the patient’s risk for infection due to alterations in biochemical barriers? Select all that apply. 1) Dysphagia 2) Dry mouth 3) Nonintact skin 4) Urinary retention 5) Clogged tear duct 25. The nurse is assessing a patient’s immune system. Which findings increase the patient’s risk for infection due to alterations in mechanical barriers? Select all that apply. 1) Dysphagia 2) Dry mouth 3) Nonintact skin 4) Urinary retention 5) Clogged tear duct
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 18: Assessment of Immune Function Answer Section MULTIPLE CHOICE 1.
ANS: 4 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Identifying key anatomical components of the immune system Chapter page reference: 321-330 Heading: Overview of Anatomy and Physiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Knowledge [Remembering] Concept: Immunity Feedback Difficulty: 1 A surgical incision can both allow microorganisms to enter the body. Easy 2 The consumption of alcoholic beverages has been known to increase the risk for 3 4
infection. Occasional smoking does not defend the body from microorganisms; it destroys the cilia in the nose that helps to filter organisms. A physiological barrier protecting patients against microorganism is adequate urinary output. The act of voiding flushes organisms that might try to enter the body through the urinary meatus.
NURSINGTB.COM CON: Immunity
PTS: 1 2. ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Discussing changes in immune function associated with aging Chapter page reference: 335-336 Heading: Age-Related Changes Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Immunity Difficulty: Easy Feedback 1 The patient who has only a slight elevation in temperature in response to pneumonia is an example of a decline in the expected NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
immune response. 2 3 4
This patient is demonstrating an expected immune response as evidenced by redness, swelling, and induration. This patient is demonstrating an expected immune response as evidenced by redness, swelling, and induration. This patient is demonstrating an expected immune response as evidenced by redness, swelling, and induration.
PTS: 1 3. ANS: 2
CON: Immunity
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Correlating relevant diagnostic examinations to immune function Chapter page reference: 332-334 Heading: Diagnostic Studies Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying} Concept: Immunity Difficulty: Moderate Feedback 1 An elevated eosinophil, not neutrophil, count indicates the body is battling a parasitic infection. 2 A bacterial infection is often indicated by an elevated neutrophil count. 3 An elevated basophil, not neutrophil, count indicates the body is experiencing an allergic reaction. 4 An elevated lymphocyte, not neutrophil, count indicates an adaptive immune response. PTS: 1 CON: Immunity 4. ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Discussing the function of the immune system Chapter page reference: 321-330 Heading: Overview of Anatomy and Physiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [UnNdeUrsRtaSndIinNgG] TB.CO Concept: Immunity Difficulty: Feedback 1 When the patient has the disease, the body stimulates the process of acquired active immunity. 2 Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity. 3 Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity. 4 Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity. PTS: 1
CON: Immunity NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5.
ANS: 4 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Discussing the function of the immune system Chapter page reference: 320-321 Heading: Introduction Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate
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1
2 3
4
Feedback It is outside the scope of nursing practice to prescribe medication and to recommend therapies. The nurse can administer antibiotics and educate the patient on gene transfer therapy, if prescribed by the health-care provider. Administering corticosteroids, per order, is a collaborative intervention. It is outside the scope of nursing practice to prescribe medication and to recommend therapies. The nurse can administer antibiotics and educate the patient on gene transfer therapy, if prescribed by the health-care provider. While these may be appropriate treatments for a patient who is experiencing a compromised immune system, the only independent nursing intervention is educating the patient on the importance of a nutritious diet.
PTS: 1 CON: Immunity 6. ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of a patient with impaired immune function Chapter page reference: 330-334 Heading: Assessment of the Immune System Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Immunity NURSINGTB.COM Difficulty: Moderate Feedback 1 A patient with leukocytosis has a white blood cell (WBC) count that is elevated above normal (>10,000 mm3), which is an indication of infection. The appropriate action by the nurse is to assess the patient for a source of the infection. 2 Instructing the patient on the use of an electric razor and soft toothbrush and assessing for bleeding and bruising would be appropriate actions for a patient with decreased platelet levels, or thrombocytopenia. 3 Placing the patient in reverse isolation precautions would be appropriate for the patient with neutropenia, a decrease in the number of neutrophils. 4 Instructing the patient on the use of an electric razor and soft toothbrush and assessing for bleeding and bruising would be NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
appropriate actions for a patient with decreased platelet levels, or thrombocytopenia. PTS: 1 CON: Immunity 7. ANS: 4 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of a patient with impaired immune function Chapter page reference: 330-334 Heading: Assessment of the Immune System Integrated Processes: Nursing Process – Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Immunity
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Difficulty: Moderate Feedback 1 While sexual activity places the adolescent at risk for sexual transmitted infections, this is not the most appropriate question for the nurse to ask to determine immune status. 2 This question is not applicable to the adolescent’s immune status. 3 While smoking can increase the risk for infection, this is not an appropriate question for the nurse to ask an adolescent patient when a parent is in the room. 4 Inquiring about the child’s immunization status is appropriate during the health history interview to determine immune status. PTS: 1 CON: Immunity 8. ANS: 2 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of a patient with impaired immune function Chapter page reference: 330-334 Heading: Assessment of the Immune System Integrated Processes: Nursing Process – Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback 1 This action is not appropriate when assessing the patient’s tonsils. 2 The tonsils are located between the palatine a rc hes on either side of the N U R S ING T B . C O M pharynx; therefore, the nurse would ask the patient to open the mouth and say “ah” during the assessment process. 3 This action is appropriate when assessing the patient’s sinuses, not the tonsils. 4 This action is appropriate when assessing the patient’s spleen, not the tonsils. PTS: 1 CON: Immunity 9. ANS: 3 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Correlating relevant diagnostic examinations to immune function Chapter page reference: 321-330 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process – Assessment NURSINGTB.COM
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Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Knowledge [Understanding] Concept: Immunity Difficulty: Easy Feedback 1 IgA is not produced during an allergic reaction. 2 IgD is not produced during an allergic reaction. 3 IgE is produced during an allergic reaction. 4 IgM is not produced during an allergic reaction. PTS: 1
CON: Immunity
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10.
11.
ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Identifying key anatomical components of the immune system Chapter page reference: 321-330 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Immunity Difficulty: Easy Feedback 1 Nutritional status is a critical component of immunocompetence. Cellular immunity, phagocyte activity, and complement ability are greatly impacted by protein deficiencies. 2 A calcium deficiency is more likely to impact bone health. 3 A potassium deficiency is more likely to impact cardiovascular health. 4 A carbohydrate deficiency does not impact a patient’s ability to mount an immune response. PTS: 1 CON: Immunity ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Correlating relevant diagnostic examinations to immune function Chapter page reference: 332-334 Heading: Diagnostic StudiesNURSINGTB.COM Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Immunity Difficulty: Easy Feedback 1 An elevated basophil count indicates an allergic reaction. 2 Monocytes are produced for phagocytosis in order to ingest engulfed microorganisms. 3 An elevated eosinophil count indicates a parasitic infection. 4 An elevated neutrophil count indicates bacterial infection. NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
12.
PTS: 1 CON: Immunity ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Discussing the function of the immune system Chapter page reference: 321-330 Heading: Overview of Anatomy and Physiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback
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1 2 3 4
13.
14.
IgA is passed from mother to newborn in breast milk and provides immunity to the newborn. IgD is not secreted in breast milk. IgE is not secreted in breast milk. IgG is passed through the placenta during pregnancy and provides the newborn with some immunity during the first few months of life.
PTS: 1 CON: Immunity ANS: 4 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to immune function Chapter page reference: 330-334 Heading: Assessment of the Immune System Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Immunity Difficulty: Easy Feedback 1 Anorexia nervosa causes malnutrition causing a decreased white blood cell (WBC) count and diminished neutrophil activity leading to a risk for infection. 2 Acute renal failure leads to decreased neutrophil action and immunoglobulin activity causing an increased risk for infection. 3 Pulmonary disease leads to decrea se n eu tro ph il a ct iv ity causing an N U R S I NG T B . C O M increased risk for infection. 4 Cirrhosis of the liver is an example of hepatic disease. This leads to a decreased neutrophil count which increases the risk for infection. PTS: 1 CON: Immunity ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to immune function Chapter page reference: 330-334 Heading: Assessment of the Immune System Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
[Understanding] Concept: Immunity Difficulty: Easy Feedback 1 Anorexia nervosa causes malnutrition causing a decreased white blood cell (WBC) count and diminished neutrophil activity leading to a risk for infection. 2 Acute renal failure leads to decreased neutrophil action and immunoglobulin activity causing an increased risk for infection. 3 Pulmonary disease leads to decrease neutrophil activity causing an increased risk for infection.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4
15.
16.
Cirrhosis of the liver is an example of hepatic disease. This leads to a decreased neutrophil count which increases the risk for infection.
PTS: 1 CON: Immunity ANS: 4 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Identifying key anatomical components of the immune system Chapter page reference: 321-330 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Immunity Difficulty: Easy Feedback 1 A splenectomy does not increase the risk for viral infection. 2 A splenectomy does not increase the risk for fungal infection. 3 A splenectomy does not increase the risk for parasitic infection. 4 The impact of a splenectomy is a loss of recognition and encapsulation of bacteria; therefore, this patient is at an increased risk for bacterial infection. PTS: 1 CON: Immunity ANS: 3 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: CorrelatinNgUrRelSevIanNt GdiTagBn.o sCtiOc eMxaminations to immune function Chapter page reference: 332-334 Heading: Diagnostic Studies Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Immunity Difficulty: Easy Feedback 1 A varicella titer is anticipated for a patient who is uncertain of his or her chicken pox status. NURSINGTB.COM
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2 3 4
17.
A type and crossmatch is anticipated for a patient who has lost blood and requires a transfusion. An ESR screens for the presence of the inflammatory process. A CBC, with differential measures total leukocytes with a breakdown of leukocyte types and percentage present.
PTS: 1 CON: Immunity ANS: 4 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Identifying key anatomical components of the immune system Chapter page reference: 321-330 Heading: Overview of Anatomy and Physiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation
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Cognitive level: Analysis [Analyzing] Concept: Immunity Difficulty: Difficult Feedback 1 This statement indicates correct understanding of first-line defenses against infection. 2 This statement indicates correct understanding of first-line defenses against infection. 3 This statement indicates correct understanding of first-line defenses against infection. 4 Pus or exudate indicates cellular infiltration which is a second line of defense against infection. This second line of defense is an inflammatory response to acute cellular injury.
18.
19.
PTS: 1 CON: Immunity ANS: 3 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of a patient with impaired immune function Chapter page reference: 330-334 Heading: Assessment of the Immune System Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback 1 This question is appropriate to assess the patient’s social history. U R S I N G TB . C O M 2 This question is appropriateNto assess the patient’s immunization history. 3 This question is appropriate to assess the patient’s current problem. 4 This question is appropriate to assess the patient’s past medical or surgical history. PTS: 1 CON: Immunity ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of a patient with impaired immune function Chapter page reference: 330-334 Heading: Assessment of the Immune System Integrated Processes: Nursing NURSINGTB.COM
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Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback 1 This question is appropriate to assess the patient’s social history. 2 This question is appropriate to assess the patient’s immunization history. 3 This question is appropriate to assess the patient’s current problem. 4 This question is appropriate to assess the patient’s past medical or surgical history. PTS: 1
CON: Immunity
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20.
ANS: 4 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of a patient with impaired immune function Chapter page reference: 330-334 Heading: Assessment of the Immune System Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback 1 This question is appropriate to assess the patient’s social history. 2 This question is appropriate to assess the patient’s immunization history. 3 This question is appropriate to assess the patient’s current problem. 4 This question is appropriate to assess the patient’s past medical or surgical history. PTS: 1
CON: Immunity
MULTIPLE RESPONSE 21. ANS: 2, 3, 4, 5 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to immune NURSINGTB.COM function Chapter page reference: 321-330 Heading: Overview of Anatomy and Physiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback NURSINGTB.COM
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1. 2. 3. 4. 5.
This is incorrect. The immune system damaging the myelin is the autoimmune response that occurs with multiple sclerosis (MS). This is correct. Antibodies directly attack and destroy antigens either before or after antigens invade body cells. This is correct. Lymph nodes filter foreign products or antigens from the lymph system and house and support proliferation of lymphocytes and macrophages. This is correct. Memory B cells and T cells remember how to identify the antigen and will reactivate at a future time if the same type of antigen is present. This is correct. Macrophages ingest antigens and signal helper T cells that antigens are present.
PTS: 1 CON: Immunity 22. ANS: 1, 3, 4, 5 Chapter number and title: 18, Assessment of Immune Function
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Chapter learning objective: Describing the procedure for completing a history and physical assessment of a patient with impaired immune function Chapter page reference: 330-334 Heading: Assessment of the Immune System Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate 1.
2.
3.
4.
5.
Feedback This is correct. The techniques of inspection and palpation are especially important in assessing a patient’s immune system: The nurse will assess the patient’s general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the patient’s ROM, including that of the spine. This is incorrect. While recommending that the patient increase fluid intake may be an appropriate intervention, this is not an action that is conducted during the physical assessment for this patient. This is correct. The techniques of inspection and palpation are especially important in assessing a patient’s immune system: The nurse will assess the patient’s general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the patient’s ROM, including that of the spine. This is correct. The techniques of inspection and palpation are especially NuUnRe S important in assessing a patient’s imm syIstN emG:TTBh e.nCu O rsM e will assess the patient’s general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the patient’s ROM, including that of the spine. This is correct. The techniques of inspection and palpation are especially important in assessing a patient’s immune system: The nurse will assess the patient’s general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the patient’s ROM, including that of the spine. NURSINGTB.COM
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PTS: 1 CON: Immunity 23. ANS: 2, 3, 4, 5 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Identifying key anatomical components of the immune system Chapter page reference: 321-330 Heading: Overview of Anatomy and Physiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Immunity Difficulty: Easy 1.
Feedback This is incorrect. The liver does not store or produce lymphocytes.
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2. 3. 4. 5.
This is correct. Lymphocytes are found in the spleen. This is correct. Lymphocytes are found in the thymus. This is correct. Lymphocytes are found in the lymph nodes. This is incorrect. Lymphocytes are found in the bone marrow.
PTS: 1 CON: Immunity 24. ANS: 2, 5 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Identifying key anatomical components of the immune system Chapter page reference: 321-330 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate 1. 2. 3. 4. 5.
Feedback This is incorrect. Swallowing is a mechanical, not biochemical, barrier to infection. This is correct. Saliva is a biochemical barrier to infection. A dry mouth increases the patient’s risk for infection. This is incorrect. Intact skin is a physical, not biochemical, barrier to infection. This is incorrect. Urination is a mechanical, not biochemical, barrier to infection. This is correct. Tears are a biochemical barrier to infection. A clogged tear duct increases this patient’s risk for infectioNnU. RSINGTB.COM
PTS: 1 CON: Immunity 25. ANS: 1, 4 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: Identifying key anatomical components of the immune system Chapter page reference: 321-330 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Immunity NURSINGTB.COM
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Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback This is incorrect. Swallowing is a mechanical barrier to infection. Dysphagia, or impaired swallowing, increases the patient’s risk for infection. This is correct. Saliva is a biochemical, not mechanical, barrier to infection. A dry mouth increases the patient’s risk for infection. This is incorrect. Intact skin is a physical, not mechanical, barrier to infection. Nonintact skin increases the patient’s risk for infection. This is incorrect. Urination is a mechanical barrier to infection. Urinary retention increases the risk for bacterial growth and infection. This is correct. Tears are a biochemical, not mechanical, barrier to infection. A clogged tear duct increases this patient’s risk for infection.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1
CON: Immunity
Chapter 19: Coordinating Care for Patients With Connective Tissue Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A patient recently diagnosed with rheumatoid arthritis (RA) asks the nurse if the disease is caused by ethnicity. Which response by the nurse is the most appropriate? 1) “RA affects all races at the same rate.” 2) “RA is most prevalent in Caucasian females.” 3) “RA affects those of German descent most often.” 4) “RA is most prevalent in men under the age of 20 years.” 2. The nurse is collecting a health history for a patient in an outpatient clinic who reports joint pain and swelling for the last two months. The patient is diagnosed with rheumatoid arthritis (RA). When planning care for this patient, which statement supports the nursing diagnosis of Activity Intolerance? 1) “I seem to get tired early in the day and require a nap.” 2) “My joints are stiffest at night before I go to sleep.” 3) “I find it difficult to move when I first get up in the morning.” 4) “I take ibuprofen for the pain as needed.” 3. The nurse is completing a health screening for a school-age child with rheumatoid arthritis (RA). The parents ask the nurse to recommend activitieN s tUhaRt SwI illNpGroTmBot.e CexOeM rcise for their child. Which recommendation by the nurse is the most appropriate? 1) Running 2) Softball 3) Football 4) Swimming 4. A patient with rheumatoid arthritis (RA) is being seen in the outpatient clinic for a progress check-up. The nurse is reviewing the patient’s plan of care and determines that the patient has met a goal of treatment when the patient makes which statement? 1) “I sleep for 10 hours at night.” 2) “I have increased pain in my joints all the time now.” 3) “I have delegated many household chores to my children and spouse.” 4) “I do not perform household chores at all anymore.” 5. The nurse is caring for a patient who was diagnosed with rheumatoid arthritis (RA) last year. The patient has recently been placed on prednisone for treatment. Which patient statement indicates that the medication teaching was successful? 1) “I will not have to limit my consumption of canned vegetables.” 2) “I will take this medication on a full stomach to enhance absorption.” NURSINGTB.COM
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3) 4)
“I will not need to monitor my blood sugar more frequently while on this medication.” “I will take the ordered dose at the same time every day.”
6. A nurse is caring for a pregnant patient who has rheumatoid arthritis (RA). Based on this data, which does the nurse anticipate when providing care to this patient? 1) A higher risk for preterm delivery
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2) 3) 4)
An increased need for medication An acute exacerbation of symptoms A continued risk for anemia
7. A nurse is caring for a patient who is newly diagnosed with rheumatoid arthritis (RA). The patient asks the nurse what the difference is between RA and osteoarthritis (OA). Which response by the nurse is most appropriate? 1) “The onset of OA is gradual while the onset of RA may be rapid.” 2) “With OA, multiple joints are symmetrically affected; RA affects one joint at a time.” 3) “The affected joints in RA feel cold to the touch while the joints affected by OA are warm or hot to the touch.” 4) “The pain and stiffness with RA is with activity; OA pain and stiffness is predominant upon arising.” 8. The patient enters the outpatient clinic and states to the triage nurse, “I think I have the flu. I'm so tired, I have no appetite, and everything hurts.” The triage nurse assesses the patient and finds a butterfly rash over the bridge of nose and on the cheeks. Based on this data, which diagnosis does the nurse anticipate? 1) Gout 2) Lyme disease 3) Fibromyalgia 4) Systemic lupus erythematosus 9. A patient asks the nurse if there are any conditions that can exacerbate systemic lupus erythematosus (SLE). Which response by the nurse is the most appropriate? 1) “Conditions causing hypotension can often exacerbate SLE.” 2) “GI upset is often associated with SLE exacerbation.” NiU 3) “Pregnancy is often associated w thRa S n SILNEGeTx aBc .erC b aOtiM o n.” 4) “Fever is a known trigger for an SLE exacerbation.” 10. The nurse is providing health education to a diverse group at a neighborhood community center. Why does the nurse plan to include signs and symptoms of systemic lupus erythematosus (SLE)? 1) The neighborhood is composed of many young female children. 2) The audience has asked the nurse to include the information. 3) The audience is mainly composed of Caucasian women. 4) The audience is mainly females of Asian-American descent. 11. The nurse is caring for a patient who is hospitalized due to an exacerbation of systemic lupus erythematosus (SLE). The nurse is reviewing the patient’s lab work and finds the white blood cell count (WBC) is shifted to the left. Based on this information, which is a priority nursing diagnosis for this patient? 1) Risk for Infection 2) Ineffective Individual Coping 3) Risk for Impaired Skin Integrity 4) Ineffective Health Maintenance NURSINGTB.COM
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12. A patient with systemic lupus erythematosus (SLE) is being treated with immunosuppressant drugs and corticosteroids. Which patient statement indicates the need for further education after teaching? 1) “I can go to events with large crowds.” 2) “I should avoid getting the flu shot.” 3) “I will use contraception to avoid pregnancy.” 4) “I will report any symptoms of infection immediately.”
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13. A nurse is caring for a patient with systemic lupus erythematosus (SLE). The patient begins to cry stating, “I am afraid I will be disfigured because of all of these lesions.” Which intervention does the nurse plan to teach this patient to minimize skin infections associated with SLE? 1) Use sunscreen with an SPF of 15 or greater 2) Remain indoors on sunny days 3) Avoid swimming in a pool or the ocean 4) Decrease sun exposure between 3:00 p.m. and 5:00 p.m. 14. The nurse is caring for a patient diagnosed with discoid lupus erythematosus. The nurse is collaborating with the patient to set goals for the nursing plan of care. Which is an appropriate goal for this patient? 1) Work through the stages of death and dying 2) Compliance with a sun protection plan 3) Gain weight to within 10 pounds of normal for height 4) Report pain no higher than 4 on a scale of 1-10 15. The nurse is planning care for an adolescent patient who has systemic lupus erythematosus (SLE). Which action by the patient indicates the implemented plan of care is appropriate? 1) Refusing to attend school 2) Discussing skin changes with a good friend 3) Refraining from attending any social functions 4) Discussing skin changes with the health-care provider 16. The nurse is providing care for a newly married woman with systemic lupus erythematosus (SLE). Which patient statement indicates an appropriate understanding of the plan of care? 1) “I will take birth control pills while I am taking cytotoxic medications.” 2) “I do not need to contact the doctor if I develop a fever or rash.” NeUekReSndIsNo GthTatBI.gCet Oo M 3) “I plan to go to the movies this w u t of the house.” 4) “I can take aspirin as indicated for pain.” 17. A nurse is caring for a patient with systemic lupus erythematous (SLE) who is taking hydroxychloroquine (Plaquenil). When providing care for this patient, the nurse monitors for which adverse effect associated with the prescribed medication? 1) Renal toxicity 2) Retinal toxicity 3) Cushingoid effects 4) Pulmonary fibrosis 18. An Asian male accompanies his spouse to the clinic and states, “I want you to fix my wife and tell her that there is nothing wrong with her.” The patient reports pain, sleep disorders, and stiffness. Which would be most appropriate for the nurse to include in a plan of care for this family? 1) Medications used to treat fibromyalgia 2) An exercise program to increase energy 3) Information and literature on fibromyalgia NURSINGTB.COM
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4)
Suggested dietary changes to help with the pain
19. The nurse identifies the nursing diagnosis of chronic pain as being appropriate for a patient with fibromyalgia. Which manifestation did the patient most likely report that caused the nurse to select this diagnosis? 1) Acute chest pain 2) Pain from eyestrain 3) Tender points in the knees 4) Pain from a severe skin rash
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20. An adult patient is diagnosed with fibromyalgia. The patient asks the nurse whether a recent of infection with the Coxsackie B virus could have caused fibromyalgia. Which response by the nurse is the most appropriate? 1) “The Coxsackie B virus has nothing to do with fibromyalgia.” 2) “The Coxsackie B virus may have triggered the fibromyalgia.” 3) “The Coxsackie virus definitely caused the fibromyalgia.” 4) “Fibromyalgia is a psychiatric disorder.” 21. The nurse is counseling an adult patient with fibromyalgia. What are some elements of counseling that can help this patient develop effective coping skills? 1) Remind the patient that the patient has a progressive disease. 2) Suggest to the patient that some symptoms may be psychosomatic. 3) Inform the patient that the patient does not need to see a specialist. 4) Teach the patient strategies including distractions, relaxation techniques, or journaling. 22. The mother of three teenagers is diagnosed with fibromyalgia and asks the nurse how to keep up with all of the children's activities. Which suggestion by the nurse is the most appropriate? 1) Ask the children to limit their activities. 2) Attempt to attend the all the functions of the children. 3) Avoid attending any afterschool functions for the children. 4) Negotiate with the children to alternate attending their functions. 23. The nurse is discussing goals to relieve pain and fatigue with a patient newly diagnosed with fibromyalgia. Which goal statement would be realistic for this patient to achieve within 30 days? 1) Join an exercise group 2) Get a job outside the home 3) Walk her son to school daily 4) Cook dinner five nights a week NURSINGTB.COM 24. During a home visit, the family of a patient with fibromyalgia asks the nurse what they can do to help the patient with painful episodes. What should the nurse suggest to the patient and family? 1) Plan a family reunion 2) Keep the patient in bed 3) Protect the patient from injury 4) Divide household chores among each member of the family Multiple Response Identify one or more choices that best complete the statement or answer the question. 25. The nurse is caring for a patient who has recently been diagnosed with fibromyalgia. Which medications does the nurse anticipate will be prescribed as part of the patient’s treatment plan? Select all that apply. 1) Ibuprofen 2) Aerobic exercise NURSINGTB.COM
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3) 4) 5)
Pregabalin (Lyrica) Zolpidem (Ambien) Tenormin (Atenolol)
26. The nurse is providing care to a patient who is receiving nonsteroidal antiinflammatory drugs (NSAIDs) in the treatment of rheumatoid arthritis. When providing care to this patient, which actions by the nurse are appropriate? Select all that apply. 1) Assessing for an allergic reaction 2) Monitoring for signs of renal problems
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3) 4) 5)
Advising against abrupt discontinuation of drugs Assuring the patient that there is no relationship between NSAIDs and heart disease Encouraging the patient to take with water, milk, or small snack to help avoid stomach distress
27. A patient, recently diagnosed with rheumatoid arthritis (RA), asks the nurse whether RA will affect her in other ways. When responding to the patient, which systems will the nurse include as possibly being affected by the diagnosis? Select all that apply. 1) Exocrine 2) Respiratory 3) Hematologic 4) Reproductive 5) Cardiovascular 28. A patient recently diagnosed with rheumatoid arthritis (RA) asks the nurse if RA always causes crippling deformities. Which teaching topics will the nurse include as ways to decrease the likelihood of crippling deformities? Select all that apply. 1) Ignore pain as a warning signal 2) Use stronger joints for most activity 3) Avoid stress to any current area of deformity 4) Type instead of handwriting items if possible 5) Stop an activity if it is beyond your ability to perform 29. Which information should the nurse include when teaching a patient information regarding limited systemic scleroderma? Select all that apply. 1) A rapid onset is anticipated. 2) An insidious onset is anticipatedN. URSINGTB.COM 3) Affects internal organs several years prior to onset 4) Can be preceded by a diagnosis of Raynaud’s phenomenon 5) Skin of extremities distal to the elbows and knees are affected 30. Which subjective findings should the nurse anticipate when assessing a patient diagnosed with gout? Select all that apply. 1) Presence of tophi 2) Tenderness on palpation 3) Reports of severe pain in the great toe 4) Patient states, “I cannot move my joint.” 5) Soft tissue swelling accompanied by warmth
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Chapter 19: Coordinating Care for Patients With Connective Tissue Disorders Answer Section MULTIPLE CHOICE 1.
ANS: 1 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Describing the epidemiology of connective tissue disorders Chapter page reference: 344351 Heading: Rheumatoid Arthritis Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback 1 RA affects 12% of the total population across all races. 2 RA is not more prevalent in Caucasian females. 3 RA does not affect those of German descent most often. 4 It affects women three times more than men, and the onset is usually between the ages of 20 and 40 years.
PTS: 1 CON: Immunity ANS: 1 2. NURSINGTB.COM Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with connective tissue disorders Chapter page reference: 344-351 Heading: Rheumatoid Arthritis Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Immunity Difficulty: Easy Feedback NURSINGTB.COM
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1
2 3 4
One hallmark symptom of RA is extreme fatigue. The patient’s statement regarding the need for a nap supports the inclusion of Activity Intolerance in the plan of care. The nurse would teach the patient about frequent rest periods during the day to conserve energy. Joints of the RA patient are stiffest in the morning. The patient with RA will be stiff early in the morning, but that would not interfere with activities later in the day. Taking ibuprofen for pain does not affect the ability for activity.
PTS: 1 CON: Immunity 3. ANS: 4 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
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Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with connective tissue disorders Chapter page reference: 344-351 Heading: Rheumatoid Arthritis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback 1 Running, softball or football could exacerbate joint discomfort. 2 Running, softball or football could exacerbate joint discomfort. 3 Running, softball or football could exacerbate joint discomfort. 4 Swimming exercises all the extremities without putting undue stress on joints. PTS: 1 CON: Immunity 4. ANS: 3 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with connective tissue disorders Chapter page reference: 344-351 Heading: Rheumatoid Arthritis Integrated Processes: Nursing Process – Evaluation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] NURSINGTB.COM Concept: Immunity Difficulty: Difficult Feedback 1 Sleeping for 10 hours at night will not alleviate the need for frequent rest periods during the day. 2 Increased joint pain would indicate that goals have not been met. 3 One technique for reducing stress on the joints is to delegate household tasks to family members. 4 The patient does not need to refrain from all household chores. PTS: 1 5. ANS: 4
CON: Immunity NURSINGTB.COM
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Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Discussing the medical management of: Rheumatoid arthritis Chapter page reference: 344-351 Heading: Rheumatoid Arthritis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Immunity Difficulty: Difficult Feedback 1 Steroids can cause fluid retention, so sodium intake should be limited. A hidden source of sodium is canned vegetables.
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2 3 4
Steroids are taken with food to minimize GI distress, not to enhance absorption. Steroids also increase blood sugar, so blood sugar may need to be monitored more frequently while on the medication regimen. Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take the medication at the same time each day.
PTS: 1 CON: Immunity 6. ANS: 4 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with connective tissue disorders Chapter page reference: 344-351 Heading: Rheumatoid Arthritis Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Immunity; Pregnancy Difficulty: Easy Feedback 1 Many pregnant patients with RA may have prolonged gestations and often experience a remission during pregnancy and relapse after delivery. 2 Due to remission, a decrease in medication is often necessitated. 3 Many pregnant patients with RA may have prolonged gestations and often experience a remission during pregnancy and relapse after delivery. 4 The pregnant patient with RANisUatR aScIonNtGin ue T Bd .risk C OfoMr anemia. PTS: 1 CON: Immunity | Pregnancy 7. ANS: 1 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Osteoarthritis Chapter page reference: 339-344 Heading: Osteoarthritis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: NURSINGTB.COM
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Immunity Difficulty: Moderate Feedback 1 The onset of OA is gradual while the onset of RA may be rapid. 2 RA affects multiple joints symmetrically while OA affects one joint at a time. 3 The affected joints in OA feel cold to the touch while the joints affected by RA are warm or hot to the touch. 4 Pain associated with RA is predominant upon arising versus the pain in OA, which is with activity. PTS: 1 CON: Immunity 8. ANS: 4 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
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Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Lupus erythematosus Chapter page reference: 354-359 Heading: Lupus Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Immunity Difficulty: Easy Feedback 1 While fibromyalgia, Lyme's disease, and gout share some symptoms of SLE, they do not cause a rash over the nose and cheeks. 2 While fibromyalgia, Lyme's disease, and gout share some symptoms of SLE, they do not cause a rash over the nose and cheeks. 3 While fibromyalgia, Lyme's disease, and gout share some symptoms of SLE, they do not cause a rash over the nose and cheeks. 4 The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for the diagnosis of systemic lupus erythematosus (SLE). PTS: 1 CON: Immunity 9. ANS: 3 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Lupus erythematosus Chapter page reference: NURSINGTB.COM 354-359 Heading: Lupus Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback 1 Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE. 2 Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE. 3 Pregnancy can be associated with an exacerbation of SLE due to the rise of estrogen levels. 4 Hypotension, fever, and GI upset are not factors that risk exacerbation NURSINGTB.COM
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of SLE.
10.
PTS: 1 CON: Immunity ANS: 4 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Lupus erythematosus Chapter page reference: 354-359 Heading: Lupus Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Immunity; Diversity
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Difficulty: Easy Feedback 1 SLE affects individuals of child-bearing age. 2 There is no evidence that the audience asked for the information. 3 Among women who are of child-bearing age, SLE is seen in more African-Americans, Hispanics, and Asian-Americans than Caucasians. 4 Among women who are of child-bearing age, SLE is seen in more African-Americans, Hispanics, and Asian-Americans than Caucasians.
11.
12.
PTS: 1 CON: Immunity | Diversity ANS: 1 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of connective tissue disorders Chapter page reference: 354-359 Heading: Lupus Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Immunity Difficulty: Difficult Feedback 1 All identified diagnoses are appropriate for a patient with SLE. However, the shift to the left in the WBC count indicates an increased risk for infection. A shift to the left in a WBC differential is indicativNeUo Rf aSlar I NgeGnTu Bmbe . Cr of O Mimmature cells, suggesting infection. Therefore, the priority diagnosis is Risk for Infection. 2 While this is an appropriate nursing diagnosis for this patient, this is not the priority based on the current WBC count. 3 While this is an appropriate nursing diagnosis for this patient, this is not the priority based on the current WBC count. 4 While this is an appropriate nursing diagnosis for this patient, this is not the priority based on the current WBC count. PTS: 1 CON: Immunity ANS: 1 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Discussing the medical management of: Lupus erythematosus Chapter page reference: NURSINGTB.COM
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354-359 Heading: Lupus Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Immunity Difficulty: Difficult Feedback 1 Crowds may increase exposure to infection. 2 Annual influenza vaccination is recommended but patients with significant immunosuppression should not receive live vaccines. 3 Immunosuppressive drugs may increase the risk of birth defects.
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4
13.
14.
Chills, fever, sore throat, fatigue, or malaise should be reported.
PTS: 1 CON: Immunity ANS: 1 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with connective tissue disorders Chapter page reference: 354-359 Heading: Lupus Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback 1 The nurse teaches the patient to live a normal life with a few extra precautions. There is a relationship between sun exposure and infection, so the patient is taught to use sunscreen with an SPF of at least 15. 2 The patient does not need to stay indoors on sunny days or to decrease sun exposure between 3:00 p.m. and 5:00 p.m. 3 The patient may swim but should reapply sunscreen after swimming. 4 The patient does not need to stay indoors on sunny days or to decrease sun exposure between 3:00 p.m. and 5:00 p.m. PTS: 1 CON: Immun ity N URSINGTB.COM ANS: 2 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with connective tissue disorders Chapter page reference: 354-359 Heading: Lupus Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback NURSINGTB.COM
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1 2 3 4
15.
It is not fatal, is not related to weight, and is rarely painful unless complications arise. Discoid lupus erythematosus is an autoimmune disorder of the skin, so the patient must protect against the sun to avoid skin cancers and other complications. It is not fatal, is not related to weight, and is rarely painful unless complications arise. It is not fatal, is not related to weight, and is rarely painful unless complications arise.
PTS: 1 CON: Immunity ANS: 2 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with connective tissue disorders Chapter page reference: 354-359
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Heading: Lupus Integrated Processes: Nursing Process – Evaluation Client Need: Psychosocial Integrity Cognitive level: Analysis [Analyzing] Concept: Immunity Difficulty: Difficult Feedback 1 Refusing to go to school or attend social functions indicates nonacceptance of the changes to body image. 2 Peer interaction is important to teens. Being able to discuss the physical changes related to SLE with a friend indicates acceptance of the change in body image. 3 Refusing to go to school or attend social functions indicates nonacceptance of the changes to body image. 4 Discussing changes only with health-care personnel does not indicate the teen has adjusted to the body image changes.
16.
PTS: 1 CON: Immunity ANS: 1 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Discussing the medical management of: Lupus erythematosus Chapter page reference: 354-359 Heading: Lupus Integrated Processes: Nursing Process – Evaluation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] NURSINGTB.COM Concept: Immunity Difficulty: Difficult Feedback 1 Treatment for SLE can include cytotoxic drugs. The patient is taught to avoid pregnancy by using contraceptives, as these drugs can cause birth defects. 2 Patients with SLE should contact their primary care providers should manifestations of infection occur, as the immune system is compromised. 3 The patient is taught to avoid crowds, as they are potential sources of infection. 4 Aspirin can cause bleeding and should be taken with extreme care. PTS: 1
CON: Immunity NURSINGTB.COM
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ANS: 2 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Discussing the medical management of: Lupus erythematosus Chapter page reference: 354-359 Heading: Lupus Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback 1 Renal toxicity is not the primary concern with Plaquenil.
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2
3 4
18.
PTS: 1 CON: Immunity ANS: 3 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with connective tissue disorders Chapter page reference: 362-364 Heading: Fibromyalgia Integrated Processes: Nursing Process – Planning Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Immunity; Diversity Difficulty: Moderate 1 2 3
4
19.
Hydroxychloroquine (Plaquenil) is an antimalarial drug used in SLE to reduce the frequency of acute episodes of SLE. The primary concern with Plaquenil is retinal toxicity and possible irreversible blindness. Cushingoid effects are a concern with corticosteroid therapy. Pulmonary fibrosis is a potential adverse effect of cyclophosphamide, not Plaquenil.
Feedback The physician orders medication and diets. There is no proof that exercise, or lack thereof, causes fibromyalgia. In many cultures, accepting a disease like fibromyalgia may be difficult due to the vagueness of the disease. Information and written literature may help the family understand that the disease is rNeal. U RSINGTB.COM The physician orders medication and diets.
PTS: 1 CON: Immunity | Diversity ANS: 3 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with connective tissue disorders Chapter page reference: 362-364 Heading: Fibromyalgia Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension NURSINGTB.COM
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[Understanding] Concept: Immunity Difficulty: Easy Feedback 1 Acute chest pain, pain from a rash, and muscle strain of the eye are not reported symptoms. 2 Acute chest pain, pain from a rash, and muscle strain of the eye are not reported symptoms. 3 Patients with fibromyalgia typically complain of multiple tender points generally including the neck, spine, and knees. 4 Acute chest pain, pain from a rash, and muscle strain of the eye are not reported symptoms.
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20.
21.
PTS: 1 CON: Immunity ANS: 2 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Describing the epidemiology of connective tissue disorders Chapter page reference: 362364 Heading: Fibromyalgia Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Immunity Difficulty: Easy Feedback 1 The exact cause of fibromyalgia is unknown. Infections such as hepatitis C virus (HCV), HIV, Coxsackie B, and parvovirus may trigger fibromyalgia. 2 The exact cause of fibromyalgia is unknown. Infections such as hepatitis C virus (HCV), HIV, Coxsackie B, and parvovirus may trigger fibromyalgia. 3 The exact cause of fibromyalgia is unknown. Infections such as hepatitis C virus (HCV), HIV, Coxsackie B, and parvovirus may trigger fibromyalgia. 4 Having a psychiatric disorder such as attention deficit/hyperactivity disorder (ADHD) or depression may be a risk factor for fibromyalgia, but the condition is not a psychiatric disorder. PTS: 1 CON: Immunity ANS: 4 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue NURSINGTB.CO Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with connective tissue disorders Chapter page reference: 362-364 Heading: Fibromyalgia Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback NURSINGTB.COM
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1 2 3 4
22.
Fibromyalgia is not a progressive disease. It is important to validate the patient’s perceptions. Getting appropriate help is important in managing fibromyalgia. Patients should be encouraged to see a fibromyalgia specialist. It helps to identify stressors that make pain and fatigue worse, and then develop strategies to avoid those stressors or to minimize symptoms when those stressors occur.
PTS: 1 CON: Immunity ANS: 4 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with connective tissue disorders Chapter page reference: 362-364 Heading: Fibromyalgia
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Integrated Processes: Nursing Process – Implementation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback 1 The children should not have to limit their activities because of the patient’s illness. 2 It is not reasonable for a patient with fibromyalgia to try to run the home and attend all of the functions of each child. 3 Not attending any functions will only add to the patient’s stress and may worsen symptoms. 4 Since it is too difficult to attend all of the children’s functions, the nurse suggests alternating the children’s functions. In this manner, the patient feels that she is partially meeting the needs of each child.
23.
PTS: 1 CON: Immunity ANS: 4 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with connective tissue disorders Chapter page reference: 362-364 Heading: Fibromyalgia Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] NURSINGTB.COM Concept: Immunity Difficulty: Moderate 1 2 3 4
Feedback Walking her son to school daily is a bit ambitious to start, as are joining an exercise group and getting a job outside the home. Walking her son to school daily is a bit ambitious to start, as are joining an exercise group and getting a job outside the home. Walking her son to school daily is a bit ambitious to start, as are joining an exercise group and getting a job outside the home. Fibromyalgia saps the patient’s energy. The patient might set as an initial goal to be able to perform daily tasks for the family such as cooking and doing the laundry. NURSINGTB.COM
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24.
PTS: 1 CON: Immunity ANS: 4 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with connective tissue disorders Chapter page reference: 362-364 Heading: Fibromyalgia Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Immunity
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Difficulty: Moderate Feedback 1 A family vacation might cause more stress to the patient, who would more than likely be planning and packing. 2 Keeping the patient in bed would not be therapeutic. 3 There is no reason to believe that this patient is at higher risk for injury than another member of the family. 4 Although the causes and treatments are not all known, there is general agreement that reducing stress may help lessen the effects of fibromyalgia. The nurse could help the family by suggesting ways to decrease stress on the patient by having the family pitch in on responsibilities. PTS: 1
CON: Immunity
MULTIPLE RESPONSE 25. ANS: 1, 2, 3 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Discussing the medical management of: Fibromyalgia Chapter page reference: 362-364 Heading: Fibromyalgia Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] NURSINGTB.COM Concept: Immunity Difficulty: Moderate 1. 2. 3. 4. 5.
Feedback This is correct. Treatment for fibromyalgia may include NSAIDs such as ibuprofen for pain, pregabalin (Lyrica), and aerobic exercise. This is correct. Treatment for fibromyalgia may include NSAIDs such as ibuprofen for pain, pregabalin (Lyrica), and aerobic exercise. This is correct. Treatment for fibromyalgia may include NSAIDs such as ibuprofen for pain, pregabalin (Lyrica), and aerobic exercise. This is incorrect. Zolpidem (Ambien) is for producing sleep. This is incorrect. Tenormin (Atenolol) is an antihypertensive drug.
PTS: 1 CON: Immunity 26. ANS: 1, 2, 3, 5 NURSINGTB.COM
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Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Discussing the medical management of: Rheumatoid Arthritis Chapter page reference: 344-351 Heading: Rheumatoid Arthritis Integrated Processes: Nursing Process -Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate
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1. 2. 3. 4. 5.
Feedback This is correct. When providing care to a patient who is receiving any medication, it is important to monitor the patient for signs of an allergic reaction. This is correct. If you take NSAIDs in high doses, the reduced blood flow can permanently damage the kidneys, and it can eventually lead to kidney failure and require dialysis. This is correct. Abrupt discontinuation can have serious side effects. This is incorrect. NSAIDs have been linked to heart failure; therefore, this action by the nurse is not appropriate when providing care to this patient. This is correct. Taking NSAIDs with food may help reduce irritation of the stomach and prevent an ulcer.
PTS: 1 CON: Immunity 27. ANS: 1, 2, 3, 5 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Rheumatoid arthritis Chapter page reference: 344-351 Heading: Rheumatoid Arthritis Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Immunity Difficulty: Easy 1.
2.
NURSINGTB.COM Feedback This is correct. RA can affect the respiratory system with pleural effusion (collection of fluid in the pleural space); the cardiovascular system with coronary heart disease; the exocrine glands, resulting in dry eyes and mouth; and the hematologic system with a variety of disorders, particularly anemia. This is correct. RA can affect the respiratory system with pleural effusion (collection of fluid in the pleural space); the cardiovascular system with coronary heart disease; the exocrine glands, resulting in dry eyes and mouth; and the hematologic system with a variety of disorders, particularly anemia.
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3.
4. 5.
This is correct. RA can affect the respiratory system with pleural effusion (collection of fluid in the pleural space); the cardiovascular system with coronary heart disease; the exocrine glands, resulting in dry eyes and mouth; and the hematologic system with a variety of disorders, particularly anemia. This is incorrect. If properly managed, RA is not considered to be a danger for pregnant women or their babies. This is correct. RA can affect the respiratory system with pleural effusion (collection of fluid in the pleural space); the cardiovascular system with coronary heart disease; the exocrine glands, resulting in dry eyes and mouth; and the hematologic system with a variety of disorders, particularly anemia.
PTS: 1 CON: Immunity 28. ANS: 2, 3, 4, 5 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
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Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with connective tissue disorders Chapter page reference: 344-351 Heading: Rheumatoid Arthritis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate 1. 2. 3. 4. 5.
Feedback This is incorrect. Pain is a warning signal, and the patient with RA should stop any activity that causes pain. This is correct. Using a stronger joint or part of the body, such as the palm, to carry items is preferable to grasping. This is correct. When performing a task, the patient should avoid stress in the area of the deformity to help prevent further deformities. This is correct. Writing requires using a strong grip, so typing is preferable. This is correct. The patient with RA should never attempt to push a joint beyond its ability.
PTS: 1 CON: Immunity 29. ANS: 2, 4, 5 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Scleroderma NURSINGTB.COM Chapter page reference: 351-354 Heading: Scleroderma Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Immunity Difficulty: Moderate 1. 2.
Feedback This is incorrect. Diffuse, not limited, systemic scleroderma has rapid onset. This is correct. Limited systemic scleroderma often has an insidious onset. NURSINGTB.COM
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3. 4. 5.
This is incorrect. Internal organ involvement is more likely with diffuse, not limited, systemic scleroderma. This is correct. Limited systemic scleroderma is often preceded by a diagnosis of Raynaud’s phenomenon. This is correct. These are clinical manifestations associated with limited systemic scleroderma.
PTS: 1 CON: Immunity 30. ANS: 3, 4 Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Gout Chapter page reference: 359-361 Heading: Gout Integrated Processes: Nursing Process – Assessment
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Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Immunity Difficulty: Easy 1. 2. 3. 4. 5.
PTS: 1
Feedback This is incorrect. This is an objective, not subjective, assessment finding for a patient diagnosed with gout. This is incorrect. This is an objective, not subjective, assessment finding for a patient diagnosed with gout. This is correct. This is a subjective assessment finding for a patient diagnosed with gout. This is correct. This is a subjective assessment finding for a patient diagnosed with gout. This is incorrect. This is an objective, not subjective, assessment finding for a patient diagnosed with gout. CON: Immunity
Chapter 20: Coordinating Care for Patients With Immune Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. NURSINGTB.COM 1. A nurse is caring for a pediatric patient who is receiving an infusion of intravenous antibiotic at the ambulatory clinic. Which clinical manifestation indicates that the patient is experiencing a type I hypersensitivity reaction? 1) Erythema 2) Fever 3) Joint pain 4) Hypotension 2. The nurse is assessing a patient who is receiving intravenous (IV) antibiotics. Which item in the patient’s health history increases the risk for experiencing a hypersensitivity reaction? 1) 26 years of age 2) Caucasian race 3) Previous antibiotic therapy 4) Concurrent chronic illness NURSINGTB.COM
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3. The nurse is admitting a pediatric patient to the hospital with a ventroperitoneal (VP) shunt malfunction. The patient’s family speaks very little English. The interpreter has arrived and the nurse is obtaining a health history from the parents and learns that the patient received the shunt at birth after a menigocele repair. Based on this data, which product should be avoided when providing care to this patient? 1) Synthetic rubber gloves 2) Polyethylene gloves 3) Nonpowdered nitrile gloves 4) Latex gloves
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4. The nurse is caring for a patient in an allergy clinic. After completing the patient history, the nurse selects the nursing diagnosis of Risk for Shock. Which item in the patient’s history supports the need for this nursing diagnosis? 1) A history of an anaphylactic reaction to shellfish. 2) A drug reaction to penicillin causing a rash. 3) A history of glomerulonephritis. 4) A history of dermatitis resulting from a response to changing laundry detergent. 5. The nurse is preparing to assess a patient when one of the patient’s family members begins showing symptoms of a latex sensitivity. Which action by the nurse is the most appropriate? 1) Ask the family member to leave the unit 2) Transfer the patient to a department that does not use latex products 3) Wait until Monday to report the problem to the supervisor of the unit 4) Obtain latex-free products for the patient’s room 6. The nurse is caring for a patient who is experiencing anaphylactic shock following the administration of a medication. Which position is the most appropriate for the nurse to place the patient based on this data? 1) Trendelenburg position 2) Flat, with legs slightly elevated 3) Supine position 4) High Fowler position 7. The nurse is caring for a patient with a history of latex allergies. The patient develops audible wheezing, pruritus, urticaria, and signs of angioedema. Which is the priority intervention for this patient? 1) Teach the patient regarding using a kit that contains treatment for allergic reactions. 2) Administer diphenhydramine (Benadryl) by mouth every four hours per the health-care provider's orders. NURSINGTB.COM 3) Administer epinephrine 1:1,000 by subcutaneous injection per the health-care provider's orders. 4) Collect a detailed history from the patient regarding the history of latex allergies. 8. A nurse has been providing a young adult patient with a history of hypersensitivity reactions. The nurse is preparing instructions on the correct methods for using an EpiPen. Which patient statement indicates understanding of the proper technique? 1) “I make sure the EpiPen is always available.” 2) “It's fine to leave the EpiPen out in the sun.” 3) “No one else in my family knows how to use the EpiPen.” 4) “I don't need a medical alert tag.” 9. A pediatric patient with a history of anaphylactic hypersensitivity reactions will be discharged with a prescription for an EpiPen. Which statement is appropriate for the nurse to include in the discharge instructions for this patient and family? 1) “This medication does not come prefilled and must be measured.” 2) “Keep the medication in the car at all times.” NURSINGTB.COM
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3) 4)
“Frequently check the expiration date of the medication.” “Keep the medication in one location that is easy to remember.”
10. A nurse is caring for a patient with seasonal hypersensitivity reactions. What teaching would the nurse provide to improve this patient’s comfort? 1) Keep doors and windows open on high-allergen days to circulate air. 2) Maintain a clean, dust-free environment. 3) Take antihistamine and leukotriene medication as ordered
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4)
Stop taking oral corticosteroids immediately once symptoms disappear.
11. The nurse suspects that the patient is experiencing a reaction to a specific antigen. Which laboratory result supports the conclusion made by the nurse? 1) Indirect Coombs’ showing no agglutination 2) Patch test with a 1-inch area of erythema 3) 2% eosinophils in the WBC count 4) Rh antigen with negative results 12. The nurse is providing care to a patient with psoriasis. Which medication should the nurse prepare to teach this patient about based on the diagnosis? 1) Epinephrine 2) Azathioprine 3) Cyclosporine 4) Mycophenolate mofetil 13. The nurse is providing care to a patient with autoimmune hepatitis. Which medication should the nurse prepare to teach this patient about based on the diagnosis? 1) Epinephrine 2) Azathioprine 3) Cyclosporine 4) Mycophenolate mofetil 14. The nurse is providing care to a patient with lupus. Which medication should the nurse prepare to teach this patient about based on the diagnosis? 1) Epinephrine 2) Azathioprine NURSINGTB.COM 3) Cyclosporine 4) Mycophenolate mofetil 15. Which is the priority nursing action to decrease the risk of a transfusion reaction? 1) Assessing the patient’s vital signs per policy 2) Documenting the procedure in the medical record 3) Verifying the patient’s identity using two identifiers 4) Checking the bag to ensure it is the correct blood type 16. The nurse is providing care for a patient diagnosed with agammaglobulinemia. Which is the anticipated treatment for this patient? 1) Oral diphenhydramine 2) Topical corticosteroids 3) Subcutaneous epinephrine 4) Intravenous immunoglobulin (IVIG) 17. The nurse is providing care to a patient diagnosed with X-linked agammaglobulinemia (XLA). Which should the nurse include in the patient’s plan of care? 1) Immunization with inactivated polio vaccine (IPV) NURSINGTB.COM
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN 2) 3) 4)
Administration of intravenous immunoglobulin every six months Education regarding the use of high dose prophylactic antibiotics Periodic magnetic resonance imagery (MRI) to monitor for respiratory complications
18. Which respiratory data should the nurse anticipate when assessing a patient diagnosed with X-linked agammaglobulinemia (XLA)?
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1) 2) 3) 4)
Wheezes Rhonchi Tachypnea Eupnea
19. Which is the priority nursing diagnosis for a patient diagnosed with X-linked agammaglobulinemia (XLA)? 1) Risk for infection 2) Decreased cardiac output 3) Anticipatory grieving 4) Fatigue 20. Which general manifestation should the nurse anticipate when providing care to a patient diagnosed with DiGeorge’s syndrome? 1) Poor muscle tone 2) Failure to thrive 3) Shortness of breath 4) Delayed development 21. Which respiratory manifestation should the nurse anticipate when providing care to a patient diagnosed with DiGeorge’s syndrome? 1) Poor muscle tone 2) Failure to thrive 3) Shortness of breath 4) Delayed development 22. Which should the nurse plan to monitor when providing care to a patient who is diagnosed with DiGeorge’s syndrome? NURSINGTB.COM 1) Sodium 2) Calcium 3) Potassiu m 4) Magnesi um 23. Which is the priority nursing action to decrease the risk for infection for a patient diagnosed with DiGeorge’s syndrome? 1) Hand hygiene 2) Reverse isolation 3) Prokinetic agents 4) Droplet precautions 24. Which should the nurse include in the plan of care for a patient diagnosed with DiGeorge’s syndrome to treat gastrointestinal reflux disorder (GERD)? 1) Hand hygiene 2) Reverse isolation NURSINGTB.COM
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Prokinetic agents Droplet precautions
25. Which immune disorder should the nurse include in the plan of care for a patient who is receiving chemotherapeutic agents in the treatment of cancer? 1) B-cell deficiency 2) T-cell deficiency 3) Excessive immune response 4) Secondary immune deficiency
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Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. A nurse is working in a summer camp for children. One of the children comes to the clinic with several bee stings. Which clinical manifestations would necessitate the need to inject the child with epinephrine (EpiPen)? Select all that apply. 1) Skin that is cold and clammy to the touch 2) Skin that is warm and dry to the touch 3) The child is hyperactive and hyperverbal. 4) Complaints of thirst 5) Restlessness and confusion 27. The nurse is providing care to a patient who is suspected of having an immune deficiency. Which information in the patient’s health history supports this suspected diagnosis? Select all that apply. 1) Persistent oral thrush 2) Tinea infection of the feet 3) One occurrence of pneumonia last year 4) Four or more infections in a one-year period 5) Two serious sinus infections in a one-year period 28. The nurse is providing care to a pediatric patient who is diagnosed with DiGeorge’s syndrome. Which data indicates a cardiovascular abnormality? Select all that apply. 1) Murmur 2) Cyanosis NURSINGTB.COM 3) Polycythemia 4) Failure to thrive 5) Cleft lip and palate
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Chapter 20: Coordinating Care for Patients With Immune Disorders Answer Section MULTIPLE CHOICE 1.
ANS: 4 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Excessive immune response Chapter page reference: 378-385 Heading: Type I Hypersensitivity Reaction Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Inflammation Difficulty: Easy Feedback 1 Erythema and fever are associated with type IV hypersensitivity reactions. 2 Fever and joint pain are associated with a type III hypersensitivity reactions. 3 Fever and joint pain are associated with a type III hypersensitivity reactions. 4 Clinical manifestations associated with a type I hypersensitivity reaction include hypotension, wheezing, gastrointestinal or uterine spasm, stridor, and urticaria.
PTS: 1 CON: Inflammation 2. ANS: 3 NURSINGTB.COM Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Explaining the pathophysiological processes of immune dysfunction Chapter page reference: 377-390 Heading: Excessive Immune Response Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate Feedback 1 Age, sex, concurrent illnesses, and previous reactions to related substances have been identified as having a role in risk for NURSINGTB.COM
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hypersensitivity; however, these pose a lower risk than previous exposure. Age, sex, concurrent illnesses, and previous reactions to related substances have been identified as having a role in risk for hypersensitivity; however, these pose a lower risk than previous exposure. Anyone can have a hypersensitivity reaction. However, risk generally increases with previous exposure, because antigens must be formed with the first exposure before hypersensitivity is likely to occur. Age, sex, concurrent illnesses, and previous reactions to related substances have been identified as having a role in risk for hypersensitivity; however, these pose a lower risk than previous exposure.
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PTS: 1 CON: Inflammation 3. ANS: 4 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune dysfunction Chapter page reference: 377-390 Heading: Excessive Immune Response Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Inflammation Difficulty: Easy Feedback 1 This product is appropriate for this patient. 2 This product is appropriate for this patient. 3 This product is appropriate for this patient. 4 Patients with a history of meningocele typically experience severe latex allergies. It is important for the nurse, and other health-care providers, to use latex alternative products on this patient. PTS: 1 CON: Inflammation 4. ANS: 1 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune dysfunction NURSINGTB.COM Chapter page reference: 377-390 Heading: Excessive Immune Response Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate Feedback 1 Type I hypersensitivities, such as anaphylactic reactions, occur immediately and may be life-threatening. Because the patient has a history of this type of reaction, Risk for Shock is an appropriate nursing diagnosis. 2 The other items would not necessitate the need for this nursing diagnosis. 3 The other items would not necessitate the need for this nursing diagnosis. 4 The other items would not necessitate the need for this nursing diagnosis. PTS: 1 CON: Inflammation 5. ANS: 4 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune dysfunction Chapter page reference: 377-390 Heading: Excessive Immune Response Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation
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Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate Feedback 1 Asking the family member to leave would be a violation of the patient’s rights. 2 Transferring the patient to a department that does not use latex products is not realistic because the family member might experience exposure on another unit. (No hospital unit can be latex-free.) 3 Waiting until Monday does not solve the problem. 4 When symptoms of sensitivity to latex occur on exposure, latex-free products should be supplied. PTS: 1 CON: Inflammation 6. ANS: 4 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune dysfunction Chapter page reference: 377-390 Heading: Excessive Immune Response Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate
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The Trendelenburg position elevates the foot of the bed and is no longer recommended for the treatment of shock, as it causes abdominal organs to press against the diaphragm, which impedes respirations and decreases coronary artery filling. Lying flat is not recommended. A person in a supine position may not be able to maintain an open airway. Placing the patient in Fowler or high Fowler position allows optimal lung expansion and ease of breathing.
PTS: 1 CON: Inflammation 7. ANS: 3 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Discussing the medical management of: Excessive immune response Chapter page reference: 377-390 Heading: Excessive Immune Response Integrated Processes: Nursing Process –Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Inflammation Difficulty: Difficult Feedback 1 Patients who have experienced an anaphylactic reaction to insect venom or another potentially unavoidable allergen should carry a bee sting kit. 2 Diphenhydramine is often given as well but by injection, not by mouth.
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4
For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should give the epinephrine first due to the symptoms. The nurse does not have time to collect a detailed history, because of the severity of the patient’s signs and symptoms.
PTS: 1 CON: Inflammation 8. ANS: 1 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Developing a teaching plan for a patient with immune dysfunction Chapter page reference: 377-390 Heading: Excessive Immune Response Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Inflammation; Medication Difficulty: Difficult Feedback 1 The patient and family should frequently check the expiration date of the EpiPen. A kit should be readily available in all settings where the patient studies, works, or plays. 2 Proper storage of the kit is important, avoiding exposure to sun or high temperature. 3 In addition to the patient, someone else should always know how to use the kit as well. 4 The patient should be encouraged to wear a medical alert bracelet or tag. PTS: 1 CON: Inflamm NaUtiRonS| IMNe dGica TBtio.nCOM 9. ANS: 3 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Developing a teaching plan for a patient with immune dysfunction Chapter page reference: 377-390 Heading: Excessive Immune Response Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Inflammation; Medication Difficulty: Moderate Feedback 1 An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic reaction. Because an anaphylactic reaction is a medical emergency, it is essential that the nurse provides thorough teaching regarding the use of the EpiPen. The EpiPen comes prefilled to ensure a quick delivery when necessary. 2 The medication should not be kept in the car at all times, as the EpiPen needs to be stored away from high heat and direct sunlight. 3 The expiration date should be checked frequently to ensure accurate strength. 4 The patient should have multiple EpiPens and they should be kept in multiple areas, not one location. PTS: 1 CON: Inflammation | Medication 10. ANS: 2 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
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Chapter learning objective: Developing a teaching plan for a patient with immune dysfunction Chapter page reference: 377-390 Heading: Excessive Immune Response Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Inflammation; Medication Difficulty: Moderate Feedback 1 The nurse should instruct the patient to keep doors and windows closed on highallergen days and to remain indoors if possible. 2 A patient with seasonal hypersensitivity should be educated regarding prevention and comfort measures. The nurse should also include teaching on maintaining a clean, dustfree environment. 3 Medication instruction should include instruction on taking antihistamine and antileukotriene medication, not leukotriene. 4 The patient should also be instructed to taper oral corticosteroids as ordered, not to immediately stop taking them. PTS: 1 CON: Inflammation | Medication 11. ANS: 2 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected immune dysfunctions Chapter page reference: 377-390 NURSINGTB.COM Heading: Excessive Immune Response Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Inflammation Difficulty: Easy Feedback 1 Indirect Coombs’ test detects the presence of circulating antibodies against RBCs. No agglutination is considered a normal finding. 2 An area of erythema after a patch test indicates a positive response to a specific antigen. 3 An eosinophil count of 2% is within the normal range. 4 An Rh antigen with a negative result indicates that the patient does not carry the antigen and is not an indicator of a reaction to a specific antigen. PTS: 1 CON: Inflammation 12. ANS: 3 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Discussing the medical management of: Excessive immune response Chapter page reference: 377-390 Heading: Excessive Immune Response Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Inflammation; Medication
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Difficulty: Moderate Feedback 1 Epinephrine is not used in the treatment of psoriasis. 2 Azathioprine is used to treat autoimmune hepatitis and rheumatoid arthritis. 3 Cyclosporine is used to treat psoriasis, rheumatoid arthritis, multiple sclerosis, myasthenia gravis, scleroderma, and is used to prevent organ transplant rejection. 4 Mycophenolate mofetil is used to treat scleroderma, lupus, and to prevent organ transplant rejection. PTS: 1 CON: Inflammation | Medication 13. ANS: 2 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Discussing the medical management of: Excessive immune response Chapter page reference: 377-390 Heading: Excessive Immune Response Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Inflammation; Medication Difficulty: Moderate Feedback 1 Epinephrine is not used in the treatment of automimmune hepatitis. 2 Azathioprine is used to treat autoimmune hepatitis and rheumatoid arthritis. 3 Cyclosporine is used to treat psoriasis, rheumatoid arthritis, multiple sclerosis, myasthenia gravis, sclerodermNa,UaR ndSiI s uNsG edTtoB pr .CevOent M organ transplant rejection. 4 Mycophenolate mofetil is used to treat scleroderma, lupus, and to prevent organ transplant rejection. PTS: 1 CON: Inflammation | Medication 14. ANS: 4 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Discussing the medical management of: Excessive immune response Chapter page reference: 377-390 Heading: Excessive Immune Response Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Inflammation; Medication Difficulty: Moderate Feedback 1 Epinephrine is not used in the treatment of lupus. 2 Azathioprine is used to treat autoimmune hepatitis and rheumatoid arthritis. 3 Cyclosporine is used to treat psoriasis, rheumatoid arthritis, multiple sclerosis, myasthenia gravis, scleroderma, and is used to prevent organ transplant rejection. 4 Mycophenolate mofetil is used to treat scleroderma, lupus, and to prevent organ transplant rejection. PTS: 1
CON: Inflammation | Medication
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15. ANS: 4 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune dysfunction Chapter page reference: 377-390 Heading: Excessive Immune Response Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Nursing Difficulty: Difficult Feedback 1 While assessing the patient’s vital signs per policy is important, this is not the priority nursing action to decrease the risk of a transfusion reaction. 2 While documenting the procedure in the medical record is important, this is not the priority nursing action to decrease the risk of a transfusion reaction. 3 While verifying the patient’s identity using two identifiers is important, this is not the priority nursing action to decrease the risk of a transfusion reaction. 4 The priority nursing action to decrease the risk of a transfusion reaction is to ensure the bag contains the correct blood type for the patient. PTS: 1 CON: Nursing 16. ANS: 4 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Discussing the medical management of: B-cell deficiencies NURSINGTB.COM Chapter page reference: 373 Heading: Primary Immune Dysfunction Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Infection; Medication Difficulty: Moderate Feedback 1 Diphenhydramine is not the anticipated pharmacological treatment for this patient. 2 Corticosteroids are not the anticipated pharmacological treatment for this patient. 3 Epinephrine is not the anticipated pharmacological treatment for this patient. 4 IVIG is the anticipated pharmacological treatment for this patient. PTS: 1 CON: Infection | Medication 17. ANS: 1 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune dysfunction Chapter page reference: 374-375 Heading: Primary Immune Dysfunction Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Infection
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Difficulty: Moderate
1 2 3 4
Feedback Patients diagnosed with XLA should be immunized with IPV versus oral polio vaccine due to the risk of developing vaccine-acquired polio. IVIG should be administered every three to four weeks, not every six months. Education regarding low, not high, dose prophylactic antibiotics is required. Periodic chest x-rays, not MRIs, to monitor for respiratory complications are included in the plan of care.
PTS: 1 CON: Infection 18. ANS: 3 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Describing complications associated with selected immune dysfunctions Chapter page reference: 374 Heading: Primary Immune Dysfunction Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Wheezing is not anticipated for this patient. 2 Rhonchi is not anticipated for this patient. 3 Tachypnea, or increased respira Nto URrySraIteN, isGTanBti.ciCp aOteMd for this patient. 4 Absent or decreased breath sounds, not eupnea, is anticipated for this patient. PTS: 1 CON: Infection 19. ANS: 1 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune dysfunction Chapter page reference: 373 Heading: Primary Immune Dysfunction Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 The priority nursing diagnosis for a patient diagnosed with XLA is an increased risk for infection. 2 This is not the priority nursing diagnosis for this patient. 3 This is not the priority nursing diagnosis for this patient. 4 This is not the priority nursing diagnosis for this patient. PTS: 1 20. ANS: 2
CON: Infection
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Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: B-cell deficiencies Chapter page reference: 368-371 Heading: Primary Immune Dysfunction Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Poor muscle tone is classified as an “other” manifestation of DiGeorge’s syndrome. 2 Failure to thrive is a general manifestation of DiGeorge’s syndrome. 3 Shortness of breath is a respiratory manifestation of DiGeorge’s syndrome. 4 Delayed development is classified as an “other” manifestation of DiGeorge’s syndrome. PTS: 1 CON: Infection 21. ANS: 3 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: B-cell deficiencies Chapter page reference: 368-371 Heading: Primary Immune Dysfunction Integrated Processes: Nursing Process – Assessment Client Need: Physiological IntegrityNURSINGTB.COM – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Poor muscle tone is classified as an “other” manifestation of DiGeorge’s syndrome. 2 Failure to thrive is a general manifestation of DiGeorge’s syndrome. 3 Shortness of breath is a respiratory manifestation of DiGeorge’s syndrome. 4 Delayed development is classified as an “other” manifestation of DiGeorge’s syndrome. PTS: 1 CON: Infection 22. ANS: 2 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune dysfunction Chapter page reference: 371-375 Heading: Primary Immune Dysfunction Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback
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3 4
Sodium is not an electrolyte the nurse should plan to monitor when providing care to this patient. A patient with DiGeorge’s syndrome often has hypoparathyroidism resulting in a decreased serum calcium level; therefore, the nurse would plan to monitor the patient’s calcium. Potassium is not an electrolyte the nurse should plan to monitor when providing care to this patient. Magnesium is not anticipated to be affected by this diagnosis.
PTS: 1 CON: Infection 23. ANS: 1 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune dysfunction Chapter page reference: 371-375 Heading: Primary Immune Dysfunction Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 Hand hygiene is the priority nursing action to decrease this patient’s risk for infection. 2 Reverse isolation decreases the risk for infection for a patient who is neutropenic. 3 Prokinetic agents are administN erU edRtoS th testinal symptoms. INis Gp ati T Ben.t CfoOr gastroin M 4 Droplet precautions are implemented for a patient with a communicable disease. PTS: 1 CON: Infection 24. ANS: 3 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune dysfunction Chapter page reference: 371-375 Heading: Primary Immune Dysfunction Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection; Medication Difficulty: Moderate Feedback 1 Hand hygiene is the priority nursing action to decrease this patient’s risk for infection. This is not appropriate to treat GERD. 2 Reverse isolation decreases the risk for infection for a patient who is neutropenic. 3 Prokinetic agents are administered to treat GERD for this patient. 4 Droplet precautions are implemented for a patient with a communicable disease. PTS: 1 25. ANS: 4
CON: Infection
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Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune dysfunction Chapter page reference: 375-377 Heading: Secondary Immune Dysfunction Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Chemotherapy does not cause B-cell deficiency. 2 Chemotherapy does not cause T-cell deficiency. 3 Chemotherapy does not cause an excessive immune response. 4 Chemotherapy often results in a secondary immune deficiency. PTS: 1
CON: Infection
MULTIPLE RESPONSE 26. ANS: 1, 4, 5 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Excessive immune response Chapter page reference: 383 NURSINGTB.COM Heading: Excessive Immune Response Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Inflammation Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is correct. General symptoms of shock that would necessitate an epinephrine injection include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. The skin may feel cold and clammy in shock. This is incorrect. The skin will not be warm and dry to the touch. This is incorrect. In shock, the patient will not be hyperactive or hyperverbal. This is correct. Thirst is a common complaint in shock. This is correct. General symptoms of shock that would necessitate an epinephrine injection include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy. The skin may feel cold and clammy in shock.
PTS: 1 CON: Inflammation 27. ANS: 1, 5 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune dysfunction
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Chapter page reference: 370 Heading: Primary Immune Dysfunction Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is correct. Persistent oral thrush is an indication of immune deficiency. This is incorrect. A tinea infection of the feet does not support suspected immune deficiency. This is incorrect. Two, not one, occurrence of pneumonia within in one-year period indicates immune deficiency. This is incorrect. Six, not four, or more infections in a one-year period supports the diagnosis of immune deficiency. This is correct. Two or more serious sinus infections in a one-year period supports the diagnosis of immune deficiency.
PTS: 1 CON: Infection 28. ANS: 1, 2, 3, 4 Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: B-cell deficiencies Chapter page reference: 371-375 Heading: Primary Immune Dysfunction NURSINGTB.COM Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate
1. 2. 3. 4. 5.
PTS: 1
Feedback This is correct. A heart murmur indicates a cardiovascular abnormality. This is correct. Cyanosis indicates a cardiovascular abnormality. This is correct. Polycythemia indicates a cardiovascular abnormality. This is correct. Failure to thrive indicates a cardiovascular abnormality. This is incorrect. While cleft lip and palate often occurs with this syndrome, this data does not indicate a cardiovascular abnormality. CON: Infection
Chapter 21 Coordinating Care for Patients With Multidrug-Resistant Organism Infectious Disorders
Chapter 21: Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders
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Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is planning care for several patients in the hospital environment. Which is a risk factor for a patient developing hospital-acquired MRSA? 1) Recent use of antibiotics 2) Recent surgical procedure 3) Current intensive care unit stay 4) Prolonged rehabilitation unit stay 2. The nurse is planning care for several patients in the hospital environment. Which is a risk factor for a patient developing Clostridium difficile? 1) Recent use of antibiotics 2) Recent surgical procedure 3) Current intensive care unit stay 4) Prolonged rehabilitation unit stay 3. The nurse is planning care for several patients in the hospital environment. Which is a risk factor for a patient developing Acinetobacter baumannii? 1) Recent use of antibiotics 2) Recent surgical procedure 3) Current intensive care unit stay 4) Prolonged rehabilitation unit stay 4. The nurse is planning care for severaN l pUatie RSn tsI NinGthTeBh.osCp OitaMl environment. Which is a risk factor for a patient developing VRE? 1) Recent use of antibiotics 2) Recent surgical procedure 3) Current intensive care unit stay 4) Prolonged rehabilitation unit stay 5. The nurse is planning care for several patients. Which is a risk factor for a patient developing communityacquired MRSA? 1) Recent use of antibiotics 2) Recent surgical procedure 3) Being younger than 2 years of age 4) Being older than 65 years of age 6. The nurse is providing care to a several patients in the hospital environment. Which patient should the nurse include education regarding the need for increased fluid intake in the plan of care? 1) The patient diagnosed with VRE 2) The patient diagnosed with MRSA 3) The patient diagnosed with Acinetobacter 4) The patient diagnosed with Clostridium difficile 7. The nurse is providing care to a several patients in the hospital environment. Which patient requires the nurse to closely monitor respiratory status? 1) The patient diagnosed with VRE 2) The patient diagnosed with MRSA 3) The patient diagnosed with Acinetobacter
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4) The patient diagnosed with Clostridium difficile 8. Which is the priority nursing action to decrease the risk of spreading infection among patients diagnosed with Multidrug-Resistant Organisms? 1) Performing hand hygiene before and after care 2) Donning appropriate personal protective equipment (PPE) 3) Administering prescribed doses of antibiotics as scheduled 4) Monitoring for clinical manifestations of bacterial illnesses 9. Which antibiotic prescription should the nurse anticipate when providing care to a patient who is diagnosed with multi-drug resistant (MDR) MRSA? 1) Vancomycin 2) Metronidazole 3) Ampicillin-sulbactam 4) Quinupristin-dalfopristin 10. Which antibiotic prescription should the nurse anticipate when providing care to a patient who is diagnosed with multi-drug resistant (MDR) VRE? 1) Vancomycin 2) Metronidazole 3) Ampicillin-sulbactam 4) Quinupristin-dalfopristin 11. Which antibiotic prescription should the nurse anticipate when providing care to a patient who is diagnosed with multi-drug resistant (MDR) Clostridium difficile? 1) Vancomycin 2) Metronidazole NURSINGTB.COM 3) Ampicillin-sulbactam 4) Quinupristin-dalfopristin 12. Which antibiotic prescription should the nurse anticipate when providing care to a patient who is diagnosed with multi-drug resistant (MDR) Acinetobacter? 1) Vancomycin 2) Metronidazole 3) Ampicillin-sulbactam 4) Quinupristin-dalfopristin 13. The nurse is providing education to a patient who is diagnosed with Clostridium difficile. Which patient statement indicates correct understanding regarding the cause of inflammation? 1) “The bacteria cause the inflammation.” 2) “Toxins released from the bacteria cause inflammation.” 3) “The bacteria directly affect the blood vessels, causing inflammation.” 4) “The toxins are released from the pseudomembrane causing inflammation.” 14. The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates correct understanding of contact transmission? 1) “It occurs when I get bit by a tick or other insect.” 2) “It occurs when I come in direct contact with a pathogen.” 3) “It occurs when I come into contact with pathogens in the air.” 4) “It occurs when I ingest food containing a disease-carrying organism.”
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15. The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates correct understanding of vector-borne transmission? 1) “It occurs when I get bit by a tick or other insect.” 2) “It occurs when I come in direct contact with a pathogen.” 3) “It occurs when I come into contact with pathogens in the air.” 4) “It occurs when I ingest food containing a disease-carrying organism.” 16. The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates correct understanding of airborne transmission? 1) “It occurs when I get bit by a tick or other insect.” 2) “It occurs when I come in direct contact with a pathogen.” 3) “It occurs when I come into contact with pathogens by breathing.” 4) “It occurs when I ingest food containing a disease-carrying organism.” 17. The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates correct understanding of vehicle transmission? 1) “It occurs when I get bit by a tick or other insect.” 2) “It occurs when I come in direct contact with a pathogen.” 3) “It occurs when I come into contact with pathogens in the air.” 4) “It occurs when I ingest food containing a disease-carrying organism.” 18. The nurse is conducting an in-service on the spread of infection in the hospital environment. Which statement should the nurse include regarding the most common mode of pathogen transmission? 1) “Contact transmission is the most common mode.” 2) “Vehicle transmission is the most common mode.” 3) “Airborne transmission is the most common mode.” 4) “Vector-bo rne transmission is thNe UmRo S st I c oNmGmToB n . mC o dOe M .” 19. The infection prevention and control nurse is providing an in-service regarding multi-drug resistant (MDR) infection. Which is the most common site of MDR MRSA colonization the nurse should include in the presentation? 1) Throat 2) Axillae 3) Perineum 4) Anterior nares 20. Which nursing action is appropriate when providing care to a patient who is diagnosed with multi-drug resistant (MDR) MRSA? 1) Implementing isolation precautions 2) Implementing standard precautions only 3) Washing hands with soap and water only 4) Wearing a gown that is tied at the neck but not at the waist Multiple Response Identify one or more choices that best complete the statement or answer the question. 21. Which is being studied when a nurse participates in the BUGG (benefits of universal gown and gloving) research initiative? Select all that apply. 1) Decreasing the length of the hospital stay 2) Decreasing the frequency of adverse events 3) Increasing the risk for antibiotic resistance
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4) Decreasing the risk for hospital-acquired infection 5) Decreasing the risk for being diagnosed with a bacterial infection during hospitalization 22. The nurse is providing care to a patient diagnosed with a MRSA skin infection. Which clinical manifestations should the nurse anticipate during the patient assessment? Select all that apply. 1) Pus 2) Edema 3) Tachypnea 4) Discomfort 5) Bradycardia 23. Which clinical manifestations should the nurse anticipate when assessing any patient diagnosed with a multidrug resistant (MDR) infection? Select all that apply. 1) Fever 2) Tachypnea 3) Tachycardia 4) Hypertension 5) Hypervolemia 24. Which assessment data supports the nursing diagnosis of deficient fluid volume for a patient diagnosed with Clostridium difficile? Select all that apply. 1) Decreased skin turgor 2) Increased urine output 3) Dry mucous membranes 4) Increased serum creatinine 5) Decreased white blood cells
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25. Which should the nurse include in the plan of care for a patient who is diagnosed with a multi-drug resistant (MDR) pneumonia? Select all that apply. 1) Encourage ambulation 2) Administer prescribed oxygen 3) Implement chest physiotherapy 4) Perform wound care as prescribed 5) Educate that alcohol-based hand gels are ineffective 26. Which nursing actions are appropriate when collecting a stool sample to determine if a patient is experiencing a C. diff. infection? Select all that apply. 1) Holding the sample for twenty-four hours 2) Keeping the sample at room temperature 3) Sending the sample to the laboratory immediately 4) Preparing a requisition for a culture and sensitivity 5) Using an alcohol-based hand gel before and after care
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Chapter 21: Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders Chapter page reference: 393-394 Heading: Multidrug-Resistant Organisms Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Recent use of antibiotics is a risk factor for Clostridium difficile. 2 Recent surgical procedure is a risk factor for Acinetobacter baumannii. 3 Current or recent hospitalization increases the risk for hospital-acquired MRSA. 4 A prolonged rehabilitation stay increases the risk for VRE. PTS: 1 CON: InfectioNn URSINGTB.COM 2. ANS: 1 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders Chapter page reference: 397-398 Heading: Multidrug-Resistant Organisms Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Recent use of antibiotics is a risk factor for Clostridium difficile. 2 Recent surgical procedure is a risk factor for Acinetobacter baumannii. 3 Current or recent hospitalization increases the risk for hospital-acquired MRSA. 4 A prolonged rehabilitation stay increases the risk for VRE. PTS: 1 CON: Infection 3. ANS: 2 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders Chapter page reference: 399 Heading: Multidrug-Resistant Organisms
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Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Recent use of antibiotics is a risk factor for Clostridium difficile. 2 Recent surgical procedure is a risk factor for Acinetobacter baumannii. 3 Current or recent hospitalization increases the risk for hospital-acquired MRSA. 4 A prolonged rehabilitation stay increases the risk for VRE. PTS: 1 CON: Infection 4. ANS: 4 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders Chapter page reference: 395-396 Heading: Multidrug-Resistant Organisms Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Recent use of antibiotics is a rN iskU fa R cto SIrNfoGr TCBlo.stCridOiuMm difficile. 2 Recent surgical procedure is a risk factor for Acinetobacter baumannii. 3 Current or recent hospitalization increases the risk for hospital-acquired MRSA. 4 A prolonged rehabilitation stay increases the risk for VRE. PTS: 1 CON: Infection 5. ANS: 3 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders Chapter page reference: 393-394 Heading: Multidrug-Resistant Organisms Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy 1 2 3 4
Feedback Recent use of antibiotics is a risk factor for Clostridium difficile. Recent surgical procedure is a risk factor for Acinetobacter baumannii. A patient who is younger than 2 years of age is at an increased risk for communityacquired MRSA. A patient who is older than 65 years of age is not at an increased risk for communityacquired MRSA.
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PTS: 1 CON: Infection 6. ANS: 4 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with multidrug-resistant organism infectious disorders Chapter page reference: 404-406 Heading: Nursing Management Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 This patient is not an increased risk for alterations in fluid and electrolytes. 2 This patient is not an increased risk for alterations in fluid and electrolytes. 3 This patient is not an increased risk for alterations in fluid and electrolytes. 4 This patient is at risk for both fluid and electrolyte imbalances; therefore, the nurse should include education regarding these topics in the patient’s plan of care. PTS: 1 CON: Infection 7. ANS: 3 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders NURSINGTB.COM Chapter learning objective: Developing a comprehensive plan of nursing care for patients with multidrugresistant organism infectious disorders Chapter page reference: 404-406 Heading: Nursing Management Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection; Oxygenation Difficulty: Moderate Feedback 1 This patient is not an increased risk for respiratory issues. 2 This patient is not an increased risk for respiratory issues. 3 This patient is at an increased risk for requiring mechanical ventilation; therefore, the nurse should monitor this patient’s respiratory status closely. 4 This patient is at risk for both fluid and electrolyte imbalances, not respiratory issues. PTS: 1 CON: Infection | Oxygenation 8. ANS: 1 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with multidrugresistant organism infectious disorders Chapter page reference: 404-406 Heading: Nursing Management
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Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 Hand hygiene, or hand washing, is the most important intervention to decrease the risk for infection. 2 While donning appropriate PPE decreases the risk for spreading infection, this is not the priority. 3 Administering prescribed doses of antibiotics as scheduled decreases the risk for antibiotic resistance, not infection. 4 While early diagnosis may decrease the risk for spreading infection, this is not the priority. PTS: 1 CON: Infection 9. ANS: 1 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Discussing the medical management of: Methicillin-resistant Staphylococcus aureus Chapter page reference: 401-404 Heading: Management of Multidrug-Resistant Organisms Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [ApplyiN ngU] RSINGTB.COM Concept: Infection; Medication Difficulty: Moderate Feedback 1 Vancomycin is a drug that the nurse anticipates administering when providing care to a patient who is diagnosed with MDR MRSA. 2 Metronidazole is a drug that the nurse anticipates administering when providing care to a patient who is diagnosed with MDR Clostridium difficile. 3 Ampicillin-sulbactam is a drug that the nurse anticipates administering when providing care to a patient who is diagnosed with MDR Acinetobacter. 4 Quinupristin-dalfopristin is a drug that the nurse anticipates administering when providing care to a patient who is diagnosed with MDR VRE. PTS: 1 CON: Infection | Medication 10. ANS: 4 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Discussing the medical management of: Vancomycin-resistant enterococci Chapter page reference: 401-404 Heading: Management of Multidrug-Resistant Organisms Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Infection; Medication
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Difficulty: Moderate Feedback 1 Vancomycin is a drug that the nurse anticipates administering when providing care to a patient who is diagnosed with MDR MRSA. 2 Metronidazole is a drug that the nurse anticipates administering when providing care to a patient who is diagnosed with MDR Clostridium difficile. 3 Ampicillin-sulbactam is a drug that the nurse anticipates administering when providing care to a patient who is diagnosed with MDR Acinetobacter. 4 Quinupristin-dalfopristin is a drug that the nurse anticipates administering when providing care to a patient who is diagnosed with MDR VRE. PTS: 1 CON: Infection | Medication 11. ANS: 2 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Discussing the medical management of: Clostridium difficile Chapter page reference: 401-404 Heading: Management of Multidrug-Resistant Organisms Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Infection; Medication Difficulty: Moderate Feedback 1 Vancomycin is a drug that theNnur URseSaIn tNicGipTatBes.adCmOiMn isterin g when providing care to a patient who is diagnosed with MDR MRSA. 2 Metronidazole is a drug that the nurse anticipates administering when providing care to a patient who is diagnosed with MDR Clostridium difficile. 3 Ampicillin-sulbactam is a drug that the nurse anticipates administering when providing care to a patient who is diagnosed with MDR Acinetobacter. 4 Quinupristin-dalfopristin is a drug that the nurse anticipates administering when providing care to a patient who is diagnosed with MDR VRE. PTS: 1 CON: Infection | Medication 12. ANS: 3 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Discussing the medical management of: Acinetobacter baumannii Chapter page reference: 401-404 Heading: Management of Multidrug-Resistant Organisms Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Infection; Medication Difficulty: Moderate Feedback 1 Vancomycin is a drug that the nurse anticipates administering when providing care to a patient who is diagnosed with MDR MRSA.
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2 3 4
Metronidazole is a drug that the nurse anticipates administering when providing care to a patient who is diagnosed with MDR Clostridium difficile. Ampicillin-sulbactam is a drug that the nurse anticipates administering when providing care to a patient who is diagnosed with MDR Acinetobacter. Quinupristin-dalfopristin is a drug that the nurse anticipates administering when providing care to a patient who is diagnosed with MDR VRE.
PTS: 1 CON: Infection | Medication 13. ANS: 2 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Clostridium difficile Chapter page reference: 398 Heading: Multidrug-Resistant Organisms Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult
1 2 3 4
Feedback This statement does not indicate correct understanding regarding the cause of inflammation for a patient diagnosed with Clostridium difficile. The bacteria release toxins whN icU h R arS e re INspGonTsBib.leCfoOr Mthe inflammation that occurs with a Clostridium difficile infection. This patient statement indicates correct understanding. This statement does not indicate correct understanding regarding the cause of inflammation for a patient diagnosed with Clostridium difficile. This statement does not indicate correct understanding regarding the cause of inflammation for a patient diagnosed with Clostridium difficile.
PTS: 1 CON: Infection 14. ANS: 2 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders Chapter page reference: 393 Heading: Introduction Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 This statement indicates correct understanding of vector-borne transmission. 2 This statement indicates correct understanding of contact transmission. 3 This statement indicates correct understanding of airborne transmission. 4 This statement indicates correct understanding of vehicle transmission.
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PTS: 1 CON: Infection 15. ANS: 1 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders Chapter page reference: 393 Heading: Introduction Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 This statement indicates correct understanding of vector-borne transmission. 2 This statement indicates correct understanding of contact transmission. 3 This statement indicates correct understanding of airborne transmission. 4 This statement indicates correct understanding of vehicle transmission. PTS: 1 CON: Infection 16. ANS: 3 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders Chapter page reference: 393 Heading: Introduction NURSINGTB.COM Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 This statement indicates correct understanding of vector-borne transmission. 2 This statement indicates correct understanding of contact transmission. 3 This statement indicates correct understanding of airborne transmission. 4 This statement indicates correct understanding of vehicle transmission. PTS: 1 CON: Infection 17. ANS: 4 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders Chapter page reference: 393 Heading: Introduction Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback
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1 2 3 4
This statement indicates correct understanding of vector-borne transmission. This statement indicates correct understanding of contact transmission. This statement indicates correct understanding of airborne transmission. This statement indicates correct understanding of vehicle transmission.
PTS: 1 CON: Infection 18. ANS: 1 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders Chapter page reference: 393 Heading: Introduction Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Knowledge [Remembering] Concept: Infection Difficulty: Easy Feedback 1 Contact transmission is the most common mode of pathogen transmission. 2 Vehicle transmission is not the most common mode of pathogen transmission. 3 Airborne transmission is not the most common mode of pathogen transmission. 4 Vector-borne transmission is not the most common mode of pathogen transmission. PTS: 1 CON: Infection 19. ANS: 4 NURSINGTB.COM Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Methicillin-resistant Staphylococcus auerus Chapter page reference: 393 Heading: Multidrug-Resistant Organisms Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 While MRSA colonization often occurs in the throat, this is not the most common site of colonization. 2 While MRSA colonization often occurs in the axillae, this is not the most common site of colonization. 3 While MRSA colonization often occurs in the perineum, this is not the most common site of colonization. 4 The most common site of MRSA colonization is the anterior nares. PTS: 1 20. ANS: 1
CON: Infection
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Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Discussing the medical management of: Methicillin-resistant Staphylococcus aureus Chapter page reference: 401 Heading: Management of Multidrug-Resistant Organisms Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 A patient diagnosed with MDR MRSA requires isolation precautions, specifically contact precautions. 2 This patient would require isolation, not standard, precautions. 3 The patient diagnosed with MDR MRSA does not require the implementation of hand hygiene with soap and water only. This intervention is appropriate for the patient diagnosed with Clostridium difficile. 4 Gowns should be tied at the neck and waist in order to decrease the risk for disease transmission. PTS: 1
CON: Infection
MULTIPLE RESPONSE
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21. ANS: 1, 2, 4, 5 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with multidrugresistant organism infectious disorders Chapter page reference: 406 Heading: Nursing Management Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Easy
1.
2.
3.
Feedback This is correct. The BUGG study will test if doctors, nurses, and others wearing gloves and a gown while caring for all patients in an intensive care unit (ICU) will decrease the length of the hospital stay. This is correct. The BUGG study will test if doctors, nurses, and others wearing gloves and a gown while caring for all patients in an intensive care unit (ICU) will decrease the frequency of adverse events. This is incorrect. The BUGG study does not test for an increase in the risk for antibiotic resistance.
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4.
5.
This is correct. The BUGG study will test if doctors, nurses, and others wearing gloves and a gown while caring for all patients in an intensive care unit (ICU) will decrease the risk for hospital-acquired infection. This is correct. The BUGG study will test if doctors, nurses, and others wearing gloves and a gown while caring for all patients in an intensive care unit (ICU) will decrease the risk for hospital-acquired infection.
PTS: 1 CON: Evidence-Based Practice 22. ANS: 1, 2, 4 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Methicillin-resistant Staphylococcus auerus Chapter page reference: 405 Heading: Multidrug-Resistant Organisms Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is correct. Pus is a clinical manifestation associated with a MRSA skin infection. T inhf iesctisiocno.rrect. Edema, or swelling, is a clinical manifestation associated with a MRSA skin
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This is incorrect. Tachypnea may occur with a systemic, not localized, MRSA skin infection. This is correct. Discomfort, or pain, is a clinical manifestation associated with a MRSA skin infection. This is incorrect. Bradycardia may occur with a systemic, not localized, MRSA skin infection.
PTS: 1 CON: Infection 23. ANS: 1, 2, 3 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with multidrugresistant organism infectious disorders Chapter page reference: 405 Heading: Multidrug-Resistant Organisms Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy
1. 2.
Feedback This is correct. Hyperthermia, or fever, is an anticipated clinical manifestation when providing care to any patient diagnosed with a MDR infection. This is correct. Tachypnea, or an increased rate of respirations, is an anticipated clinical manifestation when providing care to any patient diagnosed with a MDR infection.
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3. 4. 5.
This is correct. Tachycardia, or an increased heart rate, is an anticipated clinical manifestation when providing care to any patient diagnosed with a MDR infection. This is incorrect. Hypertension is not an anticipated clinical manifestation for a patient diagnosed with an MDR infection. This is incorrect. Hypovolemia is an anticipated clinical manifestation for a patient diagnosed with an MDR infection.
PTS: 1 CON: Infection 24. ANS: 1, 3, 4 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with multidrugresistant organism infectious disorders Chapter page reference: 404-406 Heading: Nursing Management Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is correct. Decreased skin turgor often occurs due to dehydration; therefore, this supports the current nursing diagnosis. This is incorrect. A decrN eaUseRdS , nIotNiG ncTreBas.e d, C Ou Mrine output supports the current nursing diagnosis. This is correct. Dry mucous membranes often occur due to dehydration; therefore, this supports the current nursing diagnosis. This is correct. An increased serum creatinine level often occurs due to dehydration; therefore, this supports the current nursing diagnosis. This is incorrect. Increased white blood cell count is anticipated due to infection; however, this does not support the current nursing diagnosis.
PTS: 1 CON: Infection 25. ANS: 1, 2, 3 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with multidrugresistant organism infectious disorders Chapter page reference: 404-406 Heading: Nursing Management Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection; Oxygenation Difficulty: Moderate Feedback
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1. 2. 3. 4. 5.
This is correct. The nurse should include ambulation in the patient’s plan of care to decrease the risk for atelectasis. This is correct. The nurse should include administration of prescribed oxygen in the patient’s plan of care to increase oxygen saturation. This is correct. The nurse should include chest physiotherapy in the patient’s plan of care to mobilize secretions and increase oxygen saturation. This is incorrect. Wound care is included in the plan of care for a patient with an MDR MRSA skin infection, not pneumonia. This is incorrect. Alcohol-based hand gels are effective to decrease the risk for infection with all MDR infections with the exception of Clostridium difficile, not pneumonia.
PTS: 1 CON: Infection | Oxygenation 26. ANS: 3, 4 Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of infectious disorders Chapter page reference: 400-401 Heading: Management of Multidrug-Resistant Organisms Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate
1. 2. 3.
4. 5.
PTS: 1
NURSINGTB.COM Feedback This is incorrect. The sample should be sent to the laboratory immediately as a false-negative may occur if the sample is not tested within two hours of collection. This is incorrect. The C diff toxins are unstable at room temperature, and false-negative results may occur in samples that are not tested within two hours of collection. This is correct. The sample is sent to the laboratory immediately as C diff toxins are unstable at room temperature, and false-negative results may occur in samples that are not tested within two hours of collection. This is correct. A laboratory requisition for a culture and sensitivity is required when sending a stool sample to the laboratory to determine the presence of C diff. This is incorrect. Any patient who is suspected of having C diff will require hand hygiene with soap and water as alcohol-based hand gel displaces this organism but does not kill it. CON: Infection
Chapter 22: Coordinating Care for Patients With HIV Multiple Choice Identify the choice that best completes the statement or answers the question.
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1. The nurse is caring for a patient with acquired immunodeficiency syndrome (AIDS) who is in antiretroviral therapy. The patient reports nausea, fever, severe diarrhea, and anorexia. Which prescribed medication does the nurse anticipate in order to relieve the anorexia and to stimulate the patient’s appetite? 1) Dronabinol (Marinol) 2) Abacavir (Ziagen) 3) Ciprofloxacin (Cipro) 4) Zidovudine (Retrovir, AZT) 2. A nurse is performing an admission assessment on a patient with symptoms that indicate human immunodeficiency virus (HIV). Which question from the nurse addresses a major risk factor for contracting HIV? 1) “Has your partner been experiencing these symptoms?” 2) “When was your first sexual experience?” 3) “Have you had any fever, diarrhea, or chills over the last 48 hours?” 4) “Have you ever experimented with intravenous drugs?” 3. The nurse is discharging a pediatric patient who was recently diagnosed with acquired immunodeficiency syndrome (AIDS). When discussing appropriate health promotion activities for this child, which immunization is contraindicated? 1) Varicella vaccine 2) Haemophilus influenzae type B (HIB conjugate vaccine) 3) Hepatitis B vaccine (hep B) 4) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) 4. A nurse is developing a plan of care for a patient diagnosed with human immunodeficiency virus (HIV). The patient states, “I don’t plan on giving up sex just because I am HIV positive.” Based on this data, which is the priority nursing diagnosis for this patN ieU ntR ? SINGTB.COM 1) Risk for Infection 2) Death Anxiety 3) Deficient Knowledge 4) Social Isolation 5. The nurse is caring for a patient who is newly diagnosed with human immunodeficiency virus (HIV). The patient asks the nurse if there are ways to protect the patient’s life partner from getting the HIV virus. After educating the patient, which statement indicates the need for further education? 1) “I know to use an oil-based lubricant to prevent spread of the disease to my partner.” 2) “I can still kiss and hug my partner to show affection.” 3) “I will not share my razor with my partner.” 4) “I know I have to practice safer sex with my partner by using a latex condom.” 6. A home health nurse is conducting home visits for several patients who are diagnosed with acquired immunodeficiency syndrome (AIDS). Which patient would the nurse see first? 1) A patient who is receiving lamivudine (Epivir) because of a diagnosis of a low CD4 cell count 2) A patient with Pneumocystis carinii pneumonia (PCP) who called the office this morning to report a new onset of fever, cough, and shortness of breath 3) A patient with wasting syndrome who needs modifications and education regarding dietary changes 4) A patient who is receiving IV antibiotics daily for toxoplasmosis
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7. The nurse is providing care to a pediatric patient who is HIV-positive. The patient’s mother is describing the child’s current condition and activities to the nurse. Which parental statement indicates that the child may require further intervention? 1) “My child seems somewhat isolated and doesn't have any real friends.” 2) “My child has a good appetite and eats regular meals.” 3) “My child hasn't shown any sign of infection.” 4) “My child attends school and doing well in class.” 8. A nurse working in an intensive care unit (ICU) is assigned a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Based on this data, which type of precaution does the nurse implement when providing direct care? 1) Droplet 2) Reverse 3) Standard 4) Contact 9. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of 500 cells/L. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3 10. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of 300 cells/L. Which classification of HIV should the nurse document for this patient? 1) Stage 0 NURSINGTB.COM 2) Stage 1 3) Stage 2 4) Stage 3 11. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of less than 200 cells/L. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3 12. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient has lost 15% of body weight since the last appointment. Which reason should the nurse include in a teaching session for this patient regarding this occurrence? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia 13. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient presents with a fever without other notable symptoms. Which is the most likely cause of this data? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia
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14. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient reports night sweats. Which is the most likely reason for this clinical manifestation? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia 15. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient has shortness of breath when walking, but no problems breathing at rest. Which is the most likely cause for this clinical manifestation? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia 16. The nurse is assessing a patient who is diagnosed with human immunodeficiency virus (HIV) who presents with a rash. Which assessment question is most appropriate? 1) “Are you taking Bactrim?” 2) “Have you recently used a new soap?” 3) “What have you eaten in the last few days?” 4) “Did you have unprotected sex within the last week?” 17. Which immunization should the nurse encourage for a patient who is diagnosed with Stage 2 human immunodeficiency virus? 1) Measles, mumps, and rubella (MMR) vaccine 2) Oral polio vaccine (OPV) 3) Influenza vaccine NURSINGTB.COM 4) Varicella vaccine 18. Which is the priority action for a nurse who is exposed to a needle-stick injury while providing patient care? 1) Washing the injury under running water 2) Squeezing the site to remove the patient’s blood 3) Taking two or three drugs for 28 days 4) Consenting to a human immunodeficiency virus (HIV) test 19. Which patient should the nurse offer the opportunity for human immunodeficiency virus (HIV) testing during an annual physical examination? 1) A 66-year-old male patient 2) A 75-year-old female patient 3) An 8-year-old school-age child 4) An 18-year-old young adult patient 20. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient’s CD4+ count is currently 480 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection 21. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient’s CD4+ count is less than 200 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis
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2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection 22. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient’s CD4+ count is greater than 500 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection 23. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient’s CD4+ count is currently 250 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection 24. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). Which patient statement indicates the need for further education regarding HIV management? 1) “I will eat small, frequent meals.” 2) “I will use condoms for every sexual encounter.” 3) “I will take my medications when others can see me, even if that means taking them late.” 4) “I will ask my spouse to clean the cat litter to decrease my risk for developing toxoplasmosis.”
NURSINGTB.COM Completion Complete each statement. 25. Place the progression of human immunodeficiency virus (HIV) in sequential order. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) AIDS 2) Death 3) Seroconversion 4) Viral transmission 5) Acute viral infection 6) Asymptomatic chronic infection 26. Human immunodeficiency virus (HIV) infects and destroys CD4 cells. List the following events in the order in which they occur for a patient who is HIV-positive. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Virus invades helper T cell 2) Viral RNA converts with reverse transcriptase to viral DNA 3) Viral DNA integrates with host cell DNA. 4) Virus remains latent, or actively replicates 5) Virus sheds protein coat
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Multiple Response Identify one or more choices that best complete the statement or answer the question. 27. The nurse is planning care for a pediatric patient diagnosed with human immunodeficiency virus (HIV). The nurse selects Risk for Infection as a priority nursing diagnosis for this pediatric patient. Based on this nursing diagnosis, which actions by the nurse are appropriate? Select all that apply. 1) Administering tuberculosis skin tests every six months 2) Teaching proper food-handling techniques to the family 3) Instructing on the importance of consuming ample fresh fruits and vegetables 4) Assessing the health status of all visitors 5) Monitoring hand-washing techniques used by the family 28. The nurse is reviewing the laboratory values of a patient who is newly diagnosed with acquired immunodeficiency syndrome (AIDS). Which values should be reported to the patient’s health-care provider? Select all that apply. 1) CD4 cell count 1,100/mm3 2) T4 cell count 150 3) CD4 lymphocytes 12% 4) Viral load 11,500 copies/mL 5) WBC 6,500
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Chapter 22: Coordinating Care for Patients With HIV Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological, dietary, and lifestyle considerations for patients with HIV disease Chapter page reference: 415 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Infection; Medication Difficulty: Moderate Feedback 1 Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase patient appetite and promote weight gain. 2 Abacavir (Ziagen) is a potent inhibitor of reverse transcriptase. 3 Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine (Retrovir, AZT) is an antiretroviral agent. 4 Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine (Retrovir, AZT) is an antiretroviral agent.
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PTS: 1 CON: Infection | Medication 2. ANS: 4 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Describing the etiology of HIV disorders Chapter page reference: 409-410 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Assessing recent symptoms, and asking if the patient’s partner is experiencing the same symptoms, does not assess the patient’s risk factors for HIV transmission. 2 The patient’s first sexual experience is not applicable to the patient’s current risk for HIV. 3 Assessing recent symptoms, and asking if the patient’s partner is experiencing the same symptoms, does not assess the patient’s risk factors for HIV transmission. 4 One risk factor for contracting HIV is the use of intravenous recreational drugs. This question is appropriate to determine the patient’s risk for HIV. PTS: 1 3. ANS: 1
CON: Infection
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Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological, dietary, and lifestyle considerations for patients with HIV disease Chapter page reference: 415 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Planning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 A child with an immune disorder such as HIV/AIDS should not be immunized with a live varicella vaccine, because of the risk of contracting the disease. 2 DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on schedule. 3 DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on schedule. 4 DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on schedule. PTS: 1 CON: Infection 4. ANS: 3 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological, dietary, and lifestyle considerations for patients with HIV disease NURSINGTB.COM Chapter page reference: 417 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient Knowledge due to the patient statement, “I don’t plan on giving up sex just because I am HIV positive.” The patient requires education regarding safer sex practices to decrease the risk of transmission to potential sexual partners. 2 While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient Knowledge due to the patient statement, “I don’t plan on giving up sex just because I am HIV positive.” The patient requires education regarding safer sex practices to decrease the risk of transmission to potential sexual partners. 3 While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient Knowledge due to the patient statement, “I don’t plan on giving up sex just because I am HIV positive.” The patient requires education regarding safer sex practices to decrease the risk of transmission to potential sexual partners. 4 While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient Knowledge due to the patient statement, “I don’t plan on giving up sex just because I am HIV positive.” The patient requires education regarding safer sex practices to decrease the risk of transmission to potential sexual partners.
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PTS: 1 CON: Infection 5. ANS: 1 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological, dietary, and lifestyle considerations for patients with HIV disease Chapter page reference: 416 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 The nurse should educate the patient on methods that will decrease the risk of transmitting the HIV. The patient statement regarding the use of an oil-based lubricant requires further education. The patient should use only water-based lubricants, not oilbased, such as petroleum jelly, which can result in condom damage. 2 This patient statement indicates appropriate understanding of the information presented by the nurse. 3 This patient statement indicates appropriate understanding of the information presented by the nurse. 4 This patient statement indicates appropriate understanding of the information presented by the nurse. PTS: 1 CON: InfectioNn URSINGTB.COM 6. ANS: 2 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV Chapter page reference: 417 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 The home health nurse should see the patient with PCP because of the complaint of shortness of breath with the new onset of fever. All of the patients need to be seen by the nurse, but based on the ABCs (airway, breathing, and circulation), the nurse should visit this patient first to obtain vital signs and perform a respiratory assessment. 2 This patient needs to be seen by the nurse; however, based on the ABCs (airway, breathing, and circulation) this patient is not the priority. 3 This patient needs to be seen by the nurse; however, based on the ABCs (airway, breathing, and circulation) this patient is not the priority. 4 This patient needs to be seen by the nurse; however, based on the ABCs (airway, breathing, and circulation) this patient is not the priority. PTS: 1
CON: Infection
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7. ANS: 1 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological, dietary, and lifestyle considerations for patients with HIV disease Chapter page reference: 417-419 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Assessment Client Need: Psychosocial Integrity Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 This statement indicates that the patient is not adequately coping with the current situation and requires further assessment and/or intervention by the nurse. 2 Positive outcomes for an HIV patient would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school. 3 Positive outcomes for an HIV patient would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school. 4 Positive outcomes for an HIV patient would include remaining free from secondary infection, displaying normal nutritional patterns, demonstrating adequate coping with the stress of chronic disease, and attending school. PTS: 1
CON: Infection
PTS: 1 9. ANS: 2
CON: Infection
8. ANS: 3 NURSINGTB.COM Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological, dietary, and lifestyle considerations for patients with HIV disease Chapter page reference: 418 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Droplet precautions are not necessary as HIV is not transmitted via the route. 2 Reverse precautions are needed for a patient who is experiencing neutropenia. 3 Health-care workers can prevent most exposures to HIV by using standard precautions. With standard precautions, the health-care professionals treat all patients alike, eliminating the need to know their HIV status. Treat all high-risk body fluids as if they are infectious, and use barrier precautions to prevent skin, mucous membrane, or percutaneous exposure to these fluids. 4 Contact precautions are not necessary as HIV does not require additional precautions aside from standard precautions.
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Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV Chapter page reference: 409 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Infection; Communication Difficulty: Moderate 1 2 3 4
Feedback This is not a stage for the classification of HIV. Stage 1 is documented for a patient with a CD4+ count of at least 500 cells/L. Stage 2 is documented for a patient with a CD4+ count of 200–499 cells/L. Stage 3 is documented for a patient with a CD4+ count of less than 200 cells/L.
PTS: 1 CON: Infection | Communication 10. ANS: 3 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV Chapter page reference: 409 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] NURSINGTB.COM Concept: Infection; Communication Difficulty: Moderate
1 2 3 4
Feedback This is not a stage for the classification of HIV. Stage 1 is documented for a patient with a CD4+ count of at least 500 cells/L. Stage 2 is documented for a patient with a CD4+ count of 200–499 cells/L. Stage 3 is documented for a patient with a CD4+ count of less than 200 cells/L.
PTS: 1 CON: Infection | Communication 11. ANS: 4 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV Chapter page reference: 409 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Infection; Communication Difficulty: Moderate
1
Feedback This is not a stage for the classification of HIV.
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2 3 4
Stage 1 is documented for a patient with a CD4+ count of at least 500 cells/L. Stage 2 is documented for a patient with a CD4+ count of 200–499 cells/L. Stage 3 is documented for a patient with a CD4+ count of less than 200 cells/L.
PTS: 1 CON: Infection | Communication 12. ANS: 2 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV Chapter page reference: 410 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 A fever is caused by infection. 2 Weight loss is generally caused by worsening of the disease or disease progression. 3 Night sweats are caused by a mycobacterial infection. 4 Dyspnea on exertion, but not at rest, is caused by Pneumocystis carinii pneumonia. PTS: 1 CON: Infection 13. ANS: 1 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: ComparinNgUaR ndScIo N n tG ra T s tB in . g C cliO niMcal presentation s of the disease spectrum of HIV Chapter page reference: 410 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 A fever is caused by infection. 2 Weight loss is generally caused by worsening of the disease or disease progression. 3 Night sweats are caused by a mycobacterial infection. 4 Dyspnea on exertion, but not at rest, is caused by Pneumocystis carinii pneumonia. PTS: 1 CON: Infection 14. ANS: 3 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV Chapter page reference: 410 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection
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Difficulty: Easy Feedback 1 A fever is caused by infection. 2 Weight loss is generally caused by worsening of the disease or disease progression. 3 Night sweats are caused by a mycobacterial infection. 4 Dyspnea on exertion, but not at rest, is caused by Pneumocystis carinii pneumonia. PTS: 1 CON: Infection 15. ANS: 4 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV Chapter page reference: 411 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 A fever is caused by infection. 2 Weight loss is generally caused by worsening of the disease or disease progression. 3 Night sweats are caused by a mycobacterial infection. 4 Dyspnea on exertion, but not at rest, is caused by Pneumocystis carinii pneumonia. PTS: 1 CON: InfectioNn URSINGTB.COM 16. ANS: 1 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV Chapter page reference: 413 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Infection; Assessment Difficulty: Moderate Feedback 1 A new onset rash for a patient diagnosed with HIV is often a delayed reaction to a prophylactic antibiotic, such as Bactrim. This question is the most appropriate. 2 While new soaps can cause a rash, this is not the most appropriate question for a patient diagnosed with HIV who presents with a rash. 3 While new soaps can cause a rash, this is not the most appropriate question for a patient diagnosed with HIV who presents with a rash. 4 Unprotected sex is unlikely to be the cause of a rash. PTS: 1 CON: Infection | Assessment 17. ANS: 3 Chapter number and title: 22, Coordinating Care for Patients With HIV
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Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological, dietary, and lifestyle considerations for patients with HIV disease Chapter page reference: 415 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Planning Client Need: Heath Promotion and Maintenance Cognitive level: Application [Applying] Concept: Promoting Health Difficulty: Moderate Feedback 1 This is a live virus vaccine and is contraindicated for a patient diagnosed with HIV. 2 This is a live virus vaccine and is contraindicated for a patient diagnosed with HIV. 3 The influenza vaccine is not a live virus vaccine and is recommended annually, early in the flu season, for patients with HIV. 4 This is a live virus vaccine and is contraindicated for a patient diagnosed with HIV. PTS: 1 CON: Promoting Health 18. ANS: 1 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological, dietary, and lifestyle considerations for patients with HIV disease Chapter page reference: 415 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Analysis [AnalyzingN ] URSINGTB.COM Concept: Infection Difficulty: Difficult Feedback 1 The priority nursing action in this situation is to wash the injury under running water. 2 The nurse should avoid squeezing the injury as this is likely to increase the risk for infection. 3 The nurse may be prescribed several drugs for 28 days; however, this is not the priority action. 4 The nurse is likely to consent to an HIV test; however, this is not the priority action. PTS: 1 CON: Infection 19. ANS: 4 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Discussing the epidemiology of HIV Chapter page reference: 416 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback
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1 2 3 4
This patient is not within the suggested age range for HIV testing during an annual physical examination. This patient is not within the suggested age range for HIV testing during an annual physical examination. This patient is not within the suggested age range for HIV testing during an annual physical examination. The nurse offers HIV testing to all patients between the ages of 15 years and 65 years of age.
PTS: 1 CON: Infection 20. ANS: 2 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV Chapter page reference: 417 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate 1
2 3 4
Feedback Toxoplasmosis is a complication that occurs when the patient’s CD4+ count drops below 200 cells/L. This complication typically indicates the patient has progressed from HIV to acquired immunoNdef U RicSienIcNy GsyTn dr B .o mCeO(MAIDS). Herpes zoster virus is a complication that occurs when the patient’s CD4+ is between 500 and 350 cells/L. Vaginal candidiasis is a complication that occurs when the patient’s CD4+ count is greater than 500 cells/L. Severe bacterial infection is a complication that occurs when the patient’s CD4+ is 350 and 200 cells/L.
PTS: 1 CON: Infection 21. ANS: 1 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV Chapter page reference: 417 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate 1
Feedback Toxoplasmosis is a complication that occurs when the patient’s CD4+ count drops below 200 cells/L. This complication typically indicates the patient has progressed from HIV to acquired immunodeficiency syndrome (AIDS).
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2 3 4
Herpes zoster virus is a complication that occurs when the patient’s CD4+ is between 500 and 350 cells/L. Vaginal candidiasis is a complication that occurs when the patient’s CD4+ count is greater than 500 cells/L. Severe bacterial infection is a complication that occurs when the patient’s CD4+ is 350 and 200 cells/L.
PTS: 1 CON: Infection 22. ANS: 3 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV Chapter page reference: 417 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate
1
2 3 4
Feedback Toxoplasmosis is a complication that occurs when the patient’s CD4+ count drops below 200 cells/L. This complication typically indicates the patient has progressed from HIV to acquired immunodeficiency syndrome (AIDS). Herpes zoster virus is a complication that occurs when the patient’s CD4+ is between 500 and 350 cells/L. NURSINGTB.COM Vaginal candidiasis is a complication that occurs when the patient’s CD4+ count is greater than 500 cells/L. Severe bacterial infection is a complication that occurs when the patient’s CD4+ is 350 and 200 cells/L.
PTS: 1 CON: Infection 23. ANS: 4 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV Chapter page reference: 417 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate
1
2
Feedback Toxoplasmosis is a complication that occurs when the patient’s CD4+ count drops below 200 cells/L. This complication typically indicates the patient has progressed from HIV to acquired immunodeficiency syndrome (AIDS). Herpes zoster virus is a complication that occurs when the patient’s CD4+ is between 500 and 350 cells/L.
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3 4
Vaginal candidiasis is a complication that occurs when the patient’s CD4+ count is greater than 500 cells/L. Severe bacterial infection is a complication that occurs when the patient’s CD4+ is 350 and 200 cells/L.
PTS: 1 CON: Infection 24. ANS: 3 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological, dietary, and lifestyle considerations for patients with HIV disease Chapter page reference: 419 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 This patient statement indicates correct understanding regarding HIV management. 2 This patient statement indicates correct understanding regarding HIV management. 3 Adherence is essential in managing the progression of the disease. Taking medications as ordered and at the same time each day (plan administration times around activities of daily living) helps maintain therapeutic drug levels and decreases the risk of viral resistance developing. 4 This patient statement indicateNs U coRrrSecIt N unGdT erB stan . CdiOngMregard in g HIV management. PTS: 1
CON: Infection
COMPLETION 25. ANS: 435612 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV Chapter page reference: 411 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback: The progression of HIV is as follows: first, viral transmission occurs; second, seroconversion occurs; next, the patient has symptoms of an acute viral infection; fourth, the patient has an asymptomatic chronic infection; fifth, the patient becomes symptomatic and is diagnosed with AIDS; lastly, the patient dies. PTS: 1 26. ANS:
CON: Infection
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13452 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Describing diagnostic results used to confirm the diagnosis of HIV Chapter page reference: 411 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback: The HIV virus gains entry into helper T cells, uses the cell DNA to replicate, interferes with normal function of the T cells, and destroys the normal cells. PTS: 1
CON: Infection
MULTIPLE RESPONSE 27. ANS: 2, 4, 5 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological, dietary, and lifestyle considerations for patients with HIV disease Chapter page reference: 417-419 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Implementation Client Need: Physiological IntegrityNURSINGTB.COM – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate
1. 2.
3. 4.
Feedback This is incorrect. Tuberculosis skin tests should be administered annually, not every six months. This is correct. A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. This is incorrect. Fresh fruits and vegetables are not recommended for a patient with a depressed immune system. This is correct. A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection.
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5.
This is correct. A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection.
PTS: 1 CON: Infection 28. ANS: 2, 3, 4 Chapter number and title: 22, Coordinating Care for Patients With HIV Chapter learning objective: Describing diagnostic results used to confirm the diagnosis of HIV Chapter page reference: 417-419 Heading: Human Immunodeficiency Virus (HIV) Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate
1.
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PTS: 1
Feedback This is incorrect. The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3 . All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range. This is correct. The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal TmB3.. C CD4 cell count is greateN r U th R anS1I ,0N 00G/ m AlO l M of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range. This is correct. The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range. This is correct. The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3 . All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range. This is incorrect. The risk of opportunistic infection is the most common manifestation of AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal CD4 cell count is greater than 1,000/mm3 . All of the labs are abnormal except for the CD4 cell count and the WBC, which was within normal range. CON: Infection
Chapter 23: Assessment of Respiratory Function
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Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse educator is teaching a student nurse how to auscultate the lungs. Which action by the student nurse indicates the need for further education? 1) Listening to sound over the bony structures 2) Asking the client to sit in an upright position 3) Instructing the client to breathe slowly through mouth 4) Beginning auscultation from lung apices and moving toward intercostal spaces 2. The nurse is providing care to a patient who will need a bronchoscopy. Which patient statement indicates appropriate understanding of the information presented? 1) “I will be awake and aware during the procedure.” 2) “I will require mechanical ventilation after the procedure.” 3) “I will need to have my prothrombin time drawn after the test.” 4) “I will abstain from eating or drinking for eight hours prior to the procedure.” 3. The nurse is conducting a respiratory assessment for a patient who is diagnosed with asthma. Which assessment finding indicates the patient is experiencing airway irritation? 1) Hemoptysis 2) Dry, hacking cough 3) Harsh, barky cough 4) Loose-sounding cough 4. The nurse is assessing a patient who is admitted with a persistent cough and is diagnosed with pulmonary edema. Which assessment finding supports the patient’s diagnosis? 1) Foul smelling sputum NURSINGTB.COM 2) Clear, whitish, or yellow sputum 3) Large amounts of frothy, pink tinged sputum 4) Clear to gray with occasional specks of brown sputum 5. The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding supports this diagnosis? 1) Wheezing 2) Hemoptysis 3) Grey sputum 4) Slightly whitish sputum 6. When percussing the patient’s lung fields, the nurse notes a moderately low-pitched sound over the chest. Which term does the nurse use to describe these sounds? 1) Dull 2) Tympany 3) Resonance 4) Hyperresonance 7. Which diagnostic procedure is used to remove pleural fluid for analysis? 1) Lung biopsy 2) Bronchoscopy 3) Thoracentesis 4) Sputum studies
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8. The nurse is providing care to a patient who undergoes a sputum study. Which will the sputum study help to diagnose? 1) Asthma 2) Lung cancer 3) Bacterial lung infection 4) Chronic obstructive pulmonary disease 9. While auscultating a patient’s chest, the nurse notes wheezing. Based on this data, which diagnosis does the nurse anticipate? 1) Bronchiectasis 2) Pleural effusion 3) Pulmonary edema 4) Chronic obstructive pulmonary disease 10. The nurse is conducting a health history interview for a patient who is diagnosed with chronic obstructive pulmonary disease (COPD). Which question is appropriate when assessing the patient’s nutrition-metabolic pattern? 1) “Have you lost any weight recently?” 2) “Do you have trouble getting to the toilet?” 3) “Does your breathing wake you up in the night?” 4) “Do you have any pain associated with breathing?” 11. The nurse assesses a patient who presents with tachypnea and clubbing of the fingers. Based on this data, which diagnosis does the nurse anticipate for this patient? 1) Asthma 2) Chest trauma 3) Chronic hypoxemia NURSINGTB.COM 4) Chronic pulmonary obstructive disease 12. A patient is admitted to the emergency department (ED) with dyspnea. Upon assessment, the nurse notes a bluish discoloration of the patient’s lips, fine crackles on auscultation, and dullness upon percussion of the lung fields. Based on this data, which diagnosis does the nurse anticipate? 1) Asthma 2) Pleural effusion 3) Pulmonary edema 4) Pulmonary fibrosis 13. Which is the term used to describe abnormal breath sounds? 1) Vesicular 2) Bronchial 3) Adventitious 4) Bronchovesicular 14. Which would the nurse assess when using palpation during the respiratory assessment? 1) Tracheal position 2) Bronchovesicular sounds 3) Lung density 4) Adventitious sounds 15. The nurse is performing pulmonary function testing on a patient. Which nursing action is beneficial to the patient? 1) Assessing for respiratory distress
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2) Scheduling the test after a meal 3) Providing rest before the procedure 4) Administering an inhaled bronchodilator six hours before procedure 16. The nurse is caring for a patient with a suspected pulmonary embolism. Which radiology study does the nurse anticipate to be beneficial for the patient? 1) Chest x-ray 2) Pulmonary angiogram 3) Computed tomography 4) Magnetic resonance imaging 17. The nurse is caring for a patient with shortness of breath and respiratory rate of 28 breaths per minute. Which is the most preferred method to auscultate the chest of the patient with this condition? 1) Listening at the apices 2) Listening at the lung bases 3) Listening by comparing opposite areas of the chest 4) Listening to each cycle of inspiratory and expiratory cycle 18. What is the function of the epiglottis? 1) To aid in the sensation of smell 2) To conduct gases to the alveoli 3) To filter small particles before air enters the lungs 4) To prevent the entry of solids and liquids into the lungs 19. Which interconnected structure allows the movement of air between the alveoli? 1) Bronchioles 2) Pores of Kohn NURSINGTB.COM 3) Visceral pleura 4) Parietal pleura 20. The nurse is providing care to a patient who is diagnosed with asthma. Which noninvasive method will the nurse use to assess the patient’s oxygenation status? 1) Pulse oximetry 2) Arterial blood gas 3) Venous blood gas 4) Cardiopulmonary monitor 21. The nurse is conducting a respiratory assessment. Which respiratory manifestation indicates inadequate oxygenation? 1) Mild hypertension 2) Cool, clammy skin 3) Dyspnea on exertion 4) Unexplained apprehension 22. The nurse is providing care to a patient who is diagnosed with pneumonia. The patient admits to smoking one pack of cigarettes per day. Which respiratory defense mechanism may have failed to cause the patient’s diagnosis? 1) Cough reflex 2) Filtration of air 3) Alveolar macrophages 4) Mucociliary clearance system
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23. What is the location of central chemoreceptors? 1) Lungs 2) Pores of Kohn 3) Roof of the nose 4) Medulla oblongata 24. Which structure is located in the lower respiratory tract? 1) Alveoli 2) Larynx 3) Trachea 4) Pharynx 25. Which is the major muscle of respiration? 1) Accessory muscle 2) Intercostal muscle 3) Diaphragm muscle 4) Abdominal muscle Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease (COPD). Which laboratory values will the nurse monitor when planning care for this client? Select all that apply. 1) Elevated eosinophils count 2) Decreased neutrophils count NURSINGTB.COM 3) Elevated red blood cells count 4) Decreased partial pressure of arterial oxygen 5) Decreased partial pressure of arterial carbon dioxide 27. Which questions are appropriate when assessing the effects of the patient’s respiratory diagnosis on activityexercise patterns? Select all that apply. 1) “Are you ever incontinent of urine when you cough?” 2) “Do you have trouble walking due to shortness of breath?” 3) “Does your spouse wake you in the middle of the night due to snoring?” 4) “How many flights of stairs can you walk before you are short of breath?” 5) “Do you ever feel full very quickly when eating due to your breathing issues?” 28. During the respiratory assessment, the nurse notes coarse crackles upon auscultation of the lung fields. Which diagnoses presents with this assessment finding? Select all that apply. 1) Pneumonia 2) Heart failure 3) Cystic fibrosis 4) Bronchospasm 5) Interstitial edema 29. Which are age-related changes to the respiratory system’s defense mechanisms? Select all that apply. 1) Decreased cilia function 2) Decreased chest wall compliance 3) Decreased response to hypoxemia 4) Decreased cell-mediated immunity
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5) Decreased respiratory muscle strength 30. Which are age-related changes to respiratory control that may be observed when assessing the older adult patient? Select all that apply. 1) Less forceful cough 2) Calcification of costal cartilage 3) Decreased response to hypoxemia 4) Decrease in number of functional alveoli 5) Decreased response to hypercapnia
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Chapter 23: Assessment of Respiratory Function Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 427-431 Heading: Assessment Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Oxygenation; Assessment Difficulty: Easy Feedback 1 Auscultation is performed to identify fluid, mucus, or obstruction in the respiratory system. The nurse should avoid auscultating sound over bony structures as it interferes with the sound quality. 2 Upright position optimizes airflow and allows chest expansion which facilitates clear respiratory sounds during auscultation. 3 Breathing slowly through an open mouth prevents transmission of turbulent sound and helps to hear clear sound. 4 Beginning auscultation from lN u nUgRapSicIe N s G anT dB m. o vCinOgMto ward intercostal spaces to the lung bases helps to compare one lung with the other at the same level. PTS: 1 CON: Oxygenation | Assessment 2. ANS: 4 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to respiratory function Chapter page reference: 431-438 Heading: Diagnostic Studies Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 The patient will be sedated during the procedure. 2 The patient will not require mechanical ventilation after this procedure. 3 The patient will need to have the prothrombin time evaluated prior to the procedure, not after the procedure. 4 A bronchoscopy is the insertion of a tube in the airways to view airway structure and obtain tissue sample for biopsy or culture. The patient will need to be NPO for eight hours prior to the procedure to decrease the risk for aspiration.
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PTS: 1 CON: Oxygenation 3. ANS: 2 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 427-431 Heading: Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation; Assessment Difficulty: Easy Feedback 1 Hemoptysis often occurs with tuberculosis and does not indicate airway irritation. 2 A dry, hacking cough indicates the patient is experiencing airway irritation or obstruction. 3 A harsh, barky cough suggests upper airway obstruction. 4 A loose-sounding cough indicates secretions. PTS: 1 CON: Oxygenation | Assessment 4. ANS: 3 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 427-431 NURSINGTB.COM Heading: Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 Foul smelling sputum indicates an infection process. 2 Clear, whitish, or yellow sputum is often found for patients diagnosed with chronic obstructive pulmonary disease especially in the early morning hours. 3 Large amounts of frothy pink tinged sputum support the diagnosis of pulmonary edema which is characterized by a persistent cough. 4 Clear to grey sputum with brown specks indicates the patient is a smoker. PTS: 1 CON: Oxygenation 5. ANS: 2 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 427-431 Heading: Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding]
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Concept: Oxygenation Difficulty: Easy Feedback 1 Wheezing is the term used to describe the musical sounds auscultated during assessment and indicate some degree of airway obstruction that occurs with asthma and emphysema. 2 Tuberculosis is characterized by hemoptysis, which is the term for coughing up of blood or blood-tinged sputum from the respiratory tract. 3 Grey sputum often occurs in patients who are cigarette smokers. 4 Clear, slightly whitish, and viscous sputum are often normal findings. PTS: 1 CON: Oxygenation 6. ANS: 3 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 427-431 Heading: Assessment Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Dull in not an appropriate termNtUo R deSsI cr N ib eG tTh is B .asCseOssMment finding. 2 Tympany is a drum-like loud empty quality heard over a gas filled stomach or intestine. 3 Low pitched sounds heard over normal lungs during percussion indicate resonance. 4 Hyperresonance is a loud lower pitched sound heard when percussing hyperinflated lungs, which can occur in patients who are experiencing an acute asthma exacerbation. PTS: 1 CON: Oxygenation 7. ANS: 3 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Correlating relevant diagnostic examinations to respiratory function Chapter page reference: 431-438 Heading: Diagnostic Studies Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Knowledge [Remembering] Concept: Oxygenation Difficulty: Easy Feedback 1 A lung biopsy involves taking a sample of tissue, not fluid, for analysis. 2 A bronchoscopy involves the use of a flexible fiberoptic scope for diagnosis, biopsy, or specimen collection. 3 A thoracentesis is a diagnostic procedure used to remove pleural fluid for analysis or to instill medication. 4 Sputum studies are obtained by expectoration and tracheal suction.
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PTS: 1 CON: Oxygenation 8. ANS: 3 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Correlating relevant diagnostic examinations to respiratory function Chapter page reference: 431-438 Heading: Diagnostic Studies Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 Sputum studies are not used to diagnose asthma, lung cancer, or chronic obstructive pulmonary disease. 2 Sputum studies are not used to diagnose asthma, lung cancer, or chronic obstructive pulmonary disease. 3 A sputum study is often used to diagnose bacterial lung infections via a culture and sensitivity. 4 Sputum studies are not used to diagnose asthma, lung cancer, or chronic obstructive pulmonary disease. PTS: 1 CON: Oxygenation 9. ANS: 4 Chapter number and title: 23, Assessment of Respiratory Function NURSINGTB.CO Chapter learning objective: Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 427-431 Heading: Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty:
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Feedback Rhonchi are observed in patients with bronchiectasis. Diminished breath sounds are observed in pleural effusion. Coarse crackles are observed in patients with pulmonary edema. Wheezes are continuous high-pitched squeaking or rapid sounds caused by the rapid vibration of the bronchial walls, which is caused by a blockage in airways which often occurs with chronic obstructive pulmonary disease.
PTS: 1 CON: Oxygenation 10. ANS: 1 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 427-431
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Heading: Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation; Assessment Difficulty: Moderate
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Feedback When assessing the affect that COPD has on the patient’s nutrition-metabolic pattern the appropriate question to ask is if the patient has experienced any weight loss. Asking about trouble getting to the toilet assesses the effect that COPD has on the patient’s elimination patterns. Asking the patient about waking in the middle of the night with breathing issues assesses the patient’s sleep-rest. Asking the patient if pain is associated with breathing assesses the patient’s cognition and perception.
PTS: 1 CON: Oxygenation | Assessment 11. ANS: 3 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 427-431 Heading: Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological IntegrityNURSINGTB.COM – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 Pursed lip breathing, inability to lie in flat position, and use of accessory muscles to assist in breathing are findings observed in patients with asthma and chronic obstructive pulmonary disease. 2 Voluntary decrease in tidal volume to reduce pain on chest expansion is referred as splinting, which is a common manifestation of chest trauma or pleurisy. 3 Tachypnea and clubbing of the fingers are assessment findings that support the diagnosis of chronic hypoxemia. 4 Pursed lip breathing, inability to lie in flat position, and use of accessory muscles to assist in breathing are findings observed in patients with asthma and chronic obstructive pulmonary disease. PTS: 1 CON: Oxygenation 12. ANS: 3 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 427-431 Heading: Assessment Integrated Processes: Nursing Process – Assessment
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Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 Wheezing and hyperresonance on percussion support the diagnosis of asthma. 2 Tachypnea, diminished or absent breath sounds, and dullness on percussion support the diagnosis of pleural effusion. 3 Dyspnea, cyanosis, fine crackles and dullness on percussion all support the diagnosis of pulmonary edema. 4 Tachypnea, crackles, and resonance on percussion support the diagnosis of pulmonary fibrosis. PTS: 1 CON: Oxygenation 13. ANS: 3 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Discussing the function of the respiratory system Chapter page reference: 427-431 Heading: Assessment Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Knowledge [Understanding] Concept: Oxygenation; Communication Difficulty: Easy
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Vesicular sound is relatively soft, low pitched, gentle, rustling sounds. Bronchial sounds are louder, higher pitched and resemble air blowing through a hollow pipe. Adventitious is the term used to describe abnormal breath sounds such as crackles, rhonchi, wheezes, and a pleural friction rub. Bronchovesicular sounds have a medium pitch and intensity and are heard anteriorly over the main stem bronchi on either side of the sternum and posteriorly between the scapulae.
PTS: 1 CON: Oxygenation | Communication 14. ANS: 1 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 427-431 Heading: Assessment Integrated Processes: Nursing Process – Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Oxygenation; Assessment Difficulty: Moderate Feedback 1 Palpation is used to determine tracheal position. 2 Auscultation is used to determine breath sounds, both normal and adventitious.
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Percussion is used to assess lung density. Auscultation is used to determine breath sounds, both normal and adventitious.
PTS: 1 CON: Oxygenation | Assessment 15. ANS: 1 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to respiratory function Chapter page reference: 431-438 Heading: Diagnostic Studies Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Oxygenation; Assessment Difficulty: Moderate Feedback 1 A nursing action that is appropriate when providing care to a patient who is having pulmonary function tests is to assess the patient for respiratory distress. 2 The nurse would avoid scheduling the procedure after a meal. 3 The nurse would provide rest for the patient after the procedure. 4 The nurse would avoid administering an inhaled bronchodilator six hours before the procedure. PTS: 1 CON: Oxygenation | Assessment 16. ANS: 3 NURSINGTB.COM Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Correlating relevant diagnostic examinations to respiratory function Chapter page reference: 431-438 Heading: Diagnostic Studies Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 Chest x-ray is used to screen, diagnose, and evaluate changes in respiratory system. 2 Pulmonary angiogram is used to visualize vasculature and locate obstruction or pathologic conditions. 3 Computed tomography (CT) is used in the diagnosis of lesions that are difficult to assess by conventional x-ray studies. Common types of CT are helical or spiral. Spiral CT is used to diagnose pulmonary embolism. 4 Magnetic resonance imaging is used for diagnosis of lesions that are difficult to assess by CT scan. PTS: 1 CON: Oxygenation 17. ANS: 2 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of respiratory function
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Chapter page reference: 427-431 Heading: Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation; Assessment Difficulty: Moderate Feedback 1 Generally, the auscultation should proceed from the lung apices to bases. 2 Listening at the lung bases is the most preferred method in a patient with respiratory distress. This is due to the increased respiratory rate and shortness of breath, which may tire the patient easily. 3 Listening comparing opposite areas of the chest is beneficial in patients with respiratory distress. 4 For auscultation, place the stethoscope and listen to each cycle of inspiratory and expiratory cycle. PTS: 1 CON: Oxygenation | Assessment 18. ANS: 4 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Discussing the function of the respiratory system Chapter page reference: 422-427 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process – Assessment Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [RememNb U erR inS g]INGTB.COM Concept: Oxygenation Difficulty: Easy
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Feedback The olfactory nerve endings in the roof of the nose are responsible for the sense of smell. The bronchi and the trachea act as a pathway to conduct gases to the alveoli. The nose functions to protect the lower airway by warming and humidifying air and filtering small particles before the air enters the lungs. The epiglottis is a small flap located behind the tongue that closes over the larynx during swallowing. The function of the epiglottis is to prevent solids and liquids from entering the lungs.
PTS: 1 CON: Oxygenation 19. ANS: 2 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Identifying key anatomical components of the respiratory system Chapter page reference: 422-427 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process – Assessment Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering] Concept: Oxygenation
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Difficulty: Easy Feedback 1 The main stem bronchi subdivide to form lobar, segmental and subsegmental bronchi. Further divisions form bronchioles, which cause bronchoconstriction and bronchodilation. 2 The alveoli are interconnected by pores of Kohn which allow the passage of air from alveolus to alveolus. 3 Lungs are lined by a membrane called visceral pleura. 4 The chest cavity is lined with a membrane called parietal pleura. PTS: 1 CON: Oxygenation 20. ANS: 1 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 427-431 Heading: Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Pulse oximetry is a noninvasive procedure that is used to measure oxygen levels in the blood and thereby assess the eN ffic Uien RScIy NofGgTasBe.xcChOanMge in the lungs and tissue oxygenation. 2 Arterial and venous blood gas analysis are invasive methods to monitor oxygenation status. 3 Arterial and venous blood gas analysis are invasive methods to monitor oxygenation status. 4 A cardiopulmonary monitor is used to assess heart rate and respiratory rate. While it is noninvasive, it will not allow the nurse to assess the patient’s oxygenation status. PTS: 1 CON: Oxygenation 21. ANS: 3 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 427-431 Heading: Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 Mild hypertension and cool, clammy skin are cardiovascular manifestations of inadequate oxygenation.
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Mild hypertension and cool, clammy skin are cardiovascular manifestations of inadequate oxygenation. Dyspnea on exertion, or shortness of breath with activity, is a respiratory manifestation that indicates inadequate oxygenation. Unexplained apprehension is a central nervous system manifestation of inadequate oxygenation.
PTS: 1 CON: Oxygenation 22. ANS: 3 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Identifying key anatomical components of the respiratory system Chapter page reference: 422-427 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 The cough reflex, filtration of air, and mucociliary clearance are not the respiratory defense mechanisms that failed in this scenario. 2 The cough reflex, filtration of air, and mucociliary clearance are not the respiratory defense mechanisms that failed in this scenario. 3 Alveolar macrophages rapidly phagocytize inhaled foreign particles such as bacteria and often fail as a result of cigN arU etR teSs m INokGinTg.B.COM 4 The cough reflex, filtration of air, and mucociliary clearance are not the respiratory defense mechanisms that failed in this scenario. PTS: 1 CON: Oxygenation 23. ANS: 4 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Identifying key anatomical components of the respiratory system Chapter page reference: 422-427 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process – Assessment Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering] Concept: Oxygenation Difficulty: Easy
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Feedback Mechanical receptors such as juxtacapillary and irritant receptors are located in the lungs, chest wall, and diaphragm. The alveoli are interconnected by Pores of Kohn which allow movement of air from alveolus to alveolus. Olfactory nerve endings are located in the roof of the nose that are responsible for the sense of smell. Central chemoreceptors are located in the medulla oblongata and respond to changes in pH in the cerebrospinal fluid.
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PTS: 1 CON: Oxygenation 24. ANS: 1 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Identifying key anatomical components of the respiratory system Chapter page reference: 422-427 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process – Assessment Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering] Concept: Oxygenation Difficulty: Easy
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Feedback Alveoli are structures found in the lower respiratory tract. The larynx, trachea and pharynx are structures located in the upper respiratory tract. The larynx, trachea and pharynx are structures located in the upper respiratory tract. The larynx, trachea and pharynx are structures located in the upper respiratory tract.
PTS: 1 CON: Oxygenation 25. ANS: 3 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Identifying key anatomical components of the respiratory system Chapter page reference: 422-427 Heading: Overview of Anatomy and Physiology NURSINGTB.COM Integrated Processes: Nursing Process – Assessment Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering] Concept: Oxygenation Difficulty: Easy
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Feedback Accessory muscle is a relatively rare anatomic duplication of muscle that may appear anywhere in the muscular system. The intercostal muscles are several groups of muscles that run between the ribs and help form and move their chest wall. Diaphragm is the major muscle of respiration. It is a sheet of internal skeletal muscle. Abdominal muscle supports the trunk, allows movement and hold organs in place by regulating internal abdominal pressure and assist in expelling air during labored breathing.
PTS: 1
CON: Oxygenation
MULTIPLE RESPONSE 26. ANS: 1, 3, 4 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Correlating relevant diagnostic examinations to respiratory function
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Chapter page reference: 431-438 Heading: Diagnostic Studies Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is correct. Eosinophilic airway inflammation occurs with COPD which results in elevated levels of eosinophils. This is incorrect. Viral disease like influenza decreases neutrophils count. This is correct. COPD produces hypoxic stimulus which causes excessive production of erythropoietin. It elevates the red blood cells count. This is correct. COPD reduces level of oxygen in the blood and results in decreased partial pressure of arterial oxygen. This is incorrect. COPD elevates partial pressure of arterial carbon dioxide. Decreased partial pressure of arterial carbon dioxide is observed in hyperventilation/respiratory alkalosis.
PTS: 1 CON: Oxygenation 27. ANS: 2, 4 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 427-431 NURSINGTB.COM Heading: Assessment Integrated Processes: Nursing Process – Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Oxygenation; Assessment Difficulty: Moderate
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Feedback This is incorrect. Asking the patient about urinary incontinence with coughing is appropriate when assessing elimination patterns. This is correct. When assessing the effects that a respiratory diagnosis has on activity -exercise patterns the nurse will ask the patient if walking is impacted by dyspnea and how many flights of steps can be walked before dyspnea occurs. This is incorrect. Asking the patient if the spouse wakes him or her in the middle of the night due to snoring assess sleep-rest patterns. This is correct. When assessing the effects that a respiratory diagnosis has on activity-exercise patterns the nurse will ask the patient if walking is impacted by dyspnea and how many flights of steps can be walked before dyspnea occurs. This is incorrect. Asking the patient if there is a feeling of fullness quickly upon eating is assessing the patient’s nutritional-metabolic pattern.
PTS: 1 CON: Oxygenation | Assessment 28. ANS: 1, 2 Chapter number and title: 23, Assessment of Respiratory Function
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Chapter learning objective: Describing the procedure for completing a history and physical assessment of respiratory function Chapter page reference: 427-431 Heading: Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy
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Feedback This is correct. Coarse crackles are often auscultated for patients diagnosed with pneumonia or heart failure. This is correct. Coarse crackles are often auscultated for patients diagnosed with pneumonia or heart failure. This is incorrect. Rhonchi is auscultated for patients diagnosed with cystic fibrosis. This is incorrect. Wheezes are auscultated when the patient is experiencing bronchospasm. This is incorrect. Discontinuous low pitched lung sounds are auscultated for patients experiencing interstitial edema.
PTS: 1 CON: Oxygenation 29. ANS: 1, 4 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Discussing changes in respiratory function associated with aging Chapter page reference: 438 NURSINGTB.COM Heading: Age-Related Changes of the Respiratory System Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy
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Feedback This is correct. There are three categories of age-related changes that impact the respiratory system, including changes in structure, defense mechanisms, and respiratory control. A decrease in cilia function and cell-mediated immunity are both age-related defense mechanism changes. This is incorrect. Decreased chest wall compliance is a structural change. This is incorrect. Decreased response to hypoxemia is a respiratory control change. This is correct. There are three categories of age-related changes that impact the respiratory system, including changes in structure, defense mechanisms, and respiratory control. A decrease in cilia function and cell-mediated immunity are both age-related defense mechanism changes This is incorrect. Decreased respiratory muscle strength is an age-related structural change.
PTS: 1 CON: Oxygenation 30. ANS: 3, 5 Chapter number and title: 23, Assessment of Respiratory Function Chapter learning objective: Discussing changes in respiratory function associated with aging
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Chapter page reference: 438 Heading: Age-Related Changes of the Respiratory Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy
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PTS: 1
Feedback This is incorrect. A less forceful cough is an age-related change to respiratory defense mechanisms. This is incorrect. Calcification of the costal cartilage and a decrease in functional alveoli are age-related structural changes to the respiratory system. This is correct. Age-related changes to respiratory control include decreased responses to hypoxemia and hypercapnia. This is incorrect. Calcification of the costal cartilage and a decrease in functional alveoli are age-related structural changes to the respiratory system. This is correct. Age-related changes to respiratory control include decreased responses to hypoxemia and hypercapnia. CON: Oxygenation
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Cha pter 24: Coordinating Care for Patie n ts W it h I nfe ctio us Respira tory Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is assessing several patients at a community clinic. Which patient should not receive an annual influenza vaccination? 1) A 65-year-old woman 2) A 3-year-old with cystic fibrosis 3) A 35-year-old man with a severe allergy to eggs 4) A 25-year-old pregnant woman at 20 weeks’ gestation 2. A patient with the flu is experiencing tachypnea. What intervention is inappropriate to address in the nursing diagnosis of Ineffective Breathing Pattern related to the flu? 1) Maintain adequate hydration 2) Keep the head of the bed elevated 3) Teach the patient coughing, deep breathing, and hydration 4) Prepare the patient for the possibility of a tracheostomy tube. 3. The nurse makes a home visit to a patient recovering from complications related to influenza. Which patient statement indicates the need for further intervention by the nurse? 1) “I went back to work.” 2) “I'm eating healthy foods now.” 3) “I continue to wake up coughing at night.”
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4) “I have not had chills since I left the hospital.” 4. The nurse is reviewing diagnostic and laboratory studies performed for an older adult patient with influenza. Which result should the nurse recognize as being consistent with influenza? 1) Increased BUN 2) Decreased sodium level 3) Fluid-filled lungs on chest x-ray 4) Decreased white blood cell count 5. The nurse is planning care for a patient diagnosed with influenza. Which intervention should the nurse include when planning this patient’s care? 1) Placing a ventilator in the room 2) Notifying other departments of the diagnosis 3) Placing the patient in a negative air flow room 4) Placing droplet and contact precaution signs on the patient room door 6. An older adult patient is admitted with pneumonia. Which manifestation is unexpected during the nurse’s initial assessment? 1) Lethargy 2) Hemoptysis 3) Increased appetite 4) Increased respirations 7. A nurse is caring for an older adult patient admitted to the hospital with pneumonia. The patient asks the nurse what can be done to decrease the risk for developing pneumonia in the future. Which response by the nurse is inappropriate? 1) "You should avoid alcohol.” NURSINGTB.COM 2) "You can start by not smoking." 3) "You can get the pneumonia vaccination, which may help to decrease your risk in the future." 4) "You should drink a yogurt drink once a day that is supplemented with L. casei immunitas cultures." 8. The nurse is caring for an older adult patient who is hospitalized with a second episode of pneumonia in the past 18 months. The patient has expressed frustration to the nurse and states, "I never got sick when I was younger. Why is this happening?" Which response by the nurse is most appropriate? 1) “As you grow older, your immune system just quits working.” 2) “As you grow older, there is a decrease in the immune response, which puts you at greater risk for developing an infection.” 3) “As you grow older, there in an overall increase in the speed and strength of your immune response.” 4) “As you grow older, there is an increase in the number of B cells in the circulation, which hinders the immune response.” 9. The nurse determines that the diagnosis of Ineffective Airway Clearance is appropriate for a patient with pneumonia who is experiencing copious amounts of respiratory secretions. Which intervention should the nurse include in this patient's plan of care? 1) Perform chest percussion every four hours and prn 2) Administer the pneumococcal vaccine prior to discharge 3) Limit fluid intake to 1,000 mL per day 4) Provide the patient with smoking cessation education
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10. The nurse is providing discharge teaching to a patient recovering from pneumonia. Which patient statement indicates that additional teaching is needed? 1) “I can't get the influenza vaccine due to my allergy to eggs.” 2) “I will get the influenza vaccine every year.” 3) “I will get the pneumococcal vaccine every fall.” 4) “I will get the pneumococcal vaccine as soon as I recover from this pneumonia.” 11. The nurse is providing care to a patient with pneumonia and has a fever. Which intervention should the nurse implement to attain the goal of normal body temperature? 1) Increase the temperature of the room environment to prevent shivering 2) Administer antipyretic medications 3) Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance 4) Use ice packs and a tepid bath every two hours 12. The nurse is preparing to assess an older adult patient admitted with tuberculosis. Which manifestations does the nurse anticipate for this patient? 1) Night sweats 2) Swollen lymph nodes 3) Cough 4) Hemoptysis 13. An adolescent patient is brought to the emergency department (ED) with fatigue, weight loss, a dry cough, and night sweats. The family just recently immigrated to the United States. Based on this data, for which potential risk should the nurse include when planning care for this patient? 1) Pneumothorax 2) Pneumonia 3) Renal failure NURSINGTB.COM 4) Septicemia 14. The nurse in an inner city clinic is providing a health screening for a homeless patient with a history of drug abuse. The patient has a chronic nonproductive cough. For which should the nurse expect to screen this patient? 1) Herpes zoster 2) Sickle cell disease 3) Sick sinus syndrome 4) Tuberculosis 15. The nurse is planning care for an older adult patient recently diagnosed with tuberculosis (TB). The patient lives alone in an apartment and will continue treatment at home. Which nursing diagnosis is a priority for this patient? 1) Ineffective Therapeutic Regimen Management 2) Deficient Knowledge 3) Ineffective Breathing Pattern 4) Risk for Injury 16. An occupational health nurse is screening a new employee in a long-term care facility for tuberculosis (TB). The employee questions why purified protein derivative (PPD) testing is done twice. Which is the most appropriate response by the nurse? 1) “Different medication is used in the second PPD.” 2) “The treatment for TB is six months of medication, and we want to make sure the first results of the first PPD were accurate.” 3) “The first PPD was not interpreted in the correct time frame of 48-72 hours.”
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4) “There is an increased risk for a false-negative response for people who work in long-term care facilities. The two-step is recommended to accurately screen for TB.” 17. The nurse is caring for a patient who is receiving multiple drugs for treatment of tuberculosis. The nurse teaches the patient the rationale for the multiple-drug treatment and evaluates learning as effective when the patient makes which statement? 1) “Multiple drugs are necessary to develop immunity to tuberculosis.” 2) “Multiple drugs are necessary because I became infected from an immigrant.” 3) “Multiple drugs will be required as long as I am contagious.” 4) “Multiple drugs are necessary because of the risk of resistance.” 18. The nurse is caring for a patient who is admitted to the unit with tuberculosis (TB). The patient is placed in isolation. To protect the caregivers and other patients on the unit, which type of isolation room is most appropriate? 1) Single-door room with positive air flow (air flows out of the room.) 2) Isolation room with an anteroom and negative air flow (air flows into the room.) 3) Isolation room with an anteroom and normal airflow 4) Single-door room with normal airflow 19. The charge nurse for a medical-surgical unit is notified that a patient with tuberculosis (TB) is being transported to the unit. Which nursing action for infection prevention is the most appropriate in this circumstance? 1) Stock the patient’s supply cart at the beginning of each shift 2) Wear a respirator mask and gown when caring for the patient 3) Perform hand hygiene only after leaving the room 4) Test all staff members for TB immediately
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20. A nurse is caring for a patient with tuberculosis (TB) who is taking Rifampin for treatment of the disease. Which nursing intervention is most appropriate for this patient? 1) Administer the medication with meals to reduce gastrointestinal side effects 2) Record a baseline visual examination before initiating therapy 3) Administer the medication on an empty stomach 4) Administer the medication by deep intramuscular injection into a large muscle mass 21. The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding supports this diagnosis? 1) Wheezing 2) Hemoptysis 3) Grey sputum 4) Slightly whitish sputum 22. During the respiratory assessment, the nurse notes coarse crackles upon auscultation of the lung fields. Which diagnosis presents with this assessment finding? 1) Pneumonia 2) Cystic fibrosis 3) Bronchospasm 4) Interstitial edema 23. The nurse is providing care to a patient who is diagnosed with pneumonia. The patient admits to smoking one pack of cigarettes per day. Which respiratory defense mechanism may have failed to cause the patient’s diagnosis? 1) Cough reflex
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2) Filtration of air 3) Alveolar macrophages 4) Mucociliary clearance system 24. The nurse receives a phone call from the parent of a child who is prescribed rifampin (Rimactane) for treatment of tuberculosis because she saw that the child’s urine was orange. Which response by the nurse is accurate? 1) “Encourage your child to drink cranberry juice.” 2) “An orange discoloration of urine is expected while your child is on this medication.” 3) “Bring your child to the clinic for a urinalysis.” 4) “Bring your child to the clinic for a radiograph of the kidneys.” Multiple Response Identify one or more choices that best complete the statement or answer the question. 25. The nurse caring for a homeless patient at risk for tuberculosis (TB) will include which symptoms of the disease when educating the patient? Select all that apply. 1) Fatigue 2) Low-grade morning fever 3) Productive cough that later turns to a dry, hacking cough 4) Weight loss 5) Night sweats 26. The nurse is assessing a patient with acute malaise and muscle aches. Which questions should the nurse ask to determine whether the patient is experiencing influenza? Select all that apply. 1) “Have you had a flu shot this yeN arU ?”R SINGTB.COM 2) “Is your cough productive?” 3) “Have you been exposed to anyone with the flu?” 4) “Are you having any trouble urinating?” 5) “Do you have dizziness?” 27. The school nurse is planning a teaching session with the parents of students to reduce the spread of the influenza virus throughout the school. What should the nurse include when teaching the parents of a diverse population about infection-control techniques? Select all that apply. 1) “Cover your cough” education 2) Appropriate hand hygiene 3) Safe food preparation and storage 4) Sanitizing high-touch items to kill pathogens 5) Withholding immunizations for children with compromised immune systems 28. The nurse is caring for a patient who develops a fever and productive cough after having an appendectomy. Which prescriptions should the nurse expect from the health-care provider for this health problem? Select all that apply. 1) Sputum cultures 2) Antibiotics 3) Chest physiotherapy 4) Bronchial washing for culture 5) Isolation precautions
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Chapter 24: Coordinating Care for Patients With Infectious Respiratory Disorders Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Describing the etiology of infectious airway disorders Chapter page reference: 443-447 Heading: Influenza Integrated Processes: Nursing Process – Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 People at increased risk of influenza or its complications include infants, young children, and anyone age 50 or older; therefore, this patient should receive an annual influenza vaccine. 2 Patients with chronic disorders, especially diabetes and cardiac, renal, or pulmonary diseases, are more susceptible to complications from the flu; therefore, this patient should receive an annual influenza vaccine. 3 A 35-year-old man with a severe allergy to eggs should not get a flu shot, because the vaccine contains eggs and it is not recommended. 4 Pregnant women, particularly N duUriRngSI theNsGe T c oB nd.aCn O d M third trimesters, are at increased risk of complications from the flu; therefore, this patient should receive the annual influenza vaccine. PTS: 1 CON: Infection 2. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with infectious airway disorders Chapter page reference: 443-447 Heading: Influenza Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Coughing, deep breathing, and hydration are essential for achieving airway clearance. 2 Keeping the head of the bed elevated improves lung excursion and reduces the work of breathing. 3 Coughing, deep breathing, and hydration are essential for achieving airway clearance. 4 Insertion of a tracheostomy and oxygen are not primary treatments for ineffective airway clearance.
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PTS: 1 CON: Oxygenation 3. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with infectious airway disorders Chapter page reference: 443-447 Heading: Influenza Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 This patient statement does not indicate the need for further intervention by the nurse. 2 This patient statement does not indicate the need for further intervention by the nurse. 3 A patient who continues to be awoken during the night because of coughing may require further intervention by the nurse. 4 This patient statement does not indicate the need for further intervention by the nurse. PTS: 1 CON: Oxygenation 4. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of infectious airway disorders Chapter page reference: 443-447 NURSINGTB.COM Heading: Influenza Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Laboratory tests for BUN and sodium levels are not usually associated with influenza. 2 Laboratory tests for BUN and sodium levels are not usually associated with influenza. 3 Unless the patient with influenza develops complications, the chest x-ray is clear. 4 The white blood cell count of a patient with influenza will typically be decreased. PTS: 1 CON: Infection 5. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Influenza Chapter page reference: 443-447 Heading: Influenza Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback
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There is no indication that this patient will need a ventilator. Placing signs on the door is the way to notify other departments of precautions. Negative air flow rooms are for diseases such as chicken pox, measles, and SARS. To prevent the spread of influenza, the patient is placed in a private room with signs for droplet and contact precautions. It is appropriate for the health-care workers to use appropriate PPE for these transmission-based precautions.
PTS: 1 CON: Infection 6. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Influenza Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 Frequently, caregivers or family members note that the patient looks generally ill. The patient is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis is seen in pneumonia, and the respiratory rate would be greater than 20. 2 Frequently, caregivers or family members note that the patient looks generally ill. The patient is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis is seen in pneumonia, and the N reU spRirS atI orN y G raT teBw.o uCldO be M greater than 20. 3 A decreased, not increased, appetite is anticipated when providing care to a patient diagnosed with pneumonia. 4 Frequently, caregivers or family members note that the patient looks generally ill. The patient is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis is seen in pneumonia, and the respiratory rate would be greater than 20. PTS: 1 CON: Oxygenation 7. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Research indicates a high rate of pneumonia in patients with frequent exposure to cigarette smoke and alcohol use. Alcohol interferes with the actions of macrophages. 2 Research indicates a high rate of pneumonia in patients with frequent exposure to cigarette smoke and alcohol use. Smoking injures tissues in the airways and decreases the action of cilia. Chemicals in cigarettes have a numbing effect on the cough reflex.
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Pneumonia vaccines can also be considered to decrease the risk of development in the future. There is not an established body of scientific evidence that supports the claim that L. casei immunitas cultures can improve immune function.
PTS: 1 CON: Oxygenation 8. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is not an appropriate response by the nurse. 2 As a person grows older, there is an overall decrease in the speed and strength of the immune response. The immune system does not quit working totally. There is a decrease in the number of B cells in circulation. 3 This is not an appropriate response by the nurse. 4 This is not an appropriate response by the nurse.
NURSINGTB.COM PTS: 1 CON: Oxygenation 9. ANS: 1 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Influenza Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Chest percussion can help clear secretions. 2 Providing education for smoking cessation and administering the pneumococcal vaccine are important in treating a patient with pneumonia; however, they would be aligned with a different nursing diagnosis. 3 Patients with pneumonia are encouraged to increase fluid intake. 4 Providing education for smoking cessation and administering the pneumococcal vaccine are important in treating a patient with pneumonia; however, they would be aligned with a different nursing diagnosis. PTS: 1 CON: Oxygenation 10. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
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Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 Influenza vaccine is administered annually to healthy individuals and should not be given to those with an allergy to eggs. 2 Influenza vaccine is administered annually to healthy individuals and should not be given to those with an allergy to eggs. 3 The pneumococcal vaccine is administered once. Revaccination is only recommended in persons with renal failure, those who have had splenectomies, those with malignancies, and those with HIV/AIDS. 4 This statement indicates correct understanding of the information presented. PTS: 1 CON: Oxygenation 11. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Pneumonia Chapter page reference: 447-451 Heading: Pneumonia NURSINGTB.COM Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution and only as needed. 2 Hyperthermia is an expected consequence of the infectious disease process. Fever can produce mild, short-term effects and, when prolonged, can cause life-threatening effects. The nurse should administer antipyretic medications as indicated for elevated temperatures and enforce frequent rest periods because rest increases energy reserve that is depleted by increased metabolic, heart, and respiratory rates. 3 The nurse should encourage fluid intake rather than restrict fluids because of the risk of electrolyte imbalance. 4 The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution and only as needed. PTS: 1 CON: Oxygenation 12. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Tuberculosis Chapter page reference: 451-455
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Heading: Tuberculosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation; Infection Difficulty: Easy Feedback 1 Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting symptoms of tuberculosis in the older adult. 2 Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting symptoms of tuberculosis in the older adult. 3 Presenting symptoms of tuberculosis in the older adult are often vague and include coughing, weight loss, diminished appetite, and periodic fevers. 4 Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting symptoms of tuberculosis in the older adult. PTS: 1 CON: Oxygenation | Infection 13. ANS: 1 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [UnN deUrsRtaS ndIinNgG ] TB.CO Concept: Oxygenation Difficulty: Easy Feedback 1 This patient was foreign-born, a risk factor for tuberculosis (TB), and has the classic symptoms of tuberculosis. The nurse plans frequent respiratory assessments, as this child is at risk for pneumothorax. 2 Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia. 3 Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia. 4 Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia. PTS: 1 CON: Oxygenation 14. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation; Infection Difficulty: Easy Feedback
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There is no evidence to support the need to screen the patient for sickle cell disease, herpes zoster, or sick sinus syndrome. There is no evidence to support the need to screen the patient for sickle cell disease, herpes zoster, or sick sinus syndrome. There is no evidence to support the need to screen the patient for sickle cell disease, herpes zoster, or sick sinus syndrome. The homeless patient who abuses drugs is at risk for contracting tuberculosis (TB); therefore, the nurse would expect to screen this patient for TB.
PTS: 1 CON: Oxygenation | Infection 15. ANS: 1 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with infectious airway disorders Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Oxygenation; Infection Difficulty: Difficult Feedback 1 The treatment regimen for tuberculosis requires that the patient take many medications, maintain nutrition, and be aware of potential side effects. Due to increased age and normal forgetfulness, this patien NUt iRs SatIriNskGfTorBin.eCff ec OMtive treatmen t in the home. 2 The patient may have a knowledge deficit but the priority is the treatment regimen. 3 Since the patient is being treated in the home, there is not much risk for ineffective breathing. 4 The patient is at risk for injury because of age, not TB. PTS: 1 CON: Oxygenation | Infection 16. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of infectious airway disorders Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation; Infection Difficulty: Moderate Feedback 1 PPD testing is not done twice because different medication is used. 2 Treatment for TB for six months is not a reason to complete the PPD twice. 3 Evaluating the test at the wrong interval is not the reason that the PPD is done twice for long-term care facility employees. 4 PPD testing is done in a two-step process for people who work in long-term care facilities because of the risk of false-negative responses.
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PTS: 1 CON: Oxygenation | Infection 17. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Oxygenation; Infection Difficulty: Difficult Feedback 1 Multiple drugs are used for all cases of TB. 2 There is no indication that the patient contracted TB from an immigrant. 3 Treatment must be continued long after the patient is no longer contagious. 4 Tuberculosis bacilli are likely to develop resistance to one drug, so multiple drugs must be used. PTS: 1 CON: Oxygenation | Infection 18. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis NURSINGTB.COM Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Positive flow rooms are used for those patients who are immunosuppressed so that microorganisms from the unit are not drawn into the room. 2 Patients with airborne infections such as meningococcemia, SARS, or TB are placed in an isolation room with an anteroom and negative pressure airflow. Air flows into the room and is vented in a special manner to prevent the organism from entering the rest of the unit. 3 Single-door isolation with normal airflow might be used for a patient with droplet or wound infection. 4 Single-door rooms are not equipped to have positive or negative airflow. PTS: 1 CON: Infection 19. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control
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Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Supplies to prevent transmission of disease should be stocked at the end of the shift so that adequate supplies will be available for the next health-care provider. 2 Masks and gowns should be worn when caring for patients who do not reliably cover their mouths when coughing. When a patient has an airborne disease and must go elsewhere in the hospital, the patient must wear a mask. 3 Hand hygiene should be performed before and after patient care. 4 Clinical staff receive TB testing annually. There is no reason to test all staff members at this time. PTS: 1 CON: Infection 20. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate
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Rifampin is an oral antituberculosis medication that should be administered on an empty, not full, stomach. The nurse should monitor the CBC, liver function studies, and renal function studies. A baseline visual examination before therapy is necessary with ethambutol, another antituberculosis medication. Rifampin is an oral antituberculosis medication that should be administered on an empty stomach. Rifampin is an oral antituberculosis medication.
PTS: 1 CON: Infection 21. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback
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Wheezing is the term used to describe the musical sounds auscultated during assessment and indicate some degree of airway obstruction that occurs with asthma and emphysema. Tuberculosis is characterized by hemoptysis, which is the term for coughing up of blood or blood-tinged sputum from the respiratory tract. Grey sputum often occurs in patients who are cigarette smokers. Clear, slightly whitish, and viscous sputum are often normal findings.
PTS: 1 CON: Oxygenation 22. ANS: 1 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Pneumonia Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 Coarse crackles are often auscultated for patients diagnosed with pneumonia. 2 Rhonchi is auscultated for patients diagnosed with cystic fibrosis. 3 Wheezes are auscultated when the patient is experiencing bronchospasm. 4 Discontinuous low pitched lung sounds are auscultated for patients experiencing interstitial edema. NURSINGTB.COM PTS: 1 CON: Oxygenation 23. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Describing the etiology of infectious airway disorders Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 The cough reflex, filtration of air, and mucociliary clearance are not the respiratory defense mechanisms that failed in this scenario. 2 The cough reflex, filtration of air, and mucociliary clearance are not the respiratory defense mechanisms that failed in this scenario. 3 Alveolar macrophages rapidly phagocytize inhaled foreign particles such as bacteria and often fail as a result of cigarette smoking. 4 The cough reflex, filtration of air, and mucociliary clearance are not the respiratory defense mechanisms that failed in this scenario. PTS: 1
CON: Oxygenation
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24. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options. 2 Rifampin can color the urine orange, so the parents and child should be taught that this is an expected side effect. 3 Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options. 4 Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options. PTS: 1
CON: Infection
MULTIPLE RESPONSE 25. ANS: 1, 4, 5 NURSINGTB.COM Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation; Infection Difficulty: Moderate
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Feedback This is correct. Manifestations of tuberculosis often develop insidiously and are initially nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that the patient first seeks medical attention. This is incorrect. A low-grade afternoon, not morning, fever is anticipated. This is incorrect. A dry cough develops, which later becomes productive of purulent and/or blood-tinged sputum. This is correct. Manifestations of tuberculosis often develop insidiously and are initially nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that the patient first seeks medical attention. This is correct. Manifestations of tuberculosis often develop insidiously and are initially nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that the patient first seeks medical attention.
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PTS: 1 CON: Oxygenation | Infection 26. ANS: 1, 2, 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Influenza Chapter page reference: 443-447 Heading: Influenza Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation; Infection Difficulty: Moderate
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Feedback This is correct. Based on the presenting symptoms, the nurse would ask whether the patient has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is nonproductive. A productive cough may indicate a different diagnosis. This is correct. Based on the presenting symptoms, the nurse would ask whether the patient has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is nonproductive. A productive cough may indicate a different diagnosis. This is correct. Based on the presenting symptoms, the nurse would ask whether the patient has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is nonproductive. A productive cough may indicate a different diagnosis. T inhf ilsueisnzinac. orrect. Insufficient voiding and dizziness are not routine manifestations of
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This is incorrect. Insufficient voiding and dizziness are not routine manifestations of influenza.
PTS: 1 CON: Oxygenation | Infection 27. ANS: 1, 2, 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders Chapter page reference: 443-447 Heading: Influenza Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate
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Feedback This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching children to wash their hands, and appropriate respiratory etiquette such as “cover your cough” education all control the growth and spread of microorganisms. This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching children to wash their hands, and appropriate respiratory etiquette such as “cover your cough” education all control the growth and spread of microorganisms.
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This is incorrect. Teaching parents’ safe food preparation and storage is another tool to prevent the spread of microorganisms, but is not related to the flu virus. This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching children to wash their hands, and appropriate respiratory etiquette such as “cover your cough” education all control the growth and spread of microorganisms. To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. This is incorrect. Immunizations should not be withheld from immunocompromised children, and this is not an infection-control strategy.
PTS: 1 CON: Infection 28. ANS: 1, 2, 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Pneumonia Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy
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Feedback This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and perform chest physiotherapy to help clear the respiratory secretions. This is correct. The nursN eU wR ouSldIeNx pe G TctBto.oCbOtaMin sputum cultures, administer antibiotics, and perform chest physiotherapy to help clear the respiratory secretions. This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and perform chest physiotherapy to help clear the respiratory secretions. This is incorrect. Bronchial washings are not routine testing for this scenario. This is incorrect. The patient likely has a noninfectious disease and is not contagious. Isolation precautions are usually not ordered for noncontagious infections. CON: Oxygenation
Chapter 24: Coordinating Care for Patients With Infectious Respiratory Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is assessing several patients at a community clinic. Which patient should not receive an annual influenza vaccination? 1) A 65-year-old woman 2) A 3-year-old with cystic fibrosis 3) A 35-year-old man with a severe allergy to eggs
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4) A 25-year-old pregnant woman at 20 weeks’ gestation 2. A patient with the flu is experiencing tachypnea. What intervention is inappropriate to address in the nursing diagnosis of Ineffective Breathing Pattern related to the flu? 1) Maintain adequate hydration 2) Keep the head of the bed elevated 3) Teach the patient coughing, deep breathing, and hydration 4) Prepare the patient for the possibility of a tracheostomy tube. 3. The nurse makes a home visit to a patient recovering from complications related to influenza. Which patient statement indicates the need for further intervention by the nurse? 1) “I went back to work.” 2) “I'm eating healthy foods now.” 3) “I continue to wake up coughing at night.” 4) “I have not had chills since I left the hospital.” 4. The nurse is reviewing diagnostic and laboratory studies performed for an older adult patient with influenza. Which result should the nurse recognize as being consistent with influenza? 1) Increased BUN 2) Decreased sodium level 3) Fluid-filled lungs on chest x-ray 4) Decreased white blood cell count 5. The nurse is planning care for a patient diagnosed with influenza. Which intervention should the nurse include when planning this patient’s care? 1) Placing a ventilator in the room 2) Notif ying other departments of tNheUdRiaSgI noNsiGs TB.COM 3) Placing the patient in a negative air flow room 4) Placing droplet and contact precaution signs on the patient room door 6. An older adult patient is admitted with pneumonia. Which manifestation is unexpected during the nurse’s initial assessment? 1) Lethargy 2) Hemoptysis 3) Increased appetite 4) Increased respirations 7. A nurse is caring for an older adult patient admitted to the hospital with pneumonia. The patient asks the nurse what can be done to decrease the risk for developing pneumonia in the future. Which response by the nurse is inappropriate? 1) "You should avoid alcohol.” 2) "You can start by not smoking." 3) "You can get the pneumonia vaccination, which may help to decrease your risk in the future." 4) "You should drink a yogurt drink once a day that is supplemented with L. casei immunitas cultures." 8. The nurse is caring for an older adult patient who is hospitalized with a second episode of pneumonia in the past 18 months. The patient has expressed frustration to the nurse and states, "I never got sick when I was younger. Why is this happening?" Which response by the nurse is most appropriate? 1) “As you grow older, your immune system just quits working.”
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2) “As you grow older, there is a decrease in the immune response, which puts you at greater risk for developing an infection.” 3) “As you grow older, there in an overall increase in the speed and strength of your immune response.” 4) “As you grow older, there is an increase in the number of B cells in the circulation, which hinders the immune response.” 9. The nurse determines that the diagnosis of Ineffective Airway Clearance is appropriate for a patient with pneumonia who is experiencing copious amounts of respiratory secretions. Which intervention should the nurse include in this patient's plan of care? 1) Perform chest percussion every four hours and prn 2) Administer the pneumococcal vaccine prior to discharge 3) Limit fluid intake to 1,000 mL per day 4) Provide the patient with smoking cessation education 10. The nurse is providing discharge teaching to a patient recovering from pneumonia. Which patient statement indicates that additional teaching is needed? 1) “I can't get the influenza vaccine due to my allergy to eggs.” 2) “I will get the influenza vaccine every year.” 3) “I will get the pneumococcal vaccine every fall.” 4) “I will get the pneumococcal vaccine as soon as I recover from this pneumonia.” 11. The nurse is providing care to a patient with pneumonia and has a fever. Which intervention should the nurse implement to attain the goal of normal body temperature? 1) Increase the temperature of the room environment to prevent shivering 2) Administer antipyretic medications 3) Restrict fluids during periods ofNhU y pRe S rthIe N r mGiaTbBec.a C u sO e M o f the risk of electrolyte imbalance 4) Use ice packs and a tepid bath every two hours 12. The nurse is preparing to assess an older adult patient admitted with tuberculosis. Which manifestations does the nurse anticipate for this patient? 1) Night sweats 2) Swollen lymph nodes 3) Cough 4) Hemoptysis 13. An adolescent patient is brought to the emergency department (ED) with fatigue, weight loss, a dry cough, and night sweats. The family just recently immigrated to the United States. Based on this data, for which potential risk should the nurse include when planning care for this patient? 1) Pneumothorax 2) Pneumonia 3) Renal failure 4) Septicemia 14. The nurse in an inner city clinic is providing a health screening for a homeless patient with a history of drug abuse. The patient has a chronic nonproductive cough. For which should the nurse expect to screen this patient? 1) Herpes zoster 2) Sickle cell disease 3) Sick sinus syndrome 4) Tuberculosis
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15. The nurse is planning care for an older adult patient recently diagnosed with tuberculosis (TB). The patient lives alone in an apartment and will continue treatment at home. Which nursing diagnosis is a priority for this patient? 1) Ineffective Therapeutic Regimen Management 2) Deficient Knowledge 3) Ineffective Breathing Pattern 4) Risk for Injury 16. An occupational health nurse is screening a new employee in a long-term care facility for tuberculosis (TB). The employee questions why purified protein derivative (PPD) testing is done twice. Which is the most appropriate response by the nurse? 1) “Different medication is used in the second PPD.” 2) “The treatment for TB is six months of medication, and we want to make sure the first results of the first PPD were accurate.” 3) “The first PPD was not interpreted in the correct time frame of 48-72 hours.” 4) “There is an increased risk for a false-negative response for people who work in long-term care facilities. The two-step is recommended to accurately screen for TB.” 17. The nurse is caring for a patient who is receiving multiple drugs for treatment of tuberculosis. The nurse teaches the patient the rationale for the multiple-drug treatment and evaluates learning as effective when the patient makes which statement? 1) “Multiple drugs are necessary to develop immunity to tuberculosis.” 2) “Multiple drugs are necessary because I became infected from an immigrant.” 3) “Multiple drugs will be required as long as I am contagious.” 4) “Multiple drugs are necessary because of the risk of resistance.”
SiItteNdGtoTtBh e.uCnOit M 18. The nurse is caring for a patient whoNisUaR dm with tuberculosis (TB). The patient is placed in isolation. To protect the caregivers and other patients on the unit, which type of isolation room is most appropriate? 1) Single-door room with positive air flow (air flows out of the room.) 2) Isolation room with an anteroom and negative air flow (air flows into the room.) 3) Isolation room with an anteroom and normal airflow 4) Single-door room with normal airflow 19. The charge nurse for a medical-surgical unit is notified that a patient with tuberculosis (TB) is being transported to the unit. Which nursing action for infection prevention is the most appropriate in this circumstance? 1) Stock the patient’s supply cart at the beginning of each shift 2) Wear a respirator mask and gown when caring for the patient 3) Perform hand hygiene only after leaving the room 4) Test all staff members for TB immediately 20. A nurse is caring for a patient with tuberculosis (TB) who is taking Rifampin for treatment of the disease. Which nursing intervention is most appropriate for this patient? 1) Administer the medication with meals to reduce gastrointestinal side effects 2) Record a baseline visual examination before initiating therapy 3) Administer the medication on an empty stomach 4) Administer the medication by deep intramuscular injection into a large muscle mass 21. The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding supports this diagnosis? 1) Wheezing
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2) Hemoptysis 3) Grey sputum 4) Slightly whitish sputum 22. During the respiratory assessment, the nurse notes coarse crackles upon auscultation of the lung fields. Which diagnosis presents with this assessment finding? 1) Pneumonia 2) Cystic fibrosis 3) Bronchospasm 4) Interstitial edema 23. The nurse is providing care to a patient who is diagnosed with pneumonia. The patient admits to smoking one pack of cigarettes per day. Which respiratory defense mechanism may have failed to cause the patient’s diagnosis? 1) Cough reflex 2) Filtration of air 3) Alveolar macrophages 4) Mucociliary clearance system 24. The nurse receives a phone call from the parent of a child who is prescribed rifampin (Rimactane) for treatment of tuberculosis because she saw that the child’s urine was orange. Which response by the nurse is accurate? 1) “Encourage your child to drink cranberry juice.” 2) “An orange discoloration of urine is expected while your child is on this medication.” 3) “Bring your child to the clinic for a urinalysis.” 4) “Bring your child to the clinic for a radiograph of the kidneys.”
NURSINGTB.COM Multiple Response Identify one or more choices that best complete the statement or answer the question. 25. The nurse caring for a homeless patient at risk for tuberculosis (TB) will include which symptoms of the disease when educating the patient? Select all that apply. 1) Fatigue 2) Low-grade morning fever 3) Productive cough that later turns to a dry, hacking cough 4) Weight loss 5) Night sweats 26. The nurse is assessing a patient with acute malaise and muscle aches. Which questions should the nurse ask to determine whether the patient is experiencing influenza? Select all that apply. 1) “Have you had a flu shot this year?” 2) “Is your cough productive?” 3) “Have you been exposed to anyone with the flu?” 4) “Are you having any trouble urinating?” 5) “Do you have dizziness?” 27. The school nurse is planning a teaching session with the parents of students to reduce the spread of the influenza virus throughout the school. What should the nurse include when teaching the parents of a diverse population about infection-control techniques? Select all that apply. 1) “Cover your cough” education 2) Appropriate hand hygiene
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3) Safe food preparation and storage 4) Sanitizing high-touch items to kill pathogens 5) Withholding immunizations for children with compromised immune systems 28. The nurse is caring for a patient who develops a fever and productive cough after having an appendectomy. Which prescriptions should the nurse expect from the health-care provider for this health problem? Select all that apply. 1) Sputum cultures 2) Antibiotics 3) Chest physiotherapy 4) Bronchial washing for culture 5) Isolation precautions
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Chapter 24: Coordinating Care for Patients With Infectious Respiratory Disorders Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Describing the etiology of infectious airway disorders Chapter page reference: 443-447 Heading: Influenza Integrated Processes: Nursing Process – Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 People at increased risk of influenza or its complications include infants, young children, and anyone age 50 or older; therefore, this patient should receive an annual influenza vaccine. 2 Patients with chronic disorders, especially diabetes and cardiac, renal, or pulmonary diseases, are more susceptible to complications from the flu; therefore, this patient should receive an annual influenza vaccine. 3 A 35-year-old man with a severe allergy to eggs should not get a flu shot, because the vaccine contains eggs and it is not recommended. 4 Pregnant women, particularly N duUriRngSI theNsGe T c oB nd.aCn O d M third trimesters, are at increased risk of complications from the flu; therefore, this patient should receive the annual influenza vaccine. PTS: 1 CON: Infection 2. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with infectious airway disorders Chapter page reference: 443-447 Heading: Influenza Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Coughing, deep breathing, and hydration are essential for achieving airway clearance. 2 Keeping the head of the bed elevated improves lung excursion and reduces the work of breathing. 3 Coughing, deep breathing, and hydration are essential for achieving airway clearance. 4 Insertion of a tracheostomy and oxygen are not primary treatments for ineffective airway clearance.
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PTS: 1 CON: Oxygenation 3. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with infectious airway disorders Chapter page reference: 443-447 Heading: Influenza Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 This patient statement does not indicate the need for further intervention by the nurse. 2 This patient statement does not indicate the need for further intervention by the nurse. 3 A patient who continues to be awoken during the night because of coughing may require further intervention by the nurse. 4 This patient statement does not indicate the need for further intervention by the nurse. PTS: 1 CON: Oxygenation 4. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of infectious airway disorders Chapter page reference: 443-447 NURSINGTB.COM Heading: Influenza Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Laboratory tests for BUN and sodium levels are not usually associated with influenza. 2 Laboratory tests for BUN and sodium levels are not usually associated with influenza. 3 Unless the patient with influenza develops complications, the chest x-ray is clear. 4 The white blood cell count of a patient with influenza will typically be decreased. PTS: 1 CON: Infection 5. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Influenza Chapter page reference: 443-447 Heading: Influenza Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback
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There is no indication that this patient will need a ventilator. Placing signs on the door is the way to notify other departments of precautions. Negative air flow rooms are for diseases such as chicken pox, measles, and SARS. To prevent the spread of influenza, the patient is placed in a private room with signs for droplet and contact precautions. It is appropriate for the health-care workers to use appropriate PPE for these transmission-based precautions.
PTS: 1 CON: Infection 6. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Influenza Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 Frequently, caregivers or family members note that the patient looks generally ill. The patient is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis is seen in pneumonia, and the respiratory rate would be greater than 20. 2 Frequently, caregivers or family members note that the patient looks generally ill. The patient is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis is seen in pneumonia, and the N reU spRirS atI orN y G raT teBw.o uCldO be M greater than 20. 3 A decreased, not increased, appetite is anticipated when providing care to a patient diagnosed with pneumonia. 4 Frequently, caregivers or family members note that the patient looks generally ill. The patient is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis is seen in pneumonia, and the respiratory rate would be greater than 20. PTS: 1 CON: Oxygenation 7. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Research indicates a high rate of pneumonia in patients with frequent exposure to cigarette smoke and alcohol use. Alcohol interferes with the actions of macrophages. 2 Research indicates a high rate of pneumonia in patients with frequent exposure to cigarette smoke and alcohol use. Smoking injures tissues in the airways and decreases the action of cilia. Chemicals in cigarettes have a numbing effect on the cough reflex.
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Pneumonia vaccines can also be considered to decrease the risk of development in the future. There is not an established body of scientific evidence that supports the claim that L. casei immunitas cultures can improve immune function.
PTS: 1 CON: Oxygenation 8. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 This is not an appropriate response by the nurse. 2 As a person grows older, there is an overall decrease in the speed and strength of the immune response. The immune system does not quit working totally. There is a decrease in the number of B cells in circulation. 3 This is not an appropriate response by the nurse. 4 This is not an appropriate response by the nurse.
NURSINGTB.COM PTS: 1 CON: Oxygenation 9. ANS: 1 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Influenza Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Chest percussion can help clear secretions. 2 Providing education for smoking cessation and administering the pneumococcal vaccine are important in treating a patient with pneumonia; however, they would be aligned with a different nursing diagnosis. 3 Patients with pneumonia are encouraged to increase fluid intake. 4 Providing education for smoking cessation and administering the pneumococcal vaccine are important in treating a patient with pneumonia; however, they would be aligned with a different nursing diagnosis. PTS: 1 CON: Oxygenation 10. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
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Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 Influenza vaccine is administered annually to healthy individuals and should not be given to those with an allergy to eggs. 2 Influenza vaccine is administered annually to healthy individuals and should not be given to those with an allergy to eggs. 3 The pneumococcal vaccine is administered once. Revaccination is only recommended in persons with renal failure, those who have had splenectomies, those with malignancies, and those with HIV/AIDS. 4 This statement indicates correct understanding of the information presented. PTS: 1 CON: Oxygenation 11. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Pneumonia Chapter page reference: 447-451 Heading: Pneumonia NURSINGTB.COM Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution and only as needed. 2 Hyperthermia is an expected consequence of the infectious disease process. Fever can produce mild, short-term effects and, when prolonged, can cause life-threatening effects. The nurse should administer antipyretic medications as indicated for elevated temperatures and enforce frequent rest periods because rest increases energy reserve that is depleted by increased metabolic, heart, and respiratory rates. 3 The nurse should encourage fluid intake rather than restrict fluids because of the risk of electrolyte imbalance. 4 The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution and only as needed. PTS: 1 CON: Oxygenation 12. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Tuberculosis Chapter page reference: 451-455
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Heading: Tuberculosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation; Infection Difficulty: Easy Feedback 1 Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting symptoms of tuberculosis in the older adult. 2 Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting symptoms of tuberculosis in the older adult. 3 Presenting symptoms of tuberculosis in the older adult are often vague and include coughing, weight loss, diminished appetite, and periodic fevers. 4 Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting symptoms of tuberculosis in the older adult. PTS: 1 CON: Oxygenation | Infection 13. ANS: 1 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [UnN deUrsRtaS ndIinNgG ] TB.CO Concept: Oxygenation Difficulty: Easy Feedback 1 This patient was foreign-born, a risk factor for tuberculosis (TB), and has the classic symptoms of tuberculosis. The nurse plans frequent respiratory assessments, as this child is at risk for pneumothorax. 2 Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia. 3 Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia. 4 Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia. PTS: 1 CON: Oxygenation 14. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation; Infection Difficulty: Easy Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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There is no evidence to support the need to screen the patient for sickle cell disease, herpes zoster, or sick sinus syndrome. There is no evidence to support the need to screen the patient for sickle cell disease, herpes zoster, or sick sinus syndrome. There is no evidence to support the need to screen the patient for sickle cell disease, herpes zoster, or sick sinus syndrome. The homeless patient who abuses drugs is at risk for contracting tuberculosis (TB); therefore, the nurse would expect to screen this patient for TB.
PTS: 1 CON: Oxygenation | Infection 15. ANS: 1 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with infectious airway disorders Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Oxygenation; Infection Difficulty: Difficult Feedback 1 The treatment regimen for tuberculosis requires that the patient take many medications, maintain nutrition, and be aware of potential side effects. Due to increased age and normal forgetfulness, this patien NUt iRs SatIriNskGfTorBin.eCff ec OMtive treatmen t in the home. 2 The patient may have a knowledge deficit but the priority is the treatment regimen. 3 Since the patient is being treated in the home, there is not much risk for ineffective breathing. 4 The patient is at risk for injury because of age, not TB. PTS: 1 CON: Oxygenation | Infection 16. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of infectious airway disorders Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation; Infection Difficulty: Moderate Feedback 1 PPD testing is not done twice because different medication is used. 2 Treatment for TB for six months is not a reason to complete the PPD twice. 3 Evaluating the test at the wrong interval is not the reason that the PPD is done twice for long-term care facility employees. 4 PPD testing is done in a two-step process for people who work in long-term care facilities because of the risk of false-negative responses.
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PTS: 1 CON: Oxygenation | Infection 17. ANS: 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Oxygenation; Infection Difficulty: Difficult Feedback 1 Multiple drugs are used for all cases of TB. 2 There is no indication that the patient contracted TB from an immigrant. 3 Treatment must be continued long after the patient is no longer contagious. 4 Tuberculosis bacilli are likely to develop resistance to one drug, so multiple drugs must be used. PTS: 1 CON: Oxygenation | Infection 18. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis NURSINGTB.COM Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Positive flow rooms are used for those patients who are immunosuppressed so that microorganisms from the unit are not drawn into the room. 2 Patients with airborne infections such as meningococcemia, SARS, or TB are placed in an isolation room with an anteroom and negative pressure airflow. Air flows into the room and is vented in a special manner to prevent the organism from entering the rest of the unit. 3 Single-door isolation with normal airflow might be used for a patient with droplet or wound infection. 4 Single-door rooms are not equipped to have positive or negative airflow. PTS: 1 CON: Infection 19. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control
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Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Supplies to prevent transmission of disease should be stocked at the end of the shift so that adequate supplies will be available for the next health-care provider. 2 Masks and gowns should be worn when caring for patients who do not reliably cover their mouths when coughing. When a patient has an airborne disease and must go elsewhere in the hospital, the patient must wear a mask. 3 Hand hygiene should be performed before and after patient care. 4 Clinical staff receive TB testing annually. There is no reason to test all staff members at this time. PTS: 1 CON: Infection 20. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate
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Rifampin is an oral antituberculosis medication that should be administered on an empty, not full, stomach. The nurse should monitor the CBC, liver function studies, and renal function studies. A baseline visual examination before therapy is necessary with ethambutol, another antituberculosis medication. Rifampin is an oral antituberculosis medication that should be administered on an empty stomach. Rifampin is an oral antituberculosis medication.
PTS: 1 CON: Infection 21. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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Wheezing is the term used to describe the musical sounds auscultated during assessment and indicate some degree of airway obstruction that occurs with asthma and emphysema. Tuberculosis is characterized by hemoptysis, which is the term for coughing up of blood or blood-tinged sputum from the respiratory tract. Grey sputum often occurs in patients who are cigarette smokers. Clear, slightly whitish, and viscous sputum are often normal findings.
PTS: 1 CON: Oxygenation 22. ANS: 1 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Pneumonia Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 Coarse crackles are often auscultated for patients diagnosed with pneumonia. 2 Rhonchi is auscultated for patients diagnosed with cystic fibrosis. 3 Wheezes are auscultated when the patient is experiencing bronchospasm. 4 Discontinuous low pitched lung sounds are auscultated for patients experiencing interstitial edema. NURSINGTB.COM PTS: 1 CON: Oxygenation 23. ANS: 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Describing the etiology of infectious airway disorders Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 The cough reflex, filtration of air, and mucociliary clearance are not the respiratory defense mechanisms that failed in this scenario. 2 The cough reflex, filtration of air, and mucociliary clearance are not the respiratory defense mechanisms that failed in this scenario. 3 Alveolar macrophages rapidly phagocytize inhaled foreign particles such as bacteria and often fail as a result of cigarette smoking. 4 The cough reflex, filtration of air, and mucociliary clearance are not the respiratory defense mechanisms that failed in this scenario. PTS: 1
CON: Oxygenation
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24. ANS: 2 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Tuberculosis Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options. 2 Rifampin can color the urine orange, so the parents and child should be taught that this is an expected side effect. 3 Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options. 4 Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options. PTS: 1
CON: Infection
MULTIPLE RESPONSE 25. ANS: 1, 4, 5 NURSINGTB.COM Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders Chapter page reference: 451-455 Heading: Tuberculosis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation; Infection Difficulty: Moderate
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Feedback This is correct. Manifestations of tuberculosis often develop insidiously and are initially nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that the patient first seeks medical attention. This is incorrect. A low-grade afternoon, not morning, fever is anticipated. This is incorrect. A dry cough develops, which later becomes productive of purulent and/or blood-tinged sputum. This is correct. Manifestations of tuberculosis often develop insidiously and are initially nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that the patient first seeks medical attention. This is correct. Manifestations of tuberculosis often develop insidiously and are initially nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that the patient first seeks medical attention.
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PTS: 1 CON: Oxygenation | Infection 26. ANS: 1, 2, 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Influenza Chapter page reference: 443-447 Heading: Influenza Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation; Infection Difficulty: Moderate
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Feedback This is correct. Based on the presenting symptoms, the nurse would ask whether the patient has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is nonproductive. A productive cough may indicate a different diagnosis. This is correct. Based on the presenting symptoms, the nurse would ask whether the patient has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is nonproductive. A productive cough may indicate a different diagnosis. This is correct. Based on the presenting symptoms, the nurse would ask whether the patient has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is nonproductive. A productive cough may indicate a different diagnosis. T inhf ilsueisnzinac. orrect. Insufficient voiding and dizziness are not routine manifestations of
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This is incorrect. Insufficient voiding and dizziness are not routine manifestations of influenza.
PTS: 1 CON: Oxygenation | Infection 27. ANS: 1, 2, 4 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders Chapter page reference: 443-447 Heading: Influenza Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate
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Feedback This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching children to wash their hands, and appropriate respiratory etiquette such as “cover your cough” education all control the growth and spread of microorganisms. This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching children to wash their hands, and appropriate respiratory etiquette such as “cover your cough” education all control the growth and spread of microorganisms.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
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This is incorrect. Teaching parents’ safe food preparation and storage is another tool to prevent the spread of microorganisms, but is not related to the flu virus. This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching children to wash their hands, and appropriate respiratory etiquette such as “cover your cough” education all control the growth and spread of microorganisms. To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. This is incorrect. Immunizations should not be withheld from immunocompromised children, and this is not an infection-control strategy.
PTS: 1 CON: Infection 28. ANS: 1, 2, 3 Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders Chapter learning objective: Discussing the medical management of: Pneumonia Chapter page reference: 447-451 Heading: Pneumonia Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy
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Feedback This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and perform chest physiotherapy to help clear the respiratory secretions. This is correct. The nursN eU wR ouSldIeNx pe G TctBto.oCbOtaMin sputum cultures, administer antibiotics, and perform chest physiotherapy to help clear the respiratory secretions. This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and perform chest physiotherapy to help clear the respiratory secretions. This is incorrect. Bronchial washings are not routine testing for this scenario. This is incorrect. The patient likely has a noninfectious disease and is not contagious. Isolation precautions are usually not ordered for noncontagious infections. CON: Oxygenation
Chapter 25: Coordinating Care for Patients With Upper Airway Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. An adult patient diagnosed with sleep apnea has been prescribed a continuous positive airway pressure (CPAP) machine as treatment. The nurse is instructing the patient on how to use the machine. Which instruction should the nurse include? 1) Any size mask will work 2) Straps can be loose, if that feels more comfortable 3) Use relaxation exercises to reduce uncomfortable feelings from the mask 4) Do not use a humidifier at the same time
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2. The nurse is caring for a patient being weaned from the ventilator, and wants to improve the patient’s ability to communicate. Which item will the nurse request an order for from the health-care provider? 1) Cuffed tracheostomy tube 2) Uncuffed tracheostomy tube 3) Fenestrated tracheostomy tube 4) Obturator 3. The nurse is performing tracheostomy care. Which portion of the trach will the nurse use when tying the new trach ties? 1) Inner cannula 2) Outer cannula 3) Obturator 4) Flange 4. The nurse is caring for a patient with a longstanding permanent tracheostomy that has been in place for several years in order to provide mechanical ventilation. Which type of tracheostomy does the nurse anticipate this patient may have based on the health history? 1) Uncuffed tracheostomy 2) Cuffed tracheostomy 3) Fenestrated tracheostomy 4) Uncuffed or fenestrated tracheostomy 5. The nurse is caring for a patient with a tracheostomy tube in place connected to a mechanical ventilator. When facilitating communication, which strategy is inappropriate? 1) Using a fenestrated tracheostomy tube 2) Using writing materials 3) Using a communication board NURSINGTB.COM 4) Using a Passy-Muir valve 6. When preparing to cap the patient’s tracheostomy tube with a speaking valve, which nursing action is inappropriate before placing the valve? 1) Suctioning the oropharynx if there are any secretions present 2) Asking the patient to cough 3) Suctioning the tracheostomy tube 4) Deflating the cuffed tracheostomy tube 7. When capping the patient’s tracheostomy tube with a speaking valve, the nurse assesses the patient’s breath sounds around the tube and hears no air leak. Which nursing action is the most appropriate based on this assessment finding? 1) Allowing the cap to remain in place as long as the patient tolerates it 2) Documenting the placement of the cap and relevant data regarding patient assessment 3) Removing the valve and notifying the health-care provider 4) Assisting the patient out of bed 8. The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a first generation antihistamine. Which drug should the nurse educate the patient about based on this data? 1) Loratadine 2) Fluticasone 3) Guaifenesin 4) Diphenhydramine
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9. The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a second generation antihistamine. Which drug should the nurse educate the patient about based on this data? 1) Loratadine 2) Fluticasone 3) Guaifenesin 4) Diphenhydramine 10. The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a decongestant. Which drug should the nurse educate the patient about based on this data? 1) Loratadine 2) Fluticasone 3) Guaifenesin 4) Diphenhydramine 11. The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a corticosteroid nasal spray. Which drug should the nurse educate the patient about based on this data? 1) Loratadine 2) Fluticasone 3) Guaifenesin 4) Diphenhydramine 12. The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion. Which drug should the nurse include for a patient who requires a corticosteroid? 1) Saline 2) Azelastine 3) Fluticasone 4) Oxymetazonline NURSINGTB.COM 13. The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion. Which drug should the nurse include for a patient who requires an antihistamine? 1) Saline 2) Azelastine 3) Fluticasone 4) Oxymetazonline 14. The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion. Which drug should the nurse include for a patient who requires a decongestant? 1) Saline 2) Azelastine 3) Fluticasone 4) Oxymetazonline 15. The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion. Which should the nurse recommend when the patient wants a natural? 1) Saline 2) Azelastine 3) Fluticasone 4) Oxymetazonline 16. The nurse is providing care to a patient receiving radiation in the treatment of laryngeal cancer. Which patient statement indicates the need for further education regarding radiation treatments? 1) “My skin may become red, tender, and peel.”
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2) “I should avoid the sun while I am receiving this therapy.” 3) “I will wear soft, loose fitting clothing made of cotton to limit irritation.” 4) “My therapy includes washing my skin with a harsh soap and applying lotion.” 17. The nurse is providing education to a patient receiving radiation therapy for the treatment of laryngeal cancer. Which patient statement indicates the need for further education regarding oral care? 1) “I should increase my oral intake of water.” 2) “I will avoid spicy foods to decrease my discomfort.” 3) “I can chew gum to decrease the dry mouth that may occur.” 4) “I should use a firm-bristle toothbrush to ensure food particles are removed.” 18. The nurse is providing education to a patient who is receiving chemotherapy in the treatment of laryngeal cancer. Which medication should the nurse include to decrease the risk for nausea and vomiting? 1) Antiemetic 2) Decongestant 3) Antihistamine 4) Corticosteroid 19. The nurse is providing care to a patient receiving chemotherapy for the treatment of laryngeal cancer. Which laboratory test should the nurse anticipate to monitor the patient for neutropenia? 1) Platelet count 2) Serum potassium 3) Red blood cell count 4) White blood cell count 20. The nurse is providing education to the patient who is receiving treatment for laryngeal cancer. Which patient statement regarding nutrition require N s fUurRthSe I r eNd G u cT atB io. n C f rO om M the nurse? 1) “I will eat small, frequent meals to ensure I get enough calories each day.” 2) “Even though I don’t like tomatoes, I will eat them since they are not acidic.” 3) “Liquid supplements are easy to swallow and will increase my caloric intake.” 4) “I will eat foods that taste good and are easy to eat and swallow to get enough calories each day.” 21. Which drug prescription does the nurse anticipate for empiric therapy when providing care to an adult patient diagnosed with acute bacterial rhinosinusitis (ABRS)? 1) Azithromycin 2) Clarithromycin 3) Amoxicillin-clavulante 4) Intranasal corticosteriods 22. Which drug prescription does the nurse anticipate for adjuvant therapy when providing care to an adult patient diagnosed with acute bacterial rhinosinusitis (ABRS)? 1) Azithromycin 2) Clarithromycin 3) Amoxicillin-clavulante 4) Intranasal corticosteriods 23. Which is the priority nursing diagnosis for a patient who experiences a laryngeal trauma? 1) Impaired comfort 2) Impaired swallowing 3) Ineffective airway clearance 4) Risk for impaired verbal communication
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24. Which assessment data collected by the nurse indicates a patient with laryngeal trauma is experiencing issues with airway clearance? 1) Tachypnea 2) Bradycardia 3) Hypotension 4) Increased oxygen saturation 25. Which intervention should the nurse implement for a patient who is at risk for aspiration as a result of laryngeal trauma? 1) Encouraging voice rest 2) Maintaining NPO status 3) Placing in high-Fowler’s position 4) Providing humidified air via face mask Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. Which criteria is used to diagnosis acute bacterial rhinosinusitis (ABRS) in adult patients? Select all that apply. 1) Facial pain that lasts for one day 2) Decrease in nasal discharge after six days 3) New onset of headache after five or six days 4) Symptoms that last more than 10 days without clinical improvement 5) Temperature greater than or equal to 102°F [39°C] with purulent nasal discharge for four days NURSINGTB.COM 27. Which first-line medications should the nurse include in a teaching session for a patient who wants to quit smoking? Select all that apply. 1) Clonidine 2) Bupropion 3) Varenicline 4) Nortriptyline 5) Nicotine gum 28. Which patient statements accurately reflect the benefits of physical activity during the smoking cessation process? Select all that apply. 1) “Exercise decreases stress.” 2) “Exercise decreases anxiety.” 3) “Exercise decreases cravings.” 4) “Exercise increases weight loss.” 5) “Exercise increases my support network.”
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Chapter 25: Coordinating Care for Patients With Upper Airway Disorders Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Developing a teaching plan for patients with upper airway disorders Chapter page reference: 462-265 Heading: Obstructive Sleep Apnea Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Proper fitting of the mask to the face, including wearing the right size mask and keeping the straps tight, is important. 2 Proper fitting of the mask to the face, including wearing the right size mask and keeping the straps tight, is important. 3 Relaxation exercises can reduce the claustrophobic feelings caused by wearing the mask. 4 Using a humidifier can minimize dry mouth and nose. PTS: 1 CON: OxygenNa U tioRn SINGTB.COM 2. ANS: 3 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with upper airway disorders Chapter page reference: 466-471 Heading: Laryngeal Cancer Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Oxygenation; Communication Difficulty: Moderate Feedback 1 The cuffed tracheostomy would need to be deflated in order for the fenestrated tube to function. 2 An uncuffed tube does not improve communication. 3 The fenestrated tracheostomy tube allows patients to speak, and could be safely used on the patient who is being weaned from the ventilator. 4 An obturator is used to make the tracheostomy tube more rigid during insertion, and must be removed as soon as the tube is in place, because it occludes the airway. PTS: 1 CON: Oxygenation | Communication 3. ANS: 4 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
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Chapter learning objective: Developing a comprehensive plan of nursing care for patients with upper airway disorders Chapter page reference: 466-471 Heading: Laryngeal Cancer Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate 1 2 3 4
Feedback This is an inappropriate action by the nurse when tying the new trach ties. This is an inappropriate action by the nurse when tying the new trach ties. This is an inappropriate action by the nurse when tying the new trach ties. The trach ties attach to the flange.
PTS: 1 CON: Oxygenation 4. ANS: 2 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Discussing the medical management of: Laryngeal cancer Chapter page reference: 466-471 Heading: Laryngeal Cancer Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] NURSINGTB.COM Concept: Oxygenation Difficulty: Easy Feedback 1 The patient with a long-term tracheostomy who does not require mechanical ventilation would be likely to have an uncuffed tube. 2 Cuffed tracheostomy tubes are essential when the patient requires mechanical ventilation because they provide a seal so that air does not leak when the ventilator provides a breath. 3 The patient with a long-term tracheostomy who does not require mechanical ventilation would be likely to have a fenestrated tracheostomy. 4 Uncuffed and fenestrated tracheostomies are appropriate for a patient who does not require mechanical ventilation. PTS: 1 CON: Oxygenation 5. ANS: 1 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Discussing the medical management of: Laryngeal cancer Chapter page reference: 466-471 Heading: Laryngeal Cancer Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive level: Comprehension [Understanding] Concept: Communication; Oxygenation Difficulty: Easy
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Feedback Fenestrated tracheostomy tubes require placement of the inner cannula when the patient requires mechanical ventilation, which defeats the speaking ability of the tube. Although a fenestrated tube allows a patient to speak when weaning from the ventilator, it will not improve communication for the ventilated patient. Use of writing materials is useful for improving communication if the patient is alert and strong enough to be able to use them. A communication board is indicated if the patient is not strong enough to use writing materials. A Passy-Muir valve can be used when the patient is on or off of the ventilator, allowing the patient to speak.
PTS: 1 CON: Communication | Oxygenation 6. ANS: 3 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with upper airway disorders Chapter page reference: 466-471 Heading: Laryngeal Cancer Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate
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The tracheostomy tube would only be suctioned if indicated; this would not be a routine step to perform at all times. This nursing action is routinely performed prior to capping the tube. This nursing action is routinely performed prior to capping the tube. This nursing action is routinely performed prior to capping the tube.
PTS: 1 CON: Oxygenation 7. ANS: 3 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with upper airway disorders Chapter page reference: 466-471 Heading: Laryngeal Cancer Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate
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Feedback The valve should be removed and the health-care provider notified because lack of an air leak indicates the patient will not be able to exhale and, as a result, will not tolerate the valve.
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Only after calling the health-care provider would the nurse document the inability to use the valve. The valve should be removed and the health-care provider notified because lack of an air leak indicates the patient will not be able to exhale and, as a result, will not tolerate the valve. There would be no need to assist the patient out of bed.
PTS: 1 CON: Oxygenation 8. ANS: 4 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Discussing the medical management of: Rhinitis Chapter page reference: 457-459 Heading: Rhinitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Inflammation; Medication Difficulty: Moderate Feedback 1 Loratadine is a second generation antihistamine. 2 Fluticasone is a corticosteroid nasal spray. 3 Guaifenesin is a decongestant. 4 Diphenhydramine is a first generation antihistamine. PTS: 1 CON: Inflamm NaUtiRo nS| IMNe dGicTaBtio.nCOM 9. ANS: 1 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Discussing the medical management of: Rhinitis Chapter page reference: 457-459 Heading: Rhinitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Inflammation; Medication Difficulty: Moderate Feedback 1 Loratadine is a second generation antihistamine. 2 Fluticasone is a corticosteroid nasal spray. 3 Guaifenesin is a decongestant. 4 Diphenhydramine is a first generation antihistamine. PTS: 1 CON: Inflammation | Medication 10. ANS: 3 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Discussing the medical management of: Rhinitis Chapter page reference: 457-459 Heading: Rhinitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
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Cognitive level: Application [Applying] Concept: Inflammation; Medication Difficulty: Moderate Feedback 1 Loratadine is a second generation antihistamine. 2 Fluticasone is a corticosteroid nasal spray. 3 Guaifenesin is a decongestant. 4 Diphenhydramine is a first generation antihistamine. PTS: 1 CON: Inflammation | Medication 11. ANS: 2 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Discussing the medical management of: Rhinitis Chapter page reference: 457-459 Heading: Rhinitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Inflammation; Medication Difficulty: Moderate Feedback 1 Loratadine is a second generation antihistamine. 2 Fluticasone is a corticosteroid nasal spray. 3 Guaifenesin is a decongestant. 4 Diphenhydramine is a first genNeU raR tioSnIaN n tG ihT isB tam .iCn eO. M PTS: 1 CON: Inflammation | Medication 12. ANS: 3 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Discussing the medical management of: Rhinitis Chapter page reference: 457-459 Heading: Rhinitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Inflammation; Medication Difficulty: Moderate Feedback 1 Saline is a nasal spray; however, saline is not a corticosteroid. 2 Azelastine is an antihistamine nasal spray. 3 Fluticasone is a corticosteroid nasal spray. 4 Oxymetazoline is a decongestant nasal spray. PTS: 1 CON: Inflammation | Medication 13. ANS: 2 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Discussing the medical management of: Rhinitis Chapter page reference: 457-459
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Heading: Rhinitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Inflammation; Medication Difficulty: Moderate Feedback 1 Saline is a nasal spray; however, saline is not an antihistamine. 2 Azelastine is an antihistamine nasal spray. 3 Fluticasone is a corticosteroid nasal spray. 4 Oxymetazoline is a decongestant nasal spray. PTS: 1 CON: Inflammation | Medication 14. ANS: 4 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Discussing the medical management of: Rhinitis Chapter page reference: 457-459 Heading: Rhinitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Inflammation; Medication Difficulty: Moderate Feedback 1 Saline is a nasal spray; however NU, sRalSinIe NisGn ot TBa .d eCcon OMgestan t. 2 Azelastine is an antihistamine nasal spray. 3 Fluticasone is a corticosteroid nasal spray. 4 Oxymetazoline is a decongestant nasal spray. PTS: 1 CON: Inflammation | Medication 15. ANS: 1 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Developing a teaching plan for patients with upper airway disorders Chapter page reference: 457-459 Heading: Rhinitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Inflammation; Medication Difficulty: Moderate Feedback 1 Saline can be administered by nasal spray in the treatment of congestion. Saline is considered a natural remedy. The saline liquefies the secretions and decreases the risk of crusting in the nasal cavity. 2 Azelastine is an antihistamine nasal spray. 3 Fluticasone is a corticosteroid nasal spray. 4 Oxymetazoline is a decongestant nasal spray.
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PTS: 1 CON: Inflammation | Medication 16. ANS: 4 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Describing complications associated with selected upper airway disorders Chapter page reference: 466-471 Heading: Laryngeal Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Cellular Regulation Difficulty: Difficult Feedback 1 This statement indicates correct understanding of the information related to radiation therapy. 2 This statement indicates correct understanding of the information related to radiation therapy. 3 This statement indicates correct understanding of the information related to radiation therapy. 4 A mild, not harsh, soap should be used to cleanse the site receiving radiation. Lotion should only be applied if prescribed by the radiologist. PTS: 1 CON: Cellular Regulation 17. ANS: 4 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Describing complications associated with selected upper airway disorders Chapter page reference: 466-471 NURSINGTB.COM Heading: Laryngeal Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Analysis [Analyzing] Concept: Comfort; Cellular Regulation Difficulty: Difficult Feedback 1 This patient statement indicates correct understanding of the information presented. 2 This patient statement indicates correct understanding of the information presented. 3 This patient statement indicates correct understanding of the information presented. 4 A soft-bristle brush should be used to decrease the risk of irritation and inflammation. PTS: 1 CON: Comfort | Cellular Regulation 18. ANS: 1 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Discussing the medical management of: Laryngeal cancer Chapter page reference: 466-471 Heading: Laryngeal Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Cellular Regulation; Medication Difficulty: Moderate
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1 2 3
4
Feedback An antiemetic agent is often prescribed to treat the nausea and vomiting that can occur with chemotherapy. A decongestant is more appropriate for a patient diagnosed with rhinitis. An antihistamine may be administered during a scheduled chemotherapy session. However, this drug is not prescribed for use between sessions. It is more appropriate for a patient diagnosed with rhinitis. A corticosteroid is more appropriate for a patient diagnosed with rhinitis. A corticosteroid can increase the patient’s risk of infection is prescribed and administered with chemotherapy.
PTS: 1 CON: Cellular Regulation | Medication 19. ANS: 4 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected upper airway disorders Chapter page reference: 466-471 Heading: Laryngeal Cancer Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Easy Feedback 1 A platelet count is anticipated NtoUmRoSn I itoNr th GTe pa B.tien C Ot for M thrombocytopen ia, which increases the patient’s risk for bleeding. 2 A serum potassium is anticipated to monitor the patient for electrolyte imbalances that often occur due to the nausea and vomiting that can accompany chemotherapy. 3 A red blood cell count is anticipated to monitor the patient for anemia, which can cause fatigue. 4 A white blood cell count is anticipated to monitor the patient for neutropenia, which increases the patient’s risk for infection. PTS: 1 CON: Cellular Regulation 20. ANS: 2 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Developing a teaching plan for patients with upper airway disorders Chapter page reference: 466-471 Heading: Laryngeal Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Analysis [Analyzing] Concept: Cellular Regulation; Nutrition Difficulty: Difficult Feedback 1 Small, frequent meals throughout the day ensure an adequate caloric intake. 2 Tomatoes are acid; therefore, should be avoided. Also, the patient does not like tomatoes. Nonacid containing foods that the patient enjoys should be encouraged.
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3 4
Liquid supplements are easy to swallow and increase the patient’s caloric intake when used in additional to solid foods. The patient is encouraged to eat foods that taste good and are easy to eat and swallow in order to ensure an adequate caloric intake.
PTS: 1 CON: Cellular Regulation | Nutrition 21. ANS: 3 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Discussing the medical management of: Rhinosinusitis Chapter page reference: 459-462 Heading: Rhinosinusitis Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Infection; Medication Difficulty: Easy Feedback 1 Azithromycin, a macrolide, is not recommended for empiric therapy of ABRS. 2 Clarithromycin, a macrolide, is not recommended for empiric therapy of ABRS. 3 Amoxicillin-clavulante is recommended over amoxicillin alone for five to seven days for empiric therapy of ABRS. 4 Intranasal steroids are recommended as adjuvant, not empiric, therapy of ABRS. PTS: 1 CON: Infection 22. ANS: 4 NURSINGTB.COM Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Discussing the medical management of: Rhinosinusitis Chapter page reference: 459-462 Heading: Rhinosinusitis Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Infection; Medication Difficulty: Easy Feedback 1 Azithromycin, a macrolide, is not recommended for empiric therapy of ABRS. 2 Clarithromycin, a macrolide, is not recommended for empiric therapy of ABRS. 3 Amoxicillin-clavulante is recommended over amoxicillin alone for 5 to 7 days for empiric therapy of ABRS. 4 Intranasal steroids are recommended as adjuvant, not empiric, therapy of ABRS. PTS: 1 CON: Infection 23. ANS: 3 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with upper airway disorders Chapter page reference: 471-474 Heading: Laryngeal Trauma Integrated Processes: Nursing Process – Diagnosis
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Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 While impaired comfort is an appropriate nursing diagnosis for this patient, it is not the priority when using the ABCs (airway, breathing, circulation) method for prioritization of care. 2 While impaired swallowing is an appropriate nursing diagnosis for this patient, it is not the priority when using the ABCs (airway, breathing, circulation) method for prioritization of care. 3 Ineffective airway clearance related to edema is the priority nursing diagnosis when planning care for a patient who experiences a laryngeal trauma. 4 While risk for impaired verbal communication is an appropriate nursing diagnosis for this patient, it is not the priority when using the ABCs (airway, breathing, circulation) method for prioritization of care. Also, risk for nursing diagnosis are never prioritized ahead of actual nursing diagnoses. PTS: 1 CON: Oxygenation 24. ANS: 1 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Describing complications associated with selected upper airway disorders Chapter page reference: 471-474 Heading: Laryngeal Trauma Integrated Processes: Nursing Process – Assessment Client Need: Physiological IntegrityNURSINGTB.COM – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 An increased respiratory rate, or tachypnea, indicates respiratory distress and issues with airway clearance. 2 Tachycardia, not bradycardia, indicates respiratory distress. 3 Changes in blood pressure are not expected for patients experiencing respiratory distress due to issues with airway clearance. 4 Decreased, not increased, oxygen saturation indicates respiratory distress. PTS: 1 CON: Oxygenation 25. ANS: 2 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with upper airway disorders Chapter page reference: 471-474 Heading: Laryngeal Trauma Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult
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1 2
3 4
Feedback Encouraging voice rest is important to decrease inflammation and edema, not aspiration. Due to the edema and inflammation from the injury, an NPO status decreases the patient’s risk for aspiration. NPO status is also encouraged prior to surgery for the same reason. Maintaining a high-Fowler’s position will decrease edema and maintain a patent airway. Cool, humidified air will decrease airway edema.
PTS: 1
CON: Oxygenation
MULTIPLE RESPONSE 26. ANS: 3, 4, 5 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Rhinosinusitis Chapter page reference: 459-462 Heading: Rhinosinusitis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Inflammation; Infection Difficulty: Easy NURSINGTB.COM 1. 2. 3. 4. 5.
Feedback This is incorrect. Facial pain with fever that lasts longer than three to four days would indicate ABRS. This is incorrect. An increase, not decrease, in nasal discharge after six days would indicate ABRS. This is correct. A new onset of headache after this length of time with symptoms often indicates ABRS. This is correct. Symptoms that last more than 10 days without clinical improvement often indicates ABRS. This is correct. This data supports the diagnosis of ABRS.
PTS: 1 CON: Inflammation | Infection 27. ANS: 2, 3, 5 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Discussing the medical management of: Laryngeal cancer Chapter page reference: 466-471 Heading: Laryngeal Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Medication Difficulty: Moderate
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1. 2. 3. 4. 5.
Feedback This is incorrect. Clonidine is a second, not first, line drug for smoking cessation. This is correct. Bupropion is a first-line drug for smoking cessation. This is correct. Varenicline is a first-line drug for smoking cessation. This is incorrect. Nortriptyline is a second, not first, line drug for smoking cessation. This is correct. Nicotine gum is a first-line drug for smoking cessation.
PTS: 1 CON: Medication 28. ANS: 1, 2, 3 Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders Chapter learning objective: Developing a teaching plan for patients with upper airway disorders Chapter page reference: 466-471 Heading: Laryngeal Cancer Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Analysis [Analyzing] Concept: Promoting Health Difficulty: Difficult
1. 2. 3. 4. 5. PTS: 1
Feedback This is correct. Exercise decreases stress that is often experienced during smoking cessation. This is correct. Exercise decreases anxiety that is often experienced during smoking cessation. This is correct. Exercise decreases cravings that are often experienced during smoking cessation. NURSINGTB.COM This is incorrect. While exercise is known to reduce the weight gain postcessation it is not known to increase weight loss. This is incorrect. Support groups, not exercise, increase the patient’s support network. CON: Promoting Health
Chapter 26: Coordinating Care for Patients With Lower Airway Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The student nurse is questioning the instructor about the different types of chemotherapeutic agents used to treat cancer. Which statement by the instructor best explains why lung cancers are less sensitive to antineoplastic agents than other types of cancers? 1) “Lung cancer cells have a low growth fraction, so they are less sensitive to antineoplastic agents.” 2) “Lung cancer cells grow in a high-oxygen environment, so they are not very sensitive to antineoplastic agents.” 3) “Lung cancer cells have been growing for a long time before detection, so they are less sensitive to antineoplastic agents.”
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4) “Lung cancer cells have a very erratic cell cycle, so they are not very sensitive to antineoplastic agents.” 2. The nurse is caring for a patient in a community clinic who wishes to quit smoking. The patient asks the nurse, “If I quit smoking, will my risk of lung cancer be the same as a nonsmoker?” Which is the best response by the nurse? 1) “No one knows for sure what the risk is for someone who quits smoking.” 2) “Your risk of lung cancer will be equal to that of a nonsmoker.” 3) “Your risk of lung cancer will decline if you quit, but it will remain higher than a nonsmoker’s.” 4) “Your risk of lung cancer will never drop because the damage has already been done.” 3. A male Hispanic patient has had a lung biopsy. The results indicate a poor prognosis for the patient. The family is at the patient’s bedside and begins to moan and cry loudly. The health -care provider has told the nurse that he needs to have the consent form signed for surgery. The patient has asked the nurse to allow the family private time. What should the nurse do at this time? 1) Ask the family to come back later 2) Have the doctor get the consent with the family present 3) Provide the patient and family privacy 4) Take the patient to another room 4. The nurse is caring for an older adult patient who is very thin and emaciated. The patient reports new onset of shortness of breath. A chest x-ray reveals a spot on the lungs that the physician believes is an inoperable lung cancer. Due to the patient’s poor nutritional status, chemotherapy is not an option. The health -care provider also believes that the location of the cancer would make radiation therapy unsuccessful. In advocating for this patient, what should the nurse encourage the health-care team to do? 1) Provide palliative care to keep thNeUpR a tS ie I n tNc G o mTf B o r. taC b lO e M withou t diagnostic testing 2) Perform any procedure necessary to diagnose the patient properly 3) Promote the use of blood tests to diagnose the suspected cancer 4) Determine the patient’s and family’s wishes regarding diagnostic testing 5. A nurse is caring for a patient recovering from a wedge resection of the left lung for a tumor. Which is an appropriate goal for the nursing diagnosis of ineffective airway clearance? 1) Participation in care by the patient 2) Maintain a patent airway 3) Maintain current weight 4) Express feelings and concerns 6. The nurse is caring for a patient who is undergoing diagnostic tests to rule out lung cancer. The patient asks the nurse why a computed tomography (CT) scan was ordered. What is the best response by the nurse? 1) “The doctor prefers this test.” 2) “To rule out the possibility that your problems are caused by pneumonia.” 3) “It is more specific in diagnosing your condition.” 4) “Why are you concerned about this test?” 7. The nurse is providing care to a patient admitted after experiencing an acute asthma attack. Which assessment findings indicate the need for immediate intervention by the nurse? 1) Retractions and fatigue 2) Tachycardia and tachypnea 3) Inaudible breath sounds 4) Diffuse wheezing and the use of accessory muscles when inhaling
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8. Friends of a patient hospitalized with asthma would like to bring the patient a gift. Which gift would the nurse recommend for this patient? 1) A basket of flowers 2) A stuffed animal 3) Fruit and candy 4) A book 9. A nurse is teaching environmental control to the parents of a child with asthma. Which statement by the parents indicates effective teaching? 1) “We’ll be sure to use the fireplace often to keep the house warm in the winter.” 2) “We will replace the carpet in our child’s bedroom with tile.” 3) “We’ll keep the plants in our child’s room dusted.” 4) “We’re glad the dog can continue to sleep in our child’s room.” 10. An older adult patient diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration. Based on this data, which nursing diagnosis is the most appropriate? 1) Ineffective Airway Clearance 2) Impaired Tissue Perfusion 3) Ineffective Breathing Pattern 4) Activity Intolerance 11. A patient asks why asthma medication is needed even though the patient’s last attack was several months ago. Which response by the nurse is appropriate? 1) “The medication needs to be taken or your lungs will be severely damaged and we will not be able to prevent an acute attack.” 2) “The medication needs to be taken indefinitely according to your doctor, so you should discuss this with him.” NURSINGTB.COM 3) “The medication is still needed to decrease inflammation in your airways and help prevent an attack.” 4) “The medication needs to be taken for at least a year; then, if you have not had an acute attack, you can stop it.” 12. The nurse is instructing a patient who is prescribed ipratropium bromide (Atrovent) for asthma. Which should be included in this patient’s teaching? 1) Take no more than the prescribed number of doses each day. 2) Rinse the mouth after taking this medication. 3) Take on an empty stomach. 4) Take with meals or a full glass of water. 13. The nurse instructs a patient with asthma on bronchodilator therapy. Which statement indicates patient understanding? 1) “The medication widens the airways because it acts on the parasympathetic nervous system.” 2) “The medication widens the airways because it stimulates the fight-or-flight response of the nervous system.” 3) “The medication widens the airways because it decreases the production of histamine that narrows the airways.” 4) “The medication widens the airways because it decreases the production of mucous that narrows the airways.” 14. The nurse working on a pediatric unit is caring for a patient newly diagnosed with asthma. Which assessment data indicates exhaustion and the need for immediate intervention?
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1) 2) 3) 4)
Slightly diminished breath sounds Decreased wheezing Increased crackles Increased respiratory rate
15. The nurse is providing care to an infant in the emergency department (ED). Initial assessment indicates that the infant is experiencing an asthma attack. The infant is unresponsive to medication and a chest x-ray reveals a foreign body partially obstructing the airway. While placing an oxygen mask on the infant, the nurse notes a total obstruction of the airway. Which nursing action is appropriate? 1) Attempt to clear the obstruction by delivering back blows and chest thrusts. 2) Attempt to clear the obstruction by delivering back blows. 3) Attempt to clear the obstruction by delivering back blows and abdominal thrusts. 4) Attempt to clear the obstruction by delivering abdominal thrusts. 16. The nurse is providing care to a patient newly diagnosed with asthma. When developing the patient’s plan of care, which intervention would be most appropriate to promote airway clearance? 1) Provide adequate rest periods 2) Reduce excessive stimuli 3) Assist with activities of daily living 4) Place in Fowler position 17. The nurse is reviewing discharge instructions with a patient who is newly diagnosed with asthma. Which patient statement indicates a need for further teaching? 1) “I need to rinse my mouth after every use of my inhaler.” 2) “I need to take my Singulair at least one hour before I eat.” 3) “I can resume my ephedra when I return home.” 4) “Because I am on theophylline, N IU wR ill S nI eeN d G toThB a v.e C thOerMapeu tic blood levels drawn.” 18. Which assessment finding supports the nurse’s suspicion that a patient is experiencing chronic obstructive pulmonary disease (COPD)? 1) Dysrhythmias 2) Cyanotic nail beds 3) Clubbing of the fingers 4) Cough in the morning producing clear sputum 19. The nurse is providing care to a patient diagnosed with chronic obstruction pulmonary disease (COPD) after years of experiencing emphysema. Which clinical manifestation does the nurse anticipate when assessing this patient? 1) Tachycardia 2) Cough 3) Barrel chest 4) Wheezing 20. The nurse is planning care for the patient diagnosed with chronic obstructive pulmonary disease (COPD) who has a breathing rate of 32 per minute, elevated blood pressure, and fatigue. Which nursing diagnosis is the priority for this patient? 1) Ineffective Coping 2) Ineffective Airway Clearance 3) Anxiety 4) Ineffective Breathing Pattern
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21. The nurse is providing care for a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which intervention is inappropriate to control the patient’s breathing pattern? 1) Instruct in pursed-lip breathing 2) Teach visualization and meditation 3) Deep breathing and coughing every hour 4) Instruct in abdominal breathing 22. A patient diagnosed with chronic obstructive pulmonary disease (COPD) has a pulse oximetry reading of 93%, increased red blood and white blood cell count, temperature of 101°F, pulse 100 bpm, respirations 35 bpm, and a chest x-ray that showed a flattened diaphragm with infiltrates. Based on this data, which prescription does the nurse question for this patient? 1) Antibiotic therapy 2) Nonsteroidal anti-inflammatory agents 3) Oxygen by nasal cannula at 3-4 liters/minute 4) Bronchodilators such as an adrenergic stimulating drugs or anticholinergic agents 23. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD). A nursing diagnosis for this patient is Imbalanced Nutrition: Less than Body Requirements. Which intervention is appropriate for this nursing diagnosis? 1) Encourage a diet high in protein and fats 2) Keep snacks to a minimum 3) Encourage carbohydrate-rich foods to provide needed calories for energy 4) Suggest the patient eat three meals per day to maintain energy needs 24. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which observation would indicate that care provided to this patient has been effective? Mh ile maintain in g an oxygen 1) Patient conducts morning care aN n dUaRmSbI u lN a tG e sTinBr. ooCmOw saturation of 92% on room air per oximetry reading. 2) Patient needs assistance with morning care and meals due to shortness of breath. 3) Patient states family members are discussing admission to a nursing home for continuing care. 4) Patient leaves hospital unit to smoke outside four times a day. 25. The nurse is teaching a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which patient statement indicates a need for further teaching? 1) “I should inhale by sniffing.” 2) “I should avoid aerosol sprays.” 3) “I should limit my fluid intake to 1-1.5 quarts daily.” 4) “I should get a flu vaccine every year.” Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. The nurse is planning care to address ineffective airway clearance for a patient with lung cancer. Which interventions should the nurse include in the patient’s plan of care? Select all that apply. 1) Increase fluid intake to 3000 mL per day 2) Turn, cough, and deep breathe every two hours 3) Chest percussion every eight hours 4) Smoking cessation education 5) Administer pneumococcal vaccine
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27. The nurse is planning care for a young adolescent patient diagnosed with asthma. Which evidence-based ageappropriate interventions will the nurse include in the plan of care? Select all that apply. 1) Referring to a peer-led support group 2) Teaching the parents how to administer maintenance medication prior to teaching the patient 3) Assessing peer-support when planning care 4) Collaborating with teachers for support in the school setting 5) Telling the patient to avoid medication while at school 28. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD)? Which factors in the patient’s history support the current diagnosis? Select all that apply. 1) Working in an industrial environment 2) Working in an office setting with air conditioning 3) History of asthma 4) Current cigarette smoking 5) Playing golf several times a week 29. Which assessment data would cause the nurse to suspect that an infant requires further testing for cystic fibrosis? Select all that apply. 1) Rectal prolapse 2) Constipation 3) Steatorrheic stools 4) Meconium ileus 5) Diarrhea 30. Which systems should the nurse anticipate will be affected when planning care for a patient diagnosed with cystic fibrosis? Select all that apply. NURSINGTB.COM 1) Respiratory 2) Neurological 3) Reproductive 4) Cardiovascular 5) Gastrointestinal
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Chapter 26: Coordinating Care for Patients With Lower Airway Disorders Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Describing the epidemiology of lower airway disorders Chapter page reference: 489-491 Heading: Lung Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Cellular Regulation; Oxygenation Difficulty: Moderate Feedback 1 Growth fraction is a ratio of the number of replicating cells to the number of resting cells. Antineoplastic drugs are much more toxic to tissues and tumors with high growth fractions. Breast and lung cancers have low growth fractions. 2 A high-oxygen environment is not the reason why lung cancer cells are less sensitive to antineoplastic agents. 3 Lung cancer cells may grow for a long time before detection, but this is not the primary reason they are less susceptible to antineoplastic agents. 4 Lung cancer cells do not have a very erratic cell cycle.
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PTS: 1 CON: Cellular Regulation | Oxygenation 2. ANS: 3 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Describing the epidemiology of lower airway disorders Chapter page reference: 489-491 Heading: Lung Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate
1 2 3 4
Feedback The risk for someone who quits is known to be dramatically less than for someone who continues to smoke. While the patient’s risk for lung cancer will diminish sharply upon quitting smoking, it will not drop to the level of someone who never smoked. The risk for someone who quits is known to be dramatically less than for someone who continues to smoke. Although damage has been done, the patient’s risk will drop dramatically upon quitting smoking.
PTS: 1
CON: Cellular Regulation
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3. ANS: 3 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway disorders Chapter page reference: 489-491 Heading: Lung Cancer Integrated Processes: Nursing Process – Implementation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Cellular Regulation; Diversity Difficulty: Moderate Feedback 1 Asking the family to leave may cause extreme stress to the patient and family. 2 It would not be appropriate for the doctor to try to explain the surgery while the family is grieving. 3 As the patient advocate, the nurse would allow this family to bond according to their customs. 4 Taking the patient to another room would deprive the patient from participating in his family’s customs. PTS: 1 CON: Cellular Regulation | Diversity 4. ANS: 4 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway disorders Chapter page reference: 489-491 NURSINGTB.COM Heading: Lung Cancer Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Cellular Regulation; Nursing Roles Difficulty: Moderate
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Feedback An older adult emaciated patient may have few options for treatment of cancer, if confirmed. The best course of treatment may be palliative care, but it is the choice of the patient and family that should direct the plan of care and choices of diagnostic testing. An older adult emaciated patient may have few options for treatment of cancer, if confirmed. The best course of treatment may be palliative care, but it is the choice of the patient and family that should direct the plan of care and choices of diagnostic testing. An older adult emaciated patient may have few options for treatment of cancer, if confirmed. The best course of treatment may be palliative care, but it is the choice of the patient and family that should direct the plan of care and choices of diagnostic testing.
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An older adult emaciated patient may have few options for treatment of cancer, if confirmed. The best course of treatment may be palliative care, but it is the choice of the patient and family that should direct the plan of care and choices of diagnostic testing.
PTS: 1 CON: Cellular Regulation | Nursing Roles 5. ANS: 2 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway disorders Chapter page reference: 489-491 Heading: Lung Cancer Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Cellular Regulation; Oxygenation Difficulty: Difficult
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Feedback All of the outcomes for this patient are viable, but appropriate outcomes for the diagnosis of ineffective airway clearance are maintaining a patent airway and minimizing the accumulation of fluid. All of the outcomes for this patient are viable, but appropriate outcomes for the diagnosis of ineffective airway clearance are maintaining a patent airway and minimizing the accumulation oNfUflR uiS d.INGTB.COM All of the outcomes for this patient are viable, but appropriate outcomes for the diagnosis of ineffective airway clearance are maintaining a patent airway and minimizing the accumulation of fluid. All of the outcomes for this patient are viable, but appropriate outcomes for the diagnosis of ineffective airway clearance are maintaining a patent airway and minimizing the accumulation of fluid.
PTS: 1 CON: Cellular Regulation | Oxygenation 6. ANS: 3 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of lower airway disorders Chapter page reference: 489-491 Heading: Lung Cancer Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Physician preference is not a factor as to why this diagnostic test is prescribed. 2 A chest x-ray can be used to diagnose pneumonia.
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Computed tomography (CT) is used to evaluate and localize tumors, particularly tumors in the lung parenchyma and pleura. It also is done before needle biopsy to localize the tumor. In addition, CT scanning can detect distant tumor metastasis and evaluate tumor response to treatment. The patient’s question is valid and should not be minimized by asking why the patient is having concerns about the test.
PTS: 1 CON: Cellular Regulation 7. ANS: 3 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Asthma Chapter page reference: 476-482 Heading: Asthma Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 Retractions and fatigue are also a progression of symptoms that occur with an asthma attack and represent a more severe episode. But they are not the worst or most serious set of symptoms listed, because air is still moving and exchanging. 2 During an asthma attack, tachycardia, tachypnea, and prolonged expirations are cuorgmem ncoyn.. They are early symptoms of the disease process and can be addressed without
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Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that little or no air movement into and out of the lungs is taking place. Therefore, this set of symptoms represents the most urgent need, which is immediate intervention by the nurse to open up the lungs with drug management to prevent total respiratory failure. Diffuse wheezing and the use of accessory muscles when inhaling indicate a progression of the severity of the symptoms, but airflow is still occurring; therefore, they do not require the most urgent action.
PTS: 1 CON: Oxygenation 8. ANS: 4 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with lower airway disorders Chapter page reference: 476-482 Heading: Asthma Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 A patient with asthma must not be exposed to items that can exacerbate their disease process. Specific allergens, chemicals, and foods must be avoided. Flowers, food, and items that may contain dust, such as a stuffed animal, should be avoided.
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A patient with asthma must not be exposed to items that can exacerbate their disease process. Specific allergens, chemicals, and foods must be avoided. Flowers, food, and items that may contain dust, such as a stuffed animal, should be avoided. A patient with asthma must not be exposed to items that can exacerbate their disease process. Specific allergens, chemicals, and foods must be avoided. Flowers, food, and items that may contain dust, such as a stuffed animal, should be avoided. Objects void of irritants, such as a book, would be an appropriate gift.
PTS: 1 CON: Oxygenation 9. ANS: 2 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with lower airway disorders Chapter page reference: 476-482 Heading: Asthma Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult 1 2
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Feedback Smoke from fireplaces should be eliminated. Control of dust in the child’s bedroom is an important aspect of environmental control for asthma management, and rN epUlaRc S in I g th NeG cTarp B.etCinOg Min the child’s bedroom with tile flooring will reduce dust. Plants are often an allergen that can induce symptoms of asthma; therefore, this is not appropriate. When possible, pets and plants should not be kept in the home.
PTS: 1 CON: Oxygenation 10. ANS: 3 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway disorders Chapter page reference: 476-482 Heading: Asthma Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 The patient is experiencing an increased respiratory rate and is wheezing, which is an ineffective breathing pattern. 2 Not enough information is provided to determine whether the patient has ineffective airway clearance, activity intolerance, or impaired tissue perfusion. 3 Not enough information is provided to determine whether the patient has ineffective airway clearance, activity intolerance, or impaired tissue perfusion.
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Not enough information is provided to determine whether the patient has ineffective airway clearance, activity intolerance, or impaired tissue perfusion.
PTS: 1 CON: Oxygenation 11. ANS: 3 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Discussing the medical management of: Asthma Chapter page reference: 476-482 Heading: Asthma Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Telling a patient that lungs will be severely damaged is nontherapeutic; the inability to prevent an acute attack in this patient is not true. 2 The nurse is able to answer the patient’s question; it does not need to be referred to the physician. 3 Effective treatment of asthma includes long-term treatment to prevent attacks and decrease inflammation, as well as short-term treatment when an attack occurs. 4 Long-term treatment of asthma continues indefinitely, not for just 1 year. PTS: 1 CON: Oxygenation 12. ANS: 1 NURSINGTB.COM Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Discussing the medical management of: Asthma Chapter page reference: 476-482 Heading: Asthma Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Appropriate teaching for a patient prescribed ipratropium bromide (Atrovent) includes only taking the prescribed number of doses each day to prevent a drug overdose. 2 The mouth does not need to be rinsed after taking this medication. 3 This medication does not need to be taken with meals or a full glass of water, or on an empty stomach. 4 This medication does not need to be taken with meals or a full glass of water, or on an empty stomach. PTS: 1 CON: Oxygenation 13. ANS: 2 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Discussing the medical management of: Asthma Chapter page reference: 476-482 Heading: Asthma
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Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 Bronchodilators act on the sympathetic nervous system, not the parasympathetic nervous system. 2 During the fight-or-flight response, beta 2 -adrenergic receptors of the sympathetic nervous system are stimulated, the bronchiolar smooth muscle relaxes, and bronchodilation occurs. 3 Bronchodilators do not decrease the production of mucus or the production of histamine. 4 Bronchodilators do not decrease the production of mucus or the production of histamine. PTS: 1 CON: Oxygenation 14. ANS: 2 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Asthma Chapter page reference: 476-482 Heading: Asthma Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] NURSINGTB.COM Concept: Oxygenation Difficulty: Easy Feedback 1 Respiratory status can change rapidly during an acute asthma attack. Slowed, shallow respirations with significantly, not slightly, diminished breath sounds may indicate exhaustion and impending respiratory failure. 2 Respiratory status can change rapidly during an acute asthma attack. Slowed, shallow respirations with significantly diminished breath sounds and decreased wheezing may indicate exhaustion and impending respiratory failure. Immediate intervention is necessary. 3 Increased crackles are usually associated with heart failure and are not an indication of exhaustion. 4 An increased respiratory rate indicates respiratory compromise, but not exhaustion. PTS: 1 CON: Oxygenation 15. ANS: 1 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Discussing the medical management of: Asthma Chapter page reference: 476-482 Heading: Asthma Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation
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Difficulty: Moderate Feedback 1 When a life-threatening total airway obstruction occurs, efforts to clear the obstruction include back blows and chest thrusts in an infant; therefore, the appropriate action for the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are appropriate in older children. 2 When a life-threatening total airway obstruction occurs, efforts to clear the obstruction include back blows and chest thrusts in an infant; therefore, the appropriate action for the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are appropriate in older children. 3 When a life-threatening total airway obstruction occurs, efforts to clear the obstruction include back blows and chest thrusts in an infant; therefore, the appropriate action for the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are appropriate in older children. 4 When a life-threatening total airway obstruction occurs, efforts to clear the obstruction include back blows and chest thrusts in an infant; therefore, the appropriate action for the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are appropriate in older children. PTS: 1 CON: Oxygenation 16. ANS: 4 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway disorders Chapter page reference: 476-482 NURSINGTB.COM Heading: Asthma Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 Providing adequate rest periods prevents fatigue and reduces oxygen demands. 2 Reducing excessive stimuli promotes rest. 3 Assisting with activities of daily living conserves energy and reduces oxygen demands. 4 Placing the patient in Fowler position facilitates breathing and lung expansion, promoting airway clearance. PTS: 1 CON: Oxygenation 17. ANS: 3 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with lower airway disorders Chapter page reference: 476-482 Heading: Asthma Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Oxygenation
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Difficulty: Moderate Feedback 1 This statement is accurate and requires no further education. 2 This statement is accurate and requires no further education. 3 Herbal preparations that include atropa belladonna (the natural form of atropine) or ephedra (also called ma huang), an herb that contains ephedrine, should not be used, as they can interact with prescribed medications, indicating a need for further teaching. 4 This statement is accurate and require no further education. PTS: 1 CON: Oxygenation 18. ANS: 4 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Chronic obstructive pulmonary disease Chapter page reference: 482-485 Heading: Chronic Obstructive Pulmonary Disease (COPD) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 Enlargement and thickening of the right ventricle of the heart often results in dysrhythmias. 2 With the progression of COPDN, UthR e S boIdN y co GTmBp en . CsaOteMs by producing extra red blood cells. These extra blood cells clog the small blood vessels of the fingers, leading to the development of cyanotic nail beds and clubbing of the fingertips. 3 With the progression of COPD, the body compensates by producing extra red blood cells. These extra blood cells clog the small blood vessels of the fingers, leading to the development of cyanotic nail beds and clubbing of the fingertips. 4 The earliest-presenting symptom of COPD is coughing in the morning with clear sputum unless the patient develops an infection, in which case the sputum would become yellow or green in color. PTS: 1 CON: Oxygenation 19. ANS: 3 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Chronic obstructive pulmonary disease Chapter page reference: 482-485 Heading: Chronic Obstructive Pulmonary Disease (COPD) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 While coughing, wheezing, and tachycardia may also be experienced by a patient diagnosed with COPD, these are not specific to COPD caused by emphysema.
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While coughing, wheezing, and tachycardia may also be experienced by a patient diagnosed with COPD, these are not specific to COPD caused by emphysema. Barrel chest occurs because the lungs are chronically overinflated with air, so the rib cage stays partially expanded. While coughing, wheezing, and tachycardia may also be experienced by a patient diagnosed with COPD, these are not specific to COPD caused by emphysema.
PTS: 1 CON: Oxygenation 20. ANS: 4 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway disorders Chapter page reference: 482-485 Heading: Chronic Obstructive Pulmonary Disease (COPD) Integrated Processes: Nursing Process – Diagnosis Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult
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Feedback There is no information to support Ineffective Airway Clearance, as there is no mention that the patient is coughing. There is no information to support Anxiety or Ineffective Coping. There is no information to supN poUrtR A SnIxiNetGy TorBI.neCffOecMtive Coping. The patient’s respiratory rate of 32 per minute is an indication of an ineffective breathing pattern. The elevated blood pressure and fatigue are indications of a compromised respiratory status. The diagnosis of Ineffective Breathing Pattern would be the priority for the patient at this time.
PTS: 1 CON: Oxygenation 21. ANS: 3 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway disorders Chapter page reference: 482-485 Heading: Chronic Obstructive Pulmonary Disease (COPD) Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate
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Feedback Techniques used to instruct a patient to control the breathing pattern include pursed-lip breathing, abdominal breathing, and relaxation such as visualization and meditation. Techniques used to instruct a patient to control the breathing pattern include pursed-lip breathing, abdominal breathing, and relaxation such as visualization and meditation.
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Deep breathing and coughing should be done every two hours to help keep the airway clear and prevent the pooling of secretions, not to control the breathing pattern. Techniques used to instruct a patient to control the breathing pattern include pursed-lip breathing, abdominal breathing, and relaxation such as visualization and meditation.
PTS: 1 CON: Oxygenation 22. ANS: 3 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Discussing the medical management of: Chronic obstructive pulmonary disease Chapter page reference: 482-485 Heading: Chronic Obstructive Pulmonary Disease (COPD) Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 The order for antibiotic therapy is expected, as the patient is febrile with an increase in white blood cells. 2 Nonsteroidal anti-inflammatory agents are commonly ordered to decrease the inflammation and swelling of lung tissues to maximize oxygen and carbon dioxide exchange and to improve symptoms, and would be expected for this patient. 3 The nurse should be concerned about the order for oxygen to be provided at 3-4 liters/minute. This amount of oxygen is too much for a patient with COPD because the patient’s breaths are stimulate dN by URaShIypNoGx iTc Bdr.ivCe OanMd this disease process causes the body to retain carbon dioxide. Providing this much oxygen can result in an increase in carbon dioxide levels, leading to respiratory failure. Oxygen for this patient should be at a lower rate, such as 1-2 liters/minute, with close assessments of the patient’s breathing status. 4 Bronchodilators will keep the alveoli open and increase exchange of oxygen and carbon dioxide more effectively and would be expected for this patient. PTS: 1 CON: Oxygenation 23. ANS: 1 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway disorders Chapter page reference: 482-485 Heading: Chronic Obstructive Pulmonary Disease (COPD) Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 A diet high in protein and fats without excess carbohydrates is recommended to minimize carbon dioxide production during metabolism. Frequent small meals help maintain intake and reduce fatigue associated with eating. 2 The patient should be encouraged to eat frequent snacks, not limit snacks.
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Carbohydrate-rich foods would increase the patient’s carbon dioxide production and worsen the symptoms of the disease. The patient should be encouraged to eat frequent small meals, not three meals a day.
PTS: 1 CON: Oxygenation 24. ANS: 1 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Chronic obstructive pulmonary disease Chapter page reference: 482-485 Heading: Chronic Obstructive Pulmonary Disease (COPD) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy 1
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Feedback Evidence that care provided to a patient with COPD was successful would be the patient conducting morning care and ambulating in the room while maintaining an oxygen saturation of 92%. This outcome identifies the patient’s ability to maintain adequate oxygenation and perform activities of daily living. The patient who needs assistance with morning care and meals because of shortness of breath needs additional interventions. The patient who states that hisNfam URiSly IwNouGldT pBref . er C Oh eM go to a nursing home may or may not have been positively affected by the interventions; not enough information is provided to know. The patient’s leaving the unit to smoke suggests that care has not been effective.
PTS: 1 CON: Oxygenation 25. ANS: 3 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with lower airway disorders Chapter page reference: 482-485 Heading: Chronic Obstructive Pulmonary Disease (COPD) Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 This statement is accurate and does not indicate a need for further teaching. 2 This statement is accurate and does not indicate a need for further teaching. 3 Adequate fluid intake is at least 2-2.5 quarts of fluid daily, so the statement about drinking 1-1.5 quarts daily indicates the need for further teaching. 4 This statement is accurate and does not indicate a need for further teaching. PTS: 1
CON: Oxygenation
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MULTIPLE RESPONSE 26. ANS: 1, 2, 3 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway disorders Chapter page reference: 489-491 Heading: Lung Cancer Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult
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Feedback This is correct. An adequate fluid intake is needed. Patients with pneumonia should increase their fluid intake in order to decrease the viscosity of respiratory secretions. This is correct. Turning, coughing, deep breathing, and chest percussion can help clear secretions. This is correct. Turning, coughing, deep breathing, and chest percussion can help clear secretions. This is incorrect. Administering the pneumococcal vaccine and educating the patient on smoking cessation are important in treating a patient with pneumonia, but they would be aligned with a different N n uUrsRinSg IdiNagGnT o sBis. . COM This is incorrect. Administering the pneumococcal vaccine and educating the patient on smoking cessation are important in treating a patient with pneumonia, but they would be aligned with a different nursing diagnosis.
PTS: 1 CON: Oxygenation 27. ANS: 1, 3, 4 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway disorders Chapter page reference: 476-482 Heading: Asthma Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation; Evidence-Based Practice Difficulty: Moderate
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Feedback This is correct. Age-appropriate, evidence-based interventions for a young adolescent patient diagnosed with asthma include referral to a peer-led support group, assessing peer-support of the patient, and collaborating with teachers to ensure the patient has the necessary support in the school setting. This is incorrect. While it is appropriate to include the parents in the educational process, the patient should be taught how to administer medications prior to teaching the parents.
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This is correct. Age-appropriate, evidence-based interventions for a young adolescent patient diagnosed with asthmas include referral to a peer-led support group, assessing peer-support of the patient, and collaborating with teachers to ensure the patient has the necessary support in the school setting. This is correct. Age-appropriate, evidence-based interventions for a young adolescent patient diagnosed with asthmas include referral to a peer-led support group, assessing peer-support of the patient, and collaborating with teachers to ensure the patient has the necessary support in the school setting. This is incorrect. Avoiding medication administration while in school could lead to an acute asthma attack.
PTS: 1 CON: Oxygenation | Evidence-Based Practice 28. ANS: 1, 3, 4 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Describing the epidemiology of lower airway disorders Chapter page reference: 482-485 Heading: Chronic Obstructive Pulmonary Disease (COPD) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy
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Feedback This is correct. Risk fac to rs as so c ia te d with t he dev elop men t of COPD include working in an NUaRhistory S I NGT .CO M and cigarette smoking. industrial environment, of B asthma, This is incorrect. Working in an office setting with air conditioning and playing golf several times a week are not risk factors for the development of COPD. This is correct. Risk factors associated with the development of COPD include working in an industrial environment, a history of asthma, and cigarette smoking. This is correct. Risk factors associated with the development of COPD include working in an industrial environment, a history of asthma, and cigarette smoking. This is incorrect. Working in an office setting with air conditioning and playing golf several times a week are not risk factors for the development of COPD.
PTS: 1 CON: Oxygenation 29. ANS: 1, 3 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Cystic fibrosis Chapter page reference: 486-489 Heading: Cystic Fibrosis Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation; Inflammation Difficulty: Easy Feedback
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This is correct. Steatorrhea and rectal prolapse might be signs of cystic fibrosis in an older infant or child. This is incorrect. Constipation is not a symptom of cystic fibrosis. This is correct. Steatorrhea and rectal prolapse might be signs of cystic fibrosis in an older infant or child. This is correct. Newborns with cystic fibrosis might present in the first 48 hours with meconium ileus. This is incorrect. Diarrhea is not a symptom of cystic fibrosis.
PTS: 1 CON: Oxygenation | Inflammation 30. ANS: 1, 3, 5 Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Cystic fibrosis Chapter page reference: 486-489 Heading: Cystic Fibrosis Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation; Inflammation Difficulty: Easy
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Feedback This is correct. Cystic fibrosis is a multisystem disease that produces increased amounts of thick mucus in the respira NtoURryS, gIastr NGo TinBtes.tiCnaOl (GI), M and reproductive systems. The disease is characterized by thick, viscous mucus that clogs the lungs and obstructs the pancreas. Other organs that are affected include the liver, salivary glands, and testes. This is incorrect. The neurological system is not directly affected by cystic fibrosis. This is correct. Cystic fibrosis is a multisystem disease that produces increased amounts of thick mucus in the respiratory, gastrointestinal (GI), and reproductive systems. The disease is characterized by thick, viscous mucus that clogs the lungs and obstructs the pancreas. Other organs that are affected include the liver, salivary glands, and testes. This is incorrect. The cardiovascular system is not directly affected by cystic fibrosis. This is correct. Cystic fibrosis is a multisystem disease that produces increased amounts of thick mucus in the respiratory, gastrointestinal (GI), and reproductive systems. The disease is characterized by thick, viscous mucus that clogs the lungs and obstructs the pancreas. Other organs that are affected include the liver, salivary glands, and testes. CON: Oxygenation | Inflammation
Chapter 27: Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Multiple Choice Identify the choice that best completes the statement or answers the question.
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1. The nurse is providing care to a patient who is diagnosed with acute respiratory distress syndrome (ARDS). Which clinical manifestation does the nurse anticipate for this patient who is experiencing hypoxia as a result of the ARDS diagnosis? 1) Fluid imbalance 2) Hypertension 3) Bradycardia 4) Dyspnea 2. The nurse is providing care to a patient with an infected leg wound. The patient is exhibiting symptoms of a systemic infection and is receiving intravenous antibiotics. The patient states to the nurse, “I am having trouble breathing.” Based on this data, which does the nurse suspect the patient is experiencing? 1) Allergic response from antibiotic therapy 2) Deep vein thrombosis 3) Acute respiratory distress syndrome 4) Anemia 3. A patient with a respiratory rate of eight breaths per minute has an oxygen saturation of 82%. Which nursing diagnosis is a priority for this patient? 1) Risk for Infection 2) Impaired Spontaneous Ventilation 3) Risk for Acute Confusion 4) Decreased Cardiac Output 4. A patient with acute respiratory distress syndrome (ARDS) is being weaned from mechanical ventilation. Which nursing action is appropriate for this patient? 1) Increase percentage of oxygen being provided through the ventilator 2) Place in the Fowler position NURSINGTB.COM 3) Provide morning care during the weaning procedures 4) Medicate with morphine for pain as needed 5. A patient is brought into the emergency department (ED) after being in a motor vehicle accident. The patient has suffered traumatic injury that may involve multiple body systems. Which is the priority nursing assessment for this patient? 1) Breathing and ventilation 2) Circulation with hemorrhage control 3) Airway maintenance with cervical spine protection 4) Disability and neurological assessment 6. The nurse caring for a newborn on a ventilator for acute respiratory distress syndrome (ARDS) informs the parents that the newborn is improving. Which data supports the nurse’s assessment of the newborn’s condition? 1) Increased PCO2 2) Oxygen saturation of 92% 3) Pulmonary vascular resistance increases 4) Less than 1 mL/kg/hour urine output 7. The nurse caring for a patient admitted with septic shock is aware of the need to assess for the development of acute respiratory distress syndrome (ARDS). Which early clinical manifestation would indicate the development of ARDS? 1) Intercostal retractions 2) Cyanosis 3) Tachypnea
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4) Tachycardia 8. A patient admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS). Which health-care provider prescription does the nurse anticipate for this patient? 1) Mechanical ventilation 2) Oxygen via a nasal cannula 3) Face mask oxygen administration 4) Continuous positive airway pressure 9. The nurse in the intensive care unit (ICU) is caring for a patient diagnosed with acute respiratory distress syndrome (ARDS). Vital signs prior to endotracheal intubation: HR 108 bpm, RR 32 bpm, BP 88/58 mm Hg, and oxygen saturation 82%. The patient is intubated and placed on mechanical ventilation with positive pressure ventilation. Which assessment finding indicates a further decrease of cardiac output secondary to positive pressure ventilation? 1) Blood pressure 90/60 mm Hg 2) Urine output 25mL/hr 3) Heart rate 110 bpm 4) Oxygen saturation 90% 10. The nurse caring for a patient recovering from an abdominal hysterectomy suspects the patient is experiencing a pulmonary embolism. Which clinical manifestation supports the nurse’s suspicion? 1) Nausea 2) Decreased urine output 3) Dyspnea and shortness of breath 4) Activity intolerance 11. The nurse is concerned that a patientNadUmRitSteI dN foGr T aB to . ta C l hOipMreplacement is at risk for thrombus formation and pulmonary embolism. Which assessment finding supports the nurse’s concern? 1) Body mass index (BMI) 35.8 2) Former cigarette smoker 3) Blood pressure 132/88 mm Hg 4) Age 45 years 12. The nurse is providing discharge instructions to an older adult patient who is going home after having a total knee replacement. Which will the nurse include in the discharge teaching to decrease the patient’s risk for developing a thrombosis or pulmonary embolism? 1) Place pillows under the knees when in bed 2) Use compression stockings 3) Limit ambulation 4) Limit fluids 13. A patient diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. Which is the priority nursing diagnosis for this patient? 1) Ineffective Tissue Perfusion 2) Anxiety 3) Impaired Gas Exchange 4) Impaired Physical Mobility 14. The nurse is planning care for a patient with a pulmonary embolism. Which intervention would assist with the patient’s decrease in cardiac output? 1) Provide oxygen 2) Keep protamine sulfate at the bedside
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3) Monitor pulmonary arterial pressures 4) Assess for bleeding 15. The nurse has instructed a patient recovering from a pulmonary embolism on long-term anticoagulant therapy. Which patient statement indicates that instruction has been effective? 1) “I will expect bloody sputum when I brush my teeth.” 2) “I need to use a soft toothbrush and an electric razor, and avoid injuries.” 3) “I need to eat a well-balanced diet with green salads.” 4) “I can expect to be bruised, since this is normal.” 16. A patient scheduled for surgery is being instructed in leg exercises and the pneumatic compression device. The nurse includes these instructions to decrease which postoperative complication? 1) Infection 2) Delayed wound healing 3) Contractures 4) Deep vein thrombosis 17. The nurse is preparing to discharge a patient recovering from a pulmonary embolism. Which topics are appropriate for the nurse to include in the teaching session? 1) Resume the use of any over-the-counter medications 2) Diet to include green leafy vegetables 3) Anticoagulant administration schedule 4) Resume normal activity level 18. The nurse is providing care to several patients on a medical-surgical unit. Which patient is at highest risk for a nonthrombotic pulmonary embolism? 1) The patient who is receiving intrNa vUeR noSuI s pNaG inTmBe. d iC caOtiM on 2) The patient who is postoperative from a femur fracture repair 3) The patient with a primary lung tumor 4) The patient who uses intravenous illicit drugs 19. A nurse caring for a patient with a pulmonary embolism expects to find which diagnostic result? 1) Patchy infiltrates on chest x-ray 2) Metabolic alkalosis on arterial blood gas 3) Elevated CO2 level found on end-tidal carbon dioxide monitor 4) Tachycardia and nonspecific T-wave changes on EKG 20. The nurse is planning care for a newly admitted patient diagnosed with pulmonary embolism. The nurse anticipates the patient will need anticoagulant therapy. What is true regarding this therapy for the treatment of this condition? 1) It is considered second-line treatment. 2) Major hemorrhage is common. 3) Heparin and warfarin (Coumadin) are usually initiated at the same time. 4) Heparin alters the synthesis of vitamin K–dependent clotting factors, preventing further clots. 21. The nurse working with a student nurse is providing care for a patient requiring mechanical ventilation. The student nurse asks the meaning of assist control. Which response by the nurse is the most appropriate? 1) “Assist control is a means of delivering ventilation that delivers a preset volume and/or pressure each time the patient begins an inspiration.” 2) “Assist control allows the patient to breathe independently, but supplies a breath if the patient does not begin an inhalation in a specified period of time.”
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3) “Assist control is used when weaning a patient from the ventilator because the patient must exercise the muscles of respiration in order to get a full breath.” 4) “Assist control is often used when a patient is receiving a paralytic agent.” 22. The nurse is providing care for the patient requiring mechanical ventilation. Which action by the nurse would be inappropriate when providing care to this patient? 1) Confirming airway placement by auscultating the lungs and checking the length marking of the tube at the lip 2) Assuring that tube cuff inflation is no greater than 15 cm H2 O, and that there is no audible air leak 3) Assuring ventilator tubing is secured and does not pull on the patient’s airway 4) Verifying correct ventilator settings 23. The nurse working in the intensive care unit is assigned a patient requiring mechanical ventilation. When responding to the ventilator alarm, the nurse sees a high-pressure alarm. Which nursing action is the priority? 1) Silencing the alarm 2) Removing the patient from the ventilator and using a bag-valve device to oxygenate the patient until the respiratory therapist can be summoned 3) Emptying the collected water from the ventilator tubing 4) Assessing the patient 24. The nurse is providing care for a patient requiring mechanical ventilation. When the nurse enters the room at the beginning of the shift, the patient’s monitor displays a heart rate of 64 and oxygen saturation of 88%. Which nursing action is the priority? 1) Increasing the oxygen concentration and quickly assessing the patient 2) Removing the patient from the ventilator and hyperoxygenating and hyperventilating the patient NURSINGTB.COM 3) Assessing the patient for airway obstruction 4) Checking ventilator settings Completion Complete each statement. 25. The nurse is providing care to a patient admitted to the emergency department with the diagnosis of acute respiratory distress syndrome (ARDS). When educating the patient’s family on the disease progress, in which order will the nurse present the material? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Initiation of ARDS 2) Onset of pulmonary edema 3) End-stage ARDS 4) Alveolar collapse Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. The nurse educator prepares to speak to a group of nursing students about direct and indirect insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS). Which conditions will the nurse include in the teaching session? Select all that apply.
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1) 2) 3) 4) 5)
Septic shock Viral pneumonia Aspirin overdose Head injury Angioplasty
27. A patient receiving treatment for acute respiratory distress syndrome (ARDS) is demonstrating anxiety and fear of having to stay on the ventilator indefinitely. Which interventions by the nurse are appropriate? Select all that apply. 1) Explain about care areas specifically designed for long-term ventilatory support. 2) Dim the lights and reduce distracting noise, such as the television. 3) Instruct that intubation and ventilation are temporary measures. 4) Encourage family visits and participation in care. 5) Remain with the patient as much as possible. 28. Which assessment data would cause the nurse to document the patient is experiencing early respiratory distress? Select all that apply. 1) Dyspnea 2) Restlessness 3) Tachycardia 4) Confusion 5) Cyanosis
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 27: Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Acute respiratory distress syndrome Chapter page reference: 503-508 Heading: Acute Respiratory Distress Syndrome (ARDS) Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 Fluid and electrolyte imbalances occur due to the nutritional imbalances associated with ARDS. 2 Hypertension is not an anticipated clinical manifestation for this patient. 3 The nurse would expect tachycardia, not bradycardia, as a result of hypoxia. 4 Dyspnea is a clinical manifestation that patients experiencing hypoxia secondary to ARDS. PTS: 1 CON: OxygenNa U tioRn SINGTB.COM 2. ANS: 3 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Acute respiratory distress syndrome Chapter page reference: 503-508 Heading: Acute Respiratory Distress Syndrome (ARDS) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy
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Feedback Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may not be associated with a systemic infection from an infected leg wound and are not associated with the development of ARDS. Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may not be associated with a systemic infection from an infected leg wound and are not associated with the development of ARDS. Sepsis is the most common cause of acute respiratory distress syndrome (ARDS). The patient has a systemic infection, which is sepsis, and is complaining that it is getting hard to breathe. The nurse should suspect the patient is developing acute respiratory distress.
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Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may not be associated with a systemic infection from an infected leg wound and are not associated with the development of ARDS.
PTS: 1 CON: Oxygenation 3. ANS: 2 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Developing a comprehensive plan of nursing care for critically ill patients with respiratory dysfunction Chapter page reference: 499-503 Heading: Acute Respiratory Failure Integrated Processes: Nursing Process – Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 This nursing diagnosis may be appropriate; however, this is not the priority. 2 A priority nursing diagnosis for a patient with a respiratory rate of eight breaths per minutes and an oxygen saturation of 82% is Impaired Spontaneous Ventilation. If the current pattern continues without intervention, the patient could experience respiratory arrest. 3 This nursing diagnosis may be appropriate; however, this is not the priority. 4 This nursing diagnosis may be appropriate; however, this is not the priority.
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PTS: 1 CON: Oxygenation ANS: 2 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Developing a comprehensive plan of nursing care for critically ill patients with respiratory dysfunction Chapter page reference: 503-508 Heading: Acute Respiratory Distress Syndrome (ARDS) Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 The percentage of oxygen is typically reduced during the weaning process. 2 Weaning a patient from mechanical ventilation should begin in the morning when the patient is well-rested. The patient should be in the Fowler or high-Fowler position, as this facilitates lung expansion and reduces the work of breathing. 3 Activities and care should be limited during the weaning process to reduce the demand for oxygen. 4 The patient should not be given any medication known to suppress respirations, as this would interfere with the weaning process. Medicating for pain would be appropriate when the patient is back on the ventilator after concluding the weaning procedures. PTS: 1
CON: Oxygenation
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5. ANS: 3 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Developing a comprehensive plan of nursing care for critically ill patients with respiratory dysfunction Chapter page reference: 508-512 Heading: Chest Trauma Integrated Processes: Nursing Process – Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 Assessing breathing and ventilation are important; however, this is not the priority assessment at this time. 2 Assessing breathing and ventilation are important; however, this is not the priority assessment at this time. 3 When caring for the trauma victim the nurse must always prioritize assessments, with the ABCDEs as the highest-priority concerns. It is imperative that the nurse’s first concern is airway maintenance with cervical spine protection. 4 Assessing breathing and ventilation are important; however, this is not the priority assessment at this time. PTS: 1 CON: Oxygenation 6. ANS: 2 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: DescribinNgUthReSdI iaN gnGoT stB ic.rC esO ulM ts used in the management of critically ill patients with respiratory dysfunction Chapter page reference: 503-508 Heading: Acute Respiratory Distress Syndrome (ARDS) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Moderate 1
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Feedback An expected outcome for a patient being treated for ARDS is maintaining an oxygen saturation of greater than 90%. The newborn diagnosed with ARDS with an oxygen saturation of 92% is improving. Increased PCO2 and pulmonary vascular resistance are indicative of continued distress. Increased PCO2 and pulmonary vascular resistance are indicative of continued distress. Urine output of less than 1 mL/kg/hour is an abnormal finding and does not support that the newborn is improving.
PTS: 1 CON: Oxygenation 7. ANS: 3 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Acute respiratory distress syndrome
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Chapter page reference: 503-508 Heading: Acute Respiratory Distress Syndrome (ARDS) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 As the distress progresses, the patient would demonstrate an increasing respiratory rate, intercostal retractions, and use of accessory muscles, as well as tachycardia. 2 Cyanosis is a late manifestation. 3 Dyspnea and tachypnea are early clinical manifestations of ARDS. 4 As the distress progresses, the patient would demonstrate an increasing respiratory rate, intercostal retractions, and use of accessory muscles, as well as tachycardia. PTS: 1 CON: Oxygenation 8. ANS: 1 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Discussing the medical management of: Acute respiratory distress syndrome Chapter page reference: 503-508 Heading: Acute Respiratory Distress Syndrome (ARDS) Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation NURSINGTB.COM Difficulty: Easy
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Feedback With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen therapy alone. With mechanical ventilation, the FiO 2 (fraction of inspired oxygen–the percentage of oxygen administered) is set at the lowest possible level to maintain a PaO2 higher than 60 mm Hg and oxygen saturation of approximately 90%. It is important to remember that mechanical ventilation does not cure ARDS; it simply supports respiratory function while the underlying problem is identified and treated. With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen therapy alone. With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen therapy alone. Continuous positive airway pressure will not provide the patient with the oxygenation that is required.
PTS: 1 CON: Oxygenation 9. ANS: 2 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Describing the diagnostic results used in the management of critically ill patients with respiratory dysfunction Chapter page reference: 503-508 Heading: Acute Respiratory Distress Syndrome (ARDS) Integrated Processes: Nursing Process – Assessment
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Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation; Perfusion Difficulty: Easy
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Feedback Although hypotension and tachycardia are indicative of a decreased cardiac output, this is not a change from the previous assessment and would not indicate a further decrease in cardiac output due to mechanical ventilation. Decreased cardiac output is supported by a decrease of urine output. Expected urine output is at least 30 mL/hr. This patient’s urine output is decreased; therefore, this finding supports the diagnosis of decreased cardiac output. Although hypotension and tachycardia are indicative of a decreased cardiac output, this is not a change from the previous assessment and would not indicate a further decrease in cardiac output due to mechanical ventilation. The oxygen saturation level is within normal limits for this patient and improving from the previous assessment.
PTS: 1 CON: Oxygenation | Perfusion 10. ANS: 3 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Pulmonary embolism Chapter page reference: 494-499 Heading: Pulmonary Embolism (PE) NURSINGTB.COM Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy
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Feedback Decreased urine output, activity intolerance, and nausea are not clinical manifestations of a pulmonary embolism. Decreased urine output, activity intolerance, and nausea are not clinical manifestations of a pulmonary embolism. Manifestations of a pulmonary embolism include dyspnea, shortness of breath, pleuritic chest pain, anxiety, apprehension, cough, tachycardia, tachypnea, crackles, and a lowgrade fever. Decreased urine output, activity intolerance, and nausea are not clinical manifestations of a pulmonary embolism.
PTS: 1 CON: Oxygenation 11. ANS: 1 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Describing respiratory conditions that require management in the critical care setting Chapter page reference: 494-499 Heading: Pulmonary Embolism (PE)
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Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation; Perfusion Difficulty: Easy
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Feedback Risk factors for the development of thrombus formation that could lead to a pulmonary embolism include obesity, orthopedic surgery, myocardial infarction, heart failure, and advancing age. The BMI of 35.8 falls into the category of obese, which would increase the patient’s risk of developing a thrombus and possible pulmonary embolism. The patient’s age, status as a former smoker, and blood pressure would not have as significant an impact on the development of a thrombus as the patient’s weight. The patient’s age, status as a former smoker, and blood pressure would not have as significant an impact on the development of a thrombus as the patient’s weight. The patient’s age, status as a former smoker, and blood pressure would not have as significant an impact on the development of a thrombus as the patient’s weight.
PTS: 1 CON: Oxygenation | Perfusion 12. ANS: 2 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with complications of respiratory dysfunction Chapter page reference: 494-499 Heading: Pulmonary Embolism (PE) Integrated Processes: Teaching and LNeaUrR niS ngINGTB.COM Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation; Perfusion Difficulty: Moderate
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Feedback The patient should be encouraged to ambulate, avoid placing pillows under the knees, and be well hydrated unless another physiological condition exists that would necessitate a fluid restriction. A patient being discharged after having orthopedic surgery is at increased risk for pulmonary embolism. The nurse should instruct the patient to continue with leg exercises and use compression stockings to reduce the risk of deep vein thrombosis formation. The patient should be encouraged to ambulate, avoid placing pillows under the knees, and be well hydrated unless another physiological condition exists that would necessitate a fluid restriction. The patient should be encouraged to ambulate, avoid placing pillows under the knees, and be well hydrated unless another physiological condition exists that would necessitate a fluid restriction.
PTS: 1 CON: Oxygenation | Perfusion 13. ANS: 3 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
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Chapter learning objective: Developing a comprehensive plan of nursing care for critically ill patients with respiratory dysfunction Chapter page reference: 494-499 Heading: Pulmonary Embolism (PE) Integrated Processes: Nursing Process – Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 The patient may have ineffective tissue perfusion; however, this is not the priority. 2 The patient may be experiencing anxiety; however, this is not the priority at this time either. 3 A reduction in arterial oxygen saturation level and dyspnea indicate the patient is experiencing impaired gas exchange. This would be the priority for the patient at this time. 4 There is not enough information to determine whether the patient is at risk for impaired mobility. PTS: 1 CON: Oxygenation 14. ANS: 3 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Describing the diagnostic results used in the management of critically ill patients with respiratory dysfunction Chapter page reference: 494-499 NURSINGTB.COM Heading: Pulmonary Embolism (PE) Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation; Perfusion Difficulty: Easy Feedback 1 Oxygen would be appropriate for the patient with impaired gas exchange. 2 Assessing for bleeding and keeping protamine sulfate at the bedside would be appropriate for the patient with ineffective protection. 3 The patient with a pulmonary embolism and decreased cardiac output is at risk for developing right heart failure. The nurse should monitor pulmonary arterial pressures. 4 Assessing for bleeding and keeping protamine sulfate at the bedside would be appropriate for the patient with ineffective protection. PTS: 1 CON: Oxygenation | Perfusion 15. ANS: 2 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with complications of respiratory dysfunction Chapter page reference: 494-499 Heading: Pulmonary Embolism (PE) Integrated Processes: Nursing Process – Evaluation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
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Cognitive level: Analysis [Analyzing] Concept: Perfusion; Medication Difficulty: Difficult Feedback 1 The statements about bruising being normal and expecting bloody sputum mean the patient is in need of additional instruction on anticoagulant therapy. 2 Instruction on anticoagulant therapy should include the need to avoid injury, use a soft toothbrush, and use an electric razor. 3 The patient should avoid green salads because of the vitamin K content. 4 The statements about bruising being normal and expecting bloody sputum mean the patient is in need of additional instruction on anticoagulant therapy. PTS: 1 CON: Perfusion | Medication 16. ANS: 4 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Developing a comprehensive plan of nursing care for critically ill patients with respiratory dysfunction Chapter page reference: 494-499 Heading: Pulmonary Embolism (PE) Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy
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Exercises and pneumatic compression devices do not prevent infection, encourage wound healing, or prevent contractures. Exercises and pneumatic compression devices do not prevent infection, encourage wound healing, or prevent contractures. Exercises and pneumatic compression devices do not prevent infection, encourage wound healing, or prevent contractures. The best care for a pulmonary embolism is prevention. Since surgical patients have an increased risk of developing a pulmonary embolism postoperatively, instructions should include ways to encourage movement, such as leg exercises, and the need for pneumatic compression devices to maintain lower extremity circulation and prevent the development of a deep vein thrombosis.
PTS: 1 CON: Perfusion 17. ANS: 3 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with complications of respiratory dysfunction Chapter page reference: 494-499 Heading: Pulmonary Embolism (PE) Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate
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Feedback The patient being discharged after treatment for a pulmonary embolism needs to be instructed in anticoagulant therapy, avoiding green leafy vegetables because of vitamin K, adhering to the physician’s prescribed activity level, and avoiding all over-thecounter medications. The patient being discharged after treatment for a pulmonary embolism needs to be instructed in anticoagulant therapy, avoiding green leafy vegetables because of vitamin K, adhering to the physician’s prescribed activity level, and avoiding all over-thecounter medications. The nurse should instruct the patient in symptoms of bleeding or recurrence of a pulmonary embolism and the schedule for anticoagulation administration. The patient being discharged after treatment for a pulmonary embolism needs to be instructed in anticoagulant therapy, avoiding green leafy vegetables because of vitamin K, adhering to the physician’s prescribed activity level, and avoiding all over-thecounter medications.
PTS: 1 CON: Perfusion 18. ANS: 2 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Describing respiratory conditions that require management in the critical care setting Chapter page reference: 494-499 Heading: Pulmonary Embolism (PE) Integrated Processes: Nursing Process – Assessment Client Need: Physiological IntegrityNURSINGTB.COM – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Difficult Feedback 1 Fat emboli are the most common nonthrombotic pulmonary emboli. A fat embolism usually occurs after fracture of long bone (typically the femur) releases bone marrow fat into the circulation. 2 The other patients may be at risk for pulmonary embolism; however, they are incorrect choices for the most common cause of nonthrombotic pulmonary emboli. 3 The other patients may be at risk for pulmonary embolism; however, they are incorrect choices for the most common cause of nonthrombotic pulmonary emboli. 4 The other patients may be at risk for pulmonary embolism; however, they are incorrect choices for the most common cause of nonthrombotic pulmonary emboli. PTS: 1 CON: Perfusion 19. ANS: 4 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Describing the diagnostic results used in the management of critically ill patients with respiratory dysfunction Chapter page reference: 494-499 Heading: Pulmonary Embolism (PE) Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential
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Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy
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Feedback This is not an anticipated diagnostic finding for a patient with a pulmonary embolism. The patient with a pulmonary embolism will likely have respiratory alkalosis from rapid breathing, not metabolic alkalosis. The end-tidal carbon dioxide monitor (EtCOB). will be decreased, not increased, due to rapid breathing. With pulmonary embolism, tachycardia and nonspecific T-wave changes occur on EKG.
PTS: 1 CON: Perfusion 20. ANS: 3 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Discussing the medical management of: Pulmonary embolism Chapter page reference: 494-499 Heading: Pulmonary Embolism (PE) Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy
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NURSINGTB.COM Feedback Anticoagulant therapy is the standard first-line treatment of pulmonary embolism. While major hemorrhage is uncommon, bleeding may occur. Heparin and warfarin are usually initiated at the same time for the treatment of pulmonary embolus. Warfarin, not heparin, alters the synthesis of vitamin K–dependent clotting factors.
PTS: 1 CON: Perfusion 21. ANS: 1 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Describing the indications, management, and complications associated with mechanical ventilation in the critically ill patient Chapter page reference: 503-508 Heading: Acute Respiratory Distress Syndrome (ARDS) – Mechanical Ventilation Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 Assist control allows the patient to begin inspiration, but the ventilator provides a preset pressure or volume to boost the patient’s tidal volume. 2 If the ventilator is set to provide a breath only when the patient doesn’t breathe, it is not assist control but Synchronized Intermittent Mandatory Ventilation (SIMV).
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Because the ventilator provides the breath begun by the patient, it does not improve muscle function. Assist control would not be used for the patient receiving a paralytic agent because he would be unable to initiate a breath.
PTS: 1 CON: Oxygenation 22. ANS: 2 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Describing the indications, management, and complications associated with mechanical ventilation in the critically ill patient Chapter page reference: 503-508 Heading: Acute Respiratory Distress Syndrome (ARDS) – Mechanical Ventilation Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 This nursing action is appropriate when providing care to a patient who is being mechanically ventilated. 2 Tube cuff inflation is normally set at 20–30 cm H2 O. 3 This nursing action is appropriate when providing care to a patient who is being mechanically ventilated. 4 This nursing action is appropriate when providing care to a patient who is being mechanically ventilated. NURSINGTB.COM PTS: 1 CON: Oxygenation 23. ANS: 4 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Describing the indications, management, and complications associated with mechanical ventilation in the critically ill patient Chapter page reference: 503-508 Heading: Acute Respiratory Distress Syndrome (ARDS) – Mechanical Ventilation Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 The nurse should treat the patient and not the alarm, so the first action would be to assess the patient quickly. 2 However, if the patient is in distress, it might be necessary to remove the patient from the ventilator and to bag the patient until the cause of the problem can be located and corrected. 3 If the patient is comfortable, and assessment findings are within normal limits, the cause of the alarm could be water collecting in the tubing (which should be emptied).
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4
In most instances, depending on facility policy, if a patient requires mechanical ventilation, he is placed on cardiorespiratory monitors with continuous oxygen saturation monitoring. The nurse would assess heart rate and oxygen saturation, and examine the patient for any signs of distress.
PTS: 1 CON: Oxygenation 24. ANS: 3 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Describing the indications, management, and complications associated with mechanical ventilation in the critically ill patient Chapter page reference: 503-508 Heading: Acute Respiratory Distress Syndrome (ARDS) – Mechanical Ventilation Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Difficult Feedback 1 This action might be the next priority action, but first and foremost, the nurse must assess the patient. 2 This action might be the next priority action, but first and foremost, the nurse must assess the patient. 3 Remembering the nursing process, the nurse would not intervene until assessing for the cause of the patient’s distress. 4 This action might be the next pr NioUrit RSy IacNtiGonT, bu B.t fir COstMand foremost, the nurse must assess the patient. PTS: 1
CON: Oxygenation
COMPLETION 25. ANS: 1243 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Describing respiratory conditions that require management in the critical care setting Chapter page reference: 503-508 Heading: Acute Respiratory Distress Syndrome (ARDS) Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate
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Feedback: ARDS begins with inflammatory cellular responses and biochemical mediators that damage the alveolar-capillary membrane. Increased interstitial pressure and damage to the alveolar membrane allow fluid to enter the alveoli. The inflammatory process damages surfactant-producing cells, leading to a deficit of surfactant, increased alveolar surface tension, and alveolar collapse. Multiple-organ system dysfunction of the kidneys, liver, gastrointestinal tract, central nervous system, and cardiovascular system are the leading causes of death in ARDS. PTS: 1
CON: Oxygenation
MULTIPLE RESPONSE 26. ANS: 1, 2, 3, 4 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Describing respiratory conditions that require management in the critical care setting Chapter page reference: 503-508 Heading: Acute Respiratory Distress Syndrome (ARDS) Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy
1.
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Feedback This is correct. ARDS isNaUsev RSerIe NfoGrmTBof.aCcuOteMresp iratory failure that occurs in response to pulmonary or systemic insults. Such insults include, but are not limited to, hemorrhagic or septic shock, smoke inhalation, aspiration, viral pneumonias, propoxyphene or aspirin overdose, burns, head injuries, pancreatitis, and multiple transfusions. This is correct. ARDS is a severe form of acute respiratory failure that occurs in response to pulmonary or systemic insults. Such insults include, but are not limited to, hemorrhagic or septic shock, smoke inhalation, aspiration, viral pneumonias, propoxyphene or aspirin overdose, burns, head injuries, pancreatitis, and multiple transfusions. This is correct. ARDS is a severe form of acute respiratory failure that occurs in response to pulmonary or systemic insults. Such insults include, but are not limited to, hemorrhagic or septic shock, smoke inhalation, aspiration, viral pneumonias, propoxyphene or aspirin overdose, burns, head injuries, pancreatitis, and multiple transfusions. This is correct. ARDS is a severe form of acute respiratory failure that occurs in response to pulmonary or systemic insults. Such insults include, but are not limited to, hemorrhagic or septic shock, smoke inhalation, aspiration, viral pneumonias, propoxyphene or aspirin overdose, burns, head injuries, pancreatitis, and multiple transfusions. This is incorrect. Angioplasty, a percutaneous intervention, does not lead to the development of ARDS. However, undergoing an open heart surgery with cardiopulmonary bypass could lead to the development of ARDS.
PTS: 1 CON: Oxygenation 27. ANS: 3, 4, 5 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Developing a comprehensive plan of nursing care for critically ill patients with respiratory dysfunction
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Chapter page reference: 503-508 Heading: Acute Respiratory Distress Syndrome (ARDS) Integrated Processes: Nursing Process – Implementation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Oxygenation Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback This is incorrect. Explaining that there are care areas designed for long-term ventilatory support could increase the patient’s anxiety. This is incorrect. The nurse should provide distractions such as television or radio and not dim the lights or turn off the television, which could also increase the patient’s anxiety. This is correct. The nurse should also remain with the patient as much as possible and instruct that intubation and ventilation are temporary measures to allow the lungs to rest and heal. This is correct. To reduce this patient’s anxiety, the nurse should encourage the family to visit and participate in care. This is correct. The nurse should also remain with the patient as much as possible and instruct that intubation and ventilation are temporary measures to allow the lungs to rest and heal.
PTS: 1 CON: Oxygenation 28. ANS: 1, 2, 3 Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction Chapter learning objective: Describing respiratory conditions that require management in the critical care setting NURSINGTB.COM Chapter page reference: 499-503 Heading: Acute Respiratory Failure Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy
1. 2. 3. 4. 5. PTS: 1
Feedback This is correct. Dyspnea, or shortness of breath, is an early sign of respiratory distress. This is correct. Restlessness is an early sign of respiratory distress. This is correct. Tachycardia is an early sign of respiratory distress. This is incorrect. Confusion is an intermediate sign of respiratory distress. This is incorrect. Cyanosis is a late sign of respiratory distress. CON: Oxygenation
Chapter 28: Assessment of Cardiovascular Function Multiple Choice Identify the choice that best completes the statement or answers the question.
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1. A patient is prescribed to have capillary blood glucose readings every four hours. What should the nurse include when explaining capillaries to the patient? 1) It is a low-pressure vascular circuit. 2) Capillaries are the largest vessel within the arterial system. 3) The real work of the vascular system occurs at the capillary level. 4) They are flexible to adapt to changes in volume without large changes in pressure. 2. While auscultating a patient’s heart rate the nurse hears scratching sounds. What is most likely causing this sound? 1) Epicardium adhering to the heart surface 2) Low level of fluid in the pericardial cavity 3) Parietal pericardium adhering to the sternum 4) Endocardium adhering to the heart chambers 3. The nurse is reviewing the anatomy of the heart with a patient scheduled for cardiac surgery. Which patient statement indicates additional teaching is required? 1) “Oxygenated blood returns to the left atrium through the pulmonary vein.” 2) “The right atrium receives blood from the superior and inferior vena cava.” 3) “Blood leaves the right ventricle and travels through the pulmonary vein to the lungs.” 4) “Blood leaves the right ventricle and travels through the pulmonary artery to the lungs.” 4. The nurse is preparing teaching about the coronary arteries for a group of patients scheduled for heart surgery. Which information should the nurse include in this teaching? 1) The coronary arteries originate in the cusps of the aortic valve. 2) The coronary arteries prevent the backflow of blood into the atria. 3) The coronary arteries respond to changes in pressure within the heart. 4) The coronary arteries prevent thN eU b aRckSf I lo N wG ofTbBlo.oC d O in M to the ventricles. 5. The nurse notes that a patient has a low serum potassium level. Which phase of the cardiac action potential will be most affected by this blood level? 1) Phase 0 2) Phase 1 3) Phase 3 4) Phase 4 6. A patient’s QRS complex is becoming increasingly wider. What is occurring within the heart muscle that is reflected on this tracing? 1) The ventricles are repolarizing. 2) Atrial repolarization is occurring. 3) Ventricular depolarization is prolonged. 4) The atria depolarize and the impulse at the AV node is delayed. 7. A patient with a blood pressure of 88/50 mm Hg has a heart rate of 112 beats per minute. Which mechanism should the nurse realize is occurring in this patient? 1) Positive chronotropic effect 2) Negative chronotropic effect 3) Force of the mechanical contraction 4) Reaction to ventricular volume at the end of diastole 8. The nurse suspects that a patient is experiencing a release of norepinephrine from the adrenal medulla. Which assessment finding did the nurse use to make this clinical decision? 1) Blood pressure 94/48 mm Hg 3) Heart rate 120 beats per minute
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2) Heart rate 68 beats per minute
4) Blood pressure 180/100 mm Hg
9. The nurse is preparing to determine a patient’s cardiac output. Which measurement should be used for preload? 1) Heart rate 3) Oxygen saturation 2) Blood pressure 4) Central venous pressure 10. A patient’s blood pressure is 174/98 mm Hg. Which aspect of cardiac output is most affected by this elevated reading? 1) Preload 3) Afterload 2) Heart rate 4) Contractility 11. The nurse notes that a patient has bilateral lower extremity edema. For which health problem should the nurse assess further? 1) Pericarditis 3) Lymph obstruction 2) Cardiac tamponade 4) Venous insufficiency 12. After palpating a patient’s radial pulses, the nurse proceeds to palpate the brachial, carotid, femoral, popliteal, and posterior tibial pulses. What condition caused the nurse to make this more thorough physical assessment? 1) Skin warm and dry 3) Edema of the left lower extremity 2) Various skin temperatures 4) Respiratory rate of 24 and labored 13. The nurse is preparing to auscultate the heart sounds of a patient with mitral valve regurgitation. Which sound should the nurse expect to hear? 1) Rub 3) Murmur 2) Click 4) Atrial gallop 14. A patient is being assessed for heart N diU seR asS e.IFN o rGwThB ic . h C la O boMrato ry test should the nurse instruct to avoid eating and drinking fluids for 12 hours? 1) Lipid panel 3) C-reactive protein 2) Homocysteine 4) Partial thromboplastin time 15. The nurse notes that a patient is scheduled for a brain natriuretic peptide level to be drawn. What patient teaching should the nurse prepare for this patient? 1) Low-fat diet 3) Symptoms of a heart attack 2) Signs of heart failure 4) Lung versus heart problems 16. A patient is scheduled for a transesophageal echocardiogram (TEE). What information should the nurse expect to be provided from this test? 1) Cardiac filling pressures 3) Heart function during stress 2) Integrity of cardiac arteries 4) Presence of clots in the atria 17. A patient is recovering from a cardiac catheterization. For which finding should the nurse notify the healthcare provider? 1) Warm right foot 3) Discomfort lying flat for six hours 2) Urine output 250 mL/2 hours 4) Hematoma formation at puncture site 18. An older patient is being evaluated for a cardiac click audible upon auscultation. Which age-related change should the nurse realize might be causing this heart sound? 1) Hypertension 3) Atrial fibrillation 2) Valve stenosis 4) Congestive heart failure
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19. The nurse notes that an older patient’s point of maximum impulse is displaced to the left. What age-related change should the nurse suspect as causing this assessment finding? 1) Valvular stenosis 3) Arterial wall narrowing 2) Left ventricular atrophy 4) Fibrosis of heart chambers 20. The nurse is reviewing data collected during the assessment of an older patient. Which finding should the nurse consider as being an age-related change of the cardiovascular system? 1) First heart sound louder 3) Heart rate 64 and regular 2) Friction rub auscultated 4) Blood pressure 168/96 mm Hg Completion Complete each statement. 21. The nurse is preparing a teaching tool about the cardiac electrical conduction system. In which order should the nurse explain the route of the action potential? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Impulse travels to the bundle of His 2) Sinoatrial node fires in the right atrium 3) Impulse extends through Purkinje fibers 4) Impulse travels through bundle branches 5) Impulse travels to the atrioventricular node 6) Impulse spreads through atrial myocardium 22. The clinical trainer is reviewing the renin-angiotensin-aldosterone system with graduate nurses during orientation to the telemetry unit. In which order should the trainer discuss this system? (Enter the number of each step in the proper sequence; do N noUt R usS eI puNnG ctT uaB tio.nCoO r spaces. Example: 1234) 1) Sodium and water reabsorbed in the kidneys 2) Renin reacts with angiotensin to create angiotensin 1 3) Angiotensin I is converted to angiotensin II in the lungs 4) Kidneys release renin in response to a drop in blood pressure 5) Angiotensin II influences adrenal glands to release aldosterone 23. A patient is prescribed a 12-lead electrocardiogram. In which order should the nurse apply the V leads? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Midaxillary line 2) Between V2 and V4 3) Midclavicular line 5th intercostal space 4) 4th intercostal space left of the sternum 5) 4th intercostal space right of the sternum 6) Between V4 and V6 anterior axillary line Multiple Response Identify one or more choices that best complete the statement or answer the question. 24. The nurse is preparing content for a community health fair on risk factors for heart disease. What should the nurse include as nonmodifiable risk factors? Select all that apply. 1) Age 2) Weight 3) Alcohol intake
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4) Ethnic background 5) Parents’ health history 25. Which information should the nurse include when documenting the findings of a patient’s heart sounds? Select all that apply. 1) Pitch 2) Clicks 3) Quality 4) Intensity 5) Location
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Chapter 28: Assessment of Cardiovascular Function Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Describing the major anatomical components of the heart and cardiovascular system Chapter page reference: 517 Heading: Overview of the Cardiovascular System > Capillary Bed Integrated Processes: Nursing Process – Implementation Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Easy 1 2 3 4
Feedback The veins are a low-pressure vascular circuit. Capillaries are the smallest vessels within the arterial system. The real work of the vascular system is done at the capillary bed. Veins are flexible to adapt to changes in volume without large changes in pressure.
PTS: 1 CON: Perfusion 2. ANS: 2 NURSINGTB.COM Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Describing the major anatomical components of the heart and cardiovascular system Chapter page reference: 518 Heading: Overview of the Cardiovascular System > Capillary Bed Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
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Feedback The epicardium or visceral pericardium is supposed to cover the heart surface. Between the two layers of the heart is a pericardial cavity containing serous fluid that provides a lubricant that allows the heart to beat without friction. The parietal pericardium is the outer layer of the heart. It is a tough fibrous layer that does not adhere to the sternum. The endocardium is supposed to adhere to the heart chambers.
PTS: 1 CON: Perfusion 3. ANS: 4 Chapter number and title: 28, Assessment of Cardiovascular Function
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Chapter learning objective: Describing the major anatomical components of the heart and cardiovascular system Chapter page reference: 519 Heading: Overview of the Cardiovascular System > Chambers Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4
Oxygenated blood returns to the left atrium through the pulmonary vein. The right atrium receives blood from the superior and inferior vena cava. Blood leaves the right ventricle and travels through the pulmonary vein to the lungs. Blood leaves the right ventricle and travels through the pulmonary vein to the lungs. Deoxygenated blood is delivered to the pulmonary circuit through the pulmonary artery.
PTS: 1 CON: Perfusion 4. ANS: 1 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Describing the major anatomical components of the heart and cardiovascular system Chapter page reference: 519 Heading: Overview of the Cardiovascular System > Blood Supply to the Heart Integrated Processes: Teaching and Learning Client Need: Physiological Integrity /N RU edR ucStiI onNoGf TRB is. k C PoOteMn tial Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate 1 2 3 4
Feedback The left and right coronary arteries are the first arteries branching off of the aorta as it leaves the left ventricle and actually originate in the cusps of the aortic valve. The atrioventricular valves prevent backflow of blood into the atria. Valves respond to changes in pressure within the heart. The semilunar valves prevent the backflow of blood into the ventricles.
PTS: 1 CON: Perfusion 5. ANS: 3 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Discussing the electrical and mechanical components of the cardiac cycle Chapter page reference: 521 Heading: Action Potential of the Cardiac Conduction System Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
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1 2 3 4
Feedback In phase 0 there is rapid depolarization caused by the opening of sodium (Na+) channels allowing rapid Na+ influx, moving the membrane potential to +30. In phase 1 Na+ influx decreases causing a slight movement toward negative of the membrane potential, producing an initial repolarization. In phase 3 final repolarization occurs, which is caused by the closing of the Ca++ channels and the rapid outflow of K+. In phase 4 there is a return to the resting membrane potential.
PTS: 1 CON: Perfusion 6. ANS: 3 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Discussing the electrical and mechanical components of the cardiac cycle Chapter page reference: 522 Heading: Electrocardiogram Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
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Feedback The T wave corresponds to ventricular repolarization. Atrial repolarization occurs during ventricular contraction. That waveform is not visible but is buried in the QRS compN leU x.RSINGTB.COM The QRS complex corresponds to ventricular depolarization. If the complex is widening, then ventricular depolarization is taking longer to complete. The PR interval reflects the time required for atrial depolarization and the delay of the impulse at the AV node.
PTS: 1 CON: Perfusion 7. ANS: 1 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Reviewing the components of cardiac output Chapter page reference: 525 Heading: Heart Rate Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate 1
2
Feedback Stimulus from the sympathetic nervous system initiated by information from baroreceptors in the aortic arch and the carotids that are sensitive to changes in BP increase the HR through the release of norepinephrine. This is called a positive chronotropic effect. The parasympathetic nervous system slows the HR through the release of acetylcholine, a negative chronotropic effect.
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Contractility is the force of the mechanical contraction. Preload is the amount of blood in the ventricles at the end of diastole.
PTS: 1 CON: Perfusion 8. ANS: 3 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Reviewing the components of cardiac output Chapter page reference: 525 Heading: Heart Rate Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
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Feedback Norepinephrine would be released from the adrenal medulla in response to low blood pressure. Norepinephrine would not be released since this heart rate is within normal limits. Chemicals that can increase HR include norepinephrine released from the adrenal medulla. Norepinephrine would not be released in response to an elevated blood pressure.
PTS: 1 CON: Perfusion 9. ANS: 4 NURSINGTB.COM Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Reviewing the components of cardiac output Chapter page reference: 525 Heading: Stroke Volume Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate 1 2 3 4
Feedback The heart rate is not used to determine preload. The blood pressure is not used to determine preload. Oxygen saturation is not used to determine preload. Preload is reflected by measurements obtained through a centrally located IV line. For preload the central venous pressure is used.
PTS: 1 CON: Perfusion 10. ANS: 3 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Reviewing the components of cardiac output Chapter page reference: 525 Heading: Stroke Volume Integrated Processes: Nursing Process – Assessment
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Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
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Feedback Preload is the amount of blood in the ventricles at the end of diastole. Extreme overfilling decreases the effectiveness of the contraction, decreasing CO. With the blood pressure being this elevated, the heart rate should be lower due to a negative chronotropic effect. Afterload is the resistance to flow the ventricle must overcome to open the semilunar valves and eject its contents. This is related to BP in that hypertension on the right or left is implicated in the negative effects of increased afterload. Contractility refers to the force of the mechanical contraction, which can be increased with sympathetic stimulation or calcium release or decreased when hypoxia or acidosis occurs.
PTS: 1 CON: Perfusion 11. ANS: 4 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Explaining assessment parameters incorporated into the history and physical of a cardiovascular examination Chapter page reference: 527 Heading: Inspection Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity/N PhUyR sioSlI ogN icG alTABd. apCtaOtiM on Cognitive level: Application [Applying] Concept: Perfusion; Assessment Difficulty: Moderate
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Feedback Distended jugular veins are associated with pericarditis. Distended jugular veins are associated with cardiac tamponade. Unilateral extremity edema can indicate a lymphatic obstruction. Bilateral lower extremity edema generally indicates venous insufficiency.
PTS: 1 CON: Perfusion | Assessment 12. ANS: 2 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Explaining assessment parameters incorporated into the history and physical of a cardiovascular examination Chapter page reference: 527 Heading: Palpation Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion; Assessment Difficulty: Moderate
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Feedback Adequate CO produces warm skin temperatures. Variations in temperature between different parts of the body may indicate vasoconstriction or vascular disease in the affected extremities. A more extensive examination includes femoral, popliteal, and posterior tibial pulses. Edema of the left lower extremity would cause the nurse to assess the pulses on the left leg and not necessarily the brachial and carotid pulses. Respiratory rate does not influence pulse assessment.
PTS: 1 CON: Perfusion | Assessment 13. ANS: 3 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Explaining assessment parameters incorporated into the history and physical of a cardiovascular examination Chapter page reference: 528 Heading: Heart Sounds Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion; Assessment Difficulty: Moderate
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Feedback A friction rub is described as a scratching or grating sound heard both during systole and diastole. The sound is produ NUceRdSbIy NinGflaTmBm.aCtioOnMof the pericardiu m. It is diagnostic for pericarditis and is referred to as the pericardial friction rub. A click is a high-pitched sound heard early in diastole typically caused by mitral valve stenosis. Murmurs are usually caused by turbulent flow through the valves. That turbulence can be caused by regurgitation of blood through an incompetent valve. An atrial gallop can indicate decreased ventricular compliance.
PTS: 1 CON: Perfusion | Assessment 14. ANS: 1 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to cardiovascular function Chapter page reference: 528 Heading: Laboratory Markers as Predictors of Heart Disease Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate 1 2
Feedback A lipid panel requires the patient to fast for approximately 8 to 12 hours prior to the test. Fasting is not required prior to a homocysteine level.
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Fasting is not required prior to a C-reactive protein level. Fasting is not required prior to a partial thromboplastin time level.
PTS: 1 CON: Perfusion 15. ANS: 2 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Describing the implications for selected diagnostic evaluation Chapter page reference: 529 Heading: Laboratory Markers of Acute Cardiac Damage or Injury Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate
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Feedback Brain natriuretic peptide does not measure the amount of lipids in the blood. A low-fat diet would not be applicable for this level. Brain natriuretic peptide is released from overstretched ventricular tissue. Elevations are an indicator of heart failure. Brain natriuretic peptide does not determine amounts of cardiac tissue damage. Brain natriuretic peptide does not discern between lung or heart problems.
PTS: 1 CON: Perfusion 16. ANS: 4 NURSINGTB.COM Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Describing the implications for selected diagnostic evaluation Chapter page reference: 531 Heading: Echocardiography Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate
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Feedback Cardiac catheterization is an invasive x-ray procedure during which a radiopaque catheter is advanced through an artery or vein to the heart under fluoroscopy in order to evaluate cardiac filling pressures. Coronary angiography is the primary reason cardiac catheterization is performed. It is a left-sided cardiac catheterization with the purpose of inspecting the coronary arteries for blockage. A cardiac stress test is done to evaluate heart functioning during times of increased workload. Information about the presence of clots in the atrium, a risk factor for stroke, is more easily viewed through TEE.
PTS: 1 17. ANS: 4
CON: Perfusion
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Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to cardiovascular function Chapter page reference: 532 Heading: Catheterization and Angiography Integrated Processes: Communication and Documentation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
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Feedback The limb of the puncture site should be monitored. Warmth indicates adequate perfusion of the extremity. Urine output should be monitored post procedure. A urine output of 250 mL/2 hours indicates adequate renal perfusion postprocedure. The patient will need to remain flat for two to six hours postprocedure. This could cause temporary discomfort; however, this does not need to be reported to the healthcare provider. The puncture site should be monitored for hematoma formation. This could cause occlusion of the femoral artery and should be reported to the health-care provider.
PTS: 1 CON: Perfusion 18. ANS: 2 Chapter number and title: 28, Assessment of Cardiovascular Function NURSINGTB.COM Chapter learning objective: Discussing changes in cardiovascular function related to aging Chapter page reference: 533 Heading: Age-Related Changes Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate 1 2 3 4
Feedback A cardiac click is not associated with hypertension. A cardiac click is associated with valve stenosis. A cardiac click is not associated with atrial fibrillation. A cardiac click is not associated with congestive heart failure.
PTS: 1 CON: Perfusion 19. ANS: 2 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Discussing changes in cardiovascular function related to aging Chapter page reference: 533 Heading: Age-Related Changes Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing]
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Concept: Perfusion Difficulty: Moderate
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Feedback Stenosis of heart valves can lead to hypertension in an older patient. Aging produces a number of physiological changes in the anatomy and physiology of the cardiovascular system. Physical deconditioning can result in atrophy of the left ventricle, which would displace the point of maximum impulse. In the older patient narrowing of arterial walls can lead to an increased risk of thrombosis and stroke. In the aging patient increased fibrosis of heart chambers can lead to hypertension.
PTS: 1 CON: Perfusion 20. ANS: 4 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Discussing changes in cardiovascular function related to aging Chapter page reference: 533 Heading: Age-Related Changes Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
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A louder first heart sound may be normal depending upon the area being auscultated. A friction rub is associated with pericarditis, which is not an age-related change to the cardiovascular system. A heart rate of 64 and regular is within normal limits. Hypertension is a common cardiovascular health issues related to aging.
PTS: 1
CON: Perfusion
COMPLETION 21. ANS: 265143 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Discussing the electrical and mechanical components of the cardiac cycle Chapter page reference: 521 Heading: Cells of the Electrical Conduction System Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate
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Feedback: The action potential begins in the sinoatrial node, which fires in the right atrium. Then the impulse spreads through the atrial myocardium and travels to the atrioventricular node. It then travels to the bundle of His, through the bundle branches, and extends through the Purkinje fibers. PTS: 1 CON: Perfusion 22. ANS: 42351 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Discussing the electrical and mechanical components of the cardiac cycle Chapter page reference: 525 Heading: Blood Pressure Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback: When the blood pressure drops, the kidneys respond by releasing the enzyme renin. Renin reacts with angiotensin to create angiotensin I. Angiotensin I is then converted in the lungs to angiotensin II via angiotensin-converting enzyme. Angiotensin II acts on the adrenal glands to release aldosterone. The release of aldosterone promotes sodium and water reabsorption in the kidneys, which increases circulating fluid volume. PTS: 1 CON: Perfusion 23. ANS: 542361 NURSINGTB.COM Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to cardiovascular function Chapter page reference: 530 Heading: Electrocardiography Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback: The chest positions for the V leads are: V1: 4th intercostal space, just to the right of the sternum; V2: 4th intercostal space, just to the left of the sternum; V3: Between V4 and V2; V4: on the midclavicular line and 5th intercostal space; V5: between V6 and V4 on the anterior axillary line; and V6: on the midaxillary line, horizontal with V4. PTS: 1
CON: Perfusion
MULTIPLE RESPONSE 24. ANS: 1, 4, 5 Chapter number and title: 28, Assessment of Cardiovascular Function
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Chapter learning objective: Explaining assessment parameters incorporated into the history and physical of a cardiovascular examination Chapter page reference: 526 Heading: History Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Perfusion; Promoting Health Difficulty: Easy
1. 2. 3. 4. 5.
Feedback Age is a nonmodifiable risk factor. Weight is a modifiable risk factor. Alcohol intake is a modifiable risk factor. Ethnic background is a nonmodifiable risk factor. Family history is a nonmodifiable risk factor.
PTS: 1 CON: Perfusion | Promoting Health 25. ANS: 1, 3, 4, 5 Chapter number and title: 28, Assessment of Cardiovascular Function Chapter learning objective: Explaining assessment parameters incorporated into the history and physical of a cardiovascular examination Chapter page reference: 528 Heading: Heart Sounds Integrated Processes: Communication and Documentation NURSINGTB.COM Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Application [Applying] Concept: Perfusion; Communication Difficulty: Easy 1. 2. 3. 4. 5. PTS: 1
Feedback When describing heart sounds it is important to note pitch. Clicks would be an abnormal finding, necessitating more thorough documentation. When describing heart sounds it is important to note quality When describing heart sounds it is important to note intensity. When describing heart sounds it is important to note location. CON: Perfusion | Communication
Chapter 29: Coordinating Care for Patients With Cardiac Dysrhythmia Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A patient’s heart rate is 48 beats per minute. Which structure is most likely generating this heart rate? 1) Purkinje fibers 2) Sinoatrial node
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3) Atrioventricular node 4) Ventricular pacer cells 2. The nurse is concerned that a patient is at risk for pulseless electrical activity. What information from the assessment did the nurse use to make this clinical decision? 1) Blood pH 7.30 2) Temperature 100.5 °F 3) Serum glucose level 170 mg/dL 4) Serum potassium level 4.1 mEq/L 3. A patient asks why cardiac leads are being placed on the chest. What should the nurse respond to this patient? 1) “It shows where the heart vessels are blocked.” 2) “It is used to evaluate the effectiveness of dietary changes.” 3) “It provides a graphic picture of the heart’s electrical activity.” 4) “It determines which medications are needed to improve heart function.” 4. When analyzing a patient’s electrocardiogram, the nurse notes that the P wave is normal. What criteria did the nurse use to make this decision? 1) Pointed and skinny in width 2) Small and rounded in lead II 3) Upright and rounded in lead II 4) Length 0.10 seconds and height 2.5 mm 5. A patient is being evaluated for a blockage in the cardiac ventricles. On which part of the electrocardiogram should the nurse focus as evidence of this blockage? 1) T wave 2) U wave NURSINGTB.COM 3) PR interval 4) QRS interval 6. The nurse is observed marching out the rhythm on a patient’s cardiac monitor tracing. What is this nurse assessing? 1) Rate 2) Polarity 3) Regularity 4) Amplitude 7. A patient with shortness of breath has a heart rhythm of 46 beats per minute. Which medication should the nurse anticipate being prescribed for this patient? 1) Atropine sulfate 2) Atenolol (Tenormin) 3) Diltiazem (Cardizem) 4) Adenosine (Adenocard) 8. A patient with atrial fibrillation has a heart rate of 90 beats per minute. Which manifestation should the nurse expect to assess in this patient? 1) Headache 2) Chest pain 3) Palpitations 4) Hypotension
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9. A patient with atrial fibrillation is being considered for cardioversion. Which diagnostic test should the nurse anticipate being prescribed prior to this procedure being completed? 1) Chest x-ray 2) CT scan of the chest 3) 12-lead electrocardiogram 4) Transesophageal echocardiogram (TEE) 10. A patient is experiencing supraventricular tachycardia. What should be done before determining this patient’s treatment? 1) Assess for thyroid disease 2) Identify the underlying rhythm 3) Evaluate serum electrolyte values 4) Study lifestyle and behavioral habits 11. A patient is admitted for treatment for a low junctional rhythm. Where should the nurse expect to assess the P wave on this patient’s electrocardiogram? 1) Prior to the QRS wave 2) Buried within the QRS wave 3) At the tail end of the QRS wave 4) Superimposed over the previous T wave 12. A patient’s cardiac rhythm has no identifiable P or QRS waves. What action should the nurse take first? 1) Apply oxygen 2) Assess a radial pulse 3) Insert an intravenous line 4) Begin chest compressions
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13. A patient is in normal sinus rhythm with prolonged PR intervals. What treatment should the nurse expect to be prescribed for this patient? 1) Continue to monitor 2) Anticipate defibrillating 3) Prepare for cardioversion 4) Prepare for pacemaker insertion 14. The nurse notes that PR intervals are getting progressively longer before a QRS complex is dropped on a patient’s cardiac rhythm strip. Which health problem should the nurse realize this patient is experiencing? 1) Mobitz I 2) Mobitz II 3) First-degree AV block 4) Third-degree AV block 15. A patient is being prepared for a transvenous pacemaker. What should the nurse include when explaining this pacemaker to the family? 1) “It is inserted using an internal jugular vein.” 2) “It is done by placing defibrillator pads on the torso using an anterior/posterior position.” 3) “It is done by placing a pacer wire in the atrium or the ventricle and fed out through the skin, where it is attached to an external pacemaker.” 4) “It is inserted by placing pacer wires in the atrium, ventricle, or both and attached to a small pacemaker generator placed under the skin near the clavicle.” 16. A patient is diagnosed with third-degree AV block. For which type of pacemaker should the nurse prepare this patient?
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1) 2) 3) 4)
Transvenous Biventricular Transthoracic Transcutaneous
17. The nurse is preparing to defibrillate a patient. Which setting should the nurse use for this treatment? 1) 50 J 2) 100 J 3) 150 J 4) 200 J 18. A patient is being cardioverted for symptomatic atrial fibrillation. At which point of the cardiac cycle will the electric impulse occur? 1) At the end of the P wave 2) Before the QRS complex 3) At the peak of the R wave 4) After the QRS complex but before the T wave 19. The nurse notes that a patient with a cardiac dysrhythmia is developing shortness of breath. What is the pathophysiological reason for this manifestation? 1) Decreased oxygen in the brain 2) Stimulation of the sympathetic nervous system 3) Imbalance in myocardial oxygen demand and supply 4) Increase in oxygenation because of a drop in cardiac output 20. A patient with a cardiac dysrhythmia is experiencing nausea and vomiting. What is the reason for this to occur? NURSINGTB.COM 1) Poor contractile function 2) Altered electrolyte levels 3) Blood shunted away from nonessential organ systems 4) An imbalance in myocardial oxygen supply and demand 21. A patient with a cardiac dysrhythmia asks why it is important to recognize the signs of a stroke. What should the nurse respond to this patient? 1) “So you can respond quickly and prevent adverse effects.” 2) “To encourage you to take your medication as prescribed.” 3) “So that you can recognize the signs of stroke in a family member.” 4) “Most people with a heart arrhythmia develop strokes as a side effect.” 22. During a home visit the nurse learns that a patient has been skipping doses of antiarrhythmic medication. What should the nurse include when counseling this patient? 1) Taking the medication as prescribed reduces the occurrence of side effects 2) Skipping doses increases the risk of developing chest pain and diaphoresis. 3) Adequate medication level decreases the adverse effects of the dysrhythmia. 4) Insufficient amounts of medication in the blood stream affect pacemaker functioning. Multiple Response Identify one or more choices that best complete the statement or answer the question. 23. An older client is being evaluated for a new onset of a cardiac dysrhythmia. What should the nurse consider as being the cause for this abnormal heart rhythm? Select all that apply.
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1) 2) 3) 4) 5)
Advanced age Protein malnutrition Fat deposits around the SA node Fewer pacemaker cells in the SA node Calcification around the SA node and valves
24. A patient becomes unresponsive without a palpable pulse despite showing bradycardia on the rhythm strip. What action should the nurse take immediately? Select all that apply. 1) Auscultate heart sounds 2) Begin cardiac compressions 3) Adjust cardiac monitor leads 4) Prepare for chest tube insertion 5) Place epinephrine at the bedside 25. A patient has a heart rate of 132 beats per minute. What should the nurse assess to help determine the reason for this rate? Select all that apply. 1) Muscle tone 2) Temperature 3) Urine output 4) Bowel sounds 5) Blood pressure 26. The nurse is caring for a patient with a potentially life-threatening cardiac dysrhythmia. What should be included in this patient’s plan of care? Select all that apply. 1) Document frequency of dysrhythmia 2) Administer antiarrhythmic medications 3) Maintain continuous cardiac moN niU toRriS n gINGTB.COM 4) Prepare to administer advanced cardiac life support 5) Complete preoperative checklist for pacemaker insertion Completion Complete each statement. 27. The nurse reviews the cardiac electrical cycle with a patient scheduled for pacemaker insertion surgery. In which order should the nurse explain this process? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) A. P wave B. T wave C. QRS complex D. Firing of the SA node E. Ventricular contraction F. Ventricular repolarization 28. When calculating a patient’s heart rate using the cardiac rhythm strip, the nurse notes the presence of four large boxes between the two R waves. What is this patient’s heart rate? Record your answer as a whole number.
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Chapter 29: Coordinating Care for Patients With Cardiac Dysrhythmia Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Defining the pathophysiology of rhythm disorders Chapter page reference: 537 Heading: The Normal Conduction Pathway Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy 1 2 3 4
Feedback The Purkinje fibers can generate a ventricular rate of 20 beats per minute (bpm) or less. The sinoatrial (SA) node can generate impulses at a rate of 60 to 100 bpm. The AV node can generate impulses at a rate of 40 to 60 bpm. The ventricular pacer cells can generate impulses at a rate of 40 bpm or less.
PTS: 1 CON: Perfusion 2. ANS: 1 NURSINGTB.COM Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Defining the pathophysiology of rhythm disorders Chapter page reference: 538 Heading: Safety Alert: Pulseless Electrical Activity Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
1 2 3 4
Feedback Causes of pulseless electrical activity include acidosis, which is reflected in a blood pH less than 7.35. Causes of pulseless electrical activity include hypothermia. A temperature over 100°F would not be seen in hypothermia. Causes of pulseless electrical activity include hypoglycemia. A blood glucose of 170 mg/dL would by hyperglycemia. Causes of pulseless electrical activity include hyper- or hypokalemia. A serum potassium level of 4.1 mEq/L is within normal limits.
PTS: 1 CON: Perfusion 3. ANS: 3 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia
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Chapter learning objective: Identifying a method to interpret electrocardiograms (ECGs) Chapter page reference: 538 Heading: Electrocardiogram Integrated Processes: Communication and Documentation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 An electrocardiogram does not necessarily show where the heart vessels are blocked. 2 An electrocardiogram is not used to evaluate the effectiveness of dietary changes. 3 An electrocardiogram provides a graphic representation of the heart’s electrical activity. 4 An electrocardiogram is not used to determine medications to improve heart function. PTS: 1 CON: Perfusion 4. ANS: 4 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Identifying a method to interpret electrocardiograms (ECGs) Chapter page reference: 539 Heading: Waveforms Integrated Processes: Nursing Process Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate NURSINGTB.COM Feedback 1 The QRS complex is pointed and skinny in width. 2 The U wave is small and rounded in lead II 3 The T wave is upright and rounded in lead II. 4 The P wave itself should not be longer than 0.10 sec in length and no higher than 2.5 mm. PTS: 1 CON: Perfusion 5. ANS: 4 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Identifying a method to interpret electrocardiograms (ECGs) Chapter page reference: 539 Heading: Intervals Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Feedback 1 The T wave occurs after the QRS and represents ventricular repolarization. 2 The U wave represents Purkinje fiber repolarization and is rarely seen. 3 The PR interval is the measure of time that it takes an electrical impulse to depolarize the atria and travel to the ventricles.
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4
The QRS interval is the measure of time to depolarize the ventricles. The normal interval is 0.04 to 0.10 sec in length. If the QRS is prolonged it may be a sign of a disturbance within the ventricle itself such as a block in the ventricles delaying impulse travel time through the ventricles.
PTS: 1 CON: Perfusion 6. ANS: 3 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Identifying a method to interpret electrocardiograms (ECGs) Chapter page reference: 541 Heading: Calculating Regularity Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy Feedback 1 Counting the number of small or large boxes on the tracing paper is used to calculate rate. 2 The direction of the tracing from the baseline is used to determine polarity. 3 Regularity can be determined by counting the boxes between the waveforms being measured A regular rhythm will have the same number of boxes or equal space between waveforms or complexes. This is called marching out the rhythm. 4 The height of the tracing is used to determine amplitude.
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PTS: 1 CON: Perfusion ANS: 1 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Employing the appropriate intervention for each dysrhythmia reviewed Chapter page reference: 541 Heading: Sinus Bradycardia Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perfusion; Medication Difficulty: Moderate Feedback 1 Treatment of symptomatic sinus bradycardia is atropine 0.5 mg IV push. 2 Atenolol (Tenormin) is used in the treatment of sinus tachycardia. 3 Diltiazem (Cardizem) is used in the treatment of atrial fibrillation or atrial flutter. 4 Adenosine (Adenocard) is used in the treatment of supraventricular tachycardia. PTS: 1 CON: Perfusion | Medication 8. ANS: 3 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Recognizing sinus, atrial, junctional, and ventricular dysrhythmias Chapter page reference: 546 Heading: Atrial Fibrillation Integrated Processes: Nursing Process: Assessment
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Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Feedback 1 Headache is not associated with atrial fibrillation. 2 Chest pain is not associated with atrial fibrillation. 3 Palpitations are associated with atrial fibrillation. 4 Hypotension is not associated with atrial fibrillation. PTS: 1 CON: Perfusion 9. ANS: 4 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Employing the appropriate intervention for each dysrhythmia reviewed Chapter page reference: 547 Heading: Atrial Fibrillation Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate
1 2 3 4
Feedback A chest x-ray most likely will be done; however, this does not need to be completed prior to cardioversion. NURSINGTB.COM A CT scan of the chest does not need to be done prior to cardioversion. A 12-lead electrocardiogram most likely will be done; however, this does not need to be completed prior to cardioversion. Cardioversion should be considered for atrial fibrillation only after the atrium has been evaluated for the presence of clots by transesophageal echocardiogram (TEE).
PTS: 1 CON: Perfusion 10. ANS: 2 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Employing the appropriate intervention for each dysrhythmia reviewed Chapter page reference: 549 Heading: Supraventricular Tachycardia Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 Thyroid disease is not associated with supraventricular tachycardia. 2 The key for treating supraventricular tachycardia is to figure out the underlying rhythm while slowing down the heart rate. 3 Serum electrolyte levels are not usually associated with supraventricular tachycardia. 4 Lifestyle and behavioral habits are not usually associated with supraventricular tachycardia.
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PTS: 1 CON: Perfusion 11. ANS: 3 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Recognizing sinus, atrial, junctional, and ventricular dysrhythmias Chapter page reference: 551 Heading: Junctional Rhythm Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 Retrograde P wave prior to the QRS wave is also known as a high junctional. 2 Retrograde P wave buried within the QRS wave is also known as a mid-junctional. 3 Retrograde P wave at the tail end of the QRS wave is also known as low junctional. 4 Retrograde P waves are not superimposed over the previous T wave. PTS: 1 CON: Perfusion 12. ANS: 4 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Recognizing sinus, atrial, junctional, and ventricular dysrhythmias Chapter page reference: 555 Heading: Ventricular Fibrillation Integrated Processes: Nursing Process: Implementation NURSINGTB.COM Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 The nurse would be wasting time applying oxygen. 2 Assessing a radial pulse would be wasting time. 3 Inserting an intravenous line would be wasting time. 4 In ventricular fibrillation there are no identifiable P or QRS waves. Chest compressions should be initiated immediately and maintained as continuously as possible. PTS: 1 CON: Perfusion 13. ANS: 1 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Classifying first-, second-, and third-degree blocks Chapter page reference: 558 Heading: First-Degree AV Block Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback
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1
2 3 4
First-degree AV block looks very similar to normal sinus rhythm except the PR interval is prolonged. Treatment is not typically required for first-degree AV block unless the patient is having symptoms, which is very rare. Defibrillation is not indicated for first-degree AV block. Cardioversion is not indicated for first-degree AV block. A pacemaker is not indicated for first-degree AV block.
PTS: 1 CON: Perfusion 14. ANS: 1 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Classifying first-, second-, and third-degree blocks Chapter page reference: 560 Heading: Second-Degree AV Block Type I Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate 1
2 3 4
Feedback Second-degree AV block type I, also known as Wenckebach or Mobitz I, occurs when not all atrial impulses get through the AV node to the ventricles. There are more P waves than QRS complexes and the PR interval gets progressively longer until a QRS is dropped. Second-degree AV block typeNIIU, als RSoIkNnoGwTn Bas.M CoObMitz II, drops QRS complexes, but the PR intervals are exactly the same length with each complex. First-degree AV block looks similar to a normal sinus rhythm except the PR interval is prolonged. In third-degree AV block or complete heart block the AV node is completely blocked and prevents any impulses from entering or exiting. There is no communication between the atria and the ventricles. The ECG records more P waves than QRS complexes.
PTS: 1 CON: Perfusion 15. ANS: 1 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Classifying first-, second-, and third-degree blocks Chapter page reference: 561 Heading: Second-Degree AV Block Type II Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate
1
Feedback For a transvenous pacemaker a pacer wire is inserted into the right ventricle through central venous access, usually via the internal jugular vein.
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4
Defibrillator pads are placed on the patient’s torso using an anterior/posterior position for a transcutaneous pacemaker. A pacer wire that is surgically placed in the atrium or the ventricle and fed out through the skin and attached to an external pacemaker is the process for inserting a transthoracic or epicardial pacer. For all internal pacemakers, pacer wires are placed in the atrium, ventricle, or both and attached to a small pacemaker generator placed under the skin near the clavicle.
PTS: 1 CON: Perfusion 16. ANS: 1 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Explaining the types of pacing used in the treatment of certain dysrhythmias Chapter page reference: 562 Heading: Third-Degree AV Block Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 Transcutaneous pacing is indicated in patients with symptomatic complete heart block. 2 A biventricular pacemaker is not indicated for third-degree AV block. 3 A transthoracic pacemaker is not indicated for third-degree AV block. 4 Transcutaneous pacing is used primarily for second-degree AV block.
NURSINGTB.COM PTS: 1 CON: Perfusion 17. ANS: 4 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Differentiating the use of cardioversion from defibrillation Chapter page reference: 564 Heading: Third-Degree AV Block Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 The energy level for cardioversion begins at 50 J. 2 The energy level for cardioversion can be increased to 100 J. 3 The energy level for cardioversion can be increased to 200 J. 4 The energy level for defibrillation is 200 J. PTS: 1 CON: Perfusion 18. ANS: 3 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Differentiating the use of cardioversion from defibrillation Chapter page reference: 547 Heading: Atrial Fibrillation Integrated Processes: Nursing Process: Planning
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Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 Cardioversion is not done at the end of the P wave. 2 Cardioversion is not done before the QRS complex. 3 Cardioversion is the controlled electrical discharge of energy at the peak of the R wave. 4 Cardioversion is not done after the QRS complex or before the T wave. PTS: 1 CON: Perfusion 19. ANS: 4 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Analyzing the appropriate nursing interventions for patients with cardiac dysrhythmias Chapter page reference: 562 Heading: Nursing Interventions: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
1 2 3 4
Feedback Decreased oxygen in the brainNaU lteRrsStI heNlev GTelBo.f co C OnsMciousness. Stimulation of the sympathetic nervous system causes diaphoresis. Imbalanced myocardial oxygen demand and supply causes chest pain. Because of the lack of efficient contractile function of a heart experiencing dysrhythmias, cardiac output may fall, causing a decrease in blood pressure. In an attempt to increase oxygenation in the face of decreased cardiac output, shortness of breath and tachypnea may occur.
PTS: 1 CON: Perfusion 20. ANS: 3 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Analyzing the appropriate nursing interventions for patients with cardiac dysrhythmias Chapter page reference: 564 Heading: Nursing Interventions: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
1 2
Feedback Poor contractile function causes peripheral edema. Altered electrolyte levels can indicate acute cardiac injury.
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Shunting of blood away from nonessential organ systems during low-flow states may cause nausea and vomiting. An imbalance in myocardial oxygen supply and demand causes chest pain.
PTS: 1 CON: Perfusion 21. ANS: 1 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Designing an effective patient teaching plan for a patient experiencing atrial fibrillation Chapter page reference: 564 Heading: Nursing Interventions: Implementation Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 It is important that the patient (and family) is able to detect early signs of complications such as a stroke to assure prompt treatment and reduce adverse effects. 2 Learning the manifestations of stroke is not to encourage the patient to take medication as prescribed. 3 Learning the manifestations of stroke is not to recognize the signs of a stroke in a family member. 4 Most people with a heart arrhythmia do not develop a stroke as a side effect.
NURSINGTB.COM PTS: 1 CON: Perfusion 22. ANS: 1 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Designing an effective patient teaching plan for a patient experiencing atrial fibrillation Chapter page reference: 564 Heading: Nursing Interventions: Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 There is evidence to support that taking antiarrhythmic medication as prescribed will reduce the occurrence of side effects. 2 There is no evidence to support that skipping antiarrhythmic medication doses increases the risk of developing chest pain and diaphoresis. 3 Maintaining adequate medication levels helps decrease the occurrence of adverse effects of dysrhythmias. 4 There is no evidence to support that skipping antiarrhythmic medication will adversely affect pacemaker functioning. PTS: 1
CON: Perfusion
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MULTIPLE RESPONSE 23. ANS: 1, 3, 4, 5 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Defining the pathophysiology of rhythm disorders Chapter page reference: 537 Heading: Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Age is a primary risk factor for the development of dysrhythmias. Protein malnutrition is not identified as being a risk factor for the development of dysrhythmias. Older adults may have fat deposits around the SA node causing a delay in the propagation of the action potential. Older adults have fewer pacemaker cells in the SA node causing a delay in the propagation of the action potential. Slowed impulse transmission may be related to calcification around the AV node and valves.
PTS: 1 CON: PerfusioNnURSINGTB.COM 24. ANS: 2, 5 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Defining the pathophysiology of rhythm disorders Chapter page reference: 538 Heading: Safety Alert: Pulseless Electrical Activity Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Auscultating for heart sounds will waste time when pulseless electrical activity occurs. If pulseless electrical activity occurs, the nurse should begin chest compressions. Adjusting cardiac monitor leads will waste time when pulseless electrical activity occurs. Although a pneumothorax can cause pulseless electrical activity, a chest tube is not the treatment for all episodes of this disorder. The treatment for pulseless electrical activity includes epinephrine.
PTS: 1 CON: Perfusion 25. ANS: 2, 5 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Recognizing sinus, atrial, junctional, and ventricular dysrhythmias
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Chapter page reference: 543 Heading: Sinus Tachycardia Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Muscle tone is not used to determine the cause for sinus tachycardia. Causes of sinus tachycardia include fever. Urine output is not used to determine the cause for sinus tachycardia. Bowel sounds are not used to determine the cause for sinus tachycardia. Causes of sinus tachycardia include hypotension.
PTS: 1 CON: Perfusion 26. ANS: 1, 2, 3, 4 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Analyzing the appropriate nursing interventions for patients with cardiac dysrhythmias Chapter page reference: 564 Heading: Nursing Interventions: Actions Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Application [Applying] NURSINGTB.COM Concept: Perfusion Difficulty: Moderate
1. 2. 3. 4. 5.
PTS: 1
Feedback For the patient with a potentially life-threatening dysrhythmia the nurse should document the frequency of the dysrhythmia, For the patient with a potentially life-threatening dysrhythmia the nurse should administer antiarrhythmic medication. For the patient with a potentially life-threatening dysrhythmia the nurse should maintain continuous cardiac monitoring. For the patient with a potentially life-threatening dysrhythmia the nurse should prepare to administer advanced cardiac life support. Not all patients with potentially life-threatening dysrhythmias will have a pacemaker inserted. CON: Perfusion
COMPLETION 27. ANS: 413526 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Defining the pathophysiology of rhythm disorders
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Chapter page reference: 538 Heading: Normal Sinus Rhythm Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback: When the impulse travels along the normal conduction pathway, it generates waveforms that indicate the firing of the SA node, the P wave, followed by a QRS complex indicating ventricular contraction and a T wave indicating ventricular repolarization. PTS: 1 CON: Perfusion 28. ANS: 75 Chapter number and title: 29, Coordinating Care for Patients With Cardiac Dysrhythmia Chapter learning objective: Identifying a method to interpret electrocardiograms (ECGs) Chapter page reference: 540 Heading: Calculating Heart Rate (HR) Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Perfusion Difficulty: Easy Feedback: One method to calculate HNRUiR s tSo IcoNuG n tTthBe .nC um ObMer of large boxes between two R waves and divide that number into 300. If four large boxes are present, then 300/4 = 75. PTS: 1
CON: Perfusion
Chapter 30: Coordinating Care for Patients With Cardiac Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is concerned that a patient is at risk for developing infective endocarditis. What information in the patient’s history caused the nurse to have this concern? 1) 70 years of age 2) Treatment for osteoarthritis 3) Sister being treated for chronic renal failure 4) Diagnosed with benign prostatic hyperplasia 2. A patient is admitted for treatment of pericarditis. For which additional health problem should the nurse expect the patient to be evaluated? 1) Asthma 2) Myocardial infarction 3) Infective endocarditis 4) Chronic obstructive pulmonary disease
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3. A patient is demonstrating manifestations of valvular disease. Which valve should the nurse expect to be affected with this disorder? 1) Aortic 2) Mitral 3) Pulmonic 4) Tricuspid 4. The nurse is explaining the development of atherosclerosis to a patient. What should the nurse emphasize as beginning this process? 1) Oxidation 2) Inflammatory process 3) Injury to the vessel wall 4) Trapping of low-density lipoproteins 5. The nurse explains about the development of tissue clumps within the innermost layer of the heart to a patient with infective endocarditis. What aspect of the disease process is the nurse describing? 1) Vegetation 2) Oxidation 3) Foam cells 4) Fatty streaks 6. A patient with pericarditis asks the nurse to explain the health problem. Which phrase should the nurse use when responding to this patient? 1) Heart cell dysfunction 2) Plaque buildup in vessels 3) Infection of the innermost layer of the heart 4) Inflammation of the tissue surroN u nUdR inS g I thN e G h eTarBt .COM 7. After completing a physical assessment the nurse anticipates the health-care provider to prescribe diagnostic testing for valvular disease. What did the nurse assess to come to this conclusion? 1) Heart murmur 2) Carotid artery bruit 3) Bounding peripheral pulses 4) Displaced point of maximum impulse 8. During an assessment a patient describes experiencing chest pain with exercise that disappears with rest. For which health problem should the nurse plan care for this client? 1) Stable angina 2) Variant angina 3) Unstable angina 4) Prinzmetal’s angina 9. After an assessment the nurse concludes that a patient is experiencing infective endocarditis. What finding caused the nurse to make this decision? 1) Friction rub 2) Chest pain at rest 3) Jugular vein distention 4) Painless spots on the palms and soles 10. The nurse notes that a newly admitted patient has an elevated sedimentation rate. For which health problem should the nurse plan care for this patient? 1) Pericarditis
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2) Heart failure 3) Pericardial effusion 4) Coronary artery disease 11. A patient with heart failure is having a B-type natriuretic peptide (BNP) level drawn. What is the purpose of this laboratory test? 1) Predict life expectancy 2) Rule out an ischemic event 3) Differentiate right from left heart failure 4) Evaluate effectiveness of medication therapy 12. The nurse is preparing teaching for a patient being treated for coronary artery disease. What dietary information should the nurse emphasize? 1) Restrict carbohydrate intake 2) Limit calorie intake to under 1000/day 3) Reduce saturated fat and sodium intake 4) Have the biggest meal of the day for lunch 13. A patient with infective endocarditis is being started on intravenous antibiotics. What should the nurse include when teaching about this medication? 1) “The medication may be changed every few days.” 2) “The typical course of this medication is 7 to 10 days.” 3) “Expect to continue this medication for four to six weeks at home.” 4) “Since this infection is resilient, you might be taking antibiotics for life.” 14. A patient is recovering from mechanical valve replacement surgery for valvular disease. What medication teaching should medication teaching NshUoR u lS d I thN e G n uTrsBe . p rCepOaM re for this patient? 1) Long-term use of diuretics 2) Anticoagulant therapy for life 3) Antibiotic therapy for four to six weeks 4) Episodic use of antiarrhythmic medications 15. A patient with heart failure is prescribed an angiotensin-converting enzyme inhibitor. What should the nurse explain as being the purpose of this medication? 1) Reduce afterload 2) Decrease preload 3) Increase contractility 4) Control sympathetic nervous system response to decreased cardiac output 16. The nurse applies oxygen two liters via nasal cannula on a patient with coronary artery disease. What should the nurse explain as being the purpose of the oxygen? 1) Ensures vessel dilation 2) Ensures perfusion to cerebral tissues 3) Supports myocardial oxygen demand 4) Facilitates the metabolism of medications 17. The nurse is caring for a patient with infective endocarditis. For which reason would a referral to social services be needed? 1) Lives with parents 2) Uses intravenous drugs 3) Taking a leave of absence from work 4) Has two terms of college to complete
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18. The nurse is caring for a patient with pericardial effusion. Which action should the nurse use to relieve shortness of breath and pain? 1) Elevate the head of the bed 2) Encourage ambulation in the room 3) Place in the left side-lying position 4) Coach in deep breathing and coughing 19. The nurse is concerned that a patient with heart failure is decompensating. What assessment finding supports the nurse’s clinical decision? 1) Dyspnea on exertion 2) Dry persistent cough 3) Weak peripheral pulses 4) Increased urine output 20. The nurse is evaluating teaching provided to a patient with coronary artery disease. Which patient statement indicates that additional teaching is required? 1) “I will adhere to my smoking cessation plan.” 2) “I am to reduce my daily intake of saturated fat.” 3) “I can take up to three doses of nitroglycerin 15 minutes apart.” 4) “I am to follow the exercise plan for 30 minutes, five days a week.” 21. During a home visit the nurse determines that teaching provided to a patient recovering from infective endocarditis has been effective. What did the nurse observe to make this clinical determination? 1) Drinking skim milk 2) Measuring radial pulse 3) Using a soft toothbrush NURSINGTB.COM 4) Taking anticoagulant daily 22. A patient with pericarditis is prescribed corticosteroids. What should the nurse emphasize when teaching about this medication? 1) Take the medication as prescribed 2) Increase the dose if symptoms get worse 3) Reduce the frequency when symptoms subside 4) Consider taking a dose every other day to reduce side effects Multiple Response Identify one or more choices that best complete the statement or answer the question. 23. The nurse is preparing a community program on the metrics to improve cardiovascular health. What should be included in this program? Select all that apply. 1) Healthy diet 2) Alcohol intake 3) Physical activity 4) Smoking cessation 5) Lower blood pressure 24. While planning care the nurse identified interventions to reduce a patient’s risk for developing heart failure. Which assessment findings did the nurse use to make this clinical determination? Select all that apply. 1) Body mass index 31.3 2) Smokes 1/2 pack of cigarettes
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3) Employed in a textile factory 4) Blood pressure 168/90 mm Hg 5) Fasting blood glucose 146 mg/dL 25. The nurse notes that a patient with heart failure has a normal ejection fraction. What should this information indicate to the nurse? Select all that apply. 1) It is a common diagnosis 2) It is associated with older patients with obesity 3) It is seen in patients with diabetes mellitus and atrial fibrillation 4) It is exacerbated with invasive procedures and dental examinations 5) There is less blood in the ventricle to eject because of the impaired filling 26. A patient is experiencing manifestations of infective endocarditis. Which diagnostic tests should the nurse expect to be prescribed for this client? Select all that apply. 1) Blood cultures 2) Ejection fraction 3) Electrocardiogram 4) Transthoracic echocardiogram (TTE) 5) Transesophageal echocardiogram (TEE) 27. A patient is scheduled for an exercise stress test. For which cardiac health problems is this patient being tested? Select all that apply. 1) Pericarditis 2) Heart failure 3) Valvular disease 4) Infective endocarditis 5) Coronary artery disease NURSINGTB.COM 28. A patient with pericarditis is being prepared for an emergency pericardiocentesis. What did the nurse most likely assess to support this immediate procedure? Select all that apply. 1) Hypotension 2) Pulsus paradoxus 3) Muffled heart sounds 4) Jugular vein distention 5) Lower extremity edema
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Chapter 30: Coordinating Care for Patients With Cardiac Disorders Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Describing the epidemiology of cardiac disorders Chapter page reference: 569 Heading: Infective Endocarditis > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Analysis [Analyzing] Concept: Perfusion; Promoting Health Difficulty: Moderate Feedback 1 Risk factors for infective endocarditis include age greater than 60. 2 Osteoarthritis is not a risk factor for infective endocarditis. 3 Family history of renal failure is not a risk factor for infective endocarditis. 4 Benign prostatic hyperplasia is not a risk factor for infective endocarditis. PTS: 1 CON: Perfusion | Promoting Health 2. ANS: 2 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: DescribinNgUthReSepIidNeG mT ioB lo. gyCoOf cardiac disorders Chapter page reference: 569 Heading: Pericarditis > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Feedback 1 Pericarditis is not associated with asthma. 2 Acute pericarditis is a common occurrence following MI. It has been reported to occur in 7% to 41% of post-MI patients. 3 Pericarditis is not identified as routinely occurring after infective endocarditis. 4 Pericarditis is not associated with chronic obstructive pulmonary disease. PTS: 1 CON: Perfusion 3. ANS: 1 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Describing the epidemiology of cardiac disorders Chapter page reference: 581 Heading: Valvular Disease > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing]
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Concept: Perfusion Difficulty: Moderate Feedback 1 The most commonly affected valve is the aortic valve. 2 The mitral valve is not identified as being commonly affected by valvular disease. 3 The least commonly affected valves include the pulmonic valve because of the low pressure system in the right heart. 4 The least commonly affected valves include the tricuspid valve because of the low pressure system in the right heart. PTS: 1 CON: Perfusion 4. ANS: 3 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Coronary artery disease Chapter page reference: 569 Heading: Coronary Artery Disease > Pathophysiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 Oxidation occurs after low-density lipoproteins are trapped in the tunica intima. 2 The inflammatory process occN urUs R afS teI r aNnGinTjuBry.tCo OthM e vessel wall. 3 Atherosclerosis begins with an injury to the endothelium. 4 Low-density lipoproteins become trapped after the inflammatory response begins. PTS: 1 CON: Perfusion 5. ANS: 1 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Infective endocarditis Chapter page reference: 576 Heading: Infective Endocarditis > Pathophysiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate
1
2 3
Feedback Infective endocarditis begins with damage to the endocardial lining of the heart, which leads to the development of nonbacterial thrombotic endocardial lesion. If the patient is exposed to microorganisms present in the bloodstream, they can become trapped under the layers of platelet and fibrin deposits. These clumps of tissue are known as vegetation. Oxidation is a process associated with atherosclerosis. Foam cells are created in the development of atherosclerosis.
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4
Fatty streaks occur in the development of atherosclerosis.
PTS: 1 CON: Perfusion 6. ANS: 4 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Pericarditis Chapter page reference: 578 Heading: Pericarditis > Pathophysiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Application [Applying] Concept: Perfusion; Inflammation Difficulty: Moderate Feedback 1 Heart cell dysfunction describes heart failure. 2 Plaque buildup in vessels describes atherosclerosis. 3 Infection of the innermost layer of the heart describes infective endocarditis. 4 Inflammation of the tissue surrounding the heart describes pericarditis. PTS: 1 CON: Perfusion | Inflammation 7. ANS: 1 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Valvular disease Chapter page reference: 581 NURSINGTB.COM Heading: Valvular Disease > Pathophysiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate 1 2 3 4
Feedback Often the first clinical sign of valvular disease is the auscultation of a murmur. A carotid artery bruit is not associated with valvular disease. Bounding peripheral pulses are not associated with valvular disease. A displaced point of maximum impulse is associated with cardiomyopathy and not valvular disease.
PTS: 1 CON: Perfusion 8. ANS: 1 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Coronary artery disease Chapter page reference: 571 Heading: Coronary Artery Disease > Clinical Manifestations Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing]
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Concept: Perfusion Difficulty: Moderate
1 2 3 4
Feedback Stable angina is chest pain or discomfort that is associated with physical activity. Symptoms of stable angina are often alleviated with rest. Variant angina is caused by coronary artery spasm rather than plaque formation and typically occurs at rest and in clusters. Unstable angina refers to chest pain that can occur at rest. Prinzmetal’s angina is the same as variant angina, which is caused by coronary artery spasm rather than plaque formation and typically occurs at rest and in clusters.
PTS: 1 CON: Perfusion 9. ANS: 4 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Infective heart disease Chapter page reference: 577 Heading: Infective Endocarditis > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion; Infection Difficulty: Moderate 1 2 3 4
NURSINGTB.COM Feedback The most common clinical manifestation of pericarditis is a friction rub. Chest pain at rest or unstable angina is a manifestation of coronary artery disease. Right-sided heart failure is characterized by jugular vein distention. Clinical manifestations of infective endocarditis include red, painless spots on the palms and soles, called Janeway’s lesions.
PTS: 1 CON: Perfusion | Infection 10. ANS: 1 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of cardiac
disorders Chapter page reference: 579 Heading: Pericarditis > Laboratory Tests Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Application [Applying] Concept: Perfusion; Inflammation Difficulty: Moderate Feedback 1 Positive inflammatory markers such as sedimentation rates may indicate the presence of pericarditis.
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2
3 4
Laboratory testing for heart failure includes cardiac enzymes, serum electrolytes, a complete blood count, urinalysis, fasting lipid profile, liver function testing, and serum electrolytes. The finding of cardiomegaly and clear lung fields on chest x-ray is suggestive of pericardial effusion. Electrolyte imbalances along with increases in renal or hepatic laboratory values may indicate damage caused by poor perfusion or may indicate the presence of risk factors for heart disease.
PTS: 1 CON: Perfusion | Inflammation 11. ANS: 4 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of cardiac
disorders Chapter page reference: 585 Heading: Heart Failure > Laboratory Tests Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Feedback 1 BNP will not predict life expectancy. 2 Cardiac enzymes are used to rule out an acute ischemic event. 3 Ejection fraction is used to difN f eU reR n tSiaI teNriGghTt B fr. om COlefMt heart failure. 4 Cardiac biomarkers such as BNP are used to track a patient’s response to therapy. PTS: 1 CON: Perfusion 12. ANS: 3 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Discussing the medical management of: Coronary artery disease Chapter page reference: 574 Heading: Coronary Artery Disease > Diet and Exercise Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 Carbohydrate restriction is not part of dietary teaching for the patient with CAD. 2 Calorie limits are not part of dietary teaching for the patient with CAD. 3 It is important for patients with CAD to follow a sensible diet that is low in saturated fat and sodium. 4 Meal size is not a part of dietary teaching for the patient with CAD. PTS: 1 CON: Perfusion 13. ANS: 3 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders
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Chapter learning objective: Discussing the medical management of: Infectious heart disease Chapter page reference: 577 Heading: Infective Endocarditis > Medications Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perfusion; Infection Difficulty: Moderate
1 2 3 4
Feedback The medication will not be changed every few days. The medication will be provided for 4 to 6 weeks. The standard duration of treatment is 4 to 6 weeks. These patients are often discharged to home on IV antimicrobial therapy. The patient will not be on antibiotics for life.
PTS: 1 CON: Perfusion | Infection 14. ANS: 2 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Discussing the medical management of: Valvular disease Chapter page reference: 582 Heading: Valvular disease > Surgical Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perfusion; Perioperative NURSINGTB.COM Difficulty: Moderate
1 2 3 4
Feedback Long-term use of diuretics may be indicated in the patient with heart failure. Patients who undergo valve replacement with a mechanical prosthetic valve will need to be anticoagulated for life to prevent thrombotic events. Antibiotic therapy for four to six weeks is indicated for the patient with infective endocarditis. Antiarrhythmic medication is not routinely prescribed for the patient with a mechanical heart valve.
PTS: 1 CON: Perfusion | Perioperative 15. ANS: 1 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Discussing the medical management of: Heart failure Chapter page reference: 586 Heading: Heart Failure > Medications Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate
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1 2 3 4
Feedback Angiotensin-converting enzyme inhibitors (ACE-Is) are usually the first line of medications used to reduce afterload. Aldosterone antagonist diuretics such as spironolactone (Aldactone) as well as loop diuretics are used to decrease preload. A mainstay of HF management in the past has been digoxin (Lanoxin), an oral positive inotropic medication used to increase cardiac contractility. Beta blockers are used to control the sympathetic nervous system response to decreased cardiac output, such as tachycardia, in order to decrease cardiac workload.
PTS: 1 CON: Perfusion 16. ANS: 3 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with cardiac disease Chapter page reference: 575 Heading: Coronary Artery Disease > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 Oxygen is not used to ensure vessel dilation. 2 Oxygen will not ensure perfusion to cerebral tissues. 3 The patient with CAD is pron eN tU oR exSper INienc G TinBg .inCcrOeaMsed myocardial oxygen consumption. Administering oxygen will help supplement the body’s need for oxygen. 4 Oxygen is not used to facilitate the metabolism of medications. PTS: 1 CON: Perfusion 17. ANS: 2 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with cardiac disease Chapter page reference: 578 Heading: Infective Endocarditis > Nursing Management > Actions Integrated Processes: Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive level: Analysis [Analyzing] Concept: Perfusion; Infection; Addiction Difficulty: Moderate
1 2 3 4
Feedback A social services consult would not be needed if the patient lives with parents. If drug use caused the disease, a referral to addiction counseling services would be indicated. A social services consult would not be needed because the patient is taking a leave of absence from work. A social services consult would not be needed because the patient is still enrolled in college.
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PTS: 1 CON: Perfusion | Infection | Addiction 18. ANS: 1 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with cardiac disease Chapter page reference: 580 Heading: Pericarditis > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Basic Care and Comfort Cognitive level: Application [Applying] Concept: Perfusion; Comfort Difficulty: Moderate
1
2 3 4
Feedback The nurse should keep the head of the bed elevated. Pericardial effusion exerts pressure on surrounding organs, resulting in orthopnea and dyspnea. Raising the head of bed relieves shortness of breath. Pain is also relieved by sitting in the upright position. The patient should be on bedrest. The left side-lying position will not relieve shortness of breath or pain. Deep breathing and coughing will not relieve shortness of breath or pain.
PTS: 1 CON: Perfusion | Comfort 19. ANS: 1 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with cardiac disease NURSINGTB.CO Chapter page reference: 588 Heading: Heart Failure > Nursing Management > Assessments Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
1 2 3 4
Feedback Dyspnea on exertion indicates deceased cardiac output and worsening heart failure. A dry persistent cough is a side effect of angiotensin-converting enzyme inhibitors. Weak peripheral pulses are a consequence of inadequate cardiac output. Increased urine output would be an indication of the effectiveness of diuretic therapy.
PTS: 1 CON: Perfusion 20. ANS: 3 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with cardiac disease Chapter page reference: 576 Heading: Coronary Artery Disease > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing]
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Concept: Perfusion Difficulty: Moderate Feedback 1 Patients with coronary artery disease should engage in smoking cessation activities. 2 Patients with coronary artery disease should reduce the intake of saturated fat. 3 A nitroglycerin administration regimen includes not exceeding three doses five minutes apart. 4 Patients with coronary artery disease should engage in regular exercise for 30 minutes five days a week. PTS: 1 CON: Perfusion 21. ANS: 3 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with cardiac disease Chapter page reference: 578 Heading: Infective Endocarditis > Teaching Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Analysis [Analyzing] Concept: Perfusion; Infection; Promoting Health Difficulty: Moderate Feedback 1 Drinking skim milk would be appropriate for the patient with coronary artery disease. 2 Measurin g radial pulse would NbeUaRp pr SIopNriGatTe Bfo.r thCeO pMatient with heart failure taking medication that affects the pulse rate. 3 For the patient with infective endocarditis food oral hygiene utilizing a soft toothbrush is essential. Bleeding gums provide a portal of entry for bacteria into the bloodstream. Poor dental hygiene exacerbates the problem. 4 Taking an anticoagulant every day would be appropriate for the patient with a mechanical heart valve. PTS: 1 CON: Perfusion | Infection | Promoting Health 22. ANS: 1 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with cardiac disease Chapter page reference: 580 Heading: Pericarditis > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Perfusion; Inflammation Difficulty: Moderate Feedback 1 The nurse should instruct the patient to not abruptly stop taking steroids even if feeling better. Properly tapering steroid dosages avoids acute adrenal insufficiency. 2 It is beyond the nurse’s scope of practice to instruct the patient to change the dose of the medication.
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It is beyond the nurse’s scope of practice to change the frequency of medications. It is beyond the nurse’s scope of practice to change the frequency of medications.
PTS: 1
CON: Perfusion | Inflammation
MULTIPLE RESPONSE 23. ANS: 1, 3, 4, 5 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Describing the epidemiology of cardiac disorders Chapter page reference: 569 Heading: Coronary Artery Disease > Epidemiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Perfusion; Promoting Health Difficulty: Moderate
1. 2. 3.
4. 5.
Feedback The new concept “cardiovascular health” is geared to encouraging people to maintain seven metrics in order to achieve optimal cardiovascular health. These metrics include having a healthy diet. Alcohol intake is not one of the seven metrics to achieve optimum cardiovascular health. The new concept “cardiovascular health” is geared to encouraging people to maintain seven metrics in ord er to achiN evUe RopStI i mNa G l cTarB d i. ovCaO scM u lar health. These metrics include engagin g in sufficient physical activity. The new concept “cardiovascular health” is geared to encouraging people to maintain seven metrics in order to achieve optimal cardiovascular health. These metrics include not smoking. The new concept “cardiovascular health” is geared to encouraging people to maintain seven metrics in order to achieve optimal cardiovascular health. These metrics include lower blood pressure.
PTS: 1 CON: Perfusion | Promoting Health 24. ANS: 1, 2, 4, 5 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Describing the epidemiology of cardiac disorders Chapter page reference: 584 Heading: Heart Failure > Epidemiology Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
1. 2. 3.
Feedback A risk factor for heart failure is obesity. Smoking is a risk factor for the development of heart failure. Employment is not identified as a risk factor for heart failure.
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4. 5.
Hypertension is a risk factor for the development of heart failure. Diabetes is a risk factor for the development of heart failure.
PTS: 1 CON: Perfusion 25. ANS: 1, 2, 3, 5 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Heart failure Chapter page reference: 585 Heading: Heart Failure > Pathophysiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback There is growing evidence that diastolic dysfunction is becoming more common among patients diagnosed with HF. Diastolic dysfunction is associated with patients who tend to be older and obese. Diastolic dysfunction is seen in patients with diabetes mellitus and atrial fibrillation. Infective endocarditis is exacerbated with invasive procedures and dental examinations. Diastolic dysfunction typically has a normal EF also known as HF with preserve EF (HFpEF). This is due to the fact that there is less blood in the ventricle to eject because of the impaired filling. NURSINGTB.COM
PTS: 1 CON: Perfusion 26. ANS: 1, 3, 4, 5 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of cardiac
disorders Chapter page reference: 577 Heading: Infective Endocarditis > Laboratory and Diagnostic Tests Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Perfusion; Infection Difficulty: Moderate
1. 2. 3. 4. 5. PTS: 1 27. ANS: 3, 5
Feedback Tests used to confirm infective endocarditis include blood cultures. Ejection fraction is used to diagnose the type and extent of heart failure. Tests used to confirm infective endocarditis include an electrocardiogram. Tests used to confirm infective endocarditis include a TTE. Tests used to confirm infective endocarditis include a TEE. CON: Perfusion | Infection
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Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of cardiac
disorders Chapter page reference: 571, 582 Heading: Coronary Artery Disease > Radiographical Diagnostic Tests Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback An exercise stress test is not used to diagnose pericarditis. An exercise stress test is not used to diagnose heart failure. Diagnostic tests used to diagnose valvular disease include stress testing to identify functional capacity. An exercise stress test is not used to diagnose infective endocarditis. A patient with suspected coronary artery disease may undergo an exercise stress test. This is done to assess the function of the heart during exercise.
PTS: 1 CON: Perfusion 28. ANS: 1, 2, 3, 4 Chapter number and title: 30, Coordinating Care for Patients With Cardiac Disorders Chapter learning objective: Discussing the medical management of: Pericarditis Chapter page reference: 580 NURSINGTB.COM Heading: Pericarditis > Complications Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
1. 2. 3. 4. 5. PTS: 1
Feedback If the fluid causing a pericardial effusion is not addressed, it can increase and cause cardiac tamponade, which is manifested by hypotension, If the fluid causing a pericardial effusion is not addressed, it can increase and cause cardiac tamponade. Pulsus paradoxus may occur. If the fluid causing a pericardial effusion is not addressed, it can increase and cause cardiac tamponade, which is manifested by muffled heart sounds. If the fluid causing a pericardial effusion is not addressed, it can increase and cause cardiac tamponade, which is manifested by jugular vein distention. Lower extremity edema is a manifestation of right heart failure. CON: Perfusion
Chapter 31: Coordinating Care for Patients With Vascular Disorders
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Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A patient with atherosclerosis asks why smoking cessation is important. What should the nurse respond to this patient? 1) “Tobacco causes atherosclerosis.” 2) “Tobacco reduces the effects of cholesterol in the body.” 3) “Tobacco causes the blood pressure to drop and changes the cells within the arteries.” 4) “Tobacco smoke speeds the growth of atherosclerosis in coronary arteries, aorta, and the legs.” 2. A patient is diagnosed with carotid artery disease. For which potential health problem should the nurse prepare teaching for this patient? 1) Stroke 2) Diabetes 3) Hypertension 4) Dyslipidemia 3. A patient learns of having a 1 cm abdominal aortic aneurysm. What should the nurse emphasize when discussing the health problem with this patient? 1) Stop smoking 2) Increase physical activity 3) Engage in stress management 4) Reduce the intake of saturated fat 4. The nurse suspects that a patient has atherosclerosis. What finding did the nurse use to make this clinical determination? NURSINGTB.COM 1) Dizziness 2) Headaches 3) Nosebleeds 4) Pain when walking 5. A patient with hypertension has a low serum potassium level. Which mechanism should the nurse consider as being the cause for the elevated blood pressure? 1) Aldosterone 2) Increased sodium intake 3) Sympathetic nervous system 4) Renin-angiotensin-aldosterone system (RAAS) 6. A patient experiencing pain and burning in the legs at rest. Which stage of peripheral arterial disease should the nurse suspect this patient is experiencing? 1) Stage I 2) Stage II 3) Stage III 4) Stage IV 7. An older patient seeks emergency care for a sudden onset of severe abdominal pain. Which health problem should the nurse suspect be occurring in this patient? 1) Rupture of the appendix 2) Small bowel obstruction 3) Passing of a kidney stone 4) Rupture of an abdominal aneurysm
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8. During a physical assessment the nurse suspects that a client is experiencing a femoral thrombosis. What finding did the nurse use to make this clinical determination? 1) Calf pain 2) Dilated superficial veins 3) Thigh swelling to the knee 4) Entire leg swollen and painful 9. A patient’s blood pressure is 158/90 mm Hg; however, previous measurements have been within normal limits. Which intervention would be appropriate for this patient? 1) Investigate for additional health problems 2) Prepare teaching on antihypertensive medications 3) Schedule an additional measurement in a few weeks 4) Instruct on the effects of hypertension on major body organs 10. The nurse auscultates a bruit over a patient’s carotid artery. Which noninvasive diagnostic test should the nurse expect to be prescribed for this patient? 1) Carotid angiography 2) Carotid duplex ultrasound 3) Magnetic resonance angiography 4) Computed tomography angiography 11. A patient is suspected of having an abdominal aortic aneurysm. For which gold standard diagnostic test should the nurse prepare teaching for this client? 1) Cardiac MRI 2) Abdominal ultrasound 3) CT scan with IV contrast NURSINGTB.COM 4) Transthoracic echocardiography (TTE) 12. A patient is being evaluated for medication therapy to treat atherosclerosis. For which health problem would a statin be contraindicated? 1) Diverticulitis 2) Celiac disease 3) Liver cirrhosis 4) Type 2 diabetes mellitus 13. A patient with peripheral arterial disease is instructed on the medication pentoxifylline (Trental). Which patient statement indicates that teaching has been effective? 1) “This pill will cure my arterial disease.” 2) “This medication will begin to work in a week or two.” 3) “I should take this medication every day with a baby aspirin.” 4) “I might not feel the effect of this medication for up to two months.” 14. A patient recovering from a carotid endarterectomy (CEA) has a blood pressure of 90/48 mm Hg. What should the nurse do first? 1) Raise the head of the bed 2) Lower the head of the bed 3) Assess cranial nerve function 4) Maintain head in neutral position 15. A patient is diagnosed with an abdominal aneurysm measuring 5 cm. Which teaching material should the nurse prepare for this patient?
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1) 2) 3) 4)
Dietary changes Preoperative and postoperative care Actions to reduce high blood pressure Activities to prevent aneurysm rupture
16. The nurse is planning care for a patient with peripheral arterial disease. Which nursing diagnosis would be appropriate for this patient? 1) Anxiety 2) Chronic pain 3) Risk for injury 4) Risk for decreased cardiac output 17. A client with type 2 diabetes mellitus is newly diagnosed with carotid artery disease. What should the nurse emphasize when discussing blood glucose control with this patient? 1) “Maintain blood glucose levels within normal limits.” 2) “The issue with the carotid arteries is a priority at this time.” 3) “Blood glucose control will be difficult because of the additional medications for the carotid arteries.” 4) “Once you have the carotid artery surgery you won’t need to keep blood glucose levels within normal limits.” 18. A patient is diagnosed with a 7 cm abdominal aortic aneurysm. What should the nurse include in this patient’s plan of care? 1) Keep the bed flat 2) Elevate the lower extremities 3) Raise the head of the bed 30 degrees 4) Assist to sit out of bed in a chairNtU wR i ceSaIdNayG TB.COM 19. The nurse is preparing teaching material to help a patient with atherosclerosis manage lifestyle changes. What should the nurse emphasize in this teaching? 1) Limit cigarette smoking 2) Follow a low-fat, low-cholesterol diet 3) Consider adopting an active lifestyle 4) Take medications when symptoms occur 20. The nurse is evaluating teaching provided to a patient with hypertension. Which observation indicates that additional instruction would be required? 1) Asks that no one smoke in the house 2) Takes a 15-minute walk three times a day 3) Enjoys four ounces of red wine with dinner 4) Adds salt when cooking eggs in a frying pan 21. The nurse is visiting the home of a patient with peripheral arterial disease. For which observation should the nurse immediately intervene? 1) Sits with both feet on the floor 2) Walks around the house barefoot 3) Uses a mirror to examine the bottom of the feet 4) Eats grilled chicken on whole wheat bread for lunch 22. The nurse is identifying actions to reduce a patient’s risk for developing another deep vein thrombosis (DVT). What should the nurse include? 1) Restrict fluids
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2) Wear tight leggings 3) Perform exercises every day 4) Increase the amount of time standing in place Multiple Response Identify one or more choices that best complete the statement or answer the question. 23. The nurse is preparing material about peripheral artery disease (PAD) for a community fair. What should the nurse include about modifiable risk factors for the disease? Select all that apply. 1) Diabetes 2) Smoking 3) Hypertension 4) Family history 5) Sedentary lifestyle 24. The nurse is preparing a tool to instruct patients on the manifestations of carotid artery disease. What should the nurse include with this information? Select all that apply. 1) Dizziness 2) Difficulty talking 3) Sudden vision changes 4) Sudden onset of nausea and vomiting 5) Sudden weakness on one side of the body 25. A patient with a blood pressure over 160/90 mm Hg for two office visits is being started on antihypertensive medication for the first time. For which medication classifications should the nurse prepare teaching? Select all that apply. NURSINGTB.COM 1) Diuretics 2) Vasodilators 3) ACE Inhibitors 4) Calcium channel blockers 5) Angiotensin II receptor blockers (ARBs) 26. A patient with a deep vein thrombosis (DVT) is disappointed to learn that tissue plasminogen activator (tPA) is not an option. What information was used to make this treatment decision? Select all that apply. 1) History of osteoarthritis 2) Being treated for hemophilia 3) Previous surgery for spinal stenosis 4) Symptoms of a DVT present for a week 5) Diagnosis of DVT made upon symptoms 27. A patient who comes to the community clinic for a wellness visit has a blood pressure of 164/92 mm Hg. What additional information should the nurse assess from this patient? Select all that apply. 1) Heart rate 2) Bowel sounds 3) Lower extremities 4) Neurological system 5) BMI and waist circumference Numeric Response
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28. A patient’s ankle systolic blood pressure is 148 mm Hg and brachial systolic pressure is 118 mm Hg. What is this patient’s ankle-brachial index? Record your answer as a whole number.
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Chapter 31: Coordinating Care for Patients With Vascular Disorders Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Describing the epidemiology of vascular disorders Chapter page reference: 592 Heading: Atherosclerosis/Arteriosclerosis > Epidemiology Integrated Processes: Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Perfusion; Promoting Health Difficulty: Moderate Feedback 1 Cigarette smoke does not directly cause atherosclerosis. 2 Tobacco increases circulating cholesterol. 3 Cigarette smoke causes hypertension and changes endothelial cells. 4 Tobacco smoke greatly worsens atherosclerosis and speeds its growth in the coronary arteries, aorta, and arteries in the legs. PTS: 1
CON: Perfusion | Promoting Health
2. ANS: 1 NURSINGTB.COM Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Describing the epidemiology of vascular disorders Chapter page reference: 607 Heading: Carotid Artery Disease > Epidemiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Perfusion; Promoting Health Difficulty: Moderate Feedback 1 The major complication of coronary artery disease is stroke. 2 Diabetes is a risk factor for the development of coronary artery disease. 3 Hypertension is a risk factor for the development of coronary artery disease. 4 Dyslipidemia is a risk factor for the development of coronary artery disease. PTS: 1 CON: Perfusion | Promoting Health 3. ANS: 1 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Describing the epidemiology of vascular disorders Chapter page reference: 612 Heading: Aortic Artery Disease (Aneurysms) > Epidemiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential
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Cognitive level: Application [Applying] Concept: Perfusion; Promoting Health Difficulty: Moderate
1 2 3 4
Feedback Smoking is the only risk factor that, when modified, can slow the growth of an aneurysm. Increasing physical activity is not identified as reducing the risk of abdominal aortic aneurysm development. Stress management is not identified as reducing the risk of abdominal aortic aneurysm development. Reducing the intake of saturated fat will help prevent the development of atherosclerosis; however, this will not alter an abdominal aortic aneurysm which has already developed.
PTS: 1 CON: Perfusion | Promoting Health 4. ANS: 4 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Atherosclerosis/Arteriosclerosis Chapter page reference: 593 Heading: Atherosclerosis/Arteriosclerosis > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] NURSINGTB.COM Concept: Perfusion Difficulty: Moderate Feedback 1 Dizziness is a manifestation of hypertension. 2 Headaches are associated with hypertension. 3 Nosebleeds are associated with hypertension. 4 There may be no symptoms of atherosclerosis until there is a critical narrowing of the artery that results in an emergency. If blood supply to the legs is reduced, it can cause significant pain and difficulty walking. PTS: 1 CON: Perfusion 5. ANS: 1 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Hypertension Chapter page reference: 597 Heading: Hypertension > Pathophysiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Feedback
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1 2 3
4
Excess aldosterone release results in sodium and water retention, which results in increased stroke volume and blood pressure. Increased sodium causes fluid retention, increasing stroke volume and blood pressure. Increased sympathetic activity is a primary precursor to hypertension. It can cause vasoconstriction, resulting in increased peripheral vascular resistance and increased blood pressure. It may also increase heart rate. Excess angiotensin II results in vasoconstriction and increased blood pressure. Excess angiotensin also results in increased aldosterone release.
PTS: 1 CON: Perfusion 6. ANS: 3 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Peripheral arterial disease Chapter page reference: 602 Heading: Peripheral Arterial Disease > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
1 2 3 4
Feedback In stage I the patient has no symptoms of the disease. In stage II the patient has painNwUitR h S wal Iki N nGgToBr cl.au COdiMcation. In stage III the patient has burning pain in the extremities at rest. In stage IV the patient experiences ulcers and blackened tissue on the toes, the forefoot, or the heel of the foot.
PTS: 1 CON: Perfusion 7. ANS: 4 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Aortic artery disease Chapter page reference: 613 Heading: Aortic Artery Disease (Aneurysms) > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
1 2 3
Feedback It is unlikely that the older patient is experiencing a ruptured appendix. Sudden severe abdominal pain is not necessarily associated with a small bowel obstruction. Groin and flank pain are manifestations of a kidney stone.
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4
Pain can occur depending on the location of the aneurysm. The pain is typically not related to any activity and occurs spontaneously. Pain reflects a change in the aneurysm that needs immediate attention.
PTS: 1 CON: Perfusion 8. ANS: 3 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Deep vein thrombosis Chapter page reference: 619 Heading: Deep Vein Thrombosis > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Feedback 1 Calf tenderness is associated with a thrombosis of the calf. 2 Dilated superficial veins are associated with an upper extremity thrombosis. 3 In a femoral thrombosis, swelling may extend to the knee. 4 Massive swelling of the entire extremity and pain is associated with an iliofemoral thrombosis. PTS: 1 CON: Perfusion ANS: 3 9. NURSINGTB.COM Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of vascular disorders Chapter page reference: 597 Heading: Hypertension > Diagnosis Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 For the vast majority of people hypertension has no single cause. 2 Preparing teaching material on antihypertensive medications would be premature. 3 The diagnosis of hypertension is made on the basis of the average of two or more properly measured BP readings on two or more office visits. 4 The diagnosis of hypertension has not been made. This teaching would be premature. PTS: 1 CON: Perfusion 10. ANS: 2 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of vascular disorders Chapter page reference: 608 Heading: Carotid Artery Disease > Diagnosis
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Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 Carotid angiography is the only invasive test currently used to diagnosis the severity of CAD. 2 Duplex ultrasound is the most commonly used screening tool to evaluate for atherosclerotic plaque and stenosis of the external carotid artery. 3 Magnetic resonance angiography is less frequently used to diagnose the severity of CAD. 4 Computed tomography angiography is less frequently used to diagnose the severity of CAD. PTS: 1 CON: Perfusion 11. ANS: 3 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of vascular disorders Chapter page reference: 614 Heading: Aortic Artery Disease (Aneurysms) > Diagnosis Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] NURSINGTB.COM Concept: Perfusion Difficulty: Moderate 1 2 3 4
Feedback Cardiac MRI has shown improved sensitivity and specificity in detecting aortic dilation; however, it is not the gold standard. Abdominal ultrasound is a screening modality; however, it is not the gold standard. Computed tomography scanning with IV contrast is considered the gold standard for assessing the size and location of an abdominal aneurysm. Transthoracic echocardiography (TTE) is a screening modality; however, it is not the gold standard.
PTS: 1 CON: Perfusion 12. ANS: 3 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Discussing the medical management of: Atherosclerosis/Arteriosclerosis Chapter page reference: 594 Heading: Atherosclerosis/Arteriosclerosis > Medical Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Perfusion; Medication Difficulty: Moderate Feedback
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4
A statin would not be contraindicated for diverticulitis. A statin would not be contraindicated for celiac disease. Statins reduce cholesterol synthesis in the liver and increase clearance of LDL-C from the blood. This group of medications is contraindicated in patients with active liver disease. A statin would not be contraindicated for type 2 diabetes mellitus.
PTS: 1 CON: Perfusion | Medication 13. ANS: 4 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Discussing the medical management of: Peripheral arterial disease Chapter page reference: 603 Heading: Peripheral Arterial Disease > Medical Management > Medications Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Perfusion; Medication Difficulty: Moderate
1 2 3 4
Feedback Pentoxifylline controls the symptoms of circulation problems but does not cure them. Although patients may feel the effects of this medication in two to four weeks, they may need to take it for up to eight weeks before they feel the full effect. Aspirin is typically prescribed with clopidogrel (Plavix). Although patients may feel theNeUffRecStsIoNf th GisTBm.edCicOaMtion in two to four weeks, they may need to take it for up to eight weeks before they feel the full effect.
PTS: 1 CON: Perfusion | Medication 14. ANS: 2 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Discussing the medical management of: Carotid artery disease Chapter page reference: 610 Heading: Carotid Artery Disease > Surgical Management > Carotid Endarterectomy Integrated Processes: Nursing Process; Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion; Perioperative Difficulty: Moderate
1 2
3
Feedback Raising the head of the bed would be appropriate if the patient’s blood pressure was elevated. Following a CEA, a new “normal” pressure may be sensed as a high pressure signaling the vagus nerve to respond, resulting in vasodilation, bradycardia, and hypotension. The head of the bed should be lowered and the patient placed in a flat position to ensure cerebral perfusion. Assessing cranial nerve function is appropriate if the patient were demonstrating signs of deficits.
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4
Maintaining the head in the neutral position would be appropriate if the patient’s blood pressure is elevated,
PTS: 1 CON: Perfusion | Perioperative 15. ANS: 2 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Discussing the medical management of: Aortic artery disease (aneurysms) Chapter page reference: 615 Heading: Aortic Artery Disease (Aneurysms) > Surgical Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion; Perioperative Difficulty: Moderate
1 2 3 4
Feedback Dietary changes will not affect the stability of an abdominal aortic aneurysm. Surgical intervention is shown to be the only treatment effective in preventing AAA rupture and aneurysm-related death. Patients with an aneurysm may be started on medication to ensure blood pressure control; however, this is not the most effective treatment. There are no specific activities to prevent aneurysm repair other than having surgery.
PTS: 1 CON: Perfusion | Perioperative 16. ANS: 2 NURSINGTB.COM Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with vascular disorders Chapter page reference: 606 Heading: Peripheral Arterial Disease > Nursing Management > Nursing Diagnoses Integrated Processes: Nursing Process Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 The nursing diagnosis “anxiety” is appropriate for the client with carotid artery disease. 2 The nursing diagnosis “chronic pain” is appropriate for the client with peripheral arterial disease because it is related to decreased peripheral perfusion evidenced by the inability to walk for prolonged periods of time or having pain at rest. 3 The nursing diagnosis “risk for injury” is appropriate for the client with carotid artery disease. 4 The nursing diagnosis “risk for decreased cardiac output” is appropriate for the client with hypertension. PTS: 1 CON: Perfusion 17. ANS: 1 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders
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Chapter learning objective: Developing a comprehensive plan of nursing care for patients with vascular disorders Chapter page reference: 611 Heading: Carotid Artery Disease > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate 1
2 3 4
Feedback Blood glucose levels should be maintained within normal limits. Poorly controlled diabetes mellitus results in increased plaque formation in the vessels due to the breakdown of fats from injury, increasing the risk for ischemic stroke. Both type 2 diabetes mellitus and carotid artery disease are important health issues that need to be addressed and managed. Medications for carotid artery disease do not adversely affect blood glucose levels. A person with type 2 diabetes mellitus should attempt to keep glucose levels within normal limits regardless of any other health problem or disease process.
PTS: 1 CON: Perfusion 18. ANS: 1 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with vascular disorders NURSINGTB.COM Chapter page reference: 617 Heading: Aortic Artery Disease (Aneurysms) > Nursing Management > Actions Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate
1
2 3 4
Feedback The patient with an abdominal aortic aneurysm should be on bedrest with the legs flat. The patient should be instructed to avoid elevating or crossing the legs because it restricts peripheral blood flow and increases pressure in the aorta or iliac arteries. The lower extremities should not be elevated because it increases pressure in the aorta or iliac arteries. The head of the bed would increase pressure in the aorta or iliac arteries. The patient should be on bedrest to prevent increasing pressure in the aorta or iliac arteries.
PTS: 1 CON: Perfusion 19. ANS: 2 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Designing a teaching plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with vascular disorders Chapter page reference: 595
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Heading: Atherosclerosis/Arteriosclerosis > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion; Promoting Health Difficulty: Moderate
1
2 3 4
Feedback The patient should be encouraged to stop smoking because the nicotine and carbon monoxide in cigarette smoke damage the endothelium, which sets the stage for the buildup of plaque. A low-fat, low-cholesterol diet helps manage risk factors and slows the progression of atherosclerosis. The person with atherosclerosis should be encouraged to increase activity and not just consider adding activity. Medications should be taken as prescribed.
PTS: 1 CON: Perfusion | Promoting Health 20. ANS: 4 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Designing a teaching plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with vascular disorders Chapter page reference: 601 Heading: Hypertension > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/N ReUdR ucStiI onNoGf T RB isk.PCoO teM ntial Cognitive Level: Analysis [Analyzing] Concept: Perfusion; Promoting Health Difficulty: Moderate Feedback 1 Smoking should be avoided because of damage to the blood vessels. 2 Increasing activity assists with blood pressure control. 3 Alcohol should be ingested in moderation. 4 Adding salt to foods when cooking should be avoided. PTS: 1 CON: Perfusion | Promoting Health 21. ANS: 2 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Designing a teaching plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with vascular disorders Chapter page reference: 606 Heading: Peripheral Arterial Disease > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Perfusion; Promoting Health Difficulty: Moderate Feedback
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The patient should not cross the legs at the knees or the ankles when sitting. The patient is prone to injury and should not be walking without footwear. The nurse should immediately intervene. The bottom of the feet should be examined every day. The patient should eat a heart-healthy diet that restricts additional sodium.
PTS: 1 CON: Perfusion | Promoting Health 22. ANS: 3 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Designing a teaching plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with vascular disorders Chapter page reference: 622 Heading: Deep Vein Thrombosis > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion; Promoting Health Difficulty: Moderate 1 2 3 4
Feedback Fluids should not be restricted. Dehydration can cause the blood to thicken and encourage the development of deep vein thrombosis. Tight or restrictive clothing should be avoided. Leg exercises should be performed daily or as frequently as prescribed. Standing in place should be lim NiUteRd Ssinc INe GthTisBcan . Cinc O Mrease the develop ment of deep vein thrombosis.
PTS: 1
CON: Perfusion | Promoting Health
MULTIPLE RESPONSE 23. ANS: 1, 2, 3, 5 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Describing the epidemiology of vascular disorders Chapter page reference: 601 Heading: Peripheral Arterial Disease > Epidemiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Perfusion; Promoting Health Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Diabetes is a modifiable risk factor for PAD. Smoking is a modifiable risk factor for PAD. Hypertension is a modifiable risk factor for PAD. Family history is a nonmodifiable risk factor for PAD. Sedentary lifestyle is a modifiable risk factor for PAD.
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PTS: 1 CON: Perfusion | Promoting Health 24. ANS: 1, 2, 3, 5 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Carotid artery disease Chapter page reference: 607-608 Heading: Carotid Artery Disease > Clinical Manifestations Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion; Promoting Health Difficulty: Moderate
1.
2.
3. 4. 5.
Feedback Carotid artery disease is asymptomatic until the lumen of the vessel is obstructed to the point that cerebral perfusion is impaired. The clinical manifestations of complications resulting from impaired cerebral perfusion include dizziness. Carotid artery disease is asymptomatic until the lumen of the vessel is obstructed to the point that cerebral perfusion is impaired. The clinical manifestations of complications resulting from impaired cerebral perfusion include difficulty talking. Carotid artery disease is asymptomatic until the lumen of the vessel is obstructed to the point that cerebral perfusion is impaired. The clinical manifestations of complications resulting from impaired cerebral perfusion include sudden vision problems. Sudden onset of nausea and vomiting are not associated with carotid artery disease. NaGtiTc B Carotid artery disease isNa U syR mS p tI om un.tiC l tO heMlu men of the vessel is obstructed to the point that cerebral perfusion is impaired. The clinical manifestations of complications resulting from impaired cerebral perfusion include sudden weakness sometimes noted more on one side than the other.
PTS: 1 CON: Perfusion | Promoting Health 25. ANS: 1, 2, 3, 4 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Discussing the medical management of: Hypertension Chapter page reference: 599 Heading: Hypertension > Medical Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Perfusion; Medication Difficulty: Easy
1. 2. 3. 4.
Feedback Diuretics are often the first but not the only choice in high blood pressure medications. Vasodilators relax the muscle tissue in the blood vessel walls and, in turn, lower the blood pressure. ACE Inhibitors help relax/dilate blood vessels by blocking the formation of angiotensin II, a vasoconstrictor, to reduce blood pressure. Calcium channel blockers help relax/dilate the muscles of the blood vessels.
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5.
ARBs are sometimes used in patients intolerant of ACE inhibitors. If this patient is being prescribed medication for the first time, it is unlikely that an ARB will be prescribed.
PTS: 1 CON: Perfusion | Medication 26. ANS: 2, 4, 5 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Discussing the medical management of: Deep Vein Thrombosis Chapter page reference: 620 Heading: Deep vein thrombosis > Medical Management > Medications Integrated Processes: Nursing Process Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Perfusion; Medication Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback A history of osteoarthritis is not a contraindication for tPA to treat DVT. Being treated for an existing bleeding disorder such as hemophilia increases the risk of bleeding and contraindicates the use of tPA to treat the DVT. Previous spinal surgeries are not a contraindication for tPA to treat DVT. The symptoms of a DVT must be present for less than 3 days to be considered for tPA treatment. A definite diagnosis of DVT must be made by a venography before tPA treatment will be considered.
NURSINGTB.COM PTS: 1 CON: Perfusion | Medication 27. ANS: 1, 3, 4, 5 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with vascular disorders Chapter page reference: 601 Heading: Hypertension > Nursing Management > Assessment Integrated Processes: Nursing Process; Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion; Assessment Difficulty: Moderate
1.
2. 3. 4. 5.
Feedback Heart rate should be assessed because increased peripheral vascular resistance can lead to increased heart rate or increased stroke volume to compensate for the increased peripheral vascular resistance. Abdominal arteries should be assessed for bruits; however, auscultating bowel sounds is not essential. The lower extremities should be assessed for pulses and edema. The neurological system should be assessed for signs and symptoms that could indicate cerebrovascular disease and possible complications such as stroke and aneurysm. BMI and waist circumference should be assessed because obesity and diet are major risk factors in hypertension.
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PTS: 1
CON: Perfusion | Assessment
NUMERIC RESPONSE 28. ANS: 1.25 Chapter number and title: 31, Coordinating Care for Patients With Vascular Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of vascular disorders Chapter page reference: 602 Heading: Peripheral Arterial Disease > Diagnosis Integrated Processes: Nursing Process; Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion; Assessment Difficulty: Moderate Feedback: The ankle-brachial index (ABI) uses a Doppler probe to compare the BP obtained at the ankle with the pressure obtained at the brachial artery. The value can be derived by dividing the ankle BP by the brachial BP. For this patient, the value would be calculated by dividing 118 into or 148 or 148/118 = 1.25. PTS: 1
CON: Perfusion | Assessment
NU R S I N G T B . C O M
Cha pter 32: Coordinating Care for Criti ca l ly I ll P a ti en ts With Cardiovascular Dysfunction Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The health-care provider wants an SvO2 level on a patient with a pulmonary artery catheter. From where should this sample be taken? 1) Distal lumen 2) Balloon inflation lumen 3) Proximal injectable port 4) Proximal infusion port 2. The nurse is preparing to obtain a pulmonary artery wedge pressure (PAWP) on a patient. What action should be taken to ensure for the patient’s safety? 1) Inflate the balloon 1.5 mL 2) Place the patient in the Trendelenburg position 3) Monitor the waveform after inflating the balloon 4) Deflate the balloon within five minutes of obtaining the pressure 3. The nurse wants to evaluate a patient’s right heart preload. Which approach should be used to obtain this measurement? 1) Zero the arterial line 2) Measure the central venous pressure 3) Measure the pulmonary artery wedge pressure
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4) Attach the proximal infusion port to an intravenous solution 4. The health-care provider wants to determine a patient’s cardiac contractility. What should be used to make this determination? 1) Cardiac output 2) Mean arterial pressure 3) Pulmonary artery measurement 4) Central venous pressure measurement 5. The nurse is reviewing the manifestations of an acute myocardial infarction with a patient diagnosed with type 2 diabetes mellitus. What should the nurse emphasize as being an atypical manifestation of this cardiac disorder? 1) Fatigue 2) Dyspnea 3) Tachycardia 4) Hypertension 6. The nurse suspects that a patient with cardiomyopathy is experiencing heart failure. What finding did the nurse use to make this clinical decision? 1) Dizziness 2) Chest pain 3) Palpitations 4) SOB when supine 7. A patient with dilated cardiomyopathy has developed a productive cough. What additional manifestation supports fluid overload in this patient? 1) Fainting NURSINGTB.COM 2) Sleeplessness 3) Loss of appetite 4) Jugular vein distention 8. A patient in the intensive care unit is experiencing chest pain. What assessment finding indicates that cardiogenic shock is being compensated? 1) Hypotension 2) Increased heart rate 3) Absent urine output 4) Mottled and cyanotic skin 9. The nurse suspects that a patient in cardiogenic shock is experiencing oxygen deprivation. What would confirm the nurse’s suspicion? 1) Sudden drop in serum lactate level 2) Slowly increasing serum calcium level 3) Acute reduction in hemoglobin and hematocrit 4) Metabolic acidosis upon arterial blood gas analysis 10. A patient is being evaluated for chest pain in the emergency department. Which laboratory test is the best to determine if this patient has experienced an acute myocardial infarction? 1) Troponin 2) Prothrombin time 3) Creatine kinase-MB 4) Complete blood count
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11. The nurse is reviewing medications prescribed for a patient with hypertrophic cardiomyopathy. Which medication should the nurse question before administering? 1) ACE-I 2) Diuretic 3) Digoxin 4) Beta blocker 12. The nurse is caring for a patient experiencing cardiogenic shock. Which medication should the nurse expect to be prescribed to improve this patient’s cardiac output? 1) Nitroglycerin 2) Morphine sulfate 3) Norepinephrine (Levophed) 4) Dobutamine hydrochloride (Dobutamine) 13. The nurse is caring for a patient experiencing an acute myocardial infarction. Which assessment finding indicates a decrease in this patient’s cardiac output? 1) Chest pain 2) Restlessness 3) Low urine output 4) ST segment elevation 14. The nurse is preparing medications for a patient experiencing an acute myocardial infarction. Which medication will dilate the patient’s coronary blood vessels? 1) Heparin 2) Fibrinolytics 3) Nitroglycerin 4) Beta blockers NURSINGTB.COM 15. The nurse hears crackles when auscultating the lung sounds of a patient with cardiomyopathy. What should this finding indicate to the nurse? 1) Atelectasis 2) Pneumothorax 3) Stasis pneumonia 4) Pulmonary edema 16. The nurse notes that a patient with cardiomyopathy has been prescribed an angiotensin-converting enzyme inhibitor. What is the purpose of this medication? 1) Reduce afterload 2) Improve heart muscle contractions 3) Reduce fluid accumulation in the lungs 4) Decrease sympathetic response to decreased cardiac output 17. A patient with cardiogenic shock has an intra-aortic balloon pump (IABP). What should the nurse include when caring for this patient? 1) Elevated the affected leg on a pillow 2) Elevate the head of the bed 45 degrees 3) Keep the affected leg straight at all times 4) Keep the bed flat with a small pillow under the head 18. A patient recovering from cardiogenic shock is observed walking to the patient lounge. What should the nurse recommend to this patient? 1) Call for help when wanting to walk
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2) Limit sitting out of bed to 30 minutes 3) Increase activity by 15 minutes every day 4) Important to obtain as much rest as possible 19. The nurse instructs a patient recovering from an acute myocardial infarction on the Life’s Simple 7 actions. Which patient statement indicates that additional teaching is required? 1) “I will not smoke.” 2) “I will eat a heart healthy-diet.” 3) “I will walk for at least 30 minutes three times a week.” 4) “I will make sure my blood sugar level stays under 100 mg/dL.” 20. During a home visit the nurse notes that a patient recovering from an acute myocardial infarction has not had medication prescriptions filled at the pharmacy. What should the nurse say in response to this observation? 1) “I don’t blame you. I don’t like to take medications every day either.” 2) “As long as you aren’t having any symptoms, delaying the medications is acceptable.” 3) “Most people don’t like to take medications but try to remember to get the prescriptions filled.” 4) “The medications will help treat the effects of your current health problem and prevent any future events.” 21. A patient with cardiomyopathy asks for salt when the breakfast tray arrives. What should the nurse respond to this request? 1) “I will get some for you.” 2) “You should avoid adding salt if at all possible.” 3) “Restricting salt helps prevent the development of other health problems.” 4) “I know the food tastes bad. I’ll see if there is some salt in the staff kitchen.”
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22. A patient with cardiomyopathy comes into the emergency department with chest pain and dyspnea after running a 5K race. What should the nurse explain to this patient? 1) Signs of overexertion 2) Importance to limit activity 3) Need for frequent rest periods 4) Alternatives to physical exercise Completion Complete each statement. 23. The nurse is preparing to measure a patient’s central venous pressure. In which order should the nurse perform the steps to ensure an accurate reading? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Zero the transducer 2) Ensure tubing is less than 120 cm long 3) Secure the transducer at the phlebostatic axis 4) Ensure transducer and tubing are free from blood and air Multiple Response Identify one or more choices that best complete the statement or answer the question.
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24. The nurse is assigned to a patient with a newly inserted central line. What actions should be taken to prevent the patient from developing an infection? Select all that apply. 1) Perform line care 2) Use aseptic technique 3) Minimize handling the line 4) Use normal saline to flush the line 5) Ensure an occlusive dressing is applied 25. The nurse suspects that a patient is experiencing a complication from a pulmonary artery catheter. What findings did the nurse use to make this clinical determination? Select all that apply. 1) Bleeding 2) Increased urine output 3) Elevated body temperature 4) Acute onset of shortness of breath 5) Development of a cardiac dysrhythmia 26. The nurse is preparing to determine a patient’s left heart afterload. What measurements are needed to make this calculation? Select all that apply. 1) Cardiac output 2) Mean arterial pressure 3) Central venous pressure 4) Pulmonary artery pressure 5) Pulmonary artery wedge pressure 27. A patient with atypical chest pain is prescribed a 12-lead electrocardiogram. What findings would support this patient experiencing an acute myocardial infarction? Select all that apply. 1) Q waves NURSINGTB.COM 2) Junctional rhythm 3) ST segment elevation 4) Prolonged PR interval 5) Premature ventricular contractions 28. A patient with cardiomyopathy is scheduled for a biventricular implantable cardioverter defibrillator. What should the nurse include when teaching the patient about this device? Select all that apply. 1) Part of the thickened overgrown septum is removed 2) A pacer wire is placed in the right and left ventricles 3) A small part of the thickened heart muscle is destroyed 4) The automatic defibrillator will deliver a shock if necessary 5) The automatic defibrillator monitors the heart for dysrhythmias
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Chapter 32: Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Describing the indications and nursing implications for hemodynamic monitoring in the critically ill patient Chapter page reference: 633 Heading: Hemodynamic Monitoring Systems > PA Catheter Monitoring > Oxygen Utilization Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 Oxygen utilization at the tissue level can be indirectly measured by evaluating an SvO2 level; a blood sample obtained via the distal port of the PA line. 2 The proximal infusion port is used for medications and fluid administration. 3 The balloon inflation lumen is used to inflate the balloon. 4 The proximal injection port is used for cold thermodilution fluid and for central venous pressure measurements. PTS: 1 CON: PerfusiN onURSINGTB.COM 2. ANS: 1 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Describing the indications and nursing implications for hemodynamic monitoring in the critically ill patient Chapter page reference: 633 Heading: Hemodynamic Monitoring Systems > PA Catheter Monitoring > Nursing Implications for the PA Catheter Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion; Safety Difficulty: Moderate Feedback 1 When a PAWP is obtained, the balloon must be inflated no more than 1.5 mL. 2 The patient needs to be placed in the Trendelenburg position when the line is inserted. 3 The waveform does not need to be monitored after inflating the balloon. 4 After the value is obtained, it is essential that the nurse ensure the balloon is immediately deflated. A PA catheter should never be inflated and in the wedge position for more than 10 to 15 seconds. PTS: 1 CON: Perfusion | Safety 3. ANS: 2 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction
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Chapter learning objective: Explaining the physiological relationship of hemodynamic parameters (preload, afterload, and contractility) to cardiac function Chapter page reference: 631 Heading: Hemodynamic Monitoring Systems > PA Catheter Monitoring > Cardiac Output Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 Zeroing the arterial line is not an approach to obtain measurements or pressure readings. 2 Measuring the central venous pressure is a reflection of right heart preload. 3 The pulmonary artery wedge pressure reflects left heart preload. 4 Attaching the proximal infusion port to an intravenous solution provides the patient with fluids. It is not done to evaluate pressures. PTS: 1 CON: Perfusion 4. ANS: 3 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Explaining the physiological relationship of hemodynamic parameters (preload, afterload, and contractility) to cardiac function Chapter page reference: 631 Heading: Hemodynamic Monitoring Systems > PA Catheter Monitoring > Cardiac Output Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity:NRU edRuS ctI ioN nG ofTRBis. kC PoOteMntial Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 Cardiac output is response of cardiac contractility. 2 Mean arterial pressure is not used to determine contractility. 3 Contractility is the inherent ability of the heart muscle to contract independently of preload and afterload. Contractility cannot be directly measured but can be inferred by evaluating stroke work indexes of the right and left ventricles. Stroke work indexes are measurements of work done by the heart with each contraction. They are calculated via measurements obtained through the PA catheter. 4 Central venous pressure measurement is not used to determine contractility. PTS: 1 CON: Perfusion 5. ANS: 1 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Correlating the clinical manifestations to the underlying pathophysiology of: Myocardial infarction Chapter page reference: 636 Heading: Myocardial Infarction > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying]
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Concept: Perfusion Difficulty: Moderate Feedback 1 Many patients with diabetes never get the typical symptoms but may present with fatigue. 2 Signs of a left ventricle infarct include dyspnea. 3 Signs of a left ventricle infarct include tachycardia. 4 Signs of a left ventricle infarct include hypertension. PTS: 1 CON: Perfusion 6. ANS: 4 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Correlating the clinical manifestations to the underlying pathophysiology of: Cardiomyopathy Chapter page reference: 641 Heading: Cardiomyopathy > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Feedback 1 Angina symptoms include chest pain. 2 Angina symptoms include dizziness. 3 Angina symptoms include palpi NUtatRioSn s.I NGTB.COM 4 Heart failure symptoms include shortness of breath while lying flat. PTS: 1 CON: Perfusion 7. ANS: 4 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Correlating the clinical manifestations to the underlying pathophysiology of: Cardiomyopathy Chapter page reference: 641 Heading: Cardiomyopathy > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Feedback 1 Other signs of cardiomyopathy include fainting. 2 Other signs of cardiomyopathy include sleeplessness. 3 Other signs of cardiomyopathy include loss of appetite. 4 Pulmonary congestion is evident due to fluid overload. The patient with fluid overload may present with elevated pressures in the neck (JVD). PTS: 1 8. ANS: 2
CON: Perfusion
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Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Correlating the clinical manifestations to the underlying pathophysiology of: Cardiogenic shock Chapter page reference: 645 Heading: Cardiogenic Shock > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate 1 2 3
4
Feedback Compensatory mechanisms eventually fail to maintain adequate CO, worsening inadequate organ perfusion. At this time, clinical manifestations include hypotension. Cardiogenic shock is frequently caused by MI. The initiation of compensatory mechanisms leads to increased heart rate. Compensatory mechanisms eventually fail to maintain adequate CO, worsening inadequate organ perfusion. At this time, clinical manifestations include absent urine output. Compensatory mechanisms eventually fail to maintain adequate CO, worsening inadequate organ perfusion. At this time, clinical manifestations include cold, cyanotic, and mottled skin.
PTS: 1 CON: Perfusion ANS: 4 9. NURSINGTB.COM Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Correlating the clinical manifestations to the underlying pathophysiology of: Cardiogenic shock Chapter page reference: 645 Heading: Cardiogenic Shock > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
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Feedback Serum lactate levels would increase in oxygen deprivation. Serum calcium level is not used to determine oxygenation. Reduction in hemoglobin and hematocrit would occur with bleeding. Oxygen deprivation leads to excessive production of lactic acid. Arterial blood gases reveal a metabolic acidosis.
PTS: 1 CON: Perfusion 10. ANS: 1 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Explaining the rationales for relevant medical interventions in the treatment of patients with myocardial infarction, cardiomyopathy, and cardiogenic shock Chapter page reference: 636
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Heading: Myocardial Infarction > Medical Management > Laboratory Testing Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Feedback 1 Elevated troponin levels are a specific marker of cardiac muscle damage and are defined as the blood test of choice to diagnose acute MI (AMI). 2 Prothrombin time would be used to help evaluate end-organ damage. 3 Creatine kinase-MB is the CK isoenzyme marker specific to cardiac tissue. When myocardial damage occurs, CK-MB is released from the cells. Increased levels can be seen at three hours and remain elevated for up to 36 hours before returning to normal. 4 Complete blood count would be used to help evaluate end-organ damage. PTS: 1 CON: Perfusion 11. ANS: 3 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Explaining the rationales for relevant medical interventions in the treatment of patients with myocardial infarction, cardiomyopathy, and cardiogenic shock Chapter page reference: 642 Heading: Cardiomyopathy > Medical Management > Medications Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] NURSINGTB.COM Concept: Perfusion; Medication Difficulty: Moderate
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Feedback Angiotensin-converting enzyme medications are given to improve the heart’s pumping capacity. They reduce afterload or SVR, making it easier for the heart to eject blood. Diuretics reduce fluid accumulation in the lungs that occurs because of the ineffective pumping action of the heart. Digoxin’s inotropic effects can worsen outflow obstruction in hypertrophic cardiomyopathy. Beta blockers decrease the sympathetic nervous system response to decreased CO decreasing workload and myocardial oxygen consumption. They have been shown to prevent progression of the disease and improve outcomes.
PTS: 1 CON: Perfusion | Medication 12. ANS: 4 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Explaining the rationales for relevant medical interventions in the treatment of patients with myocardial infarction, cardiomyopathy, and cardiogenic shock Chapter page reference: 645 Heading: Cardiomyopathy > Medical Management > Medications Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/ Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing]
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Concept: Perfusion; Medication Difficulty: Moderate Feedback 1 Nitroglycerin may be used to decrease preload and afterload. It decreases preload through venous dilation and decreases afterload through arterial dilation. 2 Morphine sulfate may be administered to relieve pain due to a myocardial infarction and decrease venous return and preload through its action as a venous dilator. 3 Norepinephrine (Levophed) supports blood pressure and helps maintain an adequate MAP. 4 Inotropic medications such as dobutamine hydrochloride (Dobutamine) improve CO. PTS: 1 CON: Perfusion | Medication 13. ANS: 3 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Analyzing the nursing management of patients with myocardial infarction, cardiomyopathy, and cardiogenic shock Chapter page reference: 640 Heading: Myocardial Infarction > Nursing Management > Assessments Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Feedback 1 Chest pain is an indication of M NUI. RCSonItiNnuGedT or B.cha COn gin M g pain characteristics can be indicative of a worsening condition. 2 Restlessness may be found in the early stages, but progression to severe anxiety and sense of doom is a late-stage symptom. 3 Decreased or absent urine output is a sign of decreased renal perfusion related to decreased CO. 4 ST-segment changes are indicative of ischemia or injury. PTS: 1 CON: Perfusion 14. ANS: 3 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Analyzing the nursing management of patients with myocardial infarction, cardiomyopathy, and cardiogenic shock Chapter page reference: 640 Heading: Myocardial Infarction > Nursing Management > Actions Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Perfusion; Medications Difficulty: Moderate Feedback 1 Heparin is given to prevent new clot formation. 2 Fibrinolytics work to dissolve clots. 3 Nitroglycerin dilates the coronary arteries.
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Beta blockers decrease the sympathetic response to an MI, decreasing cardiac workload and oxygen consumption.
PTS: 1 CON: Perfusion | Medications 15. ANS: 4 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Analyzing the nursing management of patients with myocardial infarction, cardiomyopathy, and cardiogenic shock Chapter page reference: 643 Heading: Cardiomyopathy > Nursing Management > Assessments Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate Feedback 1 Lung sounds would be distant or faint in the presence of atelectasis. 2 Lung sounds would be absent if a pneumothorax is present. 3 A variety of lung sounds would occur if stasis pneumonia has developed. 4 Auscultation of crackles is an indication of the development of pulmonary edema due to left heart failure. PTS: 1 CON: Perfusion 16. ANS: 1 Chapter number and title: 32, CoordiN n aUtiR n gSCIaN reGfoTrBC.riC t icOa M l ly Ill Patients With Cardiovascu lar Dysfunction Chapter learning objective: Analyzing the nursing management of patients with myocardial infarction, cardiomyopathy, and cardiogenic shock Chapter page reference: 644 Heading: Cardiomyopathy > Nursing Management > Actions Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Perfusion; Medication Difficulty: Moderate Feedback 1 Angiotensin-converting enzyme inhibitors reduce afterload, making it easier for the heart to eject blood. 2 Digoxin is a positive inotropic agent that can improve the heart muscle contractions, reducing associated heart failure symptoms. 3 Diuretics reduce fluid accumulation in the lungs that occurs because of the ineffective pumping action of the left heart. 4 Beta blockers decrease the sympathetic nervous system response to decreased CO. PTS: 1 CON: Perfusion | Medication 17. ANS: 3 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Analyzing the nursing management of patients with myocardial infarction, cardiomyopathy, and cardiogenic shock Chapter page reference: 648
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Heading: Cardiogenic Shock > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 The affected leg is to be straight at all times. 2 The head of the bed should be elevated no more than 30 degrees. 3 The affected leg is to be straight at all times. 4 The head of the bed should be elevated no more than 30 degrees. PTS: 1 CON: Perfusion 18. ANS: 4 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Developing a teaching plan for patients who have had a myocardial infarction or cardiogenic shock or who have cardiomyopathy Chapter page reference: 648 Heading: Cardiogenic Shock > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate
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There is no evidence to suggest that the patient cannot safely ambulate. There is no evidence to support restricting sitting out of bed. There is no evidence to support the increase of physical activity by 15 minutes each day. Increased activity or stress levels cause increased myocardial oxygen consumption and can worsen a shock state.
PTS: 1 CON: Perfusion 19. ANS: 3 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Developing a teaching plan for patients who have had a myocardial infarction or cardiogenic shock or who have cardiomyopathy Chapter page reference: 640 Heading: Myocardial Infarction Shock > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
1
Feedback No smoking of cigarettes is one of the American Heart Association’s Life Simple 7 strategies.
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Eating a heart-healthy diet is one of the American Heart Association’s Life Simple 7 strategies. Exercise for at least 150 minutes with moderate-intensity activity, or 75 minutes of vigorous-intensity activity, or a combination of each per week is one of the American Heart Association’s Life Simple 7 strategies. Keeping fasting blood glucose less than 100 mg/dL is one of the American Heart Association’s Life Simple 7 strategies.
PTS: 1 CON: Perfusion 20. ANS: 4 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Developing a teaching plan for patients who have had a myocardial infarction or cardiogenic shock or who have cardiomyopathy Chapter page reference: 640 Heading: Myocardial Infarction Shock > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion; Medication Difficulty: Moderate Feedback 1 The issue is with the patient not taking prescribed medications. The nurse’s opinion is inappropriate. 2 T acackeipntgabthlee. medications will prevent future MIs. Delaying the medications is not
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3 4
Telling the patient to try to remember to get the prescription filled is not sufficient. Prescribed medications are to treat the effects of MI and prevent future MIs.
PTS: 1 CON: Perfusion | Medication 21. ANS: 3 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Developing a teaching plan for patients who have had a myocardial infarction or cardiogenic shock or who have cardiomyopathy Chapter page reference: 644 Heading: Cardiomyopathy > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 The nurse should emphasize the importance of maintaining a sodium restriction. 2 The nurse should do more than encourage the patient to avoid adding salt. Salt is in processed and canned foods also. 3 Maintaining sodium restriction helps decrease volume overload, which helps avoid the development of heart failure. 4 Supporting the patient’s need for adding salt will not help the patient adhere to a sodium restriction,
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PTS: 1 CON: Perfusion 22. ANS: 1 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Developing a teaching plan for patients who have had a myocardial infarction or cardiogenic shock or who have cardiomyopathy Chapter page reference: 644 Heading: Cardiomyopathy > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback 1 The nurse should explain the importance of an exercise regimen; however, the patient needs to understand the signs of overexertion. 2 Exercise has been shown to improve symptoms and exercise capacity. 3 Exercise has been shown to improve symptoms and exercise capacity. 4 Exercise has been shown to improve symptoms and exercise capacity. PTS: 1
CON: Perfusion
COMPLETION 23. ANS: 3214 NURSINGTB.COM Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Describing the indications and nursing implications for hemodynamic monitoring in the critically ill patient Chapter page reference: 627 Heading: Hemodynamic Monitoring Systems Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate Feedback: In order to obtain accurate readings, several conditions need to be present. First, the transducer should be secured at the phlebostatic axis. Second, the tubing between the transducer and the cannula must be stiff, nonpliant, and less than 120 cm in length. Third, the transducer must be routinely calibrated, commonly referred to as “zeroing,” to offset the atmospheric and hydrostatic pressures that may alter the reading. Finally, the transducer and tubing need to be free from blood and air to ensure accurate readings and waveform. PTS: 1
CON: Perfusion
MULTIPLE RESPONSE 24. ANS: 1, 2, 4, 5
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Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Describing the indications and nursing implications for hemodynamic monitoring in the critically ill patient Chapter page reference: 630 Heading: Hemodynamic Monitoring Systems > Nursing Implications for Central Line Maintenance Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Perfusion; Infection; Safety Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback It is the nurse’s responsibility to perform line care to minimize risk of infection. It is the nurse’s responsibility to use aseptic technique to minimize risk of infection. It is the nurse’s responsibility to minimize line handling to minimize risk of infection. Flushing the line ensures line patency and does not reduce the risk of infection. It is the nurse’s responsibility to maintain an occlusive dressing to minimize risk of infection.
PTS: 1 CON: Perfusion | Infection | Safety 25. ANS: 1, 3, 4, 5 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Describing the indications and nursing implications for hemodynamic monitoring in the critically ill patient Chapter page reference: 631 Heading: Hemodynamic Monitoring Systems > Nursing Implications for Central Line Removal > NURSINGTB.CO Complications Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing] Concept: Perfusion; Infection; Safety Difficulty: Moderate 1. 2. 3. 4. 5.
Feedback A potential pulmonary artery catheter complication is bleeding. Increased urine output is not a potential pulmonary artery catheter complication. Evidence of an infection or sepsis would be an elevated body temperature. This could indicate a potential pulmonary artery catheter complication. Acute onset of shortness of breath could indicate an air embolism or pneumothorax, which are both potential pulmonary artery catheter complications. The development of a cardiac dysrhythmia especially when floating the catheter through the right ventricle is a potential pulmonary artery catheter complication.
PTS: 1 CON: Perfusion | Infection | Safety 26. ANS: 1, 2, 3 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Explaining the physiological relationship of hemodynamic parameters (preload, afterload, and contractility) to cardiac function Chapter page reference: 631 Heading: Hemodynamic Monitoring Systems > PA Catheter Monitoring > Cardiac Output
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Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Perfusion Difficulty: Moderate
1.
2.
3. 4. 5.
Feedback Left heart afterload is reflected in the systemic vascular resistance (SVR) and is representative of the force that the left heart must pump against in order to deliver the SV into the periphery. Cardiac output is used to calculate systemic vascular resistance. Left heart afterload is reflected in the systemic vascular resistance (SVR) and is representative of the force that the left heart must pump against in order to deliver the SV into the periphery. Mean arterial pressure is used to calculate systemic vascular resistance. Left heart afterload is reflected in the systemic vascular resistance (SVR) and is representative of the force that the left heart must pump against in order to deliver the SV into the periphery. Central venous pressure is used to calculate systemic vascular resistance. Pulmonary artery pressure is used to calculate pulmonary vascular resistance. Pulmonary artery wedge pressure is used to calculate pulmonary vascular resistance.
PTS: 1 CON: Perfusion 27. ANS: 1, 3 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Explaining the rationales for relevant medical interventions in the treatment of patients with myocardial infarction, cardiomyopathy, and cardiogenic shock Chapter page reference: 637 NURSINGTB.COM Heading: Myocardial Infarction > Medical Management > Diagnostic Testing Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Perfusion Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Typical electrocardiogram changes diagnostic of AMI includes the presence of Q waves. A junctional rhythm is not associated with an acute MI. Typical electrocardiogram changes diagnostic of AMI includes ST-segment elevation. Prolonged PR interval is not diagnostic for an acute MI. Premature ventricular contractions are not diagnostic for an acute MI.
PTS: 1 CON: Perfusion 28. ANS: 2, 4, 5 Chapter number and title: 32, Coordinating Care for Critically Ill Patients With Cardiovascular Dysfunction Chapter learning objective: Explaining the rationales for relevant medical interventions in the treatment of patients with myocardial infarction, cardiomyopathy, and cardiogenic shock Chapter page reference: 642 Heading: Cardiomyopathy > Medical Management > Pacemaker Intervention Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying]
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Concept: Perfusion; Perioperative Difficulty: Moderate
1. 2. 3. 4. 5. PTS: 1
Feedback Septal myectomy is an open-heart surgery in which the surgeon removes part of the thickened, overgrown heart muscle wall (septum) that separates the ventricles. When inserting a biventricular implantable cardioverter defibrillator, a pacer wire is placed in both the right and left ventricles. Septal alcohol ablation is a treatment in which a small portion of the thickened heart muscle is destroyed by injecting alcohol through a catheter into the heart muscle. This device delivers a shock if needed. This device monitors the heart for lethal ventricular dysrhythmias. CON: Perfusion | Perioperative
Chapter 33: Assessment of Hematological Function Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which is regulated by the hematologic system? 1) Oxygen 2) Pathogens 3) Coagulation NURSINGTB.COM 4) Temperature 2. Which is circulated by the hematologic system? 1) Oxygen 2) Pathogens 3) Coagulation 4) Temperature 3. Which is a function of red blood cells? 1) Facilitating osmosis between O2 and CO2 2) Transporting O2 from the lungs to the tissues 3) Transporting CO2 from the lungs to the tissues 4) Facilitating active transport between O2 and CO2 4. Which term should the nurse use when documenting an elevated red blood cell (RBC) count? 1) Anemia 2) Neutropenia 3) Polycythemia 4) Thrombocytopenia 5. Which term should the nurse use when documenting a decreased red blood cell (RBC) count? 1) Anemia 2) Neutropenia 3) Polycythemia 4) Thrombocytopenia
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6. Which is a component of plasma within the blood? 1) Platelets 2) Electrolytes 3) Red blood cells 4) White blood cells 7. The nurse is reviewing the complete blood cell (CBC) count for a patient recently admitted to the medicalsurgical unit. The CBC count is as follows: platelet 180,000/mm; hemoglobin 15 g/dL; red blood cells – 4.4 10 12 cells/L; white blood cells – 6,000/mm 3 . Which conclusion by the nurse is appropriate? 1) The patient is anemic. 2) The patient has leukopenia. 3) The patient has thrombocytopenia. 4) The patient’s laboratory values are within normal limits. 8. While assessing a patient’s laboratory data, the nurse notes the platelet count is 100,000/mm3 . Which complication does the nurse suspect? 1) Hypersplenism 2) Polycythemia vera 3) Autoimmune disease 4) Bone marrow suppression 9. The nurse is providing care to a patient who has impaired platelet aggregation. What does the nurse anticipate based on this data? 1) The patient is taking vitamin K supplements. 2) The patient is taking anti-inflammatory agents. 3) The patient has white blood cellNc oUuRn S t 4I7 0N0GcT elB ls. / mCicOroMliter. 4) The patient has red blood cell count 4.6 million cells/microliter. 10. The nurse is assisting the health-care provider with a bone marrow aspiration and biopsy on a patient who has leukemia. The patient also has thrombocytopenia. Upon completing of the test, which intervention is a priority for the nurse? 1) Dispose of the equipment used, and clean the area properly 2) Label and refrigerate the specimen obtained by the physician 3) Hold pressure on the wound for approximately five minutes 4) Make certain the patient understands the purpose of the test 11. Which laboratory test should the nurse anticipate when providing care to a patient with a clotting disorder caused by the intrinsic pathway? 1) Prothrombin time (PT) 2) Basic metabolic panel (BMP) 3) Complete blood cell (CBC) count 4) Partial thromboplastin time (PTT) 12. Which function of white blood cells (WBCs) should the nurse include in a teaching session for the family of a pediatric patient who is diagnosed with human immunodeficiency virus (HIV)? 1) Carry oxygen from the lungs to the tissues 2) Return carbon dioxide from the tissues to the lungs 3) Assist the body to fight infection and allergens 4) Form hemostatic plugs to stop bleeding 13. Which term should the nurse use when documenting a decreased white blood cell (WBC) count?
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1) 2) 3) 4)
Anemia Neutropenia Polycythemia Thrombocytopenia
14. Which term should the nurse use when documenting a decreased platelet count? 1) Anemia 2) Neutropenia 3) Polycythemia 4) Thrombocytopenia 15. The nurse is conducting a teaching session regarding clotting factors. Which clotting factor is converted to fibrin and is responsible for clot formation? 1) Fibrinogen 2) Prothrombin 3) Calcium ions 4) Tissue thromboplastin 16. Which food should the nurse recommend for a patient who is experiencing anemia caused by a deficiency in folic acid? 1) Fish 2) Poultry 3) Citrus fruits 4) Green leafy vegetables 17. Which food should the nurse recommended for a patient who is diagnosed with iron deficiency anemia? 1) Shellfish NURSINGTB.COM 2) Lima beans 3) Citrus fruits 4) Milk products 18. Which drug prescription should the nurse anticipate to prevent the formation of clots for a patient diagnosed with deep vein thrombosis (DVT)? 1) Warfarin 2) Vitamin K 3) Abciximab 4) Streptokinase 19. Which drug prescription should the nurse anticipate for a patient who presents in the emergency department with symptoms of a thrombotic stroke? 1) Warfarin 2) Vitamin K 3) Abciximab 4) Streptokinase 20. Which is an age-related hematologic change the nurse anticipates when reviewing a complete blood count (CBC) for an older adult patient? 1) Increased hematocrit 2) Increased hemoglobin 3) Increased B- and T-cells 4) Increased sedimentation rate
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Multiple Response Identify one or more choices that best complete the statement or answer the question. 21. The nurse is conducting a hematologic assessment for a new patient. Which questions should the nurse include in the general/past health history? Select all that apply. 1) “Have you had any recent changes in energy level?” 2) “Do you take any herbal supplements such as goldenseal?” 3) “Have you been prescribed blood thinners by your doctor?” 4) “Have you experienced any recent bleeding or bruising?” 5) “Do you ever experience any pain, burning, or tingling sensations?” 22. The nurse suspects that a patient with severe shortness of breath in the absence of cyanosis is experiencing anemia. Which laboratory tests should the nurse review to confirm anemia? Select all that apply. 1) Glucose 2) Hematocrit 3) Hemoglobin 4) Cardiac enzymes 5) Serum electrolytes 23. The nurse is caring for an older adult patient with hemolytic anemia. When planning care for this patient, which should the nurse take into consideration regarding this diagnosis? Select all that apply. 1) It causes the red blood cells to be microcytic. 2) It is associated with an increase in the reticulocyte count. 3) It is the result of blood loss. lo oCdOcM ells. 4) It is a result of the premature desNtrUu cRtiSo nI oNfGreTdBb. 5) It always requires treatment with folic acid Completion Complete each statement. 24. Arrange the events of the erythrocyte growth pathway in the correct order (1-7). (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Formation of reticulocyte 2) Formation of erythrocyte 3) Formation of proerythroblast 4) Formation of basophilic erythroblast 5) Formation of orthochromatic erythroblast 6) Formation of polychromatic erythroblast 7) Formation of committed myeloid stem cell 25. Place the stages of hemostasis in the correct order (1-5). (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Vasospasm 2) Clot formation 3) Clot retraction 4) Clot dissolution
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5) Formation of platelet plug
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Chapter 33: Assessment of Hematological Function Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Discussing the oxygenation function of the hematological system Chapter page reference: 660-664 Heading: Overview of Hematology Function Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering] Concept: Hematologic Regulation Difficulty: Easy 1 2 3 4
Feedback Oxygen is circulated by the hematologic system. The hematologic system protects the body against pathogens. Coagulation is maintained by the hematologic system. Temperature, along with fluids, electrolytes, acids, and bases, is regulated by this system.
PTS: 1 CON: HematoNloUgR ic SRI egNuG la T tioBn .COM 2. ANS: 1 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Identifying key anatomical components of the hematological system Chapter page reference: 660-664 Heading: Overview of Hematology Function Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering] Concept: Hematologic Regulation Difficulty: Easy
1 2 3 4
Feedback Oxygen is circulated by the hematologic system. The hematologic system protects the body against pathogens. Coagulation is maintained by the hematologic system. Temperature, along with fluids, electrolytes, acids, and bases, is regulated by this system.
PTS: 1 CON: Hematologic Regulation 3. ANS: 2 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Discussing the oxygenation function of the hematological system Chapter page reference: 660-664
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Heading: Overview of Hematology Function Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation Difficulty: Easy Feedback 1 O2 and CO2 are exchanged by diffusion, not osmosis. 2 O2 is transported from the lungs to the systemic tissues by erythrocytes (red blood cells). 3 CO2 is transported from the systemic tissue to the lungs by erythrocytes (red blood cells). 4 O2 and CO2 are exchanged by diffusion, not active transport. PTS: 1 CON: Hematologic Regulation 4. ANS: 3 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Correlating relevant diagnostic examinations to hematological function Chapter page reference: 664-675 Heading: Hematological Assessment Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Hematologic Regulation Difficulty: Moderate NURSINGTB.COM Feedback 1 Anemia is the term used to describe a decreased RBC count. 2 Neutropenia is a term used to describe a decreased white blood cell (WBC) count. 3 Polycythemia is a term used to described an increased RBC count. 4 Thrombocytopenia is a term used to described a decreased platelet count. PTS: 1 CON: Hematologic Regulation 5. ANS: 1 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Correlating relevant diagnostic examinations to hematological function Chapter page reference: 664-675 Heading: Hematological Assessment Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Hematologic Regulation Difficulty: Moderate Feedback 1 Anemia is the term used to describe a decreased RBC count. 2 Neutropenia is a term used to describe a decreased white blood cell (WBC) count. 3 Polycythemia is a term used to described an increased RBC count. 4 Thrombocytopenia is a term used to described a decreased platelet count.
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PTS: 1 CON: Hematologic Regulation 6. ANS: 2 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Identifying key anatomical components of the hematological system Chapter page reference: 652-660 Heading: Overview of Anatomy and Physiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering] Concept: Hematologic Regulation Difficulty: Easy Feedback 1 Blood is made up of plasma (a clear yellow, protein-rich fluid) and the cells and cell fragments suspended in it: RBCs, WBCs, and platelets. 2 Plasma is a clear yellow, protein-rich fluid that is found within the blood. Plasma is a complex mixture of water, proteins, nutrients, electrolytes, nitrogenous wastes, hormones, and gases. 3 Blood is made up of plasma (a clear yellow, protein-rich fluid) and the cells and cell fragments suspended in it: RBCs, WBCs, and platelets. 4 Blood is made up of plasma (a clear yellow, protein-rich fluid) and the cells and cell fragments suspended in it: RBCs, WBCs, and platelets. PTS: 1 CON: Hematologic Regulation 7. ANS: 4 Chapter number and title: 33, Assessment of Hematological Function NURSINGTB.COM Chapter learning objective: Correlating relevant diagnostic examinations to hematological function Chapter page reference: 664-675 Heading: Hematological Assessment Integrated Processes: Nursing Process – Evaluation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation Difficulty: Easy
1 2 3 4
Feedback The patient does not have decreased red blood cell count; therefore, does not have anemia. The patient does not have decreased white blood cell count; therefore, does not have leukopenia. The patient does not have decreased platelet count; therefore, does not have thrombocytopenia. Platelets of 150,000–400,000/mm 3, Hemoglobin of 12–16 g/dL, red blood cell count of 4.2-5.4 10 12 cells/L, and white blood cell count: 5000–10,000/mm3 indicates normal levels in the body.
PTS: 1 CON: Hematologic Regulation 8. ANS: 2 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Correlating relevant diagnostic examinations to hematological function
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Chapter page reference: 664-675 Heading: Hematological Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation Difficulty: Easy Feedback 1 An increased platelet count is associated with bone marrow suppression, autoimmune disease, and hypersplenism. 2 Normal platelet count is in the range of 150,000–400,000/mm 3 . A decreased platelet count indicates the patient may be experiencing polycythemia vera. 3 An increased platelet count is associated with bone marrow suppression, autoimmune disease, and hypersplenism. 4 An increased platelet count is associated with bone marrow suppression, autoimmune disease, and hypersplenism. PTS: 1 CON: Hematologic Regulation 9. ANS: 2 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to the hematological system Chapter page reference: 664-675 Heading: Hematologic Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological IntegrityNURSINGTB.COM – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Hematologic Regulation Difficulty: Difficult
1 2 3
4
Feedback Vitamin K causes hemolysis, but it does not impair platelet aggregation. Anti-inflammatory agents reduce the platelet aggregation. The normal level of white blood cell (WBC) count is 5000–10,000 cells/microliter and the normal red blood cell (RBC) count is 4.7–6.1 million cells/microliter. While the patient has a slightly decreased WBC and RBC count, this would not cause impaired platelet aggregation. The normal level of white blood cell (WBC) count is 5000–10,000 cells/microliter and the normal red blood cell (RBC) count is 4.7–6.1 million cells/microliter. While the patient has a slightly decreased WBC and RBC count, this would not cause impaired platelet aggregation.
PTS: 1 CON: Hematologic Regulation 10. ANS: 3 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to the hematological system Chapter page reference: 664-675 Heading: Hematological Assessment
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Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Hematologic Regulation Difficulty: Difficult Feedback 1 Dealing with the specimen is accomplished by a third party or after the nurse stabilizes the patient. 2 Cleaning the area is completed after the patient is stable and the specimen is sent to the laboratory. 3 The most important task for the nurse is to prevent bleeding after the biopsy. Holding pressure on the wound for five minutes is effective. 4 An explanation of the test is performed before the procedure is begun. PTS: 1 CON: Hematologic Regulation 11. ANS: 4 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Correlating relevant diagnostic examinations to hematological function Chapter page reference: 664-675 Heading: Hematological Assessment Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation Difficulty: Easy NURSINGTB.COM Feedback 1 A PT time is anticipated for a patient experiencing issues with the extrinsic pathway. 2 A BMP is anticipated for a patient experiencing issues with glucose or electrolytes. 3 A CBC is anticipated for a patient who is experiencing issues with blood components. 4 A PTT is anticipated for a patient experiencing issues with the intrinsic pathway. PTS: 1 CON: Hematologic Regulation 12. ANS: 3 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Identifying key anatomical components of the hematological system Chapter page reference: 660-664 Heading: Overview of Hematology Function Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Hematologic Regulation Difficulty: Moderate Feedback 1 A function of red blood cells, not WBCs, is to carry oxygen from the lungs to the tissues. 2 A function of red blood cells, not WBCs, is to return carbon dioxide from the tissues to the lungs. 3 A function of the WBCs is to fight infection and allergens. 4 A function of platelets, not WBCs, is to form hemostatic plugs to stop bleeding.
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PTS: 1 CON: Hematologic Regulation 13. ANS: 2 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Correlating relevant diagnostic examinations to hematological function Chapter page reference: 664-675 Heading: Hematological Assessment Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Hematologic Regulation Difficulty: Moderate Feedback 1 Anemia is the term used to describe a decreased red blood cell (RBC) count. 2 Neutropenia is a term used to describe a decreased WBC count. 3 Polycythemia is a term used to described an increased red blood cell (RBC) count. 4 Thrombocytopenia is a term used to described a decreased platelet count. PTS: 1 CON: Hematologic Regulation 14. ANS: 4 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Correlating relevant diagnostic examinations to hematological function Chapter page reference: 664-675 Heading: Hematological Assessment Integrated Processes: Communication and Documentation NURSINGTB.COM Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Hematologic Regulation Difficulty: Moderate Feedback 1 Anemia is the term used to describe a decreased red blood cell (RBC) count. 2 Neutropenia is a term used to describe a decreased white blood cell (WBC) count. 3 Polycythemia is a term used to described an increased red blood cell (RBC) count. 4 Thrombocytopenia is a term used to described a decreased platelet count. PTS: 1 CON: Hematologic Regulation 15. ANS: 1 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Explaining the role of the clotting cascade in maintaining homeostasis Chapter page reference: 660-664 Heading: Overview of Hematology Function Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation Difficulty: Easy Feedback 1 Fibrinogen is converted to fibrin and is responsible for clot formation. 2 Prothrombin is converted to thrombin, activates fibrinogen (factor I).
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3 4
In the intrinsic pathway, calcium ions combine with factor IX to activate factor X. Tissue thromboplastin activates factor VII.
PTS: 1 CON: Hematologic Regulation 16. ANS: 4 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to the hematological system Chapter page reference: 664-675 Heading: Hematological Assessment Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Hematologic Regulation; Nutrition Difficulty: Moderate Feedback 1 Fish and poultry would be recommended for a patient who requires more vitamin B 6 in the diet. 2 Fish and poultry would be recommended for a patient who requires more vitamin B 6 in the diet. 3 Citrus fruits are recommended for a patient who requires more vitamin C in the diet. 4 Green leafy vegetables are a source of folic acid. PTS: 1 CON: Hematologic Regulation | Nutrition 17. ANS: 2 NURSINGTB.COM Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to the hematological system Chapter page reference: 664-675 Heading: Hematological Assessment Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Hematologic Regulation; Nutrition Difficulty: Moderate Feedback 1 Shellfish is a source of copper, not iron. 2 Lima beans are a source of iron. 3 Citrus fruits are a source of vitamin C, not iron. 4 Milk products are a source of calcium, not iron. PTS: 1 CON: Hematologic Regulation | Nutrition 18. ANS: 1 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to the hematological system Chapter page reference: 664-675 Heading: Hematological Assessment Integrated Processes: Nursing Process – Planning
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Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation; Medication Difficulty: Easy Feedback 1 Warfarin is an anticoagulant drug that is used to prevent the formation of clots. 2 Vitamin K does not prevent the formation of clots. This drug is administered for an anticoagulant overdose. 3 Abciximab is a platelet inhibitor. 4 Streptokinase is a thrombolytic, or clot buster. PTS: 1 CON: Hematologic Regulation | Medication 19. ANS: 4 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to the hematological system Chapter page reference: 664-675 Heading: Hematological Assessment Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation; Medication Difficulty: Easy Feedback 1 Warfarin is an anticoagulant dN ruUgRthSatIisNuGseTdBto.pCrev O Men t the formation of clots. It is not effective for a patient who presents with symptoms of a thrombotic stroke. 2 Vitamin K does not prevent the formation of clots. This drug is administered for an anticoagulant overdose. 3 Abciximab is a platelet inhibitor. 4 Streptokinase is a thrombolytic, or clot buster. This drug is used within 12 hours of the initiation of symptoms for a thrombotic stroke. PTS: 1 CON: Hematologic Regulation | Medication 20. ANS: 4 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Discussing changes in hematological function associated with aging Chapter page reference: 675 Heading: Age-Related Changes to the Hematological System Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation Difficulty: Easy Feedback 1 Hematocrit is not affected by the aging process. 2 Hemoglobin is not affected by the aging process. 3 A decrease in B- and T-cells is anticipated with the aging process. 4 An increased sedimentation rate is anticipated with the aging process.
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PTS: 1
CON: Hematologic Regulation
MULTIPLE RESPONSE 21. ANS: 1, 4, 5 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of the hematological system Chapter page reference: 664-675 Heading: Hematological Assessment Integrated Processes: Nursing Process – Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Hematologic Regulation Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback This is correct. This question is appropriate when conducting the general/past health history of the patient’s hematologic system. This is incorrect. This question is more appropriate for the medication history. This is incorrect. This question is more appropriate for the medication history. This is correct. This question is appropriate when conducting the general/past health history of the patient’s hematologic system. This is correct. This queN stiUo nR iSsI apNpG roT p rBia.teCwOhM e n conducting the general/past health history of the patient’s hematologic system.
PTS: 1 CON: Hematologic Regulation 22. ANS: 2, 3 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Correlating relevant diagnostic examinations to hematological function Chapter page reference: 664-675 Heading: Hematological Assessment Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Hematologic Regulation Difficulty: Moderate
1. 2.
Feedback This is incorrect. Blood sugar, cardiac enzymes, and serum electrolytes are not implicated in this phenomenon. This is correct. In order to exhibit cyanosis, the patient’s blood must contain about 5 g or more of unoxygenated hemoglobin per 100 mL of blood and the surface blood capillaries must be dilated. Severe anemia will interfere with the development of cyanosis, so the nurse should review the hemoglobin and hematocrit.
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3.
4. 5.
This is correct. In order to exhibit cyanosis, the patient’s blood must contain about 5 g or more of unoxygenated hemoglobin per 100 mL of blood and the surface blood capillaries must be dilated. Severe anemia will interfere with the development of cyanosis, so the nurse should review the hemoglobin and hematocrit. This is incorrect. Blood sugar, cardiac enzymes, and serum electrolytes are not implicated in this phenomenon. This is incorrect. Blood sugar, cardiac enzymes, and serum electrolytes are not implicated in this phenomenon.
PTS: 1 CON: Hematologic Regulation 23. ANS: 2, 4, 5 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Discussing changes in hematological function associated with aging Chapter page reference: 675 Heading: Age-Related Changes to the Hematological System Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation Difficulty: Easy
1. 2.
3. 4. 5.
PTS: 1
Feedback This is incorrect. Hemolytic anemias are normocytic (red blood cells are normal size), not microcytic. This is correct. HemolytN icUa nReSmIiaNisGm ToBre.cCo OmMmon with aging and is caused by the premature destruction of the red blood cells. The normal life span of a red blood cell is 120 days. There is an increase in the reticulocyte (immature red blood cells) count because they are released early from the bone marrow to compensate. This is incorrect. It is not associated with blood loss. This is correct. Hemolytic anemia is more common with aging and is caused by the premature destruction of the red blood cells. This is correct. Hemolytic anemia is more common with aging and is caused by the premature destruction of the red blood cells. The normal life span of a red blood cell is 120 days. All hemolytic anemias require treatment with folic acid because this vitamin is consumed by the increased bone marrow production of red blood cells in response to the anemia. CON: Hematologic Regulation
COMPLETION 24. ANS: 7346512 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Identifying key anatomical components of the hematological system Chapter page reference: 652-660 Heading: Overview of Anatomy and Physiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance
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Cognitive level: Application [Applying] Concept: Hematologic Regulation Difficulty: Moderate Feedback: Erythrocyte growth pathway results in formation of erythrocytes through a series of events. The committed myeloid stem cell formation from the pluripotent cell initiates the erythrocyte growth pathway. The proerythroblast then forms from the committed myeloid stem cell which further results in development of the basophilic erythroblast. The basophilic erythroblast then forms from the proerythroblast. The proerythroblast can further result in the formation of polychromatic erythroblast. The orthochromatic erythroblast then forms from the polychromatic erythroblast. The polychromatic erythroblast then results in reticulocyte, which matures into erythrocytes in the body. PTS: 1 CON: Hematologic Regulation 25. ANS: 15234 Chapter number and title: 33, Assessment of Hematological Function Chapter learning objective: Explaining the role of the clotting cascade in maintaining homeostasis Chapter page reference: 652-660 Heading: Overview of Anatomy and Physiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Hematologic Regulation Difficulty: Moderate Feedback: The stages of hemostasis iN nU orRd eSrIarNe G asTf oBl. loC wO s : Mvaso spasm, formation of a platelet plug, clot formation, clot retraction, and clot dissolution. PTS: 1
CON: Hematologic Regulation
Chapter 34: Coordinating Care for Patients With Hematological Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The home healthcare nurse is preparing a care plan for a patient with severe anemia. The patient currently lives alone and states, “I can’t even walk to the kitchen without getting winded.” What would be the priority nursing diagnosis for this patient? 1) Hopelessness 2) Activity Intolerance 3) Altered Nutrition, Less than Body Requirements 4) Anxiety 2. A nurse is providing discharge teaching for a patient with iron-deficiency anemia. The patient has been prescribed ferrous sulfate and has been told to increase the intake of foods that are naturally high in iron. Which patient statement indicates correct understanding? 1) “I will decrease my intake of green leafy vegetables while taking my ferrous sulfate tablet.” 2) “I will increase my fluid intake while I am taking my ferrous sulfate.”
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3) “I will take my ferrous sulfate tablet on an empty stomach.” 4) “I will decrease milk intake while taking my ferrous sulfate tablet.” 3. The nurse is evaluating a patient’s understanding of dietary needs to treat anemia. Which patient statement indicates a need for additional teaching? 1) “I will eat more fruits and vegetables, especially green leafy ones, to get more iron in my diet.” 2) “I will need to include more protein foods in my diet such as meats, dried beans, and whole-grain breads.” 3) “I will decrease foods high in vitamin C, as they decrease my absorption of iron.” 4) “I will take vitamins with extra iron in addition to eating a balanced diet with meat to correct my anemia.” 4. The nurse is instructing a patient with iron-deficiency anemia about appropriate menu choices. Which diet choice indicates that teaching has been effective? 1) Tofu with mixed vegetables in curry, milk, whole-wheat bun 2) Broiled fish, lettuce salad, grapefruit half, carrot sticks 3) Pork chop, mashed potatoes and gravy, cauliflower, tea 4) Roast beef, steamed spinach, tomato soup, orange juice 5. A nurse is providing discharge instructions to a patient with iron-deficiency anemia who is experiencing glossitis. Which patient statement indicates the need for further education? 1) “I will monitor my lips and tongue daily.” 2) “I will use an alcohol-based mouthwash twice per day.” 3) “I will apply a petroleum-based lubricating ointment to my lips.” 4) “I will use a soft toothbrush when brushing my teeth each day.”
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6. The nurse is planning care for a patient with acute myeloid leukemia (AML). Which is the priority nursing diagnosis to minimize the risk of complications associated with AML? 1) Risk for Bleeding 2) Ineffective Thermoregulation 3) Imbalanced Nutrition 4) Fluid Volume Excess 7. A pediatric patient being treated for acute lymphocytic leukemia (ALL) has a white blood cell count of 1,000/mm3. Which nursing diagnosis would be a priority for this patient? 1) Readiness for Enhanced Immunization Status 2) Impaired Gas Exchange 3) Risk for Infection 4) Activity Intolerance 8. A pediatric nurse is caring for a child with acute lymphoblastic leukemia (ALL). When providing education to the child’s parents regarding this disease, which topic should the nurse include? 1) ALL is characterized by abnormal proliferation of all bone marrow elements. 2) This form of leukemia is the most common type among children and adolescents. 3) This form of leukemia is very rarely seen in children. 4) The onset of ALL is usually gradual. 9. A nurse is planning care for a patient with leukemia. The nurse chooses Risk for Bleeding as the nursing diagnosis. Which intervention supports this nursing diagnosis? 1) Educate patient in use of soft toothbrush for oral care 2) Limit parenteral injections
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3) Apply pressure to arterial puncture sites for five minutes 4) Encourage patient to deep breathe and huff cough 10. A patient in sickle cell crisis reports taking a recent skiing trip that caused a respiratory infection from the cold weather. Which nursing diagnosis is a priority for this patient? 1) Fluid Volume Excess 2) Risk for Self-Mutilation 3) Knowledge Deficit 4) Acute Pain 11. A patient is admitted to the emergency department in a sickle cell crisis. The nurse assesses the patient and documents the following clinical findings: temperature 102°F, O 2 saturation of 89%, and complaints of severe abdominal pain. Based on the assessment findings, which intervention is the greatest priority? 1) Apply oxygen per nasal cannula at 3 L/minute. 2) Assess and document peripheral pulses. 3) Administer morphine sulfate 10 mg IM. 4) Administer Tylenol 650 mg by mouth. 12. The nurse is caring for a patient who was admitted to a medical-surgical unit in a sickle cell crisis. Which medication should the nurse expect to administer to this patient? 1) Acetaminophen 2) Ibuprofen 3) Meperidine 4) Hydroxyurea 13. The nurse is providing care to a patient who is receiving treatment for sickle cell disease. The patient is at risk for infection. Which medication doesNtU h eRnS urIseNeGxpTeB ct.toCaOd M m in ister to this patient? 1) Acetaminophen 2) Penicillin 3) Morphine sulfate 4) Tamoxifen 14. An emergency department nurse is caring for a child in a sickle cell crisis. The nurse suspects the etiology of the crisis as being thrombotic in nature due to which clinical manifestations? 1) The patient has profound pallor and fatigue. 2) The patient is in extreme pain. 3) The patient has profound hypotension and shock. 4) The patient’s chest CT reveals a pulmonary infarct. 15. A nurse is planning care for a patient with sickle cell disease and chooses Acute Pain as the nursing diagnosis. Which intervention is inappropriate for the nurse to include in this plan of care? 1) Administer ordered analgesic medications around the clock 2) Place patient in position of comfort 3) Use heat or cold packs as tolerated 4) Support the patient’s joints and extremities with pillows 16. A child who has polycythemia is prescribed radiation. The child’s parents ask why this is necessary since the child does not have cancer. Which response by the nurse is accurate? 1) “It stimulates red blood cell production.” 2) “It suppresses the bone marrow.” 3) “It provides vitamin supplementation.” 4) “It decreases the risk of transfusion reactions.”
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17. A child diagnosed with aplastic anemia is admitted to the hospital. The parents ask the nurse what aplastic anemia is. Which response by the nurse is accurate? 1) “Aplastic anemia causes a proliferation of white blood cells.” 2) “Aplastic anemia is characterized by abnormally shaped red blood cells.” 3) “Aplastic anemia is caused by the bone marrow producing inadequate cells.” 4) “Aplastic anemia is a disorder that occurs after a viral illness.” 18. Which is the priority nursing diagnosis for the child diagnosed with idiopathic thrombocytopenic purpura (ITP)? 1) Ineffective Breathing Pattern 2) Nausea 3) Fluid Volume Deficit 4) Risk for Injury 19. Which is the priority teaching point for the nurse to include in the discharge instructions for the parents of a child who was admitted to the hospital in a sickle cell crisis? 1) Rapid weaning of pain medications 2) A diet high in protein 3) Adequate hydration 4) Restriction of activities 20. The health-care provider prescribes laboratory tests following the initiation of treatment for a child who is diagnosed with iron-deficiency anemia. Which laboratory result should the nurse share with the child’s family as an indication of improvement? 1) Low hemoglobin 2) Normal platelet count NURSINGTB.COM 3) High reticulocyte count 4) Low hematocrit 21. A patient complaining of mouth soreness had gastric bypass surgery one year ago. During the assessment, the nurse notes the patient’s tongue is beefy, red, and smooth and the patient’s skin appears yellowish. Which additional information is most likely needed before diagnosing this patient? 1) Vitamin B6 levels 2) Vitamin B12 levels 3) Potassium levels 4) Iron levels 22. A patient experiencing fatigue, pallor, and dyspnea on exertion has a complete blood count drawn. Which red blood cell disorder should the nurse anticipate the patient is experiencing? 1) Polycythemia 2) Erythropoiesis 3) Herpes simplex 4) Anemia 23. An older adult patient with renal failure is diagnosed with anemia. Based on this data, which cause of anemia will the nurse plan for when providing care? 1) Loss of the kidney hormone erythropoietin 2) A loss of appetite related to elevated blood urea nitrogen (BUN) and creatinine levels 3) The renal dialysis used to treat the chronic renal failure 4) Loss of blood through the urine because the failing kidney does not function properly
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24. A nurse is educating a patient with anemia about the pathophysiological mechanisms of anemia. Which should be excluded in the nurse’s teaching plan for this patient? 1) Altered hemoglobin synthesis 2) Altered DNA synthesis 3) Decreased hemolysis 4) Bone marrow failure 25. Parents of a newborn infant are concerned that their baby may have sickle cell disease. The nurse reviews the medical record and finds that both parents have the sickle cell trait. Which is the best response for the nurse to give the parents? 1) “Since neither of you actually has sickle cell disease, your baby is not at risk.” 2) “Your baby has the disease, as you both carry the trait.” 3) “As you both have the sickle cell trait, your baby will be tested for the disease.” 4) “Have you talked to a genetic counselor about your concerns?” Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. A patient with a history of anemia has started a vegan diet. Which addition to meals should the nurse recommend to help ensure that this patient has adequate amounts of iron in the diet? Select all that apply. 1) Legumes 2) Orange juice 3) Brewer’s yeast 4) Okra 5) Peas
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27. An adult patient reports to the nurse an inability to tolerate usual exercise and the feeling of fatigue. The patient states that these symptoms have been gradual over time. Which physical assessment findings, along with the patient’s verbal reports, would indicate chronic lymphocytic leukemia (CML)? Select all that apply. 1) Joint pain 2) Pallor 3) Splenomegaly 4) Abnormal bleeding 5) Edema 28. The nurse is teaching a class at a local community center about decreasing risk factors for cancer. Which risk factors should the nurse include in the teaching regarding leukemia? Select all that apply. 1) Alkylating agents 2) Diets low in fat 3) Exposure to infectious agents 4) Bloom syndrome 5) Decreased exercise 29. A nurse educator is teaching a group of parents how to prevent a crisis in the child with sickle cell disease. What should the nurse instruct about the precipitating factors that could contribute to a sickle cell crisis? Select all that apply. 1) Increased fluid intake 2) Altitude 3) Fever 4) Vomiting
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5) Regular exercise 30. Which parental statements regarding precipitating factors for sickle cell disease indicate correct understanding of the discharge information presented by the nurse? Select all that apply. 1) “My child should avoid regular exercise.” 2) “We should provide acetaminophen or ibuprofen to treat fever.” 3) “Our child needs to drink lots of fluid to avoid dehydration when playing sports.” 4) “High altitudes can cause exacerbation and should be avoided.” 5) “Fluid restriction is necessary to avoid exacerbations from occurring.”
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Chapter 34: Coordinating Care for Patients With Hematological Disorders Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological disorders Chapter page reference: 681 Heading: Red Blood Cell Disorders Integrated Processes: Nursing Process – Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Hematologic Regulation Difficulty: Difficult 1 2 3
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Feedback While anxiety, hopelessness, and altered nutrition may be appropriate nursing diagnoses for this patient, they are not the priority. Activity Intolerance would be a priority diagnosis for this patient. Maslow’s Hierarchy of Needs indicates physiological needs take priority over psychosocial needs. While anxiety, hopelessness, and altered nutrition may be appropriate nursing diagnoses for this patient, they are not the priority. While altered nutrition is a physiological need according N toUMRaS slI o wN, GthT erBe . isCnO o M indication that the patient is underweight. While anxiety, hopelessness, and altered nutrition may be appropriate nursing diagnoses for this patient, they are not the priority.
PTS: 1 CON: Hematologic Regulation 2. ANS: 3 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Discussing the medical management of: Iron-deficiency anemia Chapter page reference: 681 Heading: Red Blood Cell Disorders Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Hematologic Regulation Difficulty: Difficult
1 2 3
Feedback The patient should not decrease milk or green leafy vegetables from the diet as these are natural sources of iron and should be encouraged. Increasing fiber (oatmeal) and fluid intake can also help prevent constipation. Ferrous sulfate can cause gastric irritation and constipation. Taking it with a meal can help minimize gastrointestinal distress.
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4
The patient should not decrease milk or green leafy vegetables from the diet as these are natural sources of iron and should be encouraged.
PTS: 1 CON: Hematologic Regulation 3. ANS: 3 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with hematological disorders Chapter page reference: 681 Heading: Red Blood Cell Disorders Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Analysis [Analyzing] Concept: Hematologic Regulation; Nutrition Difficulty: Difficult Feedback 1 The lack of iron is the problem that needs to be addressed. Extra iron is needed to help replace RBCs and treat the dietary deficiency anemia. Green leafy vegetables will increase iron in the diet. 2 Protein foods such as meats, dried beans, and whole-grain breads do contain iron that will help dietary deficiency anemia. 3 Increasing, not decreasing, foods high in vitamin C will increase absorption of iron. 4 Protein foods such as meats, dried beans, and whole-grain breads do contain iron that will help dietary deficiency anemia.
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PTS: 1 CON: Hematologic Regulation | Nutrition ANS: 4 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with hematological disorders Chapter page reference: 681 Heading: Red Blood Cell Disorders Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Analysis [Analyzing] Concept: Hematologic Regulation; Nutrition Difficulty: Difficult 1 2 3 4
Feedback The meal of tofu with mixed vegetables in curry, milk, and a whole-wheat bun is high in calcium, but the patient has iron-deficiency anemia and requires a high-iron diet. The meal of fish, lettuce, grapefruit, and carrot sticks is high in fiber, low in fat, and moderately high in protein, but low in iron. The meal with a pork chop, mashed potatoes and gravy, cauliflower, and tea has a moderate amount of protein, but no vitamin C. This patient is anemic and needs iron. This meal contains iron in the beef, folic acid in the spinach, and vitamin C in the tomato soup and orange juice. Vitamin C helps absorption of the iron; folic acid is needed for production of red cells.
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PTS: 1 CON: Hematologic Regulation | Nutrition 5. ANS: 2 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with hematological disorders Chapter page reference: 680-681 Heading: Red Blood Cell Disorders Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Analysis [Analyzing] Concept: Hematologic Regulation; Comfort Difficulty: Difficult 1
2 3 4
Feedback Glossitis, inflammation of the tongue that may cause the tongue and lips to turn red, and cheilosis (fissures or cracks at the corners of the mouth) may occur with nutritional deficiencies of iron, folate, and vitamin B12 . Patient education should include monitoring the condition of lips and tongue daily. The patient should not use an alcohol-based mouthwash, as this would worsen the glossitis. The patient should use a petroleum-based lubricating jelly or ointment to the lips after oral care. The patient should provide frequent oral hygiene with a soft-bristle toothbrush or sponge.
PTS: 1 CON: HematoNloUgR ic SRI egNuG la T tioBn .| C CoOmMfort 6. ANS: 1 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological disorders Chapter page reference: 698 Heading: White Blood Cell Disorders Integrated Processes: Nursing Process – Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Hematologic Regulation; Cellular Regulation Difficulty: Difficult Feedback 1 AML results in neutropenia (decreased neutrophils = risk of infection) and thrombocytopenia (decreased platelets, which leads to increased risk of bleeding). Therefore, actions to minimize these risks include caution when moving or assisting the patient to move, as well as strict hand hygiene to prevent possible cross-contamination. 2 Heat intolerance is a symptom of CML, not AML. CML has heat intolerance due to hypermetabolism state present with the condition. 3 Weight loss is a symptom of chronic myeloid leukemia (CML), not AML. Therefore, dietary needs are not increased with AML.
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Restriction of fluids and salt are not needed. The patient with AML does not have a problem with fluid shifts or edema that would require these restrictions. Fluids are encouraged to remove wastes that occur with chemotherapy treatment and cellular breakdown.
PTS: 1 CON: Hematologic Regulation | Cellular Regulation 7. ANS: 3 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological disorders Chapter page reference: 698 Heading: White Blood Cell Disorders Integrated Processes: Nursing Process – Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Hematologic Regulation; Cellular Regulation Difficulty: Difficult Feedback 1 Children with cancer would not be receiving immunizations during treatment. 2 Impaired gas exchange is not evident in this patient. 3 In leukemia, the WBCs that are present are immature and incapable of fighting infection. The patient with a WBC count of 500-1,000/mm 3 is considered a moderate risk for infection. 4 dTihaegnpoastiiesn.t may or may not have activity intolerance, but it is not the priority nursing
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PTS: 1 CON: Hematologic Regulation | Cellular Regulation 8. ANS: 2 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Describing the epidemiology of disorders of the hematological system Chapter page reference: 695 Heading: White Blood Cell Disorders Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Hematologic Regulation; Cellular Regulation Difficulty: Moderate Feedback 1 Most cases of ALL result from the malignant transformation of B cells. Chronic myeloid leukemia (CML) is characterized by abnormal proliferation of all bone marrow elements. 2 Acute lymphoblastic leukemia (ALL) is the most common type of leukemia among children and adolescents. 3 Acute lymphoblastic leukemia (ALL) is the most common type of leukemia among children and adolescents. 4 The onset of ALL is usually acute and rapid. PTS: 1 9. ANS: 1
CON: Hematologic Regulation | Cellular Regulation
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Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological disorders Chapter page reference: 698 Heading: White Blood Cell Disorders Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation; Cellular Regulation Difficulty: Easy Feedback 1 The patient at risk for bleeding has specific interventions to which the nurse should adhere. The nurse should educate the patient in the use of soft toothbrush to avoid bleeding. 2 The nurse should also limit the use of parenteral injections and apply 15-20 minutes of pressure to any arterial puncture sites. 3 The nurse should also limit the use of parenteral injections and apply 15-20 minutes of pressure to any arterial puncture sites. 4 The nurse should discourage the patient to forcefully cough to prevent further bleeding. PTS: 1 CON: Hematologic Regulation | Cellular Regulation 10. ANS: 4 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological disorders NURSINGTB.COM Chapter page reference: 691 Heading: Red Blood Cell Disorders Integrated Processes: Nursing Process – Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Hematologic Regulation; Oxygenation; Comfort Difficulty: Difficult Feedback 1 Fluid volume deficit, not excess, is likely to be a priority for a patient who is experiencing a sickle cell crisis. 2 There is no evidence from the information given that the patient is at risk for selfmutilation. 3 The patient has reportedly been skiing, which would be in an area of high altitude, which is contraindicated for someone with sickle cell. This patient appears to have a knowledge deficit about self-care. This diagnosis, however, does not take priority. 4 Acute pain is a physiologic issue and is the priority for the patient who is experiencing a sickle cell crisis. PTS: 1 CON: Hematologic Regulation | Oxygenation | Comfort 11. ANS: 1 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological disorders Chapter page reference: 691
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Heading: Red Blood Cell Disorders Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Hematologic Regulation; Oxygenation Difficulty: Difficult Feedback 1 Hypoxia is often the cause of a sickle cell crisis from the clumping of damaged RBCs, which creates an obstruction and hypoxia distal to the clumping. Administering the oxygen will improve the pain and increase the oxygen saturation of body tissues. Therefore, applying the oxygen should be the first action by the nurse. 2 Full body assessment, including peripheral pulses, is significant to identify the location of the potential obstruction, but this is secondary to treating the hypoxia that is known to be present from the sickling of the cells during sickle cell crisis. 3 Morphine sulfate is a narcotic for pain, but it should be given after the oxygen is started, since the symptoms are caused by hypoxia. The morphine will decrease the pain and decrease metabolic oxygen needs by decreasing basal metabolic rates; therefore, supply is increased and demand is increased. 4 Although the temperature is elevated, and will increase oxygen demands in the body by increased basal metabolic activity, administering Tylenol is not the first action the nurse should take, because a sickle cell crisis is caused by oxygen deprivation in tissues, not by the fever. PTS: 1 CON: Hematologic Regulation | Oxygenation ANS: 4 12. NURSINGTB.COM Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Discussing the medical management of: Sickle cell anemia Chapter page reference: 690 Heading: Red Blood Cell Disorders Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation; Medication Difficulty: Easy Feedback 1 Acetaminophen or ibuprofen is used for mild pain, and would not be effective for the severe pain experienced by a patient in sickle cell pain crisis. 2 Acetaminophen or ibuprofen is used for mild pain, and would not be effective for the severe pain experienced by a patient in sickle cell pain crisis. 3 Meperidine is not used for pain control for patient in sickle cell crisis, because it can cause seizures. 4 Hydroxyurea decreases production of abnormal blood cells and leads to a lesser amount of pain being experienced. PTS: 1 CON: Hematologic Regulation | Medication 13. ANS: 2 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Discussing the medical management of: Sickle cell anemia Chapter page reference: 689-690
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Heading: Red Blood Cell Disorders Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation; Medication Difficulty: Easy Feedback 1 Morphine and acetaminophen may be given for the pain and fever the patient experiences during a sickle cell crisis. 2 Prophylactic penicillin is often prescribed to patients who are diagnosed with sickle cell disease due to the increased risk for infection. 3 Morphine and acetaminophen may be given for the pain and fever the patient experiences during a sickle cell crisis. 4 Tamoxifen is a medication used to treat breast cancer. PTS: 1 CON: Hematologic Regulation | Medication 14. ANS: 2 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Sickle cell anemia Chapter page reference: 690 Heading: Red Blood Cell Disorders Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation NURSINGTB.COM Difficulty: Easy
1 2 3 4
Feedback The patient with profound pallor and fatigue likely is in an aplastic crisis, not thrombosis. A thrombotic sickle cell crisis is manifested by extreme pain and fever. The patient in profound hypotension and shock likely has splenic sequestration as the etiology, not thrombosis. The patient with a pulmonary infarct likely has Acute Chest Syndrome, not thrombosis.
PTS: 1 CON: Hematologic Regulation 15. ANS: 3 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological disorders Chapter page reference: 690 Heading: Red Blood Cell Disorders Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation; Comfort Difficulty: Easy
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Feedback The patient with sickle cell disease who is in a sickle cell crisis will likely have extreme pain. To aid in caring for this patient, the nurse will administer ordered analgesic medications around the clock, place the patient in position of comfort, and support the patient’s joints and extremities with pillows. The patient with sickle cell disease who is in a sickle cell crisis will likely have extreme pain. To aid in caring for this patient, the nurse will administer ordered analgesic medications around the clock, place the patient in position of comfort, and support the patient’s joints and extremities with pillows. The use of heat or cold packs is contraindicated in the sickle cell patient. Ischemic tissue is fragile and has reduced sensation, increasing the risk of burn injury from hot compresses, whereas cold compresses promote sickling. The patient with sickle cell disease who is in a sickle cell crisis will likely have extreme pain. To aid in caring for this patient, the nurse will administer ordered analgesic medications around the clock, place the patient in position of comfort, and support the patient’s joints and extremities with pillows.
PTS: 1 CON: Hematologic Regulation | Comfort 16. ANS: 2 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological disorders Chapter page reference: 693 Heading: Red Blood Cell Disorders Integrated Processes: Teaching and Learning Client Need: Physiological IntegrityNURSINGTB.COM – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Hematologic Regulation; Medication Difficulty: Moderate 1 2 3 4
Feedback Radiation decreases, not increases, the production of red blood cells. Radiation suppresses the bone marrow in an attempt to decrease the production of red blood cells. Radiation does not provide vitamin supplementation. Radiation does not decrease the risk for a transfusion reaction.
PTS: 1 CON: Hematologic Regulation | Medication 17. ANS: 3 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological disorders Chapter page reference: 688 Heading: Red Blood Cell Disorders Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Hematologic Regulation Difficulty: Moderate
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1 2 3 4
Feedback All blood cells, not just white blood cells, are affected by aplastic anemia. Aplastic anemia does not cause abnormally shaped red blood cells; this is a description of sickle cell disease. In aplastic anemia, the bone marrow does not produce sufficient numbers of circulating blood cells. There is no known association between aplastic anemia and viral illness.
PTS: 1 CON: Hematologic Regulation 18. ANS: 4 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological disorders Chapter page reference: 701 Heading: Bleeding Disorders Integrated Processes: Nursing Process – Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Hematologic Regulation Difficulty: Difficult Feedback 1 Although in an advanced state thrombocytopenic purpura can impact breathing, it does not usually cause ineffective breathing patterns. 2 Nausea is not a symptom of ITP. 3 Fluid-volu me deficits are not lNikUelR y StoIoN ccGuT r w Bi.thCITOPM. 4 ITP is the most common bleeding disorder in children, so risk for injury and subsequent bleeding is the priority nursing diagnosis. PTS: 1 CON: Hematologic Regulation 19. ANS: 3 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological disorders Chapter page reference: 691-692 Heading: Red Blood Cell Disorders Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Hematologic Regulation; Fluid and Electrolyte Balance Difficulty: Difficult Feedback 1 Rapid weaning is not necessary; reduction of pain medication should proceed at a rate dictated by the child’s pain. 2 A high-protein diet is not necessary; a well-balanced diet should be promoted. 3 Adequate hydration will help prevent further sequestration and crisis. 4 Normal activities are not restricted. PTS: 1
CON: Hematologic Regulation | Fluid and Electrolyte Balance
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20. ANS: 3 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Describing the diagnostic results used to confirm disorders of the hematological system Chapter page reference: 681 Heading: Red Blood Cell Disorders Integrated Processes: Nursing Process – Implementation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation Difficulty: Easy
1 2 3 4
Feedback Low hemoglobin is a typical finding in iron-deficiency anemia. Platelet count is unrelated to iron-deficiency anemia. Reticulocytes are immature red blood cells and indicate new cells are being produced. This would be a typical finding in iron-deficiency anemia.
PTS: 1 CON: Hematologic Regulation 21. ANS: 2 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Describing the diagnostic results used to confirm disorders of the hematological system Chapter page reference: 682-683 Heading: Red Blood Cell Disorders NURSINGTB.COM Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation Difficulty: Easy
1 2
3 4
Feedback Vitamin B6 deficiencies are not typically seen with gastric bypass surgeries and are not manifested with a beefy, red, smooth tongue. Vitamin B12 deficiency is associated with gastric bypass surgery. A deficiency of vitamin B12 levels will result in pernicious anemia. This deficiency will manifest as pallor, jaundice, and weakness, and a beefy, smooth red tongue. The patient’s reports are not consistent with a potassium deficiency. Iron-deficiency anemia will manifest with weakness and fatigue.
PTS: 1 CON: Hematologic Regulation 22. ANS: 4 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Anemia Chapter page reference: 679 Heading: Red Blood Cell Disorders Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding]
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Concept: Hematologic Regulation Difficulty: Easy Feedback 1 Polycythemia is an abnormally high RBC count. 2 Herpes simplex is not a red blood cell disorder; erythropoiesis is the term for RBC production. 3 Herpes simplex is not a red blood cell disorder; erythropoiesis is the term for RBC production. 4 Anemia is the most common red blood cell disorder, involving a low count and decreased hemoglobin content. Signs and symptoms of anemia can include pallor of the skin and mucous membranes and dyspnea on exertion. PTS: 1 CON: Hematologic Regulation 23. ANS: 1 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological disorders Chapter page reference: 678-679 Heading: Red Blood Cell Disorders Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation Difficulty: Easy
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1 2 3 4
The anemia associated with renal failure is related to the loss of erythropoietin, which is produced by the healthy kidney and stimulates bone marrow to produce red blood cells. The anemia is not directly related to anorexia or hemodialysis, although these factors may be somewhat associated with the anemia. The anemia is not directly related to anorexia or hemodialysis, although these factors may be somewhat associated with the anemia. Renal failure causes the loss of protein, not blood, through the urine.
PTS: 1 CON: Hematologic Regulation 24. ANS: 3 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological disorders Chapter page reference: 679 Heading: Red Blood Cell Disorders Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation Difficulty: Easy Feedback 1 Altered hemoglobin synthesis is the mechanism involved in iron deficiency anemia, Thalassemia, and chronic inflammation.
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2 3 4
Altered DNA synthesis is the mechanism involved in Vitamin B12 malabsorption or deficiency, and folic acid malabsorption or deficiency. Altered hemolysis, not decreased hemolysis, is a pathophysiological mechanism of anemia. Bone marrow failure is the mechanism in aplastic anemia, red cell aplasia, myeloproliferative leukemia, and lymphomas.
PTS: 1 CON: Hematologic Regulation 25. ANS: 3 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hematological disorders Chapter page reference: 687-688 Heading: Red Blood Cell Disorders Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Hematologic Regulation Difficulty: Moderate 1 2 3
4
Feedback This is not an appropriate response by the nurse. This is not an appropriate response by the nurse. Sickle cell disease is an autosomal recessive disorder. Both parents must have the trait in order for a child to have a 2N 5% URchSanc INe GofThBav.inCgOthMis disease. The most appropriate response by the nurse is to tell the parents the baby will be tested for the disease. This is not an appropriate response by the nurse.
PTS: 1
CON: Hematologic Regulation
MULTIPLE RESPONSE 26. ANS: 1, 2, 5 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with hematological disorders Chapter page reference: 680 Heading: Red Blood Cell Disorders Integrated Processes: Nursing Process – Planning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation; Nutrition Difficulty: Easy
1. 2.
Feedback This is correct. Legumes and peas are good sources of nonheme iron. This is correct. Orange juice supports iron absorption from foods since it is high in vitamin C.
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3. 4. 5.
This is incorrect. Brewer’s yeast is a good source of vitamin B 12 , which is often low in vegan diets. This is incorrect. Okra is not a good source of iron. This is correct. Legumes and peas are good sources of nonheme iron.
PTS: 1 CON: Hematologic Regulation | Nutrition 27. ANS: 2, 3, 5 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Leukemia Chapter page reference: 695-696 Heading: White Blood Cell Disorders Integrated Processes: Nursing Process – Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation Difficulty: Easy
1. 2. 3. 4. 5.
PTS: 1 28. ANS: 1, 3, 4
Feedback This is incorrect. Bone and joint pain with abnormal bleeding are characteristics of AML, which also occurs in older patients. This is correct. The symptoms for CML are insidious and occur over time, affecting older adults. The patient may exhibit splenomegaly, pallor, edema, and lymphadenopathy. This is correct. The symptoms for CML are insidious and occur over time, affecting older adults. The patient may exhibit splenomegaly, pallor, edema, and lymphadenopathy. This is correct. The symN ptU om RsSfIorNCGMTLBa.reCins O Mid ious and occur over time, affecting older adults. The patient may exhibit splenomegaly, pallor, edema, and lymphadenopathy. This is incorrect. Bone and joint pain with abnormal bleeding are characteristics of AML, which also occurs in older patients. CON: Hematologic Regulation
Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Describing the epidemiology of disorders of the hematological system Chapter page reference: 695 Heading: White Blood Cell Disorders Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation; Cellular Regulation Difficulty: Easy
1.
2.
Feedback This is correct. A higher incidence of leukemia associated with chromosomal defects such as Bloom syndrome, exposure to infectious agents, and chemical agents used to treat previous cancer, such as alkylating agents. This is incorrect. Low-fat diets are not a risk factor for leukemia, and neither is lack of exercise.
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3.
4.
5.
This is correct. A higher incidence of leukemia associated with chromosomal defects such as Bloom syndrome, exposure to infectious agents, and chemical agents used to treat previous cancer, such as alkylating agents. This is correct. A higher incidence of leukemia associated with chromosomal defects such as Bloom syndrome, exposure to infectious agents, and chemical agents used to treat previous cancer, such as alkylating agents. This is incorrect. Low-fat diets are not a risk factor for leukemia, and neither is lack of exercise.
PTS: 1 CON: Hematologic Regulation | Cellular Regulation 29. ANS: 2, 3, 4 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Describing the epidemiology of disorders of the hematological system Chapter page reference: 691-692 Heading: Red Blood Cell Disorders Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Hematologic Regulation Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is incorrect. Regular exercise and increased fluid intake are recommended activities for a child with sickle cell disease and will not contribute to a sickle cell crisis. This is correct. Fever, voNmUitRinSgI , aN ndGaTltB itu.dC e O arM e some of the precipitatin g factors that contribute to a sickle cell crisis. This is correct. Fever, vomiting, and altitude are some of the precipitating factors that contribute to a sickle cell crisis. This is correct. Fever, vomiting, and altitude are some of the precipitating factors that contribute to a sickle cell crisis. This is incorrect. Regular exercise and increased fluid intake are recommended activities for a child with sickle cell disease and will not contribute to a sickle cell crisis.
PTS: 1 CON: Hematologic Regulation 30. ANS: 2, 3, 4 Chapter number and title: 34, Coordinating Care for Patients With Hematological Disorders Chapter learning objective: Describing the epidemiology of disorders of the hematological system Chapter page reference: 691-692 Heading: Red Blood Cell Disorders Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Hematologic Regulation Difficulty: Difficult
1.
Feedback This is incorrect. Regular exercise and increased fluid intake are recommended activities for a child with sickle cell disease and will not contribute to a sickle cell crisis.
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2. 3. 4. 5.
PTS: 1
This is correct. Fever, dehydration, and altitude are all precipitating factors contributing to a sickle cell crisis. This is correct. Fever, dehydration, and altitude are all precipitating factors contributing to a sickle cell crisis. This is correct. Fever, dehydration, and altitude are all precipitating factors contributing to a sickle cell crisis. This is incorrect. Regular exercise and increased fluid intake are recommended activities for a child with sickle cell disease and will not contribute to a sickle cell crisis. CON: Hematologic Regulation
Chapter 35: Assessment of Neurological Function Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A patient is diagnosed with a health problem that causes demyelization of the peripheral nerves. Which cell structure is being affected? 1) Microglia 2) Astrocytes 3) Schwann cells NURSINGTB.COM 4) Oligodendrocytes 2. A patient is experiencing changes in eye movements. Which part of the central nervous system is most likely causing these changes? 1) Pons 2) Midbrain 3) Medulla oblongata 4) Reticular formation 3. A patient experiences a cramp in the right thigh. Which spinal tract is responsible for communicating to the thigh muscle to contract? 1) Somatic motor division 2) Visceral motor division 3) Somatic sensory division 4) Visceral sensory division 4. A patient reports a change in the taste of food. Which cranial nerve should the nurse suspect as being affected? 1) CN VII Facial 2) CN V Trigeminal 3) CN XI Accessory 4) CN XII Hypoglossal 5. A patient’s blood pressure increases after hearing that diagnostic tests for a health problem have to be repeated. Which receptor of the sympathetic nervous system is responsible for this blood pressure change? 1) Beta
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2) Alpha 3) Nicotinic 4) Muscarinic 6. The nurse needs to provide a strong stimulus to illicit a response; however, the patient drifts back to unresponsiveness. What term should the nurse use to document this patient’s level of responsiveness? 1) Coma 2) Stupor 3) Lethargic 4) Conscious 7. The nurse is completing a Mini Mental Status Examination with a patient. What should the nurse ask to evaluate remote memory? 1) “Where did you park your car?” 2) “Where did you work in the 1970s?” 3) “Remember the colors red, green, blue, and yellow.” 4) “What television show was on this morning during breakfast?” 8. Which technique should the nurse use to assess a patient’s CN IX Glossopharyngeal? 1) Apply a tongue depressor to the back of the throat 2) Ask the patient to read from a book or a newspaper 3) Ask the patient to smile, frown, puff cheeks, and raise eyebrows 4) Ask the patient to follow the examiner’s finger as it is moved toward the patient’s nose 9. A patient is unable to feel light touch down the anterior left leg and top of the left foot. How should the nurse document this finding? 1) Anesthesia NURSINGTB.COM 2) Paresthesia 3) Hypoesthesia 4) Hyperesthesia 10. A patient is scheduled for a positron emission tomography (PET) scan. For which health problem should the nurse anticipate planning care for this patient? 1) Brain tumor 2) Cerebral bleed 3) Cranial fracture 4) Cerebral blood clot 11. A patient has been experiencing numbness of the right hand. Which diagnostic test should the nurse anticipate being prescribed for this patient? 1) Myelogram 2) Evoked potentials 3) Electroencephalography 4) Magnetic resonance imaging 12. The nurse notes that a patient has ataxia. Which test should the nurse use to gain more information about this patient’s gait? 1) Romberg 2) Patellar reflex 3) Plantar flexion 4) Achilles reflex
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13. During a neurologic assessment the nurse asks a patient to close the eyes and asks the patient to identify a paper clip placed in the hand. What is the nurse assessing? 1) Stereognosis 2) Hyperesthesia 3) Graphesthesia 4) Two-point discrimination 14. A patient with type 2 diabetes mellitus is scheduled for a CT scan with contrast. What should the nurse specifically instruct the patient to prepare for this test? 1) Restrict fluids for 12 hours prior to the scan 2) Drink two liters of fluid the day before the scan 3) Limit the intake of meat and dairy products prior to the scan 4) Do not take Metformin for 48 hours prior to and after the scan 15. A patient is scheduled for an electroencephalogram. What preprocedure information should the nurse emphasize with this patient? 1) Avoid washing hair for two days prior to the test 2) Avoid caffeine for 8 to 12 hours before the test 3) Restrict the intake of fluids for six hours after the test 4) Apply minimal products to the hair the morning of the test 16. A patient recovering from a lumbar puncture rates a headache as being 8 on a pain scale of 0 to 10. What should the nurse do while waiting for the health-care provider to prescribe pain medication? 1) Raise the head of the bed 2) Assist to sit out of bed in a chair 3) Encourage increasing oral fluid intake 4) Turn on the side and massage thN eU loR wS e rIspNinGeTB.COM 17. A patient is scheduled for a myelogram prior to having spinal fusion surgery. What should the nurse instruct the patient to do prior to this test? 1) Shower with antiseptic soap 2) Take nothing by mouth for four hours before the test 3) Take an over-the-counter analgesic before arriving for the test 4) Restrict the intake of caffeine products for 24 hours before the test 18. The nurse is preparing to assess an older patient’s neurologic status. What should the nurse keep in mind during this assessment? 1) Reaction time is slower 2) Flexibility is maintained 3) Pain sensation is heightened 4) Body movements are quicker 19. The nurse notes that an older patient sways when moving from a sitting to a standing position. What is this patient at risk for experiencing? 1) Falls 2) Hypothermia 3) Altered pain sensation 4) Reduced oxygen to the brain 20. Family members are concerned because a patient has been confused over the last few days. What should the nurse respond to the family? 1) “Confusion is a normal sign of aging.”
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2) “Older people get confused at the end of the day.” 3) “Unless the patient falls, there is nothing to worry about.” 4) “Confusion can mean many things that should be evaluated.” Multiple Response Identify one or more choices that best complete the statement or answer the question. 21. The nurse is preparing a teaching tool about the nervous system. Which type of tissue should the nurse identify as being a part of gray matter? Select all that apply. 1) Dendrites 2) Cell bodies 3) Myelin sheath 4) Axon terminals 5) Nodes of Ranvier 22. A patient sustains an injury to the left temporal lobe. Which body functions should the nurse expect to be affected by this injury? Select all that apply. 1) Body position 2) Long-term memory 3) Auditory perception 4) Receptive speech center 5) Expressive speech center 23. The nurse is conducting a medical history with a patient experiencing headaches. Which information should be included in this history? Select all that apply. 1) Date of last lipid screen NURSINGTB.COM 2) Past surgical procedures 3) Recent diagnostic studies 4) Treatment for chronic illnesses 5) Date of last influenza vaccination 24. The nurse notes that a patient has a positive Babinski response. For what should the nurse assess this patient? Select all that apply. 1) Alcohol abuse 2) Substance abuse 3) Multiple sclerosis 4) Parkinson’s disease 5) Traumatic brain injury 25. A patient is recovering from a cerebral angiogram. What care should the nurse provide to this patient? Select all that apply. 1) Monitor intravenous fluid infusion 2) Elevate the puncture site limb on a pillow 3) Maintain pressure on arterial puncture site 4) Enforce bedrest for 6 to 12 hours after the procedure 5) Monitor vital signs every 15 minutes for the first hour
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Chapter 35: Assessment of Neurological Function Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Identifying key anatomical components of the neurological system Chapter page reference: 709 Heading: Overview of Anatomy and Physiology > Neuroglial Cells Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Neurologic Regulation; Sensory Perception Difficulty: Easy Feedback 1 Microglia are small cells that become phagocytic when they encounter inflammation or debris. They are a means of defense. 2 Astrocytes provide structure and support. 3 Schwann cells form myelin sheaths that cover axons in the peripheral nervous system. 4 Oligodendrocytes are small cells that form myelin sheaths that cover the axons of the neurons in the central nervous system. PTS: 1
CON: Neurologic Regulation | Sensory Perception
2. ANS: 2 NURSINGTB.COM Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Identifying key anatomical components of the neurological system Chapter page reference: 713 Heading: Overview of Anatomy and Physiology > Midbrain Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Neurologic Regulation; Sensory Perception Difficulty: Moderate
1
2
3
4
Feedback The pons rests above the medulla oblongata below and anterior to the midbrain, and relays all impulses between the brain and the spinal cord. Four cranial nerves originate in the pons: trigeminal (V), abducens (V), facial (VII), and acoustic (VIII). The midbrain contains the nerve pathways between the cerebrum and the medulla oblongata. Cranial nerves III and IV, which control eye movements, have their origins here. The medulla oblongata is continuous with the spinal cord and is located at the level of and below the foramen magnum. Four cranial nerves originate here: glossopharyngeal (IX), vagus (X), spinal accessory (XI), and hypoglossal (XII). The reticular formation consists of networks of neural cells that impact motor control and coordination, balance and posture during movement, respiratory and cardiac functions, pain modulation, and alertness and sleep.
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PTS: 1 CON: Neurologic Regulation | Sensory Perception 3. ANS: 1 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Discussing the function of the neurological system Chapter page reference: 719 Heading: The Peripheral Nervous System Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Neurologic Regulation Difficulty: Moderate
1 2 3 4
Feedback The somatic motor division transports signals back to the skeletal muscles to produce a contraction. The visceral motor division transports signals back to smooth muscle, cardiac muscle, and glands at an unconscious level. The somatic sensory division transmits signals from receptors in muscles, bones, joints, and skin. The visceral sensory division transmits signals from the heart, lungs, GI tract, and bladder.
PTS: 1 CON: Neurologic Regulation 4. ANS: 1 NURSINGTB.COM Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Discussing the function of the neurological system Chapter page reference: 722 Heading: The Peripheral Nervous System > Cranial Nerves Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Moderate
1 2 3 4
Feedback CN VII Facial influences taste. CN V Trigeminal controls touch, temperature, pain sensations from the upper and lower face, and chewing. CN XI Accessory controls swallowing and head, neck, and shoulder movements. CN XII Hypoglossal controls tongue movement with speech, food manipulation, and swallowing.
PTS: 1 CON: Neurologic Regulation 5. ANS: 2 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Discussing the function of the neurological system Chapter page reference: 720 Heading: The Peripheral Nervous System > Sympathetic Nervous System
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Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 Beta receptors are usually inhibitory and dilate bronchioles, which enhances airflow. Beta receptors can also have excitatory effects on cardiac muscle, producing a stronger cardiac contraction and increased heart rate. 2 Alpha receptors typically have an excitatory effect, producing vasoconstriction that increases blood pressure. 3 Nicotinic receptors are part of the parasympathetic nervous system and have an excitatory effect. 4 Muscarinic receptors are part of the parasympathetic nervous system and have an excitatory or inhibitory response depending on the target organ system. PTS: 1 CON: Neurologic Regulation 6. ANS: 2 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of neurological function Chapter page reference: 725 Heading: Assessment > Level of Consciousness Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [ApplyN inU g]RSINGTB.COM Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 Coma means the patient is unarousable and unresponsive. 2 Stupor is defined as having minimal movement without stimulus; requires strong vigorous stimulus and then drifts back to unresponsiveness. 3 Lethargic means the patient is severely sleepy and has a slow and delayed response to stimulus. 4 Conscious means the patient is awake with appropriate speech and behavior. PTS: 1 CON: Neurologic Regulation 7. ANS: 2 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of neurological function Chapter page reference: 726 Heading: Assessment > Cognitive Function Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Cognition Difficulty: Moderate Feedback
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1 2 3 4
“Where did you park your car” assesses recent memory. “Where did you work in the 1970s” assesses remote memory. Asking the patient to remember colors assesses immediate memory. “What television show was on this morning during breakfast” assesses recent memory.
PTS: 1 CON: Neurologic Regulation | Cognition 8. ANS: 1 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of neurological function Chapter page reference: 727 Heading: Assessment > Cranial Nerve Assessment Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Moderate 1 2 3 4
Feedback CN XI Glossopharyngeal is assessed by applying a tongue depressor to the back of the throat to check for a gag reflex. Reading assesses CN II Optic. Smiling, frowning, puffing out the cheeks, and raising the eyebrows assesses CN VII Facial. Having the patient follow a finNgU erRa S s iI t iN sG mT ovBed. to CwOard M the nose assesses CN IV Trochlear.
PTS: 1 CON: Neurologic Regulation 9. ANS: 1 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of neurological function Chapter page reference: 728 Heading: Assessment > Sensory System Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Sensory Perception Difficulty: Moderate Feedback 1 Anesthesia is the absence of sensation. 2 Paresthesia is an abnormal feeling of pins and needles, itching, numbness, and tingling. 3 Hypoesthesia is a decreased feeling to touch; numbness. 4 Hyperesthesia is an increased sensitivity to touch. PTS: 1 CON: Neurologic Regulation | Sensory Perception 10. ANS: 1 Chapter number and title: 35, Assessment of Neurological Function
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Chapter learning objective: Correlating relevant diagnostic examinations to neurological function Chapter page reference: 731 Heading: Assessment > Positron Emission Tomography Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Cellular Regulation Difficulty: Moderate Feedback 1 The PET scan is a very sensitive test for detecting cancer because rapidly dividing cancer cells absorb the tracer, making them detectable with the scanner. 2 A PET scan is not used to diagnose a cerebral bleed. 3 A PET scan is not used to diagnose or identify a cranial fracture. 4 A PET scan is not used to diagnose a cerebral blood clot. PTS: 1 CON: Neurologic Regulation | Cellular Regulation 11. ANS: 2 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Correlating relevant diagnostic examinations to neurological function Chapter page reference: 733 Heading: Assessment > Evoked Potentials Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Sensory Perception
NURSINGTB.COM Difficulty: Moderate Feedback 1 A myelogram enables visualization of the entire spinal column to evaluate for lesions, cysts, injury, herniated discs, and tumors. 2 A somatosensory evoked potential focuses on nerve conduction in the arms and legs and is done with mild electrical stimulation. Somatosensory evoked potential electrodes are typically placed on the wrist (medial nerve). 3 Electroencephalography is a diagnostic test for epilepsy and other electrical activity abnormalities. 4 An MRI can be used to assess injuries of the brain and spinal column —diagnose tumors, infections, and bleeding. It is very useful in the diagnosis of a cerebrovascular accident (CVA) or stroke.
PTS: 1 CON: Neurologic Regulation | Sensory Perception 12. ANS: 1 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Correlating relevant diagnostic examinations to neurological function Chapter page reference: 727 Heading: Assessment > Cerebellar Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Easy
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1 2 3 4
Feedback The Romberg test is performed to assess balance. Reflexes are involuntary and automatic responses to stimuli that provide the body with protection and help to adjust to the environment. Reflexes are involuntary and automatic responses to stimuli that provide the body with protection and help to adjust to the environment. Reflexes are involuntary and automatic responses to stimuli that provide the body with protection and help to adjust to the environment.
PTS: 1 CON: Neurologic Regulation 13. ANS: 1 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Correlating relevant diagnostic examinations to neurological function Chapter page reference: 728 Heading: Assessment > Sensory System Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Assessment Difficulty: Easy Feedback 1 Stereognosis or the ability to identify an object by its shape by simply holding the object. 2 Hyperesthesia or an increased sensitivity to touch. 3 Graphesthesia or the ability toNidUent RSifyIlNetGteTrsBo .r nCuOmMbers when drawn on the skin. 4 Two-point discrimination is the ability to distinguish two points separately. PTS: 1 CON: Neurologic Regulation | Assessment 14. ANS: 4 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to neurological function Chapter page reference: 731 Heading: Assessment > Diagnostic Studies > Computerized Tomography Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] CON: Neurologic Regulation; Medication Difficulty: Moderate Feedback 1 2 3 4
Fluids do not need to be restricted prior to a CT scan with contrast. Fluids do not need to be increased prior to a CT scan with contrast. Meat and dairy products do not need to be restricted prior to a CT scan with contrast. Metformin is cleared primarily through the kidneys, and if it is administered prior to the examination and the administration of contrast results in renal impairment, metformin levels will remain elevated, potentially resulting in a lactic acidosis. Because of this metformin must be held 48 hours prior to and after the CT scan or until renal function is determined to be normal via normal BUN and creatinine levels.
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PTS: 1 CON: Neurologic Regulation | Medication 15. ANS: 2 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to neurological function Chapter page reference: 732 Heading: Assessment > Diagnostic Studies > Electroencephalography Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 The hair should be washed the night before and the morning of the test. 2 Caffeine should be avoided for 8 to 12 hours before the test because caffeine may alter the results. 3 Fluids do not need to be restricted for this test. 4 Hair products should be avoided prior to the test to aid in scalp electrode attachment. PTS: 1 CON: Neurologic Regulation 16. ANS: 3 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to neurological function NURSINGTB.COM Chapter page reference: 733 Heading: Assessment > Diagnostic Studies > Lumbar Puncture Integrated Processes: Nursing Process; Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 The bed should be flat to prevent the onset or worsening of a headache. 2 The patient should be on bedrest for four to six hours. 3 To avoid postlumbar puncture headaches, ask the patient to stay hydrated postprocedure. 4 Massaging the lower spine will not help reduce a spinal headache. PTS: 1 CON: Neurologic Regulation 17. ANS: 2 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to neurological function Chapter page reference: 733 Heading: Assessment > Diagnostic Studies > Myelography Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying]
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Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 The patient does not need to shower with antiseptic soap before the test. 2 For a myelogram the patient should be instructed to take nothing by mouth for four hours before the test. 3 The patient should not take anything by mouth for four hours before the test. 4 Caffeine products do not need to be restricted for this test. PTS: 1 CON: Neurologic Regulation 18. ANS: 1 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Discussing changes in neurological function associated with aging Chapter page reference: 734 Heading: Age-Related Changes Integrated Processes: Nursing Process; Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Nursing Difficulty: Moderate Feedback 1 An age-related change to the neurologic system includes decreased reaction time. 2 Flexibility is decreased in an older patient. 3 Pain sensations are decreased in an older patient. 4 Body movements are slower inN aUnRoS ldI erNpG atT ie nBt. . COM PTS: 1 CON: Neurologic Regulation | Nursing 19. ANS: 1 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Discussing changes in neurological function associated with aging Chapter page reference: 734 Heading: Age-Related Changes Integrated Processes: Nursing Process; Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation; Nursing Difficulty: Moderate Feedback 1 Instability when moving from a sitting to a standing position increases this patient’s risk of falling. 2 Instability when moving from a sitting to a standing position has no effect on temperature regulation. 3 Instability when moving from a sitting to a standing position has no effect on pain sensations. 4 Instability when moving from a sitting to a standing position has no effect on cerebral oxygenation. PTS: 1
CON: Neurologic Regulation | Nursing
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20. ANS: 4 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Discussing changes in neurological function associated with aging Chapter page reference: 734 Heading: Age-Related Changes Integrated Processes: Nursing Process; Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Nursing Difficulty: Moderate 1 2 3 4
Feedback Caution should be taken in assuming that confusion is a “normal” part of aging, as this change can also occur as a result of disease or an infection. There is no evidence to support that older people get confused at the end of the day. Confusion should be investigated. The patient should not have to wait until a fall occurs to be evaluated for confusion. Cognitive impairment can occur as a result of the aging process, disease, medications, poor nutrition, and changes in the nervous system.
PTS: 1
CON: Neurologic Regulation | Nursing
MULTIPLE RESPONSE 21. ANS: 1, 2, 4 NURSINGTB.COM Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Identifying key anatomical components of the neurological system Chapter page reference: 709 Heading: Overview of Anatomy and Physiology > Neurons Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Gray matter contains dendrites. Gray matter contains cell bodies. White matter contains myelin sheaths. Gray matter contains axon terminals. White matter contains the Nodes of Ranvier.
PTS: 1 CON: Neurologic Regulation 22. ANS: 2, 3, 4 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Discussing the function of the neurological system Chapter page reference: 712 Heading: Overview of Anatomy and Physiology > Cerebrum
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Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Body position is a function of the parietal lobe. Long-term memory is a function of the temporal lobe. Auditory perception is a function of the temporal lobe. Receptive speech is a function of the temporal lobe. Expressive speech is a function of the frontal lobe.
PTS: 1 CON: Neurologic Regulation 23. ANS: 2, 3, 4 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of neurological function Chapter page reference: 724 Heading: Assessment > History and Physical > History Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Assessment Difficulty: Moderate
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1. 2. 3. 4. 5.
Feedback Lipid screen information would be included under regular medical care. Medical history includes past surgical procedure/treatments. Medical history includes recent diagnostic studies. Medical history includes treatment for chronic diseases. Date of last influenza vaccination would be included under regular medical care.
PTS: 1 CON: Neurologic Regulation | Assessment 24. ANS: 1, 2, 3, 5 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Correlating relevant diagnostic examinations to neurological function Chapter page reference: 728 Heading: Assessment > Reflexes Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Assessment Difficulty: Moderate
1. 2. 3.
Feedback A positive Babinski’s can occur in patients with alcohol abuse. A positive Babinski’s can occur in patients with substance abuse. A positive Babinski’s can occur in patients with multiple sclerosis.
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A positive Babinski’s is not identified as occurring in patients with Parkinson’s disease. A positive Babinski’s can occur in patients with traumatic brain injury.
4. 5.
PTS: 1 CON: Neurologic Regulation | Assessment 25. ANS: 1, 3, 4, 5 Chapter number and title: 35, Assessment of Neurological Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to neurological function Chapter page reference: 732 Heading: Assessment > Diagnostic Studies > Cerebral Angiography Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Moderate Feedback After a cerebral angiogram intravenous fluids are needed to clear contrast dye from the circulation. The limb used for the puncture site should be kept straight for 6 to 12 hours. Pressure should be maintained on the puncture site. The patient should be on bedrest for 6 to 12 hours after the procedure. Vital signs should be monitored every 15 minutes for the first hour.
1. 2. 3. 4. 5. PTS:
1
CON: NeuroloNgU icRRSegIuNlaG tioTnB.COM
Chapter 36: Coordinating Care for Patients With Brain Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is preparing material for a community health fair. What should the nurse identify as being the most common cause of headache pain in adults? 1) Mixed 2) Cluster 3) Tension 4) Migraine 2. It is believed that a patient’s migraine headaches are caused by vascular constriction. Which medication should the nurse expect to be prescribed for this patient? 1) Citalopram (Celexa) 2) Imipramine (Tofranil) 3) Amlodipine (Norvasc) 4) Lamotrigine (Lamictal)
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3. A patient is diagnosed with a continuous headache syndrome. What treatment should the nurse expect to be prescribed for this patient? 1) Antibiotics 2) Diuretic therapy 3) Intravenous fluids 4) Sodium restriction 4. The health-care professional is identifying the best course of treatment for a patient with a brain tumor. What should be considered when selecting chemotherapeutic agents for this patient? 1) Cause mild neutropenia 2) Cross the blood-brain barrier 3) Restrict weight loss and hair loss 4) Limit the development of mucositis 5. The nurse is planning discharge instructions for a patient recovering from surgery to debulk a brain tumor. Why should self-monitoring of capillary blood glucose level be a part of this teaching? 1) Taking steroid medication 2) Manipulation of cerebral tissue 3) Interruption of glucose regulation in the brain 4) Alteration in oral intake from chemotherapy 6. During morning care a patient with a seizure disorder asks why the room has suddenly turned green. What should the nurse do? 1) Ask the patient to explain 2) Prepare for a seizure to begin 3) Turn on the overhead room lights 4) Document visual hallucinations N p rUesRe S n tINGTB.COM 7. A patient with a seizure disorder asks the purpose of staying awake all night prior to having an electroencephalogram in the morning. What should the nurse explain to this patient? 1) “You will be expected to sleep during the test.” 2) “Most people with seizure disorders receive too much sleep.” 3) “This is the only way to prove that you really have a seizure disorder.” 4) “Sleep deprivation can cause a seizure, which will be helpful during the test.” 8. A patient has been experiencing a tonic-clonic seizure for five minutes. What should the nurse do first? 1) Assess carotid pulse 2) Prepare to insert an airway 3) Provide rescue breathing 4) Insert an intravenous access line 9. The nurse is admitting a patient experiencing photophobia and nuchal rigidity. For which diagnostic test should the nurse prepare this patient? 1) Lumbar puncture 2) Evoked potentials 3) CT scan with contrast 4) Electroencephalogram 10. The nurse is planning care for a patient with meningitis. What teaching material should be prepared to explain the prescribed treatment for this disorder? 1) Fluid restriction 2) Low-fat, low-calorie diet
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3) Over-the-counter analgesics 4) Long-term antibiotic therapy 11. A patient with meningitis is prescribed a cooling blanket. What should the nurse explain as being the purpose of this device? 1) Relieves pain 2) Increases cerebral venous outflow 3) Decreases oxygen demand in the brain 4) Reduces the transmission of the infection 12. The nurse suspects that a patient with photophobia is experiencing encephalitis. What observation of the patient’s behavior caused the nurse to make this clinical decision? 1) Closed the eyes 2) Covered the ears with both hands 3) Placed both hands in coat pockets 4) Rubbed the thighs with both hands 13. The nurse is reviewing medical orders written for a patient with encephalitis. Which medication should the nurse expect to be prescribed as a priority for this patient? 1) Antiviral 2) Antibiotic 3) Antiemetic 4) Antiseizure 14. The nurse is preparing medications for a client with encephalitis. Which medication should the nurse question before administering? 1) Furosemide (Lasix) NURSINGTB.COM 2) Phenytoin (Dilantin) 3) Docusate sodium (Colace) 4) Prochlorperazine (Compazine) 15. During a home visit the nurse considers physical therapy for a patient recovering from encephalitis. What would be the best explanation for this referral? 1) Rehabilitation from hemiparesis 2) Deconditioning from extended bedrest 3) Improve use of limbs because of paresthesias 4) Improve balance because of cerebellum dysfunction 16. The nurse suspects that a patient is experiencing Parkinson’s disease. What did the nurse assess to make this clinical determination? 1) Photophobia 2) Nuchal rigidity 3) Slow movements 4) Elevated body temperature 17. A patient returns to the community clinic after being diagnosed with Parkinson’s disease. What should the nurse expect to see documented in the patient’s medical record to support this diagnosis? 1) Rigidity with ambulation 2) Unremarkable electroencephalogram 3) Results of serum potassium and calcium levels 4) Integrity of cerebral vessels after a cerebral angiogram
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18. A patient with Parkinson’s disease is prescribed carbidopa/levodopa (Sinemet). Which clinical manifestation should the nurse expect to be most affected with this medication? 1) Tremors 2) Mood instability 3) Impaired balance 4) Behavioral changes 19. The nurse interrupts unlicensed assistive personnel who is assisting a patient with Parkinson’s disease with breakfast. Which observation caused the nurse to immediately intervene? 1) Patient sitting out of bed in a chair 2) Head of the bed raised to 30 degrees 3) Thickener added to liquid menu items 4) Oral suction catheter equipment turned on 20. The nurse is concerned that a patient’s Alzheimer’s disease is progressing. What finding did the nurse use to confirm this suspicion? 1) Inability to recall the word for “car” 2) Misplacement of health insurance cards 3) Unable to find sweater in the waiting room 4) Leaving the practitioner’s office without taking prescriptions 21. A patient is suspected of having Alzheimer’s disease. What diagnostic testing should the nurse expect to provide a presumptive diagnosis of this disorder? 1) Echocardiogram 2) Cerebral angiogram 3) Serum medication levels 4) History and physical examinatioNn URSINGTB.COM 22. During a home visit the nurse is concerned that the patient with Alzheimer’s disease is deteriorating. What patient observation caused the nurse to have this concern? 1) Sitting in a chair watching a television program 2) Staying away from the door leading to the back yard 3) No recognition of bowel incontinence during the visit 4) Eating cheese and crackers placed on a table near the living room chair Multiple Response Identify one or more choices that best complete the statement or answer the question. 23. The staff development trainer is preparing orientation materials for new staff hired to care for patients with seizure disorders. Which type of seizure can occur in any age group? Select all that apply. 1) Absence 2) Myoclonic 3) Tonic-clonic 4) Simple partial 5) Complex partial 24. The nurse suspects that a patient is in the premonitory phase of a migraine headache. What findings did the nurse use to make this clinical decision? Select all that apply. 1) Yawning 2) Confusion 3) Food cravings
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4) Flashing lights 5) Increased urine output 25. The nurse suspects that a patient with a brain tumor is developing increased intracranial pressure (ICP). What assessment findings caused the nurse to make this conclusion? Select all that apply. 1) Ataxia 2) Nausea 3) Diarrhea 4) Vomiting 5) Headache 26. The nurse notifies the health-care provider while caring for a patient recovering from a craniotomy as treatment for a brain tumor. What did the nurse assess to cause this alarm? Select all that apply. 1) Heart rate 52 bpm 2) Temperature 99.2 °F 3) Respiratory rate 10 and irregular 4) Urine output 200 mL over 4 hours 5) Systolic blood pressure 198 mm Hg 27. A patient comes to the community clinic complaining of having a fever. What findings should suggest to the nurse that the patient is experiencing meningitis? Select all that apply. 1) Eye tearing 2) Photophobia 3) Opisthotonos 4) Nuchal rigidity 5) Auditory hallucinations
NURSINGTB.COM Numeric Response 28. A patient with a seizure disorder is prescribed a 1900-calorie diet of which 80% should be consumed as fat. How many calories should the patient consume as fat? Record your answer as a whole number.
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Chapter 36: Coordinating Care for Patients With Brain Disorders Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Describing the epidemiology of disorders of the brain Chapter page reference: 738 Heading: Headache > Epidemiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Comfort; Neurologic Regulation; Promoting Health Difficulty: Easy Feedback 1 Mixed is not identified as a type of headache. 2 Cluster headaches, found predominantly in males with an onset of 30 to 50 years, show an overall prevalence of 0.4% of the population. 3 The prevalence of tension headaches is in excess of 42%. 4 Migraine headaches have been reported in 11% of the population. PTS: 1
CON: Comfort | Neurologic Regulation | Promoting Health
2. ANS: 3 NURSINGTB.COM Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Discussing the management of: Headaches Chapter page reference: 742 Heading: Headache > Medical Management > Treatment > Medications Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Comfort; Neurologic Regulation; Medication Difficulty: Moderate
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Feedback Citalopram (Celexa) is a selective serotonin reuptake inhibitor believed to balance chemicals in the brain to prevent migraine headaches. Imipramine (Tofranil) is a tricyclic antidepressant that does not affect vascular structure. Antihypertensive medications such as amlodipine (Norvasc), a calcium channel blocker, prevents vasoconstriction or vasodilation in the cerebral blood vessels. Anticonvulsant medications used to treat seizure disorders, such as lamotrigine (Lamictal), increase the levels of many neurotransmitters and diminish pain impulses.
PTS: 1 CON: Comfort | Neurologic Regulation | Medication 3. ANS: 3 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders
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Chapter learning objective: Explaining the clinical presentation and management of complications associated with disorders of the brain Chapter page reference: 742 Heading: Headache > Medical Management > Treatment > Complications > Status Migrainosus and Hemicrania Continua Integrated Processes: Nursing Process: Planning Cognitive Level: Application [Applying] Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Concept: Comfort; Neurologic Regulation; Medication Difficulty: Moderate 1 2 3 4
Feedback Antibiotics are not used to treat continuous headache syndromes. Diuretics are not used to treat continuous headache syndromes. Treatment for continuous headache syndromes includes IV hydration. A sodium restriction is not used to treat continuous headache syndromes.
PTS: 1 CON: Comfort | Neurologic Regulation | Medication 4. ANS: 2 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Discussing the management of: Primary brain tumors Chapter page reference: 745 Heading: Primary Brain Tumor > Medical Management Integrated Processes: Nursing Process: Planning Cognitive Level: Application [Applying] Client Need: Physiological Integrity/N PhUaR rmSaI coN loG giT caBl . anCdOPM arenteral Therapies Concept: Comfort; Neurologic Regulation; Medication Difficulty: Moderate
1 2 3 4
Feedback Chemotherapeutic agents cause neutropenia. The chemotherapeutic agents used to treat brain tumors must have the ability to cross the blood-brain barrier. There is no way to eliminate weight and hair loss since these are side effects of chemotherapy. There is no way to limit the development of mucositis since this is a side effect of chemotherapy.
PTS: 1 CON: Comfort | Neurologic Regulation | Medication 5. ANS: 1 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with disorders of the brain Chapter page reference: 748 Heading: Primary Brain Tumors > Nursing Interventions > Teaching Integrated Processes: Teaching and Learning Cognitive Level: Analysis [Analyzing] Client Need: Physiological Integrity/Reduction of Risk Potential Concept: Neurologic Regulation; Promoting Health
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Difficulty: Moderate
1
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Feedback Some patients treated for a brain tumor become hyperglycemic as a result of steroid administration and require home testing of glucose levels while they are receiving glucocorticoids. Cerebral tissue manipulation does not affect blood glucose level. Surgery for a brain tumor does not interrupt glucose regulation in the brain. Capillary blood glucose monitoring is not required because of a change in oral intake caused by chemotherapy.
PTS: 1 CON: Neurologic Regulation | Promoting Health 6. ANS: 2 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Seizures Chapter page reference: 750 Heading: Seizures > Clinical Manifestations Integrated Processes: Nursing Process: Implementation Cognitive Level: Application [Applying] Client Need: Physiological Integrity/Reduction of Risk Potential Concept: Neurologic Regulation Difficulty: Moderate
1 2 3 4
Feedback Asking the patient to explain w NiUll RwSasIteNvGalua TBbl.e CtiOmeM since the patient is going to have a seizure. Seizures can be preceded by a preictal phase that may include an aura. An aura can be a visual hallucination like the room color changing to green. Turning on the overhead rooms lights indicates that the nurse is unaware of the patient experiencing an aura, which is a precursor to a seizure in many patients. The nurse should not stop to document at this time. The patient is going to seize.
PTS: 1 CON: Neurologic Regulation 7. ANS: 4 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Describing the diagnostic results used to confirm disorders of the brain Chapter page reference: 751 Heading: Seizures > Medical Management > Diagnosis Integrated Processes: Nursing Process: Implementation Cognitive Level: Application [Applying] Client Need: Physiological Integrity/Reduction of Risk Potential Concept: Neurologic Regulation Difficulty: Moderate 1 2 3
Feedback The patient will not be expected to sleep during a sleep-deprived EEG. Saying that people with seizure disorders sleep too much is inappropriate and incorrect. A sleep-deprived EEG is not the only way to prove that the patient really has a seizure disorder.
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4
A sleep-deprived EEG may be performed. Stress, such as that found when the individual is deprived of sleep, causes an increase in cortical activity and is a key trigger for seizures.
PTS: 1 CON: Neurologic Regulation 8. ANS: 2 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Explaining the clinical presentation and management of complications associated with disorders of the brain Chapter page reference: 753 Heading: Seizures > Medical Management > Complications > Status Epilepticus Integrated Processes: Nursing Process: Implementation Cognitive Level: Application [Applying] Client Need: Physiological Integrity/Reduction of Risk Potential Concept: Neurologic Regulation Difficulty: Moderate
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Feedback Assessing circulation might be required but only after establishing an airway and providing rescue breathing. In the case of status epilepticus, which is a seizure lasting longer than five minutes, emergency actions should be taken. The first is to establish an airway. Providing rescue breathing might be required but only after establishing an airway. Inserting an intravenous access line is essential but only after the ABCs of emergency care are completed. NURSINGTB.COM
PTS: 1 CON: Neurologic Regulation 9. ANS: 1 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Describing the diagnostic results used to confirm disorders of the brain Chapter page reference: 756 Heading: Meningitis > Medical Management > Diagnosis Integrated Processes: Nursing Process: Planning Cognitive Level: Application [Applying] Client Need: Physiological Integrity/Reduction of Risk Potential Concept: Neurologic Regulation Difficulty: Moderate
1 2 3
4
Feedback Examination of CSF via lumbar puncture is the hallmark for the diagnosis of meningitis. Evoked potentials are used to assess peripheral nerve function. Patients with suspicion for space-occupying lesions and new-onset seizures and those with a moderate to severe altered level of consciousness require a CT of the head prior to the procedure, as they are at higher risk for herniation. However, the patient is not demonstrating any of these manifestations. An electroencephalogram is used to diagnose a seizure disorder.
PTS: 1
CON: Neurologic Regulation
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10. ANS: 4 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Discussing the management of: Meningitis Chapter page reference: 756 Heading: Meningitis > Medical Management > Medications Integrated Processes: Teaching and Learning Cognitive Level: Application [Applying] Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Concept: Neurologic Regulation; Medication Difficulty: Moderate
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Feedback The treatment for meningitis does not include fluid restriction. The treatment for meningitis does not include a low-fat, low-calorie diet. The treatment for meningitis does not include over-the-counter analgesics. Treatment for meningitis generally requires 14 to 21 days of antibiotic treatment. Longterm IV access such as a peripherally inserted central line or other central venous access is typically initiated because of the need for long-term antibiotic therapy.
PTS: 1 CON: Neurologic Regulation | Medication 11. ANS: 3 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with disorders of the brain Chapter page reference: 758 NURSINGTB.COM Heading: Meningitis > Nursing Interventions > Actions Integrated Processes: Nursing Process: Implementation Cognitive Level: Application [Applying] Client Need: Physiological Integrity/Basic Care and Comfort Concept: Neurologic Regulation; Thermo-regulation Difficulty: Moderate 1 2 3 4
Feedback Pharmacological and nonpharmacological interventions relieve pain. Raising the head of the bed increases cerebral venous outflow. Controlling a fever with a cooling blanket decreases metabolic activity and decreases CNS oxygen demand. Standard and droplet precautions reduce the transmission of the infection.
PTS: 1 CON: Neurologic Regulation | Thermo-regulation 12. ANS: 2 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Encephalitis Chapter page reference: 759 Heading: Encephalitis > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Cognitive Level: Analysis [Analyzing] Client Need: Physiological Integrity/Reduction of Risk Potential
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Concept: Neurologic Regulation; Assessment Difficulty: Moderate
1 2 3 4
Feedback The eyes would be closed because of photophobia. Common complaints of encephalitis include phonophobia or a fear of loud noises. Cold hands is not a manifestation of encephalitis. Rubbing the thighs with the hands is not an indication of encephalitis.
PTS: 1 CON: Neurologic Regulation | Assessment 13. ANS: 1 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Discussing the management of: Encephalitis Chapter page reference: 759 Heading: Encephalitis > Medical Management Integrated Processes: Nursing Process: Planning Cognitive Level: Application [Applying] Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Concept: Neurologic Regulation; Medication Difficulty: Moderate 1 2 3 4
Feedback Antivirals are used to treat encephalitis. Acyclovir is used to treat most forms of encephalitis. Antibiotics are used to treat baNctUerRiaSl iInfe N ctGioTns B .. COM Antiemetics are used to treat nausea and vomiting, which can occur because of the encephalitis; however, this medication class is not a priority. Antiseizure medications are used to treat seizure disorders, which can occur because of the encephalitis; however, this medication class is not a priority.
PTS: 1 CON: Neurologic Regulation | Medication 14. ANS: 1 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with disorders of the brain Chapter page reference: 760 Heading: Encephalitis > Nursing Interventions > Actions Integrated Processes: Nursing Process: Planning Cognitive Level: Analysis [Analyzing] Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Concept: Neurologic Regulation; Medication Difficulty: Hard
1 2
Feedback Diuretics should be questioned because the patient is at risk for dehydration from a fever, nausea and vomiting, and other insensible losses from the disease process. Phenytoin (Dilantin) is an antiseizure medication, which would be appropriate to prevent seizures from developing.
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3 4
Docusate sodium (Colace) is a stool softener, which would be appropriate to reduce the risk of increasing ICP with bowel movements. Prochlorperazine (Compazine) is an antiemetic, which would be appropriate to treat nausea and vomiting.
PTS: 1 CON: Neurologic Regulation | Medication 15. ANS: 2 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with disorders of the brain Chapter page reference: 760 Heading: Encephalitis > Nursing Interventions > Teaching Integrated Processes: Nursing Process: Planning Cognitive Level: Analysis [Analyzing] Client Need: Physiological Integrity/Physiological Adaptation Concept: Neurologic Regulation; Mobility Difficulty: Moderate
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Feedback Hemiparesis is not an effect of encephalitis. Because the course of encephalitis may lead to an extended hospitalization and bedrest, the patient is at risk for deconditioning. Paresthesias is not a manifestation of encephalitis. Cerebellar dysfunction does not occur with encephalitis.
NURSINGTB.COM PTS: 1 CON: Neurologic Regulation | Mobility 16. ANS: 3 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Parkinson’s disease Chapter page reference: 760 Heading: Parkinson’s Disease > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Cognitive Level: Analysis [Analyzing] Client Need: Physiological Integrity/Physiological Adaptation Concept: Neurologic Regulation; Mobility Difficulty: Moderate
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Feedback Photophobia occurs with migraine headaches, meningitis, and encephalitis. Nuchal rigidity occurs with meningitis and encephalitis. One discernible symptom of Parkinson’s disease is slowness of movement or bradykinesia. Elevated body temperature can occur with meningitis and encephalitis.
PTS: 1 CON: Neurologic Regulation | Mobility 17. ANS: 1 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Describing the diagnostic results used to confirm disorders of the brain
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Chapter page reference: 761 Heading: Parkinson’s Disease > Medical Management > Diagnosis Integrated Processes: Nursing Process: Assessment Cognitive Level: Application [Applying] Client Need: Physiological Integrity/Reduction of Risk Potential Concept: Neurologic Regulation Difficulty: Moderate
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Feedback The diagnosis of Parkinson’s disease is made when two or more cardinal symptoms with asymmetrical presentation—such as rigidity—are observed in the absence of other causes. Progressive decline in motor function accompanied by rigidity is typically how the diagnosis is made. There are no specific diagnostic studies to confirm Parkinson’s disease. This would not be documented in this patient’s medical record. There are no specific diagnostic studies to confirm Parkinson’s disease. This would not be documented in this patient’s medical record. There are no specific diagnostic studies to confirm Parkinson’s disease. This would not be documented in this patient’s medical record.
PTS: 1 CON: Neurologic Regulation 18. ANS: 1 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Discussing the management of: Parkinson’s disease Chapter page reference: 761 NURSINGTB.COM Heading: Parkinson’s Disease > Medical Management > Diagnosis > Medications Integrated Processes: Nursing Process: Evaluation Cognitive Level: Analysis [Analyzing] Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Concept: Neurologic Regulation; Medication Difficulty: Moderate 1 2 3 4
Feedback Dopamine precursors such as carbidopa/levodopa (Sinemet) are later utilized and are most effective in the treatment of tremors. Dopamine precursors are not identified to target mood instability. Dopamine precursors are not identified to target impaired balance. Dopamine precursors are not identified to target behavioral changes.
PTS: 1 CON: Neurologic Regulation | Medication 19. ANS: 2 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with disorders of the brain Chapter page reference: 762 Heading: Parkinson’s Disease > Nursing Management > Actions Integrated Processes: Nursing Process: Assessment Cognitive Level: Analysis [Analyzing] Client Need: Physiological Integrity/Reduction of Risk Potential
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Concept: Neurologic Regulation; Nutrition Difficulty: Moderate
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Feedback Sitting out of bed for meals facilitates swallowing. The patient’s head of the bed should be elevated when eating and drinking. Impaired swallowing associated with Parkinson’s disease increases the risk of aspiration. Elevating the head facilitates the swallow reflex. Adding thickener to liquids improves swallowing and reduces the risk of aspiration. Oral suction equipment is a safety precaution and would be appropriate.
PTS: 1 CON: Neurologic Regulation | Nutrition 20. ANS: 1 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Alzheimer’s disease Chapter page reference: 763 Heading: Alzheimer’s Disease > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Cognitive Level: Analysis [Analyzing] Client Need: Physiological Integrity/Physiological Adaptation Concept: Neurologic Regulation; Cognition Difficulty: Moderate
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Forgetfulness is the first symptom of Alzheimer’s disease, which slowly progresses to difficulty with language (vocabulary and fluency). Forgetfulness is the first symptom of Alzheimer’s disease. Since this patient is already diagnosed, forgetfulness would be expected. Forgetfulness is the first symptom of Alzheimer’s disease. Since this patient is already diagnosed, forgetfulness would be expected. Forgetfulness is the first symptom of Alzheimer’s disease. Since this patient is already diagnosed, forgetfulness would be expected.
PTS: 1 CON: Neurologic Regulation | Cognition 21. ANS: 4 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Discussing the management of: Alzheimer’s disease Chapter page reference: 764 Heading: Alzheimer’s Disease > Medical Management > Diagnosis Integrated Processes: Nursing Process: Planning Cognitive Level: Analysis [Analyzing] Client Need: Physiological Integrity/Reduction of Risk Potential Concept: Neurologic Regulation; Cognition Difficulty: Moderate Feedback
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An echocardiogram might be prescribed to rule out the presence of atrial fibrillation as a cause for symptoms; however, this test would not provide a definitive diagnosis for Alzheimer’s disease. A cerebral angiogram might be prescribed to rule out a problem in the cerebral vasculature as a cause for symptoms; however, this test would not provide a definitive diagnosis for Alzheimer’s disease. Serum medication levels might be prescribed to rule out a problem with drug toxicity and clearance as a cause for symptoms; however, these tests would not provide a definitive diagnosis for Alzheimer’s disease. Presumptive diagnosis is made on the basis of a thorough history and physical examination that include careful recording of symptomology and onset, progression, and duration of the symptoms.
PTS: 1 CON: Neurologic Regulation | Cognition 22. ANS: 3 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Explaining the clinical presentation and management of complications associated with disorders of the brain Chapter page reference: 765 Heading: Alzheimer’s Disease > Nursing Management > Assessments Integrated Processes: Nursing Process: Assessment Cognitive Level: Analysis [Analyzing] Client Need: Physiological Integrity/Physiological Adaptation Concept: Neurologic Regulation; Cognition Difficulty: Moderate
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Feedback Watching a television program indicates the ability to focus. Avoiding doors indicates recognition of a potentially unsafe situation. Unable to recognize bowel incontinence indicates that the disease process is progressing. As cognition declines, the patient may experience incontinence. Eating cheese and crackers ensures the patient’s nutritional status and ability to perform self-feeding activities.
PTS: 1
CON: Neurologic Regulation | Cognition
MULTIPLE RESPONSE 23. ANS: 2, 3, 4 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Describing the epidemiology of disorders of the brain Chapter page reference: 749 Heading: Seizures > Epidemiology Integrated Processes: Teaching and Learning Cognitive Level: Comprehension [Understanding] Client Need: Health Promotion and Maintenance Concept: Neurologic Regulation; Promoting Health Difficulty: Easy
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1. 2. 3. 4. 5.
Feedback Absence seizures occur between the ages of 4 to 12. Myoclonic seizures can occur in any age group. Tonic-clonic seizures can occur in any age group. Simple partial seizures can occur in any age group. Complex partial seizures occur over the age of 3.
PTS: 1 CON: Neurologic Regulation | Promoting Health 24. ANS: 1, 3, 5 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Headaches Chapter page reference: 740 Heading: Headaches > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Cognitive Level: Analysis [Analyzing] Client Need: Physiological Integrity/Reduction of Risk Potential Concept: Neurologic Regulation Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Yawning is a symptom of the premonitory phase of a migraine headache. Confusion is a symptom of the postdromal phase of a migraine headache. Food craving is a symptom of the premonitory phase of a migraine headache. Auras can occur just prioNrUtoRtS h eImNiG g rT aiB n e.. COM Increased urine output is a symptom of the premonitory phase of a migraine headache.
PTS: 1 CON: Neurologic Regulation 25. ANS: 1, 2, 3, 5 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Primary brain tumors Chapter page reference: 745 Heading: Primary Brain Tumors > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Cognitive Level: Analysis [Analyzing] Client Need: Physiological Integrity/Reduction of Risk Potential Concept: Neurologic Regulation; Assessment Difficulty: Moderate
1. 2. 3. 4. 5. PTS: 1
Feedback Clinical manifestations of increased ICP include ataxia. Clinical manifestations of increased ICP include nausea. Diarrhea is not a clinical manifestation of increased ICP. Clinical manifestations of increased ICP include vomiting. Clinical manifestations of increased ICP include headache. CON: Neurologic Regulation | Assessment
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26. ANS: 1, 3, 5 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with disorders of the brain Chapter page reference: 747 Heading: Primary Brain Tumors > Nursing Interventions > Assessments Integrated Processes: Nursing Process: Assessment Cognitive Level: Analysis [Analyzing] Client Need: Physiological Integrity/Reduction of Risk Potential Concept: Neurologic Regulation; Assessment Difficulty: Moderate
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Feedback For a patient with a brain tumor, decreased heart rate is a manifestation of Cushing’s triad, which occurs late in increased ICP that signals herniation syndrome, a medical emergency. A temperature of 99.2 °F is not an indication of Cushing’s triad. For a patient with a brain tumor, an irregular respiratory rate is a manifestation of Cushing’s triad, which occurs late in increased ICP that signals herniation syndrome, a medical emergency. Urine output of 200 mL over four hours is within normal limits. For a patient with a brain tumor, increased intracranial pressure is a manifestation of Cushing’s triad, which occurs late in increased ICP that signals herniation syndrome, a medical emergency.
PTS: 1 CON: Neurolo gic Reg u la tio n | Assessmen t NUR S I N GT B .CO M 27. ANS: 2, 3, 4 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Meningitis Chapter page reference: 756 Heading: Meningitis > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Cognitive Level: Analysis [Analyzing] Client Need: Physiological Integrity/Reduction of Risk Potential Concept: Neurologic Regulation; Assessment Difficulty: Moderate
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Feedback Eye tearing is a manifestation of a cluster headache. The patient with meningitis may report photophobia. The patient with meningitis may be experiencing opisthotonos. The patient with meningitis will experience nuchal rigidity as a sign of meningeal irritation. Auditory hallucinations may be associated with a seizure disorder.
PTS: 1
CON: Neurologic Regulation | Assessment
NUMERIC RESPONSE 28. ANS:
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1520 Chapter number and title: 36, Coordinating Care for Patients With Brain Disorders Chapter learning objective: Discussing the management of: Seizures Chapter page reference: 753 Heading: Seizures > Medical Management > Diagnosis > Medications Integrated Processes: Nursing Process: Planning Cognitive Level: Application [Applying] Client Need: Physiological Integrity/Reduction of Risk Potential Concept: Neurologic Regulation Difficulty: Moderate Feedback: To calculate the number of fat calories, the total number of calories per day should be multiplied by 80%, or 1900 x 80% = 1520. The client should consume 1520 calories per day of fats. PTS: 1
CON: Neurologic Regulation
Chapter 37: Coordinating Care for Patients With Spinal Cord Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A patient asks what smoking cigarettes has to do with low back pain. How should the nurse respond to this patient? 1) “Smoking is a sedentary activity.” NURSINGTB.COM 2) “Smoking is linked to nutritional disorders.” 3) “Nicotine in cigarettes interferes with nutrients that supply the disk spaces.” 4) “Nicotine hinders the mobility of the vertebral spaces and interferes with nerve function.” 2. A patient with multiple sclerosis experiences exacerbations of new symptoms that last a few days and then disappear. Which type of multiple sclerosis is this patient most likely experiencing? 1) Relapsing-remitting 2) Primary progressive 3) Progressive relapsing 4) Secondary progressive 3. A patient is diagnosed with spinal stenosis. Which manifestation is caused by age-related loss of spinal muscle strength? 1) Fatigue 2) Constipation 3) Muscle spasm 4) Decreased stamina 4. A patient with low back pain asks why nerve conduction studies are prescribed. What explanation should the nurse provide to the patient relative to this diagnostic test? 1) “It measures damage to nerves.” 2) “It shows pressure on nerves from herniated disks.” 3) “It measures electrical impulses within muscle tissue.” 4) “It shows the structure of the vertebrae and joint outlines.”
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5. A patient with low back pain asks what aspirin is supposed to do help with the pain. How should the nurse respond to this patient? 1) “It depresses the central nervous system.” 2) “It blocks sodium channels and stops the formation of nerve impulses.” 3) “It blocks enzymes and chemicals in the body to decrease pain and inflammation.” 4) “It blocks the production of substances that trigger allergic and inflammatory reactions.” 6. The nurse is caring for a patient with unrelenting low back pain caused by a herniated disk. What instruction should the nurse provide to this patient to help with the pain? 1) Sit with the legs elevated 2) Reduce the intake of fluids 3) Limit activity until the pain subsides 4) Bend at the knees with a straight back 7. The nurse directs a patient with a herniated disk to notify the health-care provider immediately if the patient experiences which presentation? 1) New onset urinary incontinence 2) Sleepiness after taking pain medication 3) Difficulty with having a bowel movement 4) Transient pain with walking and changing position 8. A patient receives a definitive diagnosis of multiple sclerosis. What finding occurred to validate this diagnosis? 1) Onset of double vision 2) Loss of bowel and bladder control 3) Numbness and tingling of one limb 4) MRI changes in two separate locNaU t ioRnS s INGTB.COM 9. A patient with multiple sclerosis is admitted for treatment of clinical manifestations. What should the nurse expect to be prescribed for this patient? 1) Corticosteroids 2) Beta interferons 3) Muscle relaxants 4) Immunosuppressive agents 10. A patient with multiple sclerosis is developing speech difficulties. What should the nurse realize as being the reason for this new manifestation? 1) Depression 2) Medications 3) Nerve regeneration 4) Mental status changes 11. The nurse is caring for a patient with multiple sclerosis. What should the nurse do to increase venous return, prevent stiffness, and maintain muscle strength and endurance? 1) Administer interferon 2) Administer corticosteroids 3) Turn and reposition every two hours 4) Encourage range-of-motion exercises 12. A patient is experiencing increasing flaccid upper arms while the lower extremities periodically cramp and contract. On which health problem should the nurse focus when assessing this patient? 1) Brain tumor
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2) Spinal cord tumor 3) Multiple sclerosis 4) Amyotrophic lateral sclerosis (ALS) 13. A patient is admitted for diagnosis and treatment of ongoing spasticity and flaccidity of the extremities. Which diagnostic test should the nurse expect to be prescribed that will definitively determine this patient’s health problem? 1) MRI of the neck 2) CT scan of the head 3) A variety of tests will be ordered to help rule out other causes 4) Analysis of cerebrospinal fluid from a lumbar puncture 14. A client with amyotrophic lateral sclerosis is prescribed riluzole (Rilutek). What statement indicates additional teaching is required about the effects of this medication? 1) “This will cure my disease.” 2) “This will help me stay awake.” 3) “This will stop my bladder spasms.” 4) “This will increase the progression of my disease.” 15. A victim of a motor vehicle crash is diagnosed with a neck whiplash. Which manifestation should the nurse expect to assess in this patient? 1) Bladder dysfunction 2) Loss of proprioception 3) Ipsilateral loss of motor function 4) Pain below the level of the injury 16. The nurse is reviewin g orders writtenNfU o rRaSpI atN ie G n tTwBit. h C a nOeM w spinal cord injury. Which order should the nurse question before completing? 1) Place on air mattress 2) Insert a nasogastric tube and attach to low suction 3) Insert indwelling urinary catheter; strict intake and output 4) Dexamethasone (Decadron) 10 mg IVP now and repeat in 4 hours 17. The latest blood pressure reading for a patient with a spinal cord injury is 210/140 mm Hg. What action should the nurse take first? 1) Palpate for bladder distention 2) Assess for a bowel impaction 3) Re-measure the blood pressure 4) Raise the head of the bed 45 degrees 18. The nurse notes crusting of secretions around the pins of a patient with a Halo device. What action should be taken at this time? 1) Wrap the pins with gauze soaked with normal saline 2) Gently pick the crusting off of the pins with a dry gauze pad 3) Apply gauze soaked with hydrogen peroxide around the pins 4) Syringe 1/2 strength hydrogen peroxide and sterile water to the crusted areas 19. A patient has a new onset of back pain radiating down the left leg. For which health problem should the nurse expect this patient to be evaluated? 1) Meningitis 2) Spinal cord tumor 3) Multiple sclerosis
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4) Amyotrophic lateral sclerosis 20. A patient is suspected as having a spinal cord tumor. Which diagnostic test should the nurse expect to be prescribed to definitively diagnose this patient’s problem? 1) MRI 2) Myelogram 3) Cerebral angiogram 4) Nerve conduction studies 21. A patient has a 4 cm spinal cord tumor located at T10. Which therapeutic treatment should the nurse anticipate will be ordered for this patient? 1) Surgery 2) Radiation 3) Chemotherapy 4) Stereotactic radiosurgery 22. The nurse is reviewing orders written for a patient returning from surgery to remove a spinal cord tumor. Which order should the nurse implement immediately? 1) Install a bed cradle 2) Apply heel protection 3) Dexamethasone (Decadron) 10 mg IVP now and every 8 hours x 2 doses 4) Monitor bowel sounds; notify if unable to obtain or faint in any abdominal quadrant Multiple Response Identify one or more choices that best complete the statement or answer the question.
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23. The nurse is concerned that a patient is at risk for a lumbar disk herniation. What assessment information is causing the nurse to have this concern? Select all that apply. 1) Fell off of a ladder 2) Body mass index 32.3 3) Smokes 1 pack of cigarettes per day 4) Works in an automotive factory 5) Lifts 50 lb. sack of cement at work 24. A patient with low back pain asks what nonmedical treatments can be used to help with the discomfort. Which complementary and alternative therapies should the nurse recommend to this patient? Select all that apply. 1) Yoga 2) Qi gong 3) Acupuncture 4) Massage therapy 5) Chiropractic treatments 25. The nurse notes that a patient with low back pain is experiencing radiculopathy. What should the nurse expect when assessing this patient? Select all that apply. 1) Pain 2) Edema 3) Weakness 4) Numbness 5) Inability to control motor movement
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26. A patient with a herniated disk is prescribed conservative treatment. For which anticipated treatments should the nurse prepare to instruct this patient? Select all that apply. 1) Reducing body weight 2) Avoiding painful positions 3) Engaging in aerobic activities 4) Performing planned exercises 5) Taking pain medication as prescribed 27. The nurse is assessing a patient with multiple sclerosis. What should the nurse expect to assess in this patient? Select all that apply. 1) Anxiety 2) Dizziness 3) Double vision 4) Unsteady gait 5) Electric shocks with head movement 28. A patient with amyotrophic lateral sclerosis (ALS) is being prepared for discharge. What teaching would be essential for the family to receive prior to taking the patient home? Select all that apply. 1) Skin care 2) Aspiration precautions 3) Recognizing exacerbations 4) Lower extremity circulation 5) Reporting changes in continence
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Chapter 37: Coordinating Care for Patients With Spinal Cord Disorders Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Describing the epidemiology of spinal cord disorders Chapter page reference: 771 Heading: Low Back Pain > Epidemiology Integrated Processes: Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Mobility; Promoting Health Difficulty: Easy
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Feedback There is no evidence to link smoking with a sedentary lifestyle. There is no evidence to link smoking with nutritional disorders. Nicotine in cigarettes is thought to interfere with vital nutrients being absorbed by the intervertebral disks. There is no evidence to link nicotine to vertebral space mobility and nerve function.
PTS: 1
CON: Mobility | Promoting Health
2. ANS: 1 NURSINGTB.COM Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Describing the epidemiology of spinal cord disorders Chapter page reference: 777 Heading: Multiple Sclerosis > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Mobility Difficulty: Moderate
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Feedback In relapsing-remitting multiple sclerosis, relapses or exacerbations occur during which new symptoms appear and old ones worsen or reappear; these relapses can last days or months. Primary progressive multiple sclerosis has gradual progression with no remissions. Progressive relapsing multiple sclerosis has a gradual worsening of symptoms from onset, and the relapses may or may not have recovery. Secondary progressive multiple sclerosis is when the patient initially had relapsingremitting but it gradually becomes worse.
PTS: 1 CON: Mobility 3. ANS: 3 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders
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Chapter learning objective: Correlating clinical manifestations to the pathophysiological processes of: Low back pain Chapter page reference: 772 Heading: Low Back Pain > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Mobility Difficulty: Moderate Feedback 1 Fatigue could occur because of needing to be sedentary to prevent the onset of pain. 2 Constipation could occur because of decreased mobility. 3 Muscle spasm is the sudden, involuntary contraction of a single muscle or muscle group. Most back muscle spasms are due to inflammation and soreness because of sudden movement or bending, but they can also result from age-related loss of spinal muscle strength as muscles spasm to protect the worn areas of the spine. 4 Decreased stamina is possible if pain decreases activity and the patient becomes more sedentary. PTS: 1 CON: Mobility 4. ANS: 1 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Describing the diagnostic results used to confirm spinal cord disorders Chapter page reference: 773 Heading: Low Back Pain > Medical Management > Diagnosis RpSleImNeG Integrated Processes: Nursing ProcesN s:UIm ntT atB io. n CO Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Mobility Difficulty: Moderate Feedback 1 Nerve conduction studies (NCS) measure the electrical nerve impulse that indicates damage to the nerve. 2 A myelogram shows pressure on the spinal cord or nerves from herniated disks. 3 Electromyography (EMG) measures the electrical impulse within muscle tissue. 4 X-rays show the structure of the vertebrae and joint outlines. PTS: 1 CON: Mobility 5. ANS: 3 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with disorders of the spinal cord Chapter page reference: 773 Heading: Low Back Pain > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Mobility; Comfort; Medication Difficulty: Moderate
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Feedback Muscle relaxants depress the central nervous system. Tricyclic antidepressants block the sodium channels and decrease formation of ectopic neuronal pacemakers. NSAIDs block enzymes and prostaglandins throughout the body, thereby decreasing pain and inflammation. Corticosteroids block the production of substances that trigger allergic and inflammatory reactions.
PTS: 1 CON: Mobility | Comfort | Medication 6. ANS: 4 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with disorders of the spine Chapter page reference: 777 Heading: Herniated Nucleus Pulposus > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Mobility; Promoting Health; Medication; Comfort Difficulty: Moderate
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Feedback Sittin g with the legs elevated pNuU tsRp S re I ssuNrG e on TBthe .CloOwMer spine. Reducing the intake of fluids can cause constipation, which worsens back pain. Activity should be performed as prescribed to build core muscle strength and stabilize and support the spine. Bending at the knees with the back straight uses the leg muscles to lift and decreases strain on the back muscles.
PTS: 1 CON: Mobility | Promoting Health | Medication | Comfort 7. ANS: 1 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Explaining the clinical presentation and management of complications associated with disorders of the spinal cord Chapter page reference: 776 Heading: Herniated Nucleus Pulposus > Medical Management > Complications Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Mobility Difficulty: Moderate
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Feedback Common complications of a herniated disk include loss of bladder control. The development of this complication may require surgical intervention to prevent permanent loss of function. Depending upon the pain medication, sleepiness may be expected.
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Difficulty with having a bowel movement indicates constipation, which can be addressed with increased roughage and fluids. Transient pain with walking and changing position is a manifestation of a herniated disk.
PTS: 1 CON: Mobility 8. ANS: 4 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Describing the diagnostic results used to confirm spinal cord disorders Chapter page reference: 779 Heading: Multiple Sclerosis > Medical Management > Diagnosis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Mobility Difficulty: Moderate Feedback 1 Double vision is a manifestation of multiple sclerosis; however, it does not provide a definitive diagnosis of the disease. 2 Loss of bowel and bladder control is a manifestation of a herniated disk. 3 Numbness and tingling of one limb is a manifestation of multiple sclerosis; however, it does not provide a definitive diagnosis of the disease. 4 For a definitive diagnosis multiple sclerosis, the patient must have MRI changes in at least two separate locations.
NURSINGTB.COM PTS: 1 CON: Mobility 9. ANS: 3 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Discussing the management of: Multiple sclerosis Chapter page reference: 779 Heading: Multiple Sclerosis > Medical Management > Treatment Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Mobility Difficulty: Moderate
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Feedback Corticosteroids are used to treat attacks. Beta interferons are used to modify the disease course. Medications used to treat clinical manifestations include muscle relaxants. Immunosuppressive agents are used to modify the disease course.
PTS: 1 CON: Mobility 10. ANS: 2 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Explaining the clinical presentation and management of complications associated with disorders of the spinal cord Chapter page reference: 781
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Heading: Multiple Sclerosis > Medical Management > Treatment > Complications Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Mobility; Communication Difficulty: Moderate Feedback 1 Depression is an adverse effect of the disease. It does not cause speech deficits. 2 Speech defects due to muscle weakness may be due to medications. 3 Nerve regeneration would improve speech. 4 Mental status changes is an adverse effect of the disease. It does not cause speech deficits. PTS: 1 CON: Mobility | Communication 11. ANS: 4 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with disorders of the spinal cord Chapter page reference: 782 Heading: Multiple Sclerosis > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application [Applying] Concept: Mobility Difficulty: Moderate
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Feedback Interferon decreases exacerbations and slows disease progression. Corticosteroids decreases the inflammatory processes associated with the flare. Turning and repositioning every two hours prevents skin breakdown. Range-of-motion exercises increases venous return, prevents stiffness, and maintains muscle strength and endurance.
PTS: 1 CON: Mobility 12. ANS: 4 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Correlating clinical manifestations to the pathophysiological processes of: Amyotrophic lateral sclerosis Chapter page reference: 782 Heading: Amyotrophic Lateral Sclerosis > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Mobility Difficulty: Moderate Feedback 1 The manifestations of a brain tumor will depend upon the location of the mass in the cerebrum.
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The manifestations of a spinal cord tumor will depend upon the location of the mass within the cord. Both spasticity and flaccidity do not need to be present to diagnose multiple sclerosis. To be diagnosed with ALS, patients must have clinical manifestations of both upper and lower motor neuron damage that cannot be attributed to other causes. Upper motor neuron damage is associated with spasticity, while lower motor neuron damage is characterized by flaccidity.
PTS: 1 CON: Mobility 13. ANS: 3 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Describing the diagnostic results used to confirm spinal cord disorders Chapter page reference: 783 Heading: Amyotrophic Lateral Sclerosis > Medical Management > Diagnosis Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application [Applying] Concept: Mobility Difficulty: Moderate Feedback 1 An MRI of the neck may be completed to rule out nerve compression. 2 A CT scan of the head may be completed to rule out masses or other structural abnormalities causing the patient’s symptoms. 3 No single test can be used to diagnose ALS; therefore, a complete history and physical examination must be performeNdUb yR th SeI hNeGalTthB-c.arCe pr OMovider. 4 Analysis of the cerebrospinal fluid will be done; however, this will not definitively diagnose the patient with ALS. PTS: 1 CON: Mobility 14. ANS: 4 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Discussing the management of: Amyotrophic lateral sclerosis Chapter page reference: 783 Heading: Amyotrophic Lateral Sclerosis > Medical Management > Diagnosis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Mobility; Medication Difficulty: Moderate 1 2 3 4
Feedback Riluzole (Rilutek) does not repair damaged neurons but has been shown both to increase survival and to extend the period without the need for ventilator support. Analeptics improve wakefulness. Antispasmodics improve bladder spasms. Riluzole (Rilutek) is the first drug approved to slow disease progression.
PTS: 1 15. ANS: 1
CON: Mobility | Medication
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Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Correlating clinical manifestations to the pathophysiological processes of: Spinal cord injury Chapter page reference: 786 Heading: Spinal Cord Injury > Pathophysiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Mobility Difficulty: Moderate Feedback 1 A hyperextension injury causes central cord syndrome. A clinical manifestation of this syndrome is bladder dysfunction. 2 Posterior cord syndrome is caused by acute compression. A manifestation of this syndrome is a loss of proprioception. 3 Brown-Sequard syndrome is caused by a penetrating injury. A manifestation of this syndrome is an ipsilateral loss of motor function. 4 Anterior cord syndrome is caused by acute compression from bony fragments or acute disk herniation. A manifestation of this syndrome is pain below the level of the injury. PTS: 1 CON: Mobility 16. ANS: 4 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Discussing the management of: Spinal cord injury Chapter page reference: 788 NURSINGTB.COM Heading: Spinal Cord Injury > Medical Management > Pharmacological and Fluid Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Mobility; Medication Difficulty: Moderate 1 2 3
4
Feedback A patient with a spinal cord injury is at risk for skin breakdown and pressure ulcers. An air mattress would be appropriate. A patient with a spinal cord injury is at risk for paralytic ileus, septic or necrotic bowel, and a GI bleed. A nasogastric tube to suction would be appropriate. A patient with a spinal cord injury is at risk for urinary incontinence, urinary tract infection, neurogenic bladder, and chronic kidney disease. An indwelling urinary catheter and strict intake and output measurement would be appropriate. Current guidelines for the management of acute SCIs no longer recommend the use of corticosteroids for acute SCI. Because there is no strong medical evidence supporting benefits from the administration of corticosteroids, this therapy is avoided because of stronger evidence that the administration of high-dose steroids is associated with harmful side effects, including hyperglycemia and immunosuppression.
PTS: 1 CON: Mobility | Medication 17. ANS: 4 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders
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Chapter learning objective: Explaining the clinical presentation and management of complications associated with disorders of the spinal cord Chapter page reference: 790 Heading: Spinal Cord Injury > Medical Management > Complications > Autonomic Dysreflexia Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Mobility Difficulty: Moderate 1 2 3 4
Feedback After the head of the bed is raised the nurse can begin to assess for the cause of autonomic dysreflexia, which includes palpating the bladder. After the head of the bed is raised the nurse can begin to assess for the cause of autonomic dysreflexia, which includes assessing for a bowel impaction. Re-measuring the blood pressure will take precious time that is better spent beginning interventions. The head of the bed should be raised first so that blood can pool in the lower extremities and help reduce the blood pressure.
PTS: 1 CON: Mobility 18. ANS: 1 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with disorders of the spinal cord NURSINGTB.COM Chapter page reference: 793 Heading: Spinal Cord Injury > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Mobility Difficulty: Moderate 1
2 3 4
Feedback If crusting is noted, wrap gauze soaked with normal saline around the pin site for 15 minutes. After removing the gauze, use a clean cotton-tipped applicator to gently remove the crust from the pin site. The crusting should not be picked off the pins. Hydrogen peroxide is not used to remove crusting from the pins. Solutions should not be syringed on the pins. Hydrogen peroxide is not used to remove crusting from the pins.
PTS: 1 CON: Mobility 19. ANS: 2 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Correlating clinical manifestations to the pathophysiological processes of: Spinal cord tumors Chapter page reference: 794 Heading: Spinal Cord Tumors > Clinical Manifestations
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Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Mobility Difficulty: Moderate Feedback 1 Back pain radiating down the leg is not a manifestation of meningitis. 2 Many of the symptoms of a spinal cord tumor are the same as a low back injury or herniated disk. 3 Although spinal cord tumors can mimic the manifestations of multiple sclerosis, the patient’s symptoms are limited to low back pain radiating down the leg. Multiple sclerosis has many additional manifestations which this patient is not experiencing. 4 Manifestations of back pain radiating down the leg are not associated with amyotrophic lateral sclerosis. PTS: 1 CON: Mobility 20. ANS: 1 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Describing the diagnostic results used to confirm spinal cord disorders Chapter page reference: 794 Heading: Spinal Cord Tumors > Diagnosis Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Mobility NURSINGTB.COM Difficulty: Moderate
1 2 3 4
Feedback MRI is considered to be the gold standard for examining spinal structures. A myelogram may be used if an MRI is not available; however, the myelogram is not identified as being the gold standard for the examination of spinal structures. A cerebral angiogram would not be indicated for a spinal cord tumor. Nerve conduction studies would not be indicated for a spinal cord tumor. However, if a tumor is ruled out, nerve conduction studies might be indicated to determine nerve damage and function.
PTS: 1 CON: Mobility 21. ANS: 1 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Discussing the management of: Spinal cord tumors Chapter page reference: 794 Heading: Spinal Cord Tumors > Medical and Surgical Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Mobility; Nursing Roles Difficulty: Moderate Feedback
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1 2 3 4
Surgery is usually the first step in treating tumors that can be removed with an acceptable risk of nerve damage. Radiation therapy is used following an operation to eliminate the tumor remnants or to treat inoperable tumors. Chemotherapy has not been proven effective for most spinal cord tumors. Stereotactic radiosurgery is currently being studied for spinal cord tumors.
PTS: 1 CON: Mobility | Nursing Roles 22. ANS: 3 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with disorders of the spinal cord Chapter page reference: 795 Heading: Spinal Cord Tumors > Nursing Management > Actions Integrated Processes: Nursing Process; Implementation Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Mobility; Medication Difficulty: Moderate Feedback 1 A bed cradle can be installed at any time. 2 Heel protection can be applied at any time. 3 Corticosteroid therapy is prescribed after surgery to decrease swelling and inflammation. This is the priority. 4 Monitorin g of bowel sounds cN anUoRc cu SIr aNftGerTthe B.mCeOd iMcation is provided. PTS: 1
CON: Mobility | Medication
MULTIPLE RESPONSE 23. ANS: 2, 3, 4, 5 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Describing the epidemiology of spinal cord disorders Chapter page reference: 775 Heading: Herniated Nucleus Pulposus > Epidemiology Integrated Processes: Nursing Process; Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Mobility Difficulty: Moderate
1. 2. 3. 4.
Feedback A traumatic event such as a fall or a blow to the back rarely causes a herniated disk. Factors that increase the risk of a herniated disk include obesity. Factors that increase the risk of a herniated disk include smoking. Factors that increase the risk of a herniated disk include occupation that includes repetitive lifting, pulling, pushing, bending sideways, and twisting.
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Factors that increase the risk of a herniated disk include occupation that includes repetitive lifting, pulling, pushing, bending sideways, and twisting.
PTS: 1 CON: Mobility 24. ANS: 1, 2, 3, 4 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Discussing the management of: Low back pain Chapter page reference: 774 Heading: Low Back Pain > Medical Management > Treatment Integrated Processes: Nursing Process; Implementation Client Need: Physiological Integrity/Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Mobility; Comfort Difficulty: Moderate
1.
2. 3.
4.
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Feedback Yoga can be used as part of a general health regimen, to cope with illness, to improve physiological balance, or to increase relaxation; techniques include physical postures and breathing techniques with either a focused attention or an open attitude toward distractions. Qi gong is an ancient Chinese discipline involving physical and mental exercises that focus on specific parts of the body. Acupuncture is the insertion of small needles or exerting pressure on “energy” points in the body; the patient is supposed to experience a feeling of fullness, numbness, tingling, and warmth. Massage therapy consistNs U ofRaS lteIrnNa G tinTgBle.v el CsO oMf concentrated pressure on the areas of spasm; once pressure is applied, it should not vary for 10 to 30 seconds. Massage also leads to increased endorphin levels (chemicals associated with decreased pain and increased euphoria) that are effective in chronic pain management. Chiropractic treatments are not identified as a complementary or alternative therapy for low back pain.
PTS: 1 CON: Mobility | Comfort 25. ANS: 1, 3, 4, 5 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Correlating clinical manifestations to the pathophysiological processes of: Herniated nucleus pulposus Chapter page reference: 775 Heading: Herniated Nucleus Pulposus > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Mobility; Assessment Difficulty: Moderate
1. 2. 3. 4.
Feedback Radiculopathy is nerve root compression and can result in pain in the affected extremity. Edema is not a manifestation of radiculopathy. Radiculopathy is nerve root compression and can result in weakness in the affected extremity. Radiculopathy is nerve root compression and can result in numbness in the affected extremity.
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5.
Radiculopathy is nerve root compression and can result in the inability to control motor movement in the affected area.
PTS: 1 CON: Mobility | Assessment 26. ANS: 1, 2, 4, 5 Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Discussing the management of: Herniated nucleus pulposus Chapter page reference: 775 Heading: Herniated Nucleus Pulposus > Medical Management > Treatment Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Mobility; Promoting Health Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback If obesity is a contributing factor, weight-loss measures are also indicated. Conservative treatment consists of avoiding painful positions. Conservative treatment consists of avoiding painful positions, which might include aerobic activities. Conservative treatment consists of following a regimen of planned exercise. Conservative treatment consists of following a regimen of pain medications.
PTS: 1 CON: Mobility | Promoting Health 27. ANS: 2, 3, 4, 5 NURSINGTB.COM Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Correlating clinical manifestations to the pathophysiological processes of: Multiple sclerosis Chapter page reference: 778 Heading: Multiple Sclerosis > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Mobility; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
PTS: 1 28. ANS: 1, 2, 4
Feedback Anxiety is not an identified manifestation of multiple sclerosis. Depending on the location of the affected nerve fibers, a manifestation of multiple sclerosis includes dizziness. Depending on the location of the affected nerve fibers, a manifestation of multiple sclerosis includes double vision. Depending on the location of the affected nerve fibers, a manifestation of multiple sclerosis includes unsteady gait. Depending on the location of the affected nerve fibers, a manifestation of multiple sclerosis includes electric shocks with head movement. CON: Mobility | Assessment
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Chapter number and title: 37, Coordinating Care for Patients With Spinal Cord Disorders Chapter learning objective: Explaining the clinical presentation and management of complications associated with disorders of the spinal cord Chapter page reference: 783 Heading: Amyotrophic Lateral Sclerosis > Medical Management > Complications Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Mobility; Promoting Health Difficulty: Moderate
1. 2. 3. 4. 5. PTS: 1
Feedback Amyotrophic lateral sclerosis is a progressive disease that leads to the inability to move. Complications include pressure ulcers. Amyotrophic lateral sclerosis is a progressive disease that leads to the inability to move. Complications include aspiration of food or fluid, respiratory failure, and pneumonia. Exacerbations occur with multiple sclerosis and not ALS. Amyotrophic lateral sclerosis is a progressive disease that leads to the inability to move. Complications include deep vein thrombosis (DVT) and pulmonary embolism (PE). Changes in continence would be a potential complication of a herniated disk. CON: Mobility | Promoting Health
Chapter 38: Coordinating Care for Patients With Peripheral Nervous System Disorders
NURSINGTB.COM Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A client is diagnosed with myasthenia gravis. What should the nurse explain about this disease process? 1) “Your nerve endings are worn out.” 2) “Your body does not recognize the neurotransmitter needed for movement.” 3) “Your body does not make enough of the neurotransmitter needed for movement.” 4) “Your nerves have lost their protective covering and impulses cannot reach body areas.” 2. The nurse is reading the results of a single-fiber electromyography completed on a patient suspected of having myasthenia gravis. Which information would validate this patient’s diagnosis? 1) Increased jitter 2) Nerve compression 3) Increased antibodies 4) Decreased muscle response 3. A patient is being prepared for a tensilon test. What should the nurse ensure is available prior to the beginning of this test? 1) Oxygen 2) Atropine sulfate 3) Intravenous fluids 4) Nasogastric suction
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4. A patient with myasthenia gravis is experiencing sweating and pallor. After administering edrophonium (Tensilon), which finding suggests the patient is experiencing a cholinergic crisis? 1) Clear vision 2) Fasciculations 3) Strong hand grasps 4) Equal shoulder shrugs 5. The nurse is caring for a patient with myasthenia gravis. Which assessment should the nurse complete to determine respiratory functioning? 1) Vital capacity 2) Pulse oximetry 3) Auscultate lung sounds 4) Arterial blood gas analysis 6. A patient with myasthenia gravis has lost 6 kg of weight over the last two months. What should the nurse suggest to improve this patient’s nutritional status? 1) Eat three large meals per day 2) Plan medication doses to occur before meals 3) Restrict drinking fluids prior to and during meals 4) Increase the amount of fat and carbohydrates in meals 7. The nurse is reviewing discharge instructions for a patient with myasthenia gravis. What should the nurse emphasize regarding medications? 1) Keep extra doses of medication in the car 2) Store extra doses of medication in the refrigerator 3) Take an extra dose of medication before leaving the house 4) Pack prescribed medications in N aU suR i tcSa I s e Nb G ef T o rB e . f lyCinOgMon an airplane 8. A patient seeks treatment for progressively deteriorating motor and sensory function. What question is essential for the nurse to ask when completing this patient’s health history? 1) “Have you been around any small children?” 2) “When was the last time you had anything to eat?” 3) “When was the last time you traveled out of the country?” 4) “Have you recently experienced any lung or stomach infections?” 9. A patient with Guillain-Barré syndrome (GBS) asks how the illness develops. What should the nurse respond about the pathophysiology of the disorder? 1) “An infection eats away at the nerve endings.” 2) “An infection enters the spinal cord and erodes the nerves at the roots.” 3) “The nerves are killed by infiltration of your body’s white blood cells used to fight an infection.” 4) “After an infection your immune system created antibodies that affect the covering of the nerves.” 10. A patient is experiencing bilateral symmetrical muscle weakness and sensory changes of both feet and legs. What should the nurse expect to assess that determines the presence of Guillain-Barré syndrome (GBS)? 1) Areflexia 2) Hyporeflexia 3) Hyperreflexia 4) Hyperanalgesia
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11. A patient with Guillain-Barré syndrome (GBS) loses respiratory function three weeks into the acute phase. When should the nurse expect respiratory function to return in this patient? 1) During the plateau phase 2) Early in the recovery stage 3) At the end of the plateau stage 4) At the end of the recovery stage 12. A patient with progressively deteriorating lower extremity motor and sensory function is having a lumbar puncture. What finding suggests that this patient has Guillain-Barré syndrome (GBS)? 1) Elevated protein level 2) Elevated glucose level 3) Reduction in white blood cell count 4) Increased number of red blood cells 13. A patient with Guillain-Barré syndrome (GBS) is receiving plasmapheresis. What finding should the nurse identify as being a complication of this treatment? 1) Septicemia 2) Flu-like symptoms 3) Aseptic meningitis 4) Acute renal failure 14. The nurse notes that a patient with Guillain-Barré syndrome (GBS) sweats profusely. What should the nurse do about this finding? 1) Place on a cooling blanket 2) Notify the health-care provider 3) Monitor body temperature every two hours 4) Change linen and gown and keeN pU c oRmSfoIrtN abGleTB.COM 15. The nurse is planning care for a patient with Guillain-Barré syndrome (GBS). Which intervention will help with neuropathic pain? 1) Administer gabapentin 2) Turn and reposition every two hours 3) Apply sequential compression devices 4) Perform passive range of motion several times a day 16. The nurse notes that a patient has been diagnosed with trigeminal neuralgia. What should the nurse expect the patient to be experiencing? 1) Pain 2) Nausea 3) Sensory deficit 4) Motor weakness 17. The nurse is concerned that a patient is at risk for trigeminal neuralgia. What information in the patient’s medical record did the nurse use to make this clinical decision? 1) Has a BMI of 34 2) Takes birth control pills 3) History of hypertension 4) Works as a computer operator 18. The nurse notes that a patient’s primary complaint is burning pain on the right side of the face. What should the nurse realize this patient is describing? 1) Referred pain
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2) Atypical pain 3) Vascular compression 4) Peripheral neuropathy 19. The nurse is conducting a physical examination on a female patient experiencing trigeminal neuralgia. What observation indicates that the pain is triggered by hygienic practices? 1) Limited talking 2) Hair not combed 3) Wearing tennis shoes 4) Not wearing makeup 20. The nurse is reviewing orders written for a patient with trigeminal neuralgia. Which medication should the nurse expect to be prescribed for this patient? 1) Cogentin 2) Compazine 3) Carbamazepine 4) Hydrochlorothiazide 21. A patient is scheduled for surgery to treat trigeminal neuralgia. For which procedure should the nurse explain that a complication resulting in permanent numbness of the facial area might occur? 1) Plasmapheresis 2) Percutaneous rhizotomy 3) Stereotactic radiosurgery 4) Microvascular decompression 22. A patient with trigeminal neuralgia asks if there are any nonpharmacological strategies to treat the pain. What should the nurse suggest to this patieN n tU ? RSINGTB.COM 1) Massage 2) Apply heat 3) Apply cold 4) Acupuncture Multiple Response Identify one or more choices that best complete the statement or answer the question. 23. During an assessment the nurse suspects that patient should be evaluated for myasthenia gravis. What did the nurse assess to make this clinical determination? Select all that apply. 1) Ptosis 2) Diplopia 3) Abdominal pain 4) Left leg weakness 5) Epigastric burning 24. The nurse notes that a patient with myasthenia gravis is experiencing bulbar manifestations. On what should the nurse focus when assessing this patient? Select all that apply. 1) Swallowing 2) Eye opening 3) Blood pressure 4) Tongue movement 5) Head and neck movement
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25. The nurse is reviewing orders written for a patient with myasthenia gravis. Which medication order should the nurse question before administering? Select all that apply. 1) Verapamil 2) Furosemide 3) Erythromycin 4) Nicotine patch 5) Warfarin sodium 26. A patient is admitted for diagnosis and treatment of Guillain-Barré syndrome (GBS). What should the nurse expect to assess during the acute stage of this syndrome? Select all that apply. 1) Edema 2) Paralysis 3) Difficulty breathing 4) Urinary incontinence 5) Numbness and tingling Numeric Response 27. A patient who takes pyridostigmine (Mestinon) 30 mg 4 times a day is scheduled for surgery. How many mg of intravenous neostigmine (Prostigmin) should be prescribed for an entire day? Record your answer as a whole number. 28. A patient who weighs 176 lbs. is prescribed intravenous immunoglobulin 2 g/kg to be infused over three days. How many grams of the medication should the nurse have sent from the pharmacy? Record your answer as a whole number.
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Chapter 38: Coordinating Care for Patients With Peripheral Nervous System Disorders Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Explaining the pathophysiological processes of peripheral nervous system disorders Chapter page reference: 801 Heading: Myasthenia Gravis > Pathophysiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Sensory Perception Difficulty: Moderate Feedback 1 The nerve endings are not worn out in myasthenia gravis. 2 In myasthenia gravis the postsynaptic receptor sites are unavailable. 3 The amount of neurotransmitter is not altered in myasthenia gravis. 4 The nerves in myasthenia gravis have not lost their protective covering or myelin sheath. PTS: 1 CON: NeuroloNgU icRRSegIuNlaG tioTnB| . SeCnO soMry Perception 2. ANS: 1 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected disorders of the peripheral nervous system Chapter page reference: 803 Heading: Myasthenia Gravis > Medical Management > Repetitive Nerve Stimulation and Electromyography Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation; Sensory Perception Difficulty: Moderate
1 2 3 4
Feedback In myasthenia gravis, there is increased “jitter” in a single-fiber electromyography test. Specific nerve function and status is not measured through a single-fiber electromyography. Antibodies would be measured through the use of serology testing. In myasthenia gravis, decreased muscle response would be seen in a repetitive nerve stimulation test.
PTS: 1 CON: Neurologic Regulation | Sensory Perception 3. ANS: 2 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders
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Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected disorders of the peripheral nervous system Chapter page reference: 803 Heading: Myasthenia Gravis > Medical Management > Tensilon Test Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Sensory Perception; Medication Difficulty: Moderate 1 2
3 4
Feedback Oxygen is not required for a tensilon test. Edrophonium (Tensilon) is a rapid-acting AChE inhibitor. This leads to increased levels of ACh at the neuromuscular junction, leading to improved muscle strength in patients with myasthenia. However, ACh accumulates in the parasympathetic autonomic nervous system and can cause side effects such as bronchospasm, bradycardia, and diarrhea. Atropine is a muscarinic blocker, and thus the side effects of edrophonium and other AChE inhibitors can be reversed with this medication. Intravenous fluids are not required for a tensilon test. Nasogastric suction is not required for a tensilon test.
PTS: 1 CON: Neurologic Regulation | Sensory Perception | Medication 4. ANS: 2 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Discussing the medical management of selected disorders of the peripheral NURSINGTB.COM nervous system Chapter page reference: 806 Heading: Myasthenia Gravis > Medical Management > Complications > Cholinergic Crisis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation; Sensory Perception; Medication Difficulty: Moderate 1 2 3 4
Feedback When Tensilon is administered, if the patient demonstrates muscle strength improvement, it is determined to be a myasthenic crisis. If Tensilon is administered and the patient demonstrates fasciculations and muscle weakness, including respiratory muscles, it is a cholinergic crisis. When Tensilon is administered, if the patient demonstrates muscle strength improvement, it is determined to be a myasthenic crisis. When Tensilon is administered, if the patient demonstrates muscle strength improvement, it is determined to be a myasthenic crisis.
PTS: 1 CON: Neurologic Regulation | Sensory Perception | Medication 5. ANS: 1 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with peripheral nervous system disorders
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Chapter page reference: 807 Heading: Myasthenia Gravis > Nursing Management > Assessment and Analysis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Oxygenation Difficulty: Moderate
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Feedback Because of the potential for respiratory weakness, a bedside test known as the vital capacity is performed. Pulse oximetry is not helpful in determining respiratory deterioration in a patient with myasthenia gravis because failure is due to weakness of the diaphragm and intercostal muscles. Auscultating lung sounds will not help determine oxygenation at the cellular and capillary level. An arterial blood gas is a prescribed and obtained by a health-care provider. It is beyond the nurse’s scope of practice to draw this sample for analysis.
PTS: 1 CON: Neurologic Regulation | Oxygenation 6. ANS: 2 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with peripheral nervous system disorders Chapter page reference: 807 NURSINGTB.COM Heading: Myasthenia Gravis > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Nutrition Difficulty: Moderate Feedback 1 Small, frequent meals will help maintain calorie intake. 2 Plan meals when medications are at peak levels. Often patients take pyridostigmine an hour before meals to minimize difficulty with chewing and swallowing. 3 The patient does not have difficulty with digestion. Fluids do not need to be restricted prior to or during meals. 4 It is not recommended to alter the amount of fat and carbohydrates in the diet of a patient with myasthenia gravis. PTS: 1 CON: Neurologic Regulation | Nutrition 7. ANS: 1 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Developing a teaching plan for a patient with a peripheral nervous system disorder Chapter page reference: 807 Heading: Myasthenia Gravis > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying]
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Concept: Neurologic Regulation; Medication Difficulty: Moderate Feedback 1 The patient should be instructed to keep medication available at all times. Spare doses should be kept in the car. 2 Extra doses of the medication do not need to be stored in the refrigerator. 3 The medication should be taken as prescribed. Efforts should be taken to not miss doses but not to take extra doses. 4 When the patient travels, medication should remain with the patient in carry-on luggage. PTS: 1 CON: Neurologic Regulation | Medication 8. ANS: 4 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Describing the epidemiology of peripheral nervous system disorders Chapter page reference: 808 Heading: Guillain-Barré Syndrome (GBS) > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Sensory Perception Difficulty: Moderate
1 2 3 4
Feedback There is no evidence to sugge st N UthRatSGIBNS GisTtrBan.sCmOittMed from small children. Recent ingestion of food most likely did not cause the patient’s symptoms. Traveling out of the country is not directly linked to the development of GBS. About two-thirds of patients who develop GBS demonstrate clinical manifestations of an infection three weeks prior to onset. Respiratory or gastrointestinal infections are the most common sources.
PTS: 1 CON: Neurologic Regulation | Sensory Perception 9. ANS: 4 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Explaining the pathophysiological processes of peripheral nervous system disorders Chapter page reference: 809 Heading: Guillain-Barré Syndrome (GBS) > Pathophysiology Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Sensory Perception Difficulty: Easy
1 2 3
Feedback An infection does not eat away at the nerve endings in GBS. An infection does not enter the spinal cord and erode the nerves at the roots in GBS. The nerves are not killed by the body’s white blood cells in GBS.
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4
In GBS, the patient’s own immune system begins to destroy the myelin that surrounds the peripheral nerves. Destruction occurs between the nodes of Ranvier that results in slowing of impulses or conduction block. There is infiltration of lymphocytes into the peripheral nervous system, which attracts macrophages; the macrophages penetrate the Schwann cell and invade the myelin resulting in demyelination.
PTS: 1 CON: Neurologic Regulation | Sensory Perception 10. ANS: 1 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: GuillainBarré syndrome (GBS) Chapter page reference: 809 Heading: Guillain-Barré Syndrome (GBS) > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Sensory Perception Difficulty: Moderate
1 2 3 4
Feedback Areflexia is recognized as a key finding in GBS. The reflexes in a patient with GBS will be absent and not just diminished. The reflexes in a patient with GBS will be absent and not exaggerated. T rehseproenisse.no evidence to suggest that the patient with GBS will have a heightened pain
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PTS: 1 CON: Neurologic Regulation | Sensory Perception 11. ANS: 2 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: GuillainBarré Syndrome (GBS) Chapter page reference: 809 Heading: Guillain-Barré syndrome (GBS) > Clinical Manifestations Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Sensory Perception; Oxygenation Difficulty: Moderate
1 2 3 4
Feedback No further damage or repair occurs during the plateau stage. The pattern of recovery is the reverse of onset, and the nerves that were affected last are the first to improve. The respiratory nerves will repair first. No further damage or repair occurs during the plateau stage. The pattern of recovery is the reverse of onset, and the nerves that were affected last are the first to improve. The respiratory nerves will repair first.
PTS: 1 12. ANS: 1
CON: Neurologic Regulation | Sensory Perception | Oxygenation
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Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected disorders of the peripheral nervous system Chapter page reference: 809 Heading: Guillain-Barré Syndrome (GBS) > Medical Management > Diagnostic Tests Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation; Sensory Perception Difficulty: Moderate 1 2 3 4
Feedback In GBS, cerebrospinal fluid findings include an elevated protein level. In GBS, there is no evidence to suggest that glucose is elevated in the cerebrospinal fluid. In GBS, the cell count in the cerebrospinal fluid is normal. In GBS, the cell count in the cerebrospinal fluid is normal.
PTS: 1 CON: Neurologic Regulation | Sensory Perception 13. ANS: 1 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Discussing the medical management of selected disorders of the peripheral nervous system Chapter page reference: 810 Heading: Guillain-Barré Syndrome (GBS) > Medical Management > Medications Integrated Processes: Nursing ProcesN s:UARssSesIsN mG enT t B.CO Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation; Sensory Perception Difficulty: Moderate 1 2 3 4
Feedback Plasmapheresis increases the risk for infection. Septicemia is a complication of plasmapheresis. Flu-like symptoms are associated with intravenous immunoglobulin therapy. Aseptic meningitis is associated with intravenous immunoglobulin therapy. Acute renal failure is associated with intravenous immunoglobulin therapy.
PTS: 1 CON: Neurologic Regulation | Sensory Perception 14. ANS: 4 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Discussing the medical management of selected disorders of the peripheral nervous system Chapter page reference: 810 Heading: Guillain-Barré Syndrome (GBS) > Medical Management > Complications Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Sensory Perception
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Difficulty: Moderate
1 2 3 4
Feedback Autonomic dysfunction is causing the sweating. The patient does not have a temperature. The health-care provider does not need to be notified. The patient does not have a fever. Autonomic dysfunction is causing the sweating. Patients with GBS may perspire because of autonomic manifestations, and the patient’s clothing and linens require frequent changes.
PTS: 1 CON: Neurologic Regulation | Sensory Perception 15. ANS: 1 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with peripheral nervous system disorders Chapter page reference: 811 Heading: Guillain-Barré Syndrome (GBS) > Nursing Management > Actions Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Sensory Perception; Medication Difficulty: Moderate
1 2 3 4
Feedback Gabapentin may be used to relNieU veRnSe I urN opGa T thB ic .p ain C O. M Frequent repositioning promotes comfort and prevents complications of immobility including thromboembolism and impaired skin integrity. Sequential compression devices prevent venous stasis. Range-of-motion exercises promote joint mobility and function.
PTS: 1 CON: Neurologic Regulation | Sensory Perception | Medication 16. ANS: 1 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Describing the epidemiology of peripheral nervous system disorders Chapter page reference: 812 Heading: Trigeminal Neuralgia Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Neurologic Regulation; Comfort Difficulty: Easy Feedback 1 Trigeminal neuralgia is a pain disorder, and the patient seeks medical attention for relief. It is not unusual for the patient to present to a primary care practitioner with a chief complaint of facial pain. 2 Nausea is not typically associated with trigeminal neuralgia. 3 Sensory deficits are not typically associated with trigeminal neuralgia. 4 Motor weakness is not typically associated with trigeminal neuralgia.
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PTS: 1 CON: Neurologic Regulation | Comfort 17. ANS: 3 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Describing the epidemiology of peripheral nervous system disorders Chapter page reference: 813 Heading: Trigeminal Neuralgia > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Neurologic Regulation; Comfort Difficulty: Easy Feedback 1 Obesity is not a risk factor for the development of trigeminal neuralgia. 2 Birth control pills are not identified as causing trigeminal neuralgia. 3 Hypertension is a risk factor for the development of trigeminal neuralgia. 4 Specific occupations are not identified as causing trigeminal neuralgia. PTS: 1 CON: Neurologic Regulation | Comfort 18. ANS: 2 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Explaining the pathophysiological processes of peripheral nervous system disorders Chapter page reference: 813 Heading: Trigeminal Neuralgia > Pathophysiology NURSINGTB.COM Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Neurologic Regulation; Comfort Difficulty: Easy Feedback 1 Referred pain is pain felt somewhere on the body but occurs in another body organ or location. 2 In trigeminal neuralgia, atypical pain is a constant burning sensation that covers a more diffuse region of the face. 3 Vascular compression is identified as a cause for the classic pain seen in trigeminal neuralgia. 4 The pain of trigeminal neuralgia is not considered peripheral neuropathy. PTS: 1 CON: Neurologic Regulation | Comfort 19. ANS: 2 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Trigeminal neuralgia Chapter page reference: 813 Heading: Trigeminal Neuralgia > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing]
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Concept: Neurologic Regulation; Comfort Difficulty: Moderate
1 2 3 4
Feedback Talking can be a trigger for pain; however, this is not a hygienic practice. Hygiene activities such as combing the hair may be neglected because it triggers pain. Wearing tennis shoes is a personal choice and is not a hygienic practice. Not all females wear makeup. Wearing makeup is not necessarily a hygienic practice.
PTS: 1 CON: Neurologic Regulation | Comfort 20. ANS: 3 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Discussing the medical management of selected disorders of the peripheral nervous system Chapter page reference: 813 Heading: Trigeminal Neuralgia > Medical Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation; Comfort; Medication Difficulty: Moderate
1 2 3
4
Feedback Cogentin is a medication used to treat Parkinson’s disease. Compazine is a medication used NUtoR tSreIatNnGauTsBea.and COvMo mitin g. Carbamazepine is the first line of drug therapy used in the treatment of trigeminal neuralgia, and it works by reducing the excitability of neurons by inhibiting neuronal sodium channels. Hydrochlorothiazide is a medication used to treat hypertension.
PTS: 1 CON: Neurologic Regulation | Comfort | Medication 21. ANS: 2 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Discussing the medical management of selected disorders of the peripheral nervous system Chapter page reference: 813 Heading: Trigeminal Neuralgia > Medical Management Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Perioperative Difficulty: Moderate Feedback 1 Plasmapheresis is not a treatment for trigeminal neuralgia. 2 An adverse effect of a percutaneous rhizotomy is permanent facial numbness in the region supplied by the branch that was destroyed. 3 Stereotactic radiosurgery does not cause residual facial numbness. 4 Microvascular decompression does not cause residual facial numbness.
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PTS: 1 CON: Neurologic Regulation | Perioperative 22. ANS: 4 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with peripheral nervous system disorders Chapter page reference: 814 Heading: Trigeminal Neuralgia > Nursing Management > Actions Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Comfort Difficulty: Moderate Feedback 1 Massage could be a trigger for trigeminal neuralgia. 2 Heat could be a trigger for trigeminal neuralgia. 3 Cold could be a trigger for trigeminal neuralgia. 4 Acupuncture has been found to have efficacy similar to that of Tegretol. PTS: 1
CON: Neurologic Regulation | Comfort
MULTIPLE RESPONSE 23. ANS: 1, 2 Chapter number and title: 38, CoordiN n aUtiR n gSCIaN reGf T o rBP. a tC ie O n tM s With Peripheral Nervous System Disorders Chapter learning objective: Describing the epidemiology of peripheral nervous system disorders Chapter page reference: 801 Heading: Myasthenia Gravis > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation; Sensory Perception Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Ptosis is an ocular manifestation of myasthenia gravis. Diplopia is an ocular manifestation of myasthenia gravis. Abdominal pain is not a manifestation of myasthenia gravis. Left leg weakness is not a specific manifestation of myasthenia gravis. Epigastric burning is not a manifestation of myasthenia gravis.
PTS: 1 CON: Neurologic Regulation | Sensory Perception 24. ANS: 1, 3, 4, 5 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Myasthenia gravis (MG) Chapter page reference: 802 Heading: Myasthenia Gravis > Clinical Manifestations
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Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Mobility; Sensory Perception Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Bulbar manifestations affect CN IX, which controls swallowing. Eye opening is an ocular manifestation of myasthenia gravis. Bulbar manifestations affect CN IX, which has a role in blood pressure control. Bulbar manifestations affect CN XII, which controls tongue movement. Bulbar manifestations affect CN XI, which controls movement of the head and neck.
PTS: 1 CON: Neurologic Regulation | Mobility | Sensory Perception 25. ANS: 1, 3, 4 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Discussing the medical management of selected disorders of the peripheral nervous system Chapter page reference: 805 Heading: Myasthenia Gravis > Medical Management > Medications Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Medication Difficulty: Moderate
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1. 2. 3. 4. 5.
Feedback The antiarrhythmic verapamil is known to aggravate myasthenia gravis. Furosemide is not identified as aggravating myasthenia gravis. Erythromycin is an antibiotic known to aggravate myasthenia gravis. Nicotine patch is known to aggravate myasthenia gravis. Warfarin sodium, an anticoagulant, is not identified as aggravating myasthenia gravis.
PTS: 1 CON: Neurologic Regulation | Medication 26. ANS: 1, 2, 3, 5 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Explaining the pathophysiological processes of peripheral nervous system disorders Chapter page reference: 809 Heading: Guillain-Barré Syndrome (GBS) > Pathophysiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Sensory Perception; Assessment Difficulty: Easy
1. 2.
Feedback Edema is seen in the acute stage of GBS. Paralysis is seen in the acute stage of GBS.
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3. 4. 5.
Difficulty breathing is seen in the acute stage of GBS. Urinary incontinence is not identified as a manifestation of GBS. Numbness and tingling are seen in the acute stage of GBS.
PTS: 1
CON: Neurologic Regulation | Sensory Perception | Assessment
NUMERIC RESPONSE 27. ANS: 2 Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Discussing the medical management of selected disorders of the peripheral nervous system Chapter page reference: 804 Heading: Myasthenia Gravis > Medical Management > Medications Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Sensory Perception; Medication Difficulty: Moderate Feedback: The patient should receive 1 mg intravenous neostigmine (Prostigmin) for every 60 mg of pyridostigmine (Mestinon). This patient should receive 0.5 mg for every 30 mg. Since the patient takes 4 doses of oral pyridostigmine (Mestinon) 0.5 mg x 4 or 2 mg of pyridostigmine (Mestinon) should be prescribed. NURSINGTB.COM PTS: 1 CON: Neurologic Regulation | Sensory Perception | Medication 28. ANS: 160 grams Chapter number and title: 38, Coordinating Care for Patients With Peripheral Nervous System Disorders Chapter learning objective: Discussing the medical management of selected disorders of the peripheral nervous system Chapter page reference: 805 Heading: Myasthenia Gravis > Medical Management > Medications Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Sensory Perception; Medication Difficulty: Moderate Feedback: First determine the patient’s weight in kg by dividing the weight in pounds by 2.2 or 176/2.2 = 80 kg. Then multiply the ordered dose by the weight or 2 g x 80 = 160 g. The nurse needs to have 160 grams of the medication available to be infused over three days. PTS: 1
CON: Neurologic Regulation | Sensory Perception | Medication
Chapter 39: Coordinating Care for Critically Ill Patients With Neurological Dysfunction
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Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is preparing a patient for insertion of an intraventricular catheter intracranial pressure (ICP) monitoring device. What is an advantage of this device? 1) Must be inserted in the operating room 2) Catheter tip located in the lateral ventricle 3) Less mechanical drift of the measurement over time 4) Lower rate of infection because of no fluid reservoir 2. A patient with increased intracranial pressure (ICP) is sensitive to fluid-volume shifts. Which approach would be the safest to reduce this patient’s cerebral edema? 1) Mannitol 2) 3% normal saline 3) Bacteriostatic saline 4) Preservative-free saline 3. The nurse is caring for a patient in a barbiturate coma for increased intracranial pressure (ICP). What should the nurse assess to determine this patient’s cerebral function? 1) Gag reflex 2) Glasgow coma scale 3) Pupillary size and reaction 4) Blood pressure and heart rate 4. A patient with increased intracran ial N prU esRsuSreI(NICGPT) ha B.s Ca bo OMdy temperature of 100 °F. What action should the nurse take to address this temperature elevation? 1) Place head in a neutral position 2) Administer antipyretic as prescribed 3) Auscultate lung sounds and increase fluids 4) Send a urine sample for culture and sensitivity 5. A patient in a barbiturate coma for increased intracranial pressure (ICP) has audible gurgling through the endotracheal tube. What should the nurse do first before suctioning this patient? 1) Administer 100% oxygen 2) Elevate the head of the bed 3) Interrupt sedative administration 4) Place the head in a neutral position 6. The nurse is concerned that a patient is at high risk for having a stroke. What finding did the nurse use to make this clinical decision? 1) BMI 24.8 2) Heart rate 90 bpm 3) Blood pressure 182/90 mm Hg 4) Pulse oximetry 98% on room air 7. The nurse suspects that a patient is experiencing a hemorrhagic stroke from a ruptured cerebral aneurysm. What assessment finding caused the nurse to make this conclusion? 1) Slurred speech 2) Visual field deficits 3) Sudden severe headache
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4) Lower extremity weakness 8. A patient is diagnosed with a subarachnoid hemorrhage caused by a cerebral aneurysm that has a wide neck and tortuous vascular anatomy. For which procedure should the nurse prepare teaching material for this patient? 1) Aneurysm coiling 2) Aneurysm clipping 3) Reinforcing aneurysm wall 4) Evacuation of the hematoma 9. A patient recovering from a hemorrhagic stroke has a blood pressure of 90/50 mm Hg. What action should the nurse take? 1) Increase the head of the bed 2) Notify the health-care provider 3) Place the head in a neutral position 4) Reassess the pressure in 15 minutes 10. A patient with a cerebral vasospasm is receiving triple H therapy. What parameter should the nurse use to determine adequacy of hemodilution? 1) Hemoglobin level = 30 g/dL 2) Blood pressure 154/80 mm Hg 3) Serum sodium level less than 160 mg/dL 4) Serum potassium level between 4.0 and 4.5 mEq/L 11. The nurse is preparing materials for the families of patients who have sustained a stroke. What information should the nurse include to reduce the risk for additional strokes? 1) Heart-healthy diet NURSINGTB.COM 2) Smoking cessation 3) Stress management 4) Weight-reduction strategies 12. A patient recovering from an ischemic stroke is prescribed verapamil (Calan). In preparation for patient teaching, which medication category will the nurse review? 1) Diuretic 2) Beta blocker 3) Lipid-lowering agent 4) Calcium channel blocker 13. The nurse is assessing a patient who sustained a traumatic brain injury several years ago. What finding should the nurse expect when completing the assessment? 1) Dysphagia 2) Hemiparesis 3) Memory loss 4) Visual field deficits 14. An adolescent seeks medical care after being in a street fight. Which observation indicates that this patient has sustained a basilar skull fracture? 1) Hyperthermia 2) Episodic tachycardia 3) Bruising around the ears 4) Rapid deterioration to comatose
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15. The nurse is caring for a patient with a diffuse axonal injury. What treatment plan should the nurse expect to be prescribed for this patient? 1) Craniotomy 2) Wound debridement 3) Monitor and observe 4) Evacuation of the hematoma 16. A patient with a traumatic brain injury is leaking clear fluid from the nose. What action should the nurse take? 1) Collect the fluid with gauze 2) Check the fluid for red blood cells 3) Send a specimen for a protein level 4) Insert a nasal plug in the nostril leaking the fluid 17. The family of a patient with a traumatic brain injury asks why the bed side rails are padded. What should the nurse explain to the family? 1) “There is a risk for seizure activity after a head injury.” 2) “The padding prevents injury when turning the patient.” 3) “The padding prevents the patient from climbing out of bed.” 4) “The padding ensures the side rails are kept elevated at all times.” 18. A patient recovering from a stroke has profound bradycardia. What should the nurse suspect as the cause of this manifestation? 1) Parasympathetic nervous system disruption 2) Irritation of the sympathetic nervous system 3) Shunting of fluid from the cerebral vasculature 4) Alteration in the vasomotor center in the brainstem
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19. The nurse is caring for a patient with neurogenic shock. What finding should the nurse expect to assess in this patient? 1) Tachycardia 2) Hypertension 3) Warm dry skin 4) Rapid shallow respirations 20. A patient with neurogenic shock is demonstrating vagal stimulation. What should the nurse expect to be prescribed for this patient? 1) Atropine 2) Epinephrine 3) Phenylephrine 4) Norepinephrine 21. A patient with neurogenic shock has a sustained heart rate of 38 beats per minute. Based on this observation, for what should the nurse prepare the patient? 1) Intravenous fluids 2) Pacemaker insertion 3) Cardiac catheterization 4) Arterial blood gas analysis 22. The nurse is caring for a patient with hypotension caused by neurogenic shock. What action should the nurse take to reduce the risk of developing orthostatic hypotension? 1) Raise the head of the bed slowly 2) Elevate the foot of the bed 30 degrees
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3) Place in the supine position with the head flat 4) Keep the head of the bed elevated at 60 degrees Multiple Response Identify one or more choices that best complete the statement or answer the question. 23. The nurse contacts the health-care provider with data collected from a patient recovering from a stroke. Which information indicated the patient was experiencing central herniation? Select all that apply. 1) Coma 2) Bradycardia 3) Positive Babinski’s 4) Unilateral dilated pupil 5) Increased systolic blood pressure 24. A patient is demonstrating signs of increasing intracranial pressure (ICP). What physical actions should the nurse take to reduce this pressure? Select all that apply. 1) Placing the head in a neutral position 2) Turning into a left side-lying position 3) Raising the head of the bed 60 degrees 4) Elevating the foot of the bed 45 degrees 5) Placing supine with a pillow under the head 25. The nurse suspects a patient is experiencing an ischemic stroke of the basilar artery. What manifestations did the nurse most likely assess in this patient? Select all that apply. 1) Ataxia 2) Nausea NURSINGTB.COM 3) Dysphasia 4) Inability to swallow 5) Difficulty with speech 26. A patient with an ischemic stroke is being considered for recombinant tissue plasminogen activator (rt-PA). What would cause this procedure to be contraindicated in this patient? Select all that apply. 1) Age 83 years 2) Symptoms present for 45 minutes 3) CT scan demonstrates area of ischemia 4) 10-year history of type 2 diabetes mellitus 5) Takes warfarin sodium for atrial fibrillation 27. A patient is being discharged after treatment for an ischemic stroke. Which medications should the nurse expect to be prescribed for this patient? Select all that apply. 1) Antibiotics 2) Anticoagulant 3) Antihypertensive 4) Antiplatelet therapy 5) Lipid-lowering agent Numeric Response 28. A patient has an intracranial pressure measurement of 22 mm Hg and blood pressure of 174/88 mm Hg. What is the patient’s cerebral perfusion pressure?
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Chapter 39: Coordinating Care for Critically Ill Patients With Neurological Dysfunction Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Describing the indications and nursing implications for ICP monitoring in the critically ill patient Chapter page reference: 821 Heading: Increased Intracranial Pressure > Intracranial Pressure Monitoring Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 The intraventricular catheter ICP monitoring device can be inserted at the bedside or the operating room. This is not an advantage. 2 The intraventricular catheter ICP monitoring device is considered the gold standard for ICP measurement because the catheter tip is located in the lateral ventricle. 3 The intraparenchymal sensor/probe has less mechanical drift of the measurement over time. 4 The subarachnoid bolt (SAB) N h aUs R aS loI wN e rGraTteBo.f C inO f eM c tion because of no fluid reservoir. PTS: 1 CON: Neurologic Regulation 2. ANS: 2 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Explaining the rationales for relevant medical interventions in the treatment of patients with increased ICP, stroke, traumatic brain injury, and neurogenic shock Chapter page reference: 827 Heading: Increased Intracranial Pressure > Medical Management > Medications Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation Difficulty: Moderate
1
2
3
Feedback Mannitol pulls water from the interstitial spaces across the blood-brain barrier into the vascular space for diuresis through the kidney. This medication can cause dramatic fluid shifts and should be provided with intravenous fluids to prevent reactions to fluid imbalances. High-concentration sodium chloride solutions pull water from the interstitial spaces into the vascular space without the dramatic fluid shifts caused when osmotic diuretics are utilized Bacteriostatic saline is used to flush the intracranial pressure monitoring device.
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4
Preservative-free saline solution is used to flush the intracranial pressure monitoring device.
PTS: 1 CON: Neurologic Regulation 3. ANS: 3 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Describing the indications and nursing implications for ICP monitoring in the critically ill patient Chapter page reference: 829 Heading: Increased Intracranial Pressure > Nursing Management > Assessment and Analysis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Assessment Difficulty: Moderate
1 2 3
4
Feedback The patient in a barbiturate coma will not have a gag reflex. The Glasgow coma scale would be inconclusive since the patient is in a coma. The ability to elicit a neurological assessment from a patient in a barbiturate coma is limited because of the suppression caused by the medication; therefore, other parameters such as pupillary size and reaction must be used. Blood pressure and heart rate will not provide maximum information about the patient’s cerebral functioning.
NURSINGTB.COM 4.
PTS: 1 CON: Neurologic Regulation | Assessment ANS: 2 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Discussing the nursing management of patients with increased ICP, stroke, traumatic brain injury, and neurogenic shock Chapter page reference: 830 Heading: Increased Intracranial Pressure > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Moderate 1 2 3
4
Feedback Placing the head in a neutral position will not affect body temperature. Antipyretics should be administered for temperature elevations because it will prevent an increase in cerebral metabolism. Auscultating lung sounds and increasing fluids assumes the temperature is caused by a lung infection or pooling of secretions. This is not an identified action for a temperature elevation. Sending a urine specimen for analysis assumes that the temperature elevation is caused by a urinary tract infection. This is not an identified action for a temperature elevation.
PTS: 1
CON: Neurologic Regulation
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5. ANS: 1 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Discussing the nursing management of patients with increased ICP, stroke, traumatic brain injury, and neurogenic shock Chapter page reference: 830 Heading: Increased Intracranial Pressure > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Moderate
1 2 3 4
Feedback Administering 100% oxygen just prior to suctioning is performed to prevent hypoxia, which can occur during the interruption of mechanical ventilation. The patient’s head of the bed should already be elevated. Interrupting sedative administration would be appropriate if a complete neurologic assessment is going to be conducted. The head should already be in the neutral position.
PTS: 1 CON: Neurologic Regulation 6. ANS: 3 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Describing the epidemiology of disorders of the nervous system requiring critical care management NURSINGTB.COM Chapter page reference: 831 Heading: Stroke > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Neurologic Regulation Difficulty: Easy
1 2 3 4
Feedback Overweight is not identified as a risk factor for stroke. Heart rate of 90 bpm is within normal limits and is not a risk factor for stroke. A significant risk factor for stroke is hypertension. A pulse oximeter reading of 98% on room air indicates adequate oxygenation and is not a risk factor for stroke.
PTS: 1 CON: Neurologic Regulation 7. ANS: 3 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Correlating the clinical manifestations to pathological processes of: Stroke: Hemorrhagic Chapter page reference: 839 Heading: Hemorrhagic Stroke > Pathophysiology and Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential
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Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation; Assessment Difficulty: Moderate
1 2 3 4
Feedback Slurred speech is not identified as a manifestation of a ruptured cerebral aneurysm. Visual field deficits are not identified as a manifestation of a ruptured cerebral aneurysm. Subarachnoid hemorrhage is characterized by a sudden severe headache, often termed a “thunderclap” headache because of the intensity of the pain experienced at the onset. Lower extremity weakness is not identified as a manifestation of a ruptured cerebral aneurysm.
PTS: 1 CON: Neurologic Regulation | Assessment 8. ANS: 2 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Explaining the rationales for relevant medical interventions in the treatment of patients with increased ICP, stroke, traumatic brain injury, and neurogenic shock Chapter page reference: 840 Heading: Hemorrhagic Stroke > Medical and Surgical Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Perioperative Difficulty: Moderate
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4
Feedback Patients with high-grade Hunt and Hess scores (grade 4 or 5), as well as patients with multiple comorbid conditions and with hemodynamic instability at baseline, may be better candidates for aneurysm coiling. Aneurysms with a wide neck and tortuous vascular anatomy may be better candidates for aneurysm clipping. In cases where neither clipping nor coiling the aneurysm is feasible, reinforcement of the aneurysmal wall by wrapping the outside of the aneurysm with synthetic material or muscle during the surgery may be accomplished. Surgical management of intracranial hemorrhage above the tentorium cerebelli has not been shown to improve outcomes unless a hematoma is superficial in location.
PTS: 1 CON: Neurologic Regulation | Perioperative 9. ANS: 2 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Discussing the nursing management of patients with increased ICP, stroke, traumatic brain injury, and neurogenic shock Chapter page reference: 842 Heading: Stroke > Nursing Management > Assessments Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation
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Difficulty: Moderate
1 2
3 4
Feedback Increasing the head of the bed could further reduce blood flow to the brain. A protective mechanism of the brain, cerebral autoregulation, is dysfunctional after stroke, rendering the brain vulnerable to hypotension because the cerebral blood vessels are not able to automatically dilate ensuring adequate oxygen delivery to brain tissue. The health-care provider should be notified with the blood pressure measurement. Placing the head in a neutral position will not impact the patient’s blood pressure. The patient’s condition could deteriorate in 15 minutes. The blood pressure should be reported immediately.
PTS: 1 CON: Neurologic Regulation 10. ANS: 1 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Discussing the nursing management of patients with increased ICP, stroke, traumatic brain injury, and neurogenic shock Chapter page reference: 841 Heading: Stroke > Medical Management > Complications Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Medication Difficulty: Moderate
1 2 3 4
NURSINGTB.COM Feedback Minimum thresholds for hemoglobin hemodilution are typically maintained at approximately 30 g/dL. A blood pressure of 154/80 mm Hg would indicate adequacy of hypertension within the triple H therapy. Serum sodium is not an indicator of effectiveness of triple H therapy. Serum potassium is not an indicator of effectiveness of triple H therapy.
PTS: 1 CON: Neurologic Regulation | Medication 11. ANS: 2 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Developing a teaching plan for stroke and traumatic brain injury patients Chapter page reference: 842 Heading: Stroke > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Promoting Health Difficulty: Moderate
1
Feedback A heart-healthy diet might be appropriate if the stroke is caused by atherosclerosis.
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2
3 4
Smoking cessation is essential for the nurse to include. Exposure to nicotine due to cigarette smoking causes a decrease in oxygen levels in the blood, which may contribute to blood clot formation and vasoconstriction with each inhalation of smoke. Additionally, nicotine may cause more rapid deposition and accumulation of atherosclerotic plaque. Patients may be more willing to consider smoking cessation after an illness such as stroke. Stress management has not been identified as essential teaching to reduce the risk of stroke. Weight reduction has not been identified as essential teaching to reduce the risk of stroke.
PTS: 1 CON: Neurologic Regulation | Promoting Health 12. ANS: 4 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Developing a teaching plan for stroke and traumatic brain injury patients Chapter page reference: 844 Heading: Stroke > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Medication Difficulty: Moderate
1 2 3 4
Feedback Verapamil (Calan) is a calcium channel blocker and not a diuretic. Verapamil (Calan) is a calcium channel blocker and not a beta blocker. Verapamil (Calan) is a calcium channel blocker and not a lipid-lowering agent. Verapamil (Calan) is a calcium channel blocker.
PTS: 1 CON: Neurologic Regulation | Medication 13. ANS: 3 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Describing the epidemiology of disorders of the nervous system requiring critical care management Chapter page reference: 844 Heading: Traumatic Brain Injury > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Neurologic Regulation Difficulty: Easy Feedback 1 Dysphagia is associated with a stroke. 2 Hemiparesis is associated with a stroke. 3 Many who sustain even a mild head injury suffer long-term effects such as memory loss 4 Visual field deficits are associated with a stroke. PTS: 1 14. ANS: 3
CON: Neurologic Regulation
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Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Correlating the clinical manifestations to pathological processes of: Traumatic brain injury Chapter page reference: 847 Heading: Traumatic Brain Injury > Pathophysiology > Skull Fractures Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Neurologic Regulation; Assessment Difficulty: Easy 1 2 3 4
Feedback Hyperthermia is a manifestation of a diffuse axonal injury. Episodic tachycardia is a manifestation of a diffuse axonal injury. A late sign of a basilar fracture is bruising around the eyes (raccoon’s eyes) or the ears, termed Battle’s sign. Rapid deterioration to comatose is a manifestation of an epidural hematoma.
PTS: 1 CON: Neurologic Regulation | Assessment 15. ANS: 3 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Explaining the rationales for relevant medical interventions in the treatment of patients with increased ICP, stroke, traumatic brain injury, and neurogenic shock Chapter page reference: 850 Heading: Traumatic Brain Injury > Surgical Management Integrated Processes: Nursing ProcesN s:UPR laS nnIinNgGTB.COM Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Moderate 1 2 3 4
Feedback A craniotomy may be indicated in patients with hemorrhagic injuries and typically involve opening of the skull and removal of blood accumulations. With skull fractures, there is a need to débride and clean the wound area as well as to remove any bone fragments that may be at the area of impact. Surgery is not indicated in patients with diffuse axonal injuries because there is no specific area of blood removal. Both epidural and subdural hematomas are surgically evacuated to decrease ICP.
PTS: 1 CON: Neurologic Regulation 16. ANS: 1 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Discussing the nursing management of patients with increased ICP, stroke, traumatic brain injury, and neurogenic shock Chapter page reference: 850 Heading: Traumatic Brain Injury > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential
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Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Moderate
1 2 3 4
Feedback If clear fluid is draining from the ear or nose, it should be collected using loosely applied gauze. Clear drainage would be checked for glucose and not red blood cells. Clear drainage would be checked for glucose and not protein. If clear fluid is draining from the ear or nose, it should not be stopped.
PTS: 1 CON: Neurologic Regulation 17. ANS: 1 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Developing a teaching plan for stroke and traumatic brain injury patients Chapter page reference: 851 Heading: Traumatic Brain Injury > Nursing Management > Actions Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Nursing Difficulty: Moderate
1 2 3 4
Feedback After a head injury, the patientN sU hoRuS ldIbN e G onTsB ei.zuCreOpMrecau tion s because of the risk of seizure activity. Padding is not placed on a bed to prevent injury when turning the patient. Padding is not used to prevent the patient from climbing out of the bed. Padding is not used to ensure that the side rails remain elevated at all times. This would be a form of physical restraint necessitating a health-care provider’s order.
PTS: 1 CON: Neurologic Regulation | Nursing 18. ANS: 4 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Correlating the clinical manifestations to pathological processes of: Neurogenic shock Chapter page reference: 851 Heading: Neurogenic Shock > Pathophysiology and Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 Neurogenic shock is caused by a disruption in the sympathetic nervous system. 2 Neurogenic shock is caused by a disruption in the sympathetic nervous system. 3 Neurogenic shock is not caused by the shunting of fluid from the cerebral vasculature. 4 When neurogenic shock is caused by stroke in the brainstem, symptoms of neurogenic shock arise from the vasomotor center in the brainstem.
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PTS: 1 CON: Neurologic Regulation 19. ANS: 3 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Correlating the clinical manifestations to pathological processes of: Neurogenic shock Chapter page reference: 852 Heading: Neurogenic Shock > Pathophysiology and Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation; Assessment Difficulty: Moderate Feedback 1 The clinical presentation of neurogenic shock includes profound bradycardia. 2 The clinical presentation of neurogenic shock includes hypotension. 3 Patients with neurogenic shock typically have warm and dry skin due to systemic vasodilation. 4 The clinical presentation of neurogenic shock includes metabolic acidosis. Rapid shallow respirations would be seen in respiratory alkalosis. PTS: 1 CON: Neurologic Regulation | Assessment 20. ANS: 1 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Explaining the rationales for relevant medical interventions in the treatment of NURSINGTB.CO patients with increased ICP, stroke, traumatic brain injury, and neurogenic shock Chapter page reference: 852 Heading: Neurogenic Shock > Medical Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Physiological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation; Medication Difficulty: Moderate Feedback 1 Atropine would be prescribed to block vagal (parasympathetic) stimulation. 2 Epinephrine is used to treat the loss of vascular tone. 3 Phenylephrine is used to treat the loss of vascular tone. 4 Epinephrine is used to treat the loss of vascular tone. PTS: 1 CON: Neurologic Regulation | Medication 21. ANS: 2 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Explaining the rationales for relevant medical interventions in the treatment of patients with increased ICP, stroke, traumatic brain injury, and neurogenic shock Chapter page reference: 852 Heading: Neurogenic Shock > Medical Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying]
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Concept: Neurologic Regulation Difficulty: Moderate
1 2 3 4
Feedback Intravenous fluids are not indicated to treat sustained bradycardia. In neurogenic shock, transcutaneous and then transvenous pacing may be utilized to treat repeated episodes of profound bradycardia. Cardiac catheterization is not indicated for the patient in neurogenic shock experiencing bradycardia. Arterial blood gas analysis is not indicated for the patient in neurogenic shock experiencing bradycardia.
PTS: 1 CON: Neurologic Regulation 22. ANS: 1 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Discussing the nursing management of patients with increased ICP, stroke, traumatic brain injury, and neurogenic shock Chapter page reference: 853 Heading: Neurogenic Shock > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Moderate
1
2 3 4
NURSINGTB.COM Feedback The nurse should raise the head of bed slowly (10–15 degrees per hour) in a systematic manner. Because of loss of systemic vasomotor tone, raising a patient’s head of bed may cause orthostatic hypotension because of an inability of the peripheral blood vessels to constrict upon position change. Elevating the foot of the bed will not prevent the development of orthostatic hypotension. The supine position with the head flat will not prevent the development of orthostatic hypotension. Keeping the head of the bed elevated at 60 degrees may precipitate the development of orthostatic hypotension.
PTS: 1
CON: Neurologic Regulation
MULTIPLE RESPONSE 23. ANS: 1, 2, 3, 5 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Correlating the clinical manifestations to pathological processes of: Increased intracranial pressure (ICP) Chapter page reference: 817 Heading: Increased Intracranial Pressure > Pathophysiology and Clinical Manifestations Integrated Processes: Nursing Process: Assessment
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Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Clinical manifestations of central herniation include coma. Clinical manifestations of central herniation include bradycardia. Clinical manifestations of central herniation include positive Babinski’s. Unilateral dilated pupil is a clinical manifestation of uncal herniation. Clinical manifestations of central herniation include increased systolic blood pressure.
PTS: 1 CON: Neurologic Regulation | Assessment 24. ANS: 1, 3 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Describing the indications and nursing implications for ICP monitoring in the critically ill patient Chapter page reference: 827 Heading: Increased Intracranial Pressure > Medical Management > Physical Interventions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Neurologic Regulation Difficulty: Moderate
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1. 2. 3. 4. 5.
Feedback Positioning a patient so that the neck is in a neutral position assists in facilitating venous drainage from the head. Positioning a patient so that hip flexion is minimized assists in facilitating venous drainage from the head. The side-lying position uses hip flexion to maintain the position. Blood volume in the intracranial space may be decreased by raising the head of the bed to greater than 45 degrees to facilitate drainage of venous blood through the jugular venous system. Elevating the foot of the bed would increase ICP. The supine position with a pillow under the head would increase ICP.
PTS: 1 CON: Neurologic Regulation 25. ANS: 1, 2, 4, 5 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Correlating the clinical manifestations to pathological processes of: Stroke: Ischemic Chapter page reference: 833 Heading: Ischemic Stroke > Pathophysiology and Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation; Assessment Difficulty: Moderate
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1. 2. 3. 4. 5.
Feedback Manifestations of basilar artery syndrome include ataxia. Manifestations of basilar artery syndrome include nausea. Dysphagia is a manifestation of left middle cerebral artery syndrome. Manifestations of basilar artery syndrome include difficulty swallowing. Manifestations of basilar artery syndrome include difficulty in the articulation of speech.
PTS: 1 CON: Neurologic Regulation | Assessment 26. ANS: 1, 4, 5 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Explaining the rationales for relevant medical interventions in the treatment of patients with increased ICP, stroke, traumatic brain injury, and neurogenic shock Chapter page reference: 835 Heading: Ischemic Stroke > Medical Management Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Neurologic Regulation; Assessment Difficulty: Moderate 1. 2. 3. 4. 5.
Feedback Exclusion criteria for rt-PA include age greater than 80 years. Include criteria for re-PA include symptoms present for at least 30 minutes. Include criteria for re-PA include a CT scan consistent with an ischemic stroke. Exclusion criteria for rtN-PUARiS n cIluNd eG aTpBri. oC r hOisM to ry of diabetes. Exclusion criteria for re-PA include receiving anticoagulants.
PTS: 1 CON: Neurologic Regulation | Assessment 27. ANS: 2, 3, 4, 5 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Explaining the rationales for relevant medical interventions in the treatment of patients with increased ICP, stroke, traumatic brain injury, and neurogenic shock Chapter page reference: 836 Heading: Ischemic Stroke > Medical Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Medication Difficulty: Moderate
1. 2. 3. 4.
Feedback Antibiotics are not routinely prescribed in the treatment of an ischemic stroke. According to primary stroke center accreditation guidelines, stroke patients should be discharged with anticoagulation if indicated for atrial fibrillation. According to primary stroke center accreditation guidelines, stroke patients should be discharged with a blood pressure control strategy in patients with hypertension. According to primary stroke center accreditation guidelines, stroke patients should be discharged with antiplatelet therapy.
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5.
According to primary stroke center accreditation guidelines, stroke patients should be discharged with lipid-lowering therapy if indicated.
PTS: 1
CON: Neurologic Regulation | Medication
NUMERIC RESPONSE 28. ANS: 95 Chapter number and title: 39, Coordinating Care for Critically Ill Patients With Neurological Dysfunction Chapter learning objective: Describing the indications and nursing implications for ICP monitoring in the critically ill patient Chapter page reference: 820 Heading: Increased Intracranial Pressure > Intracranial Pressure Monitoring Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application [Applying] Concept: Neurologic Regulation; Assessment Difficulty: Moderate Feedback: The equation MAP – ICP = CPP is used to determine cerebral perfusion pressure. First determine the patient’s mean arterial pressure: (2(88) + 174)/3 = (176 + 174)/3 = 350/3 = 117. Then use the equation MAP – ICP = CPP or 117 – 22 = 95. The patient’s cerebral perfusion pressure is 95. PTS:
1
CON: NeuroloNgU icRRSegIuNlaG tioTnB| . AC ssO e sM s men t
Chapter 40: Assessment of Endocrine Function Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is preparing a teaching tool that focuses on the endocrine system. How should the nurse explain the negative feedback system? 1) Hormone secretion increases when circulating levels drop. 2) Hormone secretion increases when target organs send signals. 3) Hormone secretion increases when circulating levels increase. 4) Hormone secretion increases when the target tissue does not recognize the level. 2. A patient is diagnosed with a disorder of the hypothalamus. To which other gland is this structure attached? 1) Thyroid 2) Thalamus 3) Pituitary gland 4) Adrenal glands 3. The nurse notes that a patient’s aldosterone level is elevated. Which structure is responsible for controlling this hormone? 1) Thyroid 2) Hypothalamus
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3) Adrenal cortex 4) Adrenal medulla 4. The nurse notes that a patient has a tumor on the thyroid gland. Where should the nurse expect to palpate this tumor? 1) Anteriorly below the chin 2) At the level of the clavicle 3) Below the cricoid cartilage 4) Slightly above the angle of Louis 5. The nurse is preparing a teaching tool on the major hormones of the body for a community program. Which gland should the nurse identify as controlling calcium levels in the body? 1) Thyroid 2) Parathyroid 3) Hypothalamus 4) Posterior pituitary 6. An adolescent is experiencing delayed puberty. Which gland function should be evaluated? 1) Pancreas 2) Adrenal cortex 3) Anterior pituitary 4) Posterior pituitary 7. A patient has not eaten for 18 hours because of diagnostic testing. Which pancreatic hormone is maintaining this patient’s blood glucose level? 1) Insulin 2) Cortisol NURSINGTB.COM 3) Glucagon 4) Epinephrine 8. The nurse is planning to assess a patient’s endocrine system. What should be included in this assessment? 1) Lung sounds 2) Body weight 3) Bowel sounds 4) Peripheral pulses 9. Upon inspection the nurse notes that a patient’s face is puffy. Which endocrine gland should the nurse assess for function? 1) Thyroid 2) Pancreas 3) Parathyroid 4) Adrenal cortex 10. The nurse is conducting a physical assessment of a patient’s endocrine system. What should the nurse include with auscultation? 1) Lung sounds 2) Bowel sounds 3) Carotid arteries 4) Abdominal aorta 11. The nurse is preparing to complete a physical assessment on a patient’s endocrine system. Which gland should the nurse prepare to palpate?
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1) 2) 3) 4)
Testes Ovaries Pancreas Parathyroid
12. The nurse is preparing to palpate a patient’s thyroid gland. Which technique should be used for this assessment? 1) Palpate the left lobe with the patient’s head turned to the right 2) Palpate the right lobe with the patient’s head turned to the left 3) Stand behind the patient and place fingers on both sides of the neck 4) Stand in front of the patient and palpate the lobes when the patient swallows 13. A patient’s vitamin D level is below normal. Which endocrine gland will need additional investigation? 1) Thyroid 2) Parathyroid 3) Hypothalamus 4) Anterior pituitary 14. A patient is having a test to suppress cortisol levels. Which response suggests that additional testing of the adrenal cortex would be required? 1) Increase in urine output 2) Increase in cortisol level 3) Decrease in cortisol level 4) No change in cortisol level 15. A patient with an endocrine disorder is being considered for diagnostic tests. What test should the nurse expect to be prescribed for this patienNt?URSINGTB.COM 1) CT scan 2) Urinalysis 3) Sedimentation rate 4) Hemoglobin and hematocrit 16. A 60-year-old patient asks why endocrine testing is being done. Which is the best response for the nurse to make? 1) “Endocrine organs atrophy with aging.” 2) “Endocrine function can change through the lifespan.” 3) “Endocrine function remains the same through the lifespan.” 4) “Endocrine testing identifies which hormone replacement therapy you will need.” 17. The nurse suspects that an older patient’s new diagnosis of hypothyroidism is caused by downregulation. How should the nurse explain this to the patient? 1) “The organ making the hormones is degenerating.” 2) “The strength of the hormones being synthesized is weaker.” 3) “The body becomes confused about the purpose of the hormones. 4) “There are fewer receptors on the surface of target tissues.” 18. An older patient with several chronic diseases asks why some of the health problems are being caused by hormone imbalances. What explanation should the nurse provide to this patient? 1) “The hormone imbalance caused the chronic disease.” 2) “The chronic diseases exposed the underlying hormone imbalance.” 3) “Other health problems can affect the normal production and response of hormones.”
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4) “The treatment for the chronic diseases adversely affected the organs and hormone production.” 19. The nurse notes that an older patient is wearing a sweater and scarf on a warm summer day. What should this observation indicate to the nurse? 1) The patient’s target organs are diseased. 2) The patient’s metabolism is slowing down. 3) The patient needs hormone replacement therapy. 4) The patient’s endocrine organs are malfunctioning. 20. An older patient’s fluid balance record shows a significant increase in urine output over the last few weeks with no other reported clinical symptoms. For which potential health problem should the nurse plan care for this patient? 1) Diabetes 2) Dehydration 3) Hyponatremia 4) Urinary tract infection Multiple Response Identify one or more choices that best complete the statement or answer the question. 21. A patient is experiencing dysfunction of the hypothalamus. Which hormones will be affected by this dysfunction? Select all that apply. 1) Follicle-stimulating hormone (FSH) 2) Thyrotropin-releasing hormone (TRH) 3) Cortico trop in -releasin g hormoneNU (CRRS HI ) NGTB.COM 4) Gonadotropin-releasing hormone (Gn-RH) 5) Growth hormone-releasing hormone (GHRH) 22. A patient is diagnosed with insufficient growth hormone. What effects will this have on the patient? Select all that apply. 1) Change in hair color 2) Alteration in bone density 3) Sluggish protein synthesis 4) Increased use of fatty acids 5) Increase in circulating blood glucose 23. A patient is being evaluated for elevated levels of antidiuretic hormone (ADH). What findings would cause ADH to be secreted? Select all that apply. 1) Dehydration 2) Decreased heart rate 3) Decreased blood pressure 4) Increased serum osmolarity 5) Elevated blood glucose level 24. A patient’s cortisol level is elevated. How will this elevation affect the patient? Select all that apply. 1) Alteration in fat metabolism 2) Enhance secretion of sodium 3) Alteration in protein metabolism 4) Alteration in carbohydrate metabolism 5) Suppression of the immune response
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25. The nurse suspects that a patient’s beta 2 receptors are being stimulated. What did the nurse assess to make this clinical determination? Select all that apply. 1) Diaphoresis 2) Dilated pupils 3) Warm dry skin 4) Urinary incontinence 5) Elevated blood pressure
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Chapter 40: Assessment of Endocrine Function Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Discussing the actions of hormones excreted by endocrine glands Chapter page reference: 858 Heading: Overview of Anatomy and Physiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Metabolism; Promoting Health Difficulty: Easy Feedback 1 Hormonal release is controlled by a negative feedback system that increases hormone secretion when circulating levels are decreased. 2 Increasing hormone secretion when the target organ send signals does not describe a negative feedback system. 3 Increasing secretion when the circulating levels increase describes a positive feedback system. 4 Increasing secretion when the target tissue does not recognize the level does not describe a negative feedback system.
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PTS: 1 CON: Metabolism | Promoting Health 2. ANS: 3 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Describing the location and function of endocrine glands Chapter page reference: 861 Heading: Overview of Anatomy and Physiology > Hypothalamus and Pituitary Gland Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Metabolism Difficulty: Easy 1 2 3 4
Feedback The thyroid gland is in the neck. The hypothalamus is a small structure located beneath the thalamus. The hypothalamus is connected to the pituitary gland by the infundibulum. The adrenal glands sit atop the kidneys.
PTS: 1 CON: Metabolism 3. ANS: 3 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Describing the location and function of endocrine glands Chapter page reference: 862
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Heading: Overview of Anatomy and Physiology > Adrenal Cortex Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Metabolism Difficulty: Easy Feedback 1 The thyroid gland is not responsible for the hormone aldosterone. 2 The hypothalamus is not responsible for the hormone aldosterone. 3 Aldosterone is the primary mineralocorticoid secreted from the adrenal cortex. 4 Epinephrine and norepinephrine are secreted from the adrenal medulla. PTS: 1 CON: Metabolism 4. ANS: 3 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Describing the location and function of endocrine glands Chapter page reference: 863 Heading: Overview of Anatomy and Physiology > Thyroid Gland Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Metabolism Difficulty: Easy Feedback 1 The thyroid gland is not directNlyUbRelS ow INthGe ch TBin.. COM 2 The thyroid gland is not at the level of the clavicle. 3 Located in the anterior neck, the thyroid gland lies directly below the cricoid cartilage. 4 The thyroid gland is not slightly above the angle of Louis. PTS: 1 CON: Metabolism 5. ANS: 2 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Discussing the actions of hormones excreted by endocrine glands Chapter page reference: 864 Heading: Overview of Anatomy and Physiology > Parathyroid Glands Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Easy
1 2 3 4
Feedback The thyroid gland does not control calcium levels. Thyrocalcitonin (calcitonin) has a role in the regulation of calcium, along with parathyroid hormone (PTH; parathormone secreted from the parathyroid glands). The hypothalamus does not control calcium levels. The posterior pituitary gland does not control calcium levels.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1 CON: Metabolism 6. ANS: 3 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Discussing the actions of hormones excreted by endocrine glands Chapter page reference: 865 Heading: Overview of Anatomy and Physiology > Gonads Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate Feedback 1 Sexual development hormones are not controlled by the pancreas. 2 Sexual development hormones are not controlled by the adrenal cortex. 3 Sexual development and function are controlled by hormones secreted from the ovaries and testes. Both glands are controlled by tropic hormones released from the anterior pituitary gland. 4 Sexual development hormones are not controlled by the posterior pituitary gland. PTS: 1 CON: Metabolism 7. ANS: 3 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Discussing the actions of hormones excreted by endocrine glands Chapter page reference: 865 Heading: Overview of Anatomy and Physiology > Pancreas NURSINGTB.COM Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate Feedback 1 Insulin is released from the pancreatic beta cells in response to elevated blood glucose levels. 2 Cortisol is an adrenal cortex hormone. 3 In response to low blood glucose levels, the hormone glucagon is released from the pancreatic alpha cells. Glucagon stimulates production and release of glucose from glycogen stores in the liver leading to increased blood glucose levels. 4 Epinephrine is an adrenal medulla hormone. PTS: 1 CON: Metabolism 8. ANS: 2 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Explaining the procedure for completing a history and physical assessment of the endocrine system. Chapter page reference: 866 Heading: Assessment > History Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying]
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 Lung sounds are not included in the assessment of the endocrine system. 2 Because the endocrine system affects homeostasis and metabolic activity, the nurse must assess changes in body weight. 3 Bowel sounds are not included in the assessment of the endocrine system. 4 Peripheral pulses are not included in the assessment of the endocrine system. PTS: 1 CON: Metabolism | Assessment 9. ANS: 4 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Explaining the procedure for completing a history and physical assessment of the endocrine system. Chapter page reference: 866 Heading: Assessment > Physical Assessment > Inspection Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application [Applying] Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 The thyroid gland does not control cortisol levels. 2 The pancreas does not control cortisol levels. 3 The parath yroid gland does noNt co URntSroIl co NGrtTisoBl.leCveOlsM. 4 With elevated levels of cortisol, the nurse may note puffiness of the face. Cortisol is the main glucocorticoid controlled by the adrenal cortex. PTS: 1 CON: Metabolism | Assessment 10. ANS: 3 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Explaining the procedure for completing a history and physical assessment of the endocrine system. Chapter page reference: 867 Heading: Assessment > Physical Assessment > Auscultation Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application [Applying] Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 Lung sounds are not typically included in the endocrine system assessment. 2 Bowel sounds are not typically included in the endocrine system assessment, 3 Because of the increased vascularity associated with hyperthyroidism, the nurse also listens over the carotid arteries for carotid bruits. 4 Auscultating the abdominal aorta is not typically included in the endocrine system assessment.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1 CON: Metabolism | Assessment 11. ANS: 1 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Explaining the procedure for completing a history and physical assessment of the endocrine system. Chapter page reference: 867 Heading: Assessment > Physical Assessment > Palpation Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application [Applying] Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 The nurse uses palpation to assess the testes and evaluate for size, symmetry, shape, and any nodules or changes in texture. 2 The ovaries are not directly palpated. 3 The pancreas is not directly palpated. 4 The parathyroid glands are not directly palpated. PTS: 1 CON: Metabolism | Assessment 12. ANS: 3 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Explaining the procedure for completing a history and physical assessment of the endocrine system. Chapter page reference: 867 NURSINGTB.COM Heading: Assessment > Physical Assessment > Palpation Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application [Applying] Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 The left lobe is evaluated by having the patient turn the head to the left. 2 The right lobe is palpated while the patient’s head is turned to the right. 3 The thyroid gland may be best palpated by standing behind the patient. The thumbs of both hands are placed on the back of the neck, and the fingers are curved to the front of the neck on either side of the trachea. 4 The patient is asked to swallow when the nurse is standing behind the patient. When facing the patient, the nurse palpates each lobe individually. PTS: 1 CON: Metabolism | Assessment 13. ANS: 2 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Correlating diagnostic examinations to endocrine function Chapter page reference: 868 Heading: Diagnostic Testing Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing]
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 The thyroid does not control vitamin D levels. 2 Vitamin D levels are decreased in hypoparathyroidism. The parathyroid glands need further examination. 3 The hypothalamus does not control vitamin D levels. 4 The anterior pituitary gland does not control vitamin D levels. PTS: 1 CON: Metabolism | Assessment 14. ANS: 4 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Correlating diagnostic examinations to endocrine function Chapter page reference: 867 Heading: Diagnostic Testing Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate
1 2 3 4
Feedback Urine output is not affected by suppression testing of the adrenal cortex. An increase in cortisol level would be expected during a stimulation test. A decrease in the cortisol leveN l iU ndRicSa I te N s tG haTt th B.e ad COreMnal cortex is functioning as expected. Suppression tests are indicated when there are excess levels of circulating hormone. When levels of circulating hormone do not decrease with suppression testing, hyperfunction of the gland is indicated.
PTS: 1 CON: Metabolism | Assessment 15. ANS: 1 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Correlating diagnostic examinations to endocrine function Chapter page reference: 867 Heading: Diagnostic Testing > Imaging Studies Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate
1 2 3 4
Feedback Computed tomography (CT) is used to confirm abnormalities of the endocrine glands. Urinalysis is not used to confirm an abnormality of the endocrine glands. Sedimentation rate is used to evaluate inflammation and not the integrity of the endocrine glands. Hemoglobin and hematocrit are not used to confirm and abnormality of the endocrine glands.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1 CON: Metabolism 16. ANS: 2 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Discussing changes in endocrine function associated with aging Chapter page reference: 867 Heading: Age-Related Changes Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate Feedback 1 Not all endocrine organs atrophy with aging. 2 Changes in endocrine function are associated with aging, and early detection and treatment can minimize long-term consequences. 3 Endocrine function does not necessarily stay the same through the lifespan. 4 The use of hormone replacement therapy is controversial. PTS: 1 CON: Metabolism 17. ANS: 4 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Discussing changes in endocrine function associated with aging Chapter page reference: 868 Heading: Age-Related Changes NURSINGTB.COM Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate Feedback 1 Downregulation does not mean that the endocrine organ making the hormones is degenerating. 2 Downregulation does not mean that the strength of the hormones is weaker. 3 Downregulation does not mean that the body is confused about the purpose of the hormones. 4 Some of the endocrine changes associated with age are secondary to hypoactive function of endocrine glands secondary to downregulation or a decreased number of receptors on the surface of the target tissue. PTS: 1 CON: Metabolism 18. ANS: 3 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Discussing changes in endocrine function associated with aging Chapter page reference: 868 Heading: Age-Related Changes Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying]
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Concept: Metabolism Difficulty: Moderate Feedback 1 It is unlikely that the hormone imbalance caused the chronic disease. 2 It is unlikely that the chronic disease exposed the underlying hormone imbalance. 3 Chronic disease may affect hormone production and tissue response. 4 It is possible that the treatment for the chronic disease may affect endocrine balance; however, it is unlikely that the treatment targeted the endocrine organ and hormone production directly. PTS: 1 CON: Metabolism 19. ANS: 2 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Discussing changes in endocrine function associated with aging Chapter page reference: 869 Heading: Age-Related Changes Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate Feedback 1 Feeling cold does not mean that an older person’s target organs are diseased. 2 Decreased metabolism is associated with susceptibility to cold intolerance. 3 Feeling cold does not mean that NUthRe So Ild Ner Gp er T so B .n CneOeds M hormone replacement therap y. 4 Feeling cold does not mean that the older person’s endocrine organs are malfunctioning. PTS: 1 CON: Metabolism 20. ANS: 2 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Discussing changes in endocrine function associated with aging Chapter page reference: 869 Heading: Age-Related Changes Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate
1 2 3 4
Feedback Although polyuria is a manifestation of diabetes, the patient is not demonstrating other symptoms. It is unlikely that the patient has diabetes. Decreased synthesis of antidiuretic hormone in the older adult is associated with increased urine frequency and dilute urine, leading to an increased risk of dehydration. Increased urination will not necessarily lead to hyponatremia. Urinary frequency is a manifestation of urinary tract infection; however, the volume of urine would not be affected.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1
CON: Metabolism
MULTIPLE RESPONSE 21. ANS: 2, 3, 4, 5 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Discussing the actions of hormones excreted by endocrine glands Chapter page reference: 861 Heading: Overview of Anatomy and Physiology > Hypothalamus and Pituitary Gland Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback FSH is controlled by the anterior pituitary gland. TRH is controlled by the hypothalamus. CRH is controlled by the hypothalamus. Gn-RH is controlled by the hypothalamus. GHRH is controlled by the hypothalamus.
PTS: 1 CON: Metabolism NURSINGTB.COM 22. ANS: 2, 3, 4, 5 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Discussing the actions of hormones excreted by endocrine glands Chapter page reference: 861 Heading: Overview of Anatomy and Physiology > Hypothalamus and Pituitary Gland Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Melanocyte-stimulating hormone from the anterior pituitary gland affects skin and hair color. Growth hormone is necessary for maintaining bone density. Growth hormone facilitates protein synthesis. Growth hormone increases the use of fatty acids. Growth hormone affects blood glucose levels by decreasing the use of glucose for energy.
PTS: 1 CON: Metabolism 23. ANS: 1, 3, 4 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Discussing the actions of hormones excreted by endocrine glands Chapter page reference: 862 Heading: Overview of Anatomy and Physiology > Hypothalamus and Pituitary Gland
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Antidiuretic hormone is secreted in response to dehydration. Antidiuretic hormone is not secreted in response to a decreased heart rate. Antidiuretic hormone is secreted in response to decreased blood pressure. Antidiuretic hormone is secreted in response to increased serum osmolarity. Antidiuretic hormone is not secreted in response to an elevated blood glucose level.
PTS: 1 CON: Metabolism 24. ANS: 1, 3, 4, 5 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Discussing the actions of hormones excreted by endocrine glands Chapter page reference: 862 Heading: Overview of Anatomy and Physiology > Adrenal Cortex Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate
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1. 2. 3. 4. 5.
Feedback Glucocorticoids affect fat metabolism. Glucocorticoids cause reabsorption of sodium. Glucocorticoids affect protein metabolism. Glucocorticoids affect carbohydrate metabolism. Glucocorticoids suppress immune function.
PTS: 1 CON: Metabolism 25. ANS: 3, 4, 5 Chapter number and title: 40, Assessment of Endocrine Function Chapter learning objective: Discussing the actions of hormones excreted by endocrine glands Chapter page reference: 863 Heading: Overview of Anatomy and Physiology > Adrenal Medulla Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate
1. 2. 3.
Feedback Alpha receptors in the skin affect sweating. Alpha receptors in the eyes cause pupil dilation. Beta 2 receptors in the blood vessels promote vasodilation, causing warm dry skin.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4. 5. PTS: 1
Beta 2 receptors in the bladder cause relaxation of the detrusor muscle, causing incontinence. Beta 2 receptors in the kidney affect renin, causing elevation in blood pressure. CON: Metabolism
Chapter 41: Coordinating Care for Patients With Pituitary Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A patient is diagnosed with hypopituitarism. Which additional body structure will most like be examined to determine the root cause of this disorder? 1) Thyroid 2) Cerebrum 3) Hypothalamus 4) Parathyroid glands 2. A patient is demonstrating signs of low pituitary gland function. Which diagnostic test should the nurse expect to be prescribed for this patient? 1) MRI 2) Lumbar puncture 3) Cerebral angiogram 4) Carotid Doppler studies 3. The nurse is reviewing orders writtenNfU o rRaSpI a tN i eG n tTwBit. h C h yOp M o pituitarism. What should the nurse expect to be prescribed for this patient? 1) Diuretics 2) Antibiotics 3) Antihypertensives 4) Electrolyte supplements 4. The bone density report for a patient with hypopituitarism shows areas of thinning and demineralization. What teaching should the nurse prepare for this patient? 1) Importance of avoiding extremes in temperature 2) Need to reduce exposure to people with infections 3) Food sources containing high amounts of calcium 4) Strategies to increase rest periods throughout the day 5. A patient with hypopituitarism is experiencing muscle weakness. Which referral should the nurse make to help this patient? 1) Home care 2) Physical therapy 3) Recreational therapy 4) Occupational therapy 6. A patient is being evaluated for possible hyperpituitarism. Which manifestation most likely caused this patient to seek medical treatment? 1) Hair loss 2) Headaches 3) Sore throat
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4) Muscle cramps 7. A patient is concerned because facial features are changing and the hands are becoming larger and painful. Which hormone should the nurse suspect is causing this patient’s manifestations? 1) Testosterone 2) Growth hormone 3) Thyroid-stimulating hormone 4) Adrenocorticotropic hormone (ACTH) 8. A patient is recovering from surgery to remove a pituitary tumor. Why should the nurse schedule frequent mouth care for this patient? 1) Medications dry mucous membranes 2) Maintenance of nothing by mouth status 3) Mouth breathing because of nasal packing 4) Stomatitis caused by the hormone imbalance 9. The patient is preparing discharge teaching for a patient recovering from surgery to treat hyperpituitarism. Which interdisciplinary team member should be consulted to ensure medication teaching is appropriate? 1) Surgeon 2) Pharmacist 3) Charge nurse 4) Endocrinologist 10. A patient is being discharged after surgery for hyperpituitarism. What should the nurse emphasize to reduce the risk of postoperative infection? 1) Restrict fluids 2) Avoid straining the suture line NURSINGTB.COM 3) Maintain bedrest for several days 4) Expect clear nasal drainage to occur 11. A patient is suspected of having a disorder of the posterior pituitary gland. For which additional health problem should the nurse anticipate planning care for this patient? 1) Acromegaly 2) Osteoporosis 3) Diabetes insipidus 4) Type 1 diabetes mellitus 12. A patient is being treated for diabetes insipidus (DI). Which medication should the nurse prepare to administer? 1) Calcium 2) Synthroid 3) Vitamin D 4) Desmopressin (DDAVP) 13. The nurse notes that patient with diabetes insipidus (DI) has a loss of free water. Which nursing diagnosis should the nurse use to guide care for this patient? 1) Fluid Volume Deficit 2) Alteration in Comfort 3) Body Image Disturbance 4) Sensory Perceptual Alteration
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
14. A patient with diabetes insipidus (DI) is experiencing extreme dehydration. What should be used to guide intravenous fluid replacement therapy for this patient? 1) Skin turgor 2) Urine output total 3) Hemoglobin level 4) Serum sodium level 15. The nurse is reviewing discharge instructions with a patient being treated for diabetes insipidus (DI). What should the nurse direct the patient to do regarding changes in body weight? 1) Restrict fluids for a day 2) Notify the health-care provider 3) Increase the intake of salty foods 4) Take an extra dose of medication 16. A patient with osteoarthritis develops the syndrome of inappropriate antidiuretic hormone (SIADH). What information in the patient’s history should the nurse identify as being the best reason for the development of this disorder? 1) Male gender 2) Age 70 years 3) Use of NSAIDs 4) African American 17. A patient with syndrome of inappropriate antidiuretic hormone (SIADH) is experiencing a headache and confusion. Which laboratory test would best explain the reason for this patient’s symptoms? 1) Sodium 2) Calcium 3) Potassium NURSINGTB.COM 4) Hematocrit 18. The nurse is reviewing laboratory values for a female patient who has had minimal urine output over the last shift. Which finding suggests that this patient may be experiencing syndrome of inappropriate antidiuretic hormone (SIADH)? 1) Hematocrit 40% 2) Serum sodium 136 mEq/L 3) Urine specific gravity 1.035 4) Serum potassium 3.9 mEq/L 19. The nurse is reviewing orders written for a patient with syndrome of inappropriate antidiuretic hormone (SIADH). Which order should the nurse clarify? 1) No added salt diet 2) Fluid restriction 1L/day 3) IV fluids 0.9% normal saline 125 mL/hr 4) Furosemide (Lasix) 20 mg by mouth every day 20. A patient has a serum sodium level of 126 mEq/L. What action should the nurse take to ensure for this patient’s safety? 1) Apply wrist restraints 2) Implement seizure precautions 3) Prepare for nasogastric tube insertion 4) Plan for intermittent urinary catheterization
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
21. The nurse is preparing medications for a patient with syndrome of inappropriate antidiuretic hormone (SIADH). Which medication would most likely be prescribed for this patient? 1) Ampicillin 2) Tetracycline 3) Vancomycin 4) Demeclocycline 22. A patient with a history of syndrome of inappropriate antidiuretic hormone (SIADH) reports a low urine output for several days. What should the nurse respond to this patient? 1) “Drink more fluids.” 2) “Avoid eating salty foods.” 3) “Go to the emergency room now.” 4) “Take an over-the-counter NSAID.” Multiple Response Identify one or more choices that best complete the statement or answer the question. 23. A patient’s thyroid-stimulating hormone (TSH) is below normal. What should the nurse expect to assess in this patient? Select all that apply. 1) Weight gain 2) Thinning hair 3) Decreased bone density 4) Decreased muscle strength 5) Complaints of decreased libido 24. The nurse is planning care for a patieN ntUwRitS hI hyNpG opTitB ui.taCri O s mM. What interventions would be a priority for this patient? Select all that apply. 1) Fertility 2) Skin care 3) Vital signs 4) Bone density 5) Fluid balance 25. A patient is being evaluated for hyperpituitarism. Which laboratory studies should the nurse expect to be prescribed for this patient? Select all that apply. 1) Calcium level 2) Growth hormone 3) Cortrosyn stimulation test 4) Follicle-stimulating hormone level (FSH) 5) Thyroid-stimulating hormone level (TSH) 26. The nurse is preparing discharge teaching for a patient recovering from a transsphenoidal hypophysectomy for a pituitary tumor. What should the nurse emphasize in this teaching? Select all that apply. 1) No lifting 2) Avoid coughing 3) Do not bend over 4) Sneeze with an open mouth 5) Avoid driving for several weeks 27. The nurse is preparing to assess a patient with diabetes insipidus (DI). Which manifestations should the nurse expect? Select all that apply.
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1) 2) 3) 4) 5)
Fatigue Extreme thirst Extreme hunger Large amounts of urine output Waking up to urinate during the night
28. Laboratory results have been posted for a male patient experiencing manifestations of diabetes insipidus (DI). Which results would confirm the diagnosis? Select all that apply. 1) Hematocrit 52% 2) White blood cells 8000 3) Serum sodium 150 mEq/L 4) Urine specific gravity 1.002 5) Serum potassium 5.5 mEq/L
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 41: Coordinating Care for Patients With Pituitary Disorders Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Describing the epidemiology of pituitary disorders Chapter page reference: 873 Heading: Hypopituitarism > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Metabolism Difficulty: Easy
1 2 3 4
Feedback Hypopituitarism is not caused by dysfunction of the thyroid gland. Hypopituitarism is not caused by dysfunction of the cerebrum. The etiology of anterior pituitary dysfunction is often secondary to damage to the hypothalamus. Hypopituitarism is not caused by dysfunction of the parathyroid glands.
PTS: 1
CON: Metabolism
2. ANS: 1 NURSINGTB.COM Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of pituitary disorders Chapter page reference: 874 Heading: Hypopituitarism > Medical Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Easy
1 2 3 4
Feedback If a tumor of the brain or pituitary is suspected, a head MRI may be completed. A lumbar puncture is not indicated for a disorder of the pituitary gland. A cerebral angiogram is not indicated for a disorder of the pituitary gland. Carotid Doppler studies are not indicated for a disorder of the pituitary gland.
PTS: 1 CON: Metabolism 3. ANS: 4 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Discussing the medical management of: Hypopituitarism Chapter page reference: 874 Heading: Hypopituitarism > Medical Management
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Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Metabolism; Medication Difficulty: Moderate
1 2 3 4
Feedback Diuretics are not routinely prescribed for a patient with hypopituitarism. Antibiotics are not required to treat hypopituitarism. Antihypertensives are not routinely prescribed for a patient with hypopituitarism. Supportive therapies such as electrolyte replacement are the key to managing the patient with hypopituitarism.
PTS: 1 CON: Metabolism | Medication 4. ANS: 3 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with pituitary disorders Chapter page reference: 874 Heading: Hypopituitarism > Nursing Management > Actions Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Metabolism; Promoting Health Difficulty: Moderate
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1 2 3 4
Feedback The patient with hypopituitarism does not need to avoid extremes in temperature. The patient with hypopituitarism is not at risk for infections. The nurse should instruct the patient on ways to increase calcium intake since this helps to treat osteoporosis secondary to decreased growth hormone. The patient with hypopituitarism is not fatigued and will not need additional rest periods throughout the day.
PTS: 1 CON: Metabolism | Promoting Health 5. ANS: 2 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Coordinating the interprofessional plan of care for the patient undergoing treatment for pituitary disorders Chapter page reference: 874 Heading: Hypopituitarism > Nursing Management > Actions Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Metabolism; Mobility; Safety; Collaboration Difficulty: Moderate 1
Feedback The patient does not have a need for skilled nursing care.
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2
3 4
Physical therapy would be helpful to maximize this patient’s mobility. Osteoporosis increases the risk for falls, and the physical therapist can provide input into safe transfers from bed to chair and measures to decrease the incidence of falls. There is no evidence that the patient is psychosocially stressed or in need of assistance with coping. Occupational therapy would be helpful for activities of daily living. There is no evidence that the patient needs this type of support.
PTS: 1 CON: Metabolism | Mobility | Safety | Collaboration 6. ANS: 2 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Describing the epidemiology of pituitary disorders Chapter page reference: 875 Heading: Hyperpituitarism > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Comfort Difficulty: Moderate 1 2
3 4
Feedback The patient most likely would not seek medical treatment for hair loss. Hyperpituitarism is usually related to a hypersecreting tumor. The patient presentation is consistent with clinical manifestations associated to the over-secreted hormone, and the tumor itself may lead to heNadUaR chSe I s. NGTB.COM A sore throat is a common symptom of the common cold and other upper respiratory disorders. Medical treatment is not often sought for a sore throat. Muscle cramps are not a manifestation of hyperpituitarism.
PTS: 1 CON: Metabolism | Comfort 7. ANS: 2 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Hyperpituitarism Chapter page reference: 876 Heading: Hyperpituitarism > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate
1 2 3
Feedback Testosterone is not a hormone controlled by the pituitary gland. Increased levels of growth hormone in an adult can cause course facial features and alter the bone structure of the hands and feet. Manifestations of increased thyroid-stimulating hormone include weight loss and exophthalmos.
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4
Elevated levels of adrenocorticotropic hormone (ACTH) cause hyperglycemia, hypertension, hypernatremia, and hypokalemia.
PTS: 1 CON: Metabolism 8. ANS: 3 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with pituitary disorders Chapter page reference: 878 Heading: Hyperpituitarism > Nursing Management > Actions Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate
1 2 3 4
Feedback The patient is not on any medications that dry the mucous membranes. The patient most likely is no longer on nothing by mouth status. Because of the surgical procedure and postoperative packing, the patient breathes primarily through the mouth, increasing the chance of dry mouth. Hormone imbalances do not cause stomatitis.
PTS: 1 CON: Metabolism 9. ANS: 2 NURSINGTB.COM Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Coordinating the interprofessional plan of care for the patient undergoing treatment for pituitary disorders Chapter page reference: 878 Heading: Hyperpituitarism > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Metabolism; Collaboration Difficulty: Moderate
1 2
3 4
Feedback The surgeon would be consulted regarding the surgical procedure. Because of the complexity of the disease process and possible side effects of medications (that may decrease secretion of other anterior pituitary hormones), the patient and family need to understand the specific changes to be reported to the healthcare provider. Collaborate with the pharmacist for mediation teaching. The charge nurse would not have the specific information required about the medications. The endocrinologist would be consulted regarding the hormone imbalance and the effects.
PTS: 1 10. ANS: 2
CON: Metabolism | Collaboration
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Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with pituitary disorders Chapter page reference: 877 Heading: Hyperpituitarism > Medical Management > Complications Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Metabolism; Infection; Promoting Health Difficulty: Moderate
1 2 3 4
Feedback Restricting fluids would not reduce the risk of postoperative infection. Strain on the suture line could introduce microorganisms into the surgical site and enter the central nervous system. Cerebrospinal fluid leak could lead to meningitis. The client does not need to be on bedrest for several days. Clear nasal drainage could indicate a cerebrospinal fluid leak that should be reported since this increases the patient’s risk of developing meningitis postoperatively.
PTS: 1 CON: Metabolism | Infection | Promoting Health 11. ANS: 3 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Describing the epidemiology of pituitary disorders: Diabetes Insipidus Chapter page reference: 879 Heading: Diabetes Insipidus > Epidemiology Integrated Processes: Nursing ProcesN s:UPR laS nnIinNgGTB.COM Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Easy
1 2 3 4
Feedback Acromegaly is caused by over-secretion of growth hormone. Osteoporosis is an adverse effect of hypopituitarism. Central diabetes insipidus is caused by a decreased secretion of antidiuretic hormone (ADH) from the posterior pituitary gland. Type 1 diabetes mellitus is caused by a malfunction of the cells within the pancreas.
PTS: 1 CON: Metabolism 12. ANS: 4 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Discussing the medical management of: Diabetes insipidus Chapter page reference: 880 Heading: Diabetes Insipidus > Medical Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Metabolism; Medication Difficulty: Moderate
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1 2 3 4
Feedback Calcium supplements would be required for a patient with hypopituitarism. Synthroid is a replacement for hypothyroidism. Vitamin D would be appropriate for a patient with osteoporosis caused by low growth hormone levels. Desmopressin (DDAVP), a synthetic analog of ADH, is the drug of choice in patients with DI.
PTS: 1 CON: Metabolism | Medication 13. ANS: 1 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with pituitary disorders Chapter page reference: 880 Heading: Diabetes Insipidus > Nursing Management > Nursing Diagnoses Integrated Processes: Nursing Process: Diagnosis Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism; Nursing Difficulty: Moderate
1 2 3 4
Feedback The diagnosis Fluid Volume Deficit related to loss of free water secondary to lack of ADH would be appropriate forNtU hiR s pa SItien N Gt. TB.COM The patient might be uncomfortable because of dehydration; however, this is not an ideal nursing diagnosis for this patient. Body image disturbance would be appropriate for the patient with hyperpituitarism. Sensory perception alteration would address vision changes and not fluid balance.
PTS: 1 CON: Metabolism | Nursing 14. ANS: 4 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with pituitary disorders Chapter page reference: 880 Heading: Diabetes Insipidus > Nursing Management > Actions Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism; Nursing Difficulty: Moderate 1 2 3 4
Feedback Skin turgor would not be used to guide intravenous fluid replacement therapy. The urine output total would not be used to guide intravenous fluid replacement therapy. Hemoglobin level is not used to guide intravenous fluid replacement therapy. The solution ordered is based upon serum sodium level.
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PTS: 1 CON: Metabolism | Nursing 15. ANS: 2 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Coordinating the interprofessional plan of care for the patient undergoing treatment for pituitary disorders Chapter page reference: 881 Heading: Diabetes Insipidus > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate
1 2 3 4
Feedback It is beyond the nurse’s scope of practice to prescribe therapy for weight changes. Weight is directly associated with water loss or gain, and changes of more than 2 lb per day should be reported to the health-care provider. Salty foods would cause more water weight gain. It is beyond the nurse’s scope of practice to alter the prescribed medication dose for the patient.
PTS: 1 CON: Metabolism 16. ANS: 3 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders NURSINGTB.CO Chapter learning objective: Describing the epidemiology of pituitary disorders Chapter page reference: 881 Heading: Syndrome of Inappropriate Antidiuretic Hormone > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate
1 2 3 4
Feedback There are no specific relationships between the development of SIADH and sex. There are no specific relationships between the development of SIADH and age. Causes of SIADH vary and include side effects of medications such as non-steroidal anti-inflammatory drugs (NSAIDs). There are no specific relationships between the development of SIADH and race.
PTS: 1 CON: Metabolism 17. ANS: 1 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Syndrome of inappropriate antidiuretic hormone (SIADH) Chapter page reference: 881 Heading: Syndrome of Inappropriate Antidiuretic Hormone > Clinical Manifestations Integrated Processes: Nursing Process: Assessment
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Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Metabolism Difficulty: Easy
1
2 3 4
Feedback The clinical presentation of the patient with SIADH is primarily related to the resultant hyponatremia. The neurological signs associated with the hyponatremia are related to osmotic fluid shifts in the brain that lead to cerebral edema and increased intracranial pressure. The manifestations of SIADH are not caused by a calcium imbalance. The manifestations of SIADH are not caused by a potassium imbalance. The manifestations of SIADH are not caused by a change in hematocrit level.
PTS: 1 CON: Metabolism 18. ANS: 3 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of pituitary disorders Chapter page reference: 882 Heading: Syndrome of Inappropriate Antidiuretic Hormone > Medical Management Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism NURSINGTB.COM Difficulty: Moderate
1 2 3
4
Feedback The hematocrit level is within normal limits for a female. The serum sodium level is within normal limits. The urine specific gravity is elevated, which is seen in patients with SIADH. In patients with SIADH, due to excessive ADH secretion, they present with scant urine output and elevated urine specific gravity. The serum potassium level is within normal limits even though this electrolyte is not used in the diagnosis of SIADH.
PTS: 1 CON: Metabolism 19. ANS: 1 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Discussing the medical management of: Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Chapter page reference: 882 Heading: Syndrome of Inappropriate Antidiuretic Hormone > Medical Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Hard
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1 2 3 4
Feedback Medical management is primarily focused on treating the hyponatremia. The nurse should question a no added salt diet. The patient is placed on a fluid restriction, usually less than 1000 mL/day. IV administration of a saline solution would be expected. Diuretics may be administered to increase urine output.
PTS: 1 CON: Metabolism 20. ANS: 2 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with pituitary disorders Chapter page reference: 882 Heading: Syndrome of Inappropriate Antidiuretic Hormone > Nursing Management Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Metabolism; Safety Difficulty: Moderate 1 2 3 4
Feedback There is no indication that wrist restraints are needed for this patient. If the serum sodium level goes below 125 mEq/L, the patient is at risk of seizures. The patient does not need a nasogastric tube. Intermitten t urinary catheteriz aNtU io nR iSs I noNt G inT diBca.teCd OfoMr this patient.
PTS: 1 CON: Metabolism | Safety 21. ANS: 4 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with pituitary disorders Chapter page reference: 882 Heading: Syndrome of Inappropriate Antidiuretic Hormone > Nursing Management > Actions Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Metabolism; Medication Difficulty: Moderate
1 2 3 4
Feedback Ampicillin is not used to treat SIADH. Tetracycline is not used to treat SIADH. Vancomycin is not used to treat SIADH. Demeclocycline (Declomycin), a tetracycline derivative, may also be used because it increases water excretion by the kidneys.
PTS: 1 22. ANS: 3
CON: Metabolism | Medication
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Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Coordinating the interprofessional plan of care for the patient undergoing treatment for pituitary disorders Chapter page reference: 883 Heading: Syndrome of Inappropriate Antidiuretic Hormone > Nursing Management > Teaching Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate
1 2 3 4
Feedback Drinking fluids will exacerbate the low sodium level and make the condition worse. The patient most likely has a low sodium level. Restricting salt would make the condition worse. The patient needs medical attention immediately. NSAIDs can cause SIADH. This could make the condition worse.
PTS: 1
CON: Metabolism
MULTIPLE RESPONSE 23. ANS: 1, 2, 5 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: CorrelatiN n gUcRli S n iI c aN l G mT anB ife.sC taO t ioMn s to pathophysiolo gical processes of: Hypopituitarism Chapter page reference: 873 Heading: Hypopituitarism > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application [Applying] Concept: Metabolism; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Manifestations of low TSH levels include weight gain. Manifestations of low TSH levels include thinning hair. Manifestations of low growth hormone include decreased bone density. Manifestations of low growth hormone include decreased muscle strength. Manifestations of low TSH levels include decreased libido.
PTS: 1 CON: Metabolism | Assessment 24. ANS: 1, 3, 4 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with pituitary disorders Chapter page reference: 874 Heading: Hypopituitarism > Nursing Management > Assessments
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Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Changes in fertility can occur in hypopituitarism. Skin care is not an identified issue in hypopituitarism. Vital signs can be altered in hypopituitarism. Bone density can decrease in hypopituitarism. Fluid balance is not an identified issue in hypopituitarism.
PTS: 1 CON: Metabolism 25. ANS: 2, 3, 4, 5 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of pituitary disorders Chapter page reference: 876 Heading: Hyperpituitarism > Medical Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate
NURSINGTB.COM
1. 2. 3. 4. 5.
Feedback Calcium level would be appropriate if a parathyroid gland disorder is suspected. Hormonal studies conducted to assess for hyperpituitarism include growth hormone provocative tests. Hormonal studies conducted to assess for hyperpituitarism include the ACTH (Cortrosyn) stimulation test. Hormonal studies conducted to assess for hyperpituitarism include measurements of FSH. Hormonal studies conducted to assess for hyperpituitarism include measurements of TSH.
PTS: 1 CON: Metabolism 26. ANS: 2, 3 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Discussing the medical management of: Hyperpituitarism Chapter page reference: 876 Heading: Hyperpituitarism > Surgical Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism; Perioperative Difficulty: Moderate
1.
Feedback No lifting is not identified as important to teach this patient.
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2. 3. 4. 5.
The patient should be instructed to avoid activities that increase pressure at the incision site such as coughing. The patient should be instructed to avoid activities that increase pressure at the incision site such as bending over. The patient should be instructed to avoid all sneezing. There is no evidence that driving is restricted after this surgery.
PTS: 1 CON: Metabolism | Perioperative 27. ANS: 1, 2, 4, 5 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Diabetes insipidus (DI) Chapter page reference: 879 Heading: Diabetes Insipidus > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Fatigue is a sign of fluid volume deficit. Polydipsia or extreme thirst is a primary clinical manifestation of DI. Extreme hunger is a manifestation of diabetes mellitus. Polyuria is a primary cliN niU caRl m San INifGesTtaBtio.nCoOf DMI. Nocturia or waking up during the night to void is a primary clinical manifestation of DI.
PTS: 1 CON: Metabolism | Assessment 28. ANS: 1, 3, 4 Chapter number and title: 41, Coordinating Care for Patients With Pituitary Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of pituitary disorders Chapter page reference: 879 Heading: Diabetes Insipidus > Medical Management Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate
1. 2. 3. 4. 5. PTS: 1
Feedback Hematocrit is increased in DI. White blood cells are not measured specifically for DI. Serum sodium is elevated in DI. Urine specific gravity is decreased in DI. Serum potassium is not measured specifically for DI. CON: Metabolism | Assessment
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Chapter 42: Coordinating Care for Patients With Adrenal Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A patient asks for a definition of adrenal insufficiency. Which response should the nurse make? 1) Increased secretion of hormones from the adrenal cortex 2) Decreased secretion of hormones from the adrenal medulla 3) Increased secretion of hormones from the anterior pituitary gland 4) Decreased secretion of hormones from the anterior pituitary gland 2. A patient with adrenal insufficiency asks why the skin looks so tan. What should the nurse respond to this patient? 1) “The darker skin means the hormone from the hypothalamus is low.” 2) “The darker skin is caused by the destruction of the cells of the adrenal glands.” 3) “The darker skin means that you have too much of the hormones cortisol and aldosterone.” 4) “The hormone causing the darker skin shares the same hormone as the one helping to overcome the insufficiency.” 3. A patient is prescribed to have a cortisol blood level drawn. At which time should this sample be drawn? 1) Midnight 2) 0700 hours 3) 1200 hours 4) 2200 hours 4. The results of a patient’s MRI show eNvU idRenSc eI oNfGe nTlaBrg.eC dO adMrenal glands. Which health problem is most likely causing this finding? 1) Cancer 2) Stenosis 3) Infection 4) Autoimmunity 5. A patient being treated for adrenal insufficiency has a serum potassium level of 5.9 mEq/L. What should the nurse expect to be prescribed for this patient? 1) Kayexalate 2) Hydrocortisone 3) Dexamethasone 4) Dextrose 5% and 0.45% normal saline 6. A patient recovering from emergency surgery after a motor vehicle crash is demonstrating signs of adrenal insufficiency. What medication should the nurse expect to be prescribed for this patient? 1) Regular insulin 10 units 2) Potassium chloride 20 mEq 3) Intravenous infusion 0.9% normal saline 4) Hydrocortisone sodium succinate (Solu-Cortef) 7. The nurse notes that a patient with adrenal insufficiency has muscular weakness. To what should the nurse attribute this finding? 1) Infection 2) Inflammation 3) Hyperkalemia
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4) Hypernatremia 8. The nurse is reviewing data collected on a patient with adrenal insufficiency. Which finding suggests that the patient is experiencing dehydration? 1) Hematocrit 52% 2) Serum cortisol 11 mcg/dL 3) Serum sodium 134 mEq/L 4) Serum potassium 4.8 mEq/L 9. The nurse is providing discharge instructions to a patient with adrenal insufficiency. Which statement indicates that additional teaching is required? 1) “I should obtain a MedicAlert bracelet.” 2) “I should report changes in urine output.” 3) “I should take my medication every day.” 4) “I should expect to gain weight every day.” 10. A patient is admitted for treatment of Cushing’s syndrome. What is the primary reason for this disorder? 1) Elevated glucocorticoid level 2) Elevated aldosterone secretion 3) Decreased glucocorticoid level 4) Decreased aldosterone secretion 11. The nurse suspects that a patient with Conn’s syndrome has a decreased potassium level. What finding did the nurse use to make this clinical decision? 1) Muscle wasting 2) Elevated blood glucose 3) Abnormal fat distribution NURSINGTB.COM 4) Development of U waves on the cardiac monitor 12. A patient is being evaluated for hypercortisolism. Which laboratory test should the nurse expect to be prescribed initially for this patient? 1) Serum sodium level 2) Serum potassium level 3) 24-hour urine for cortisol 4) Fasting blood glucose level 13. The nurse plans to evaluate a patient for hypoglycemia and hypernatremia. Which medication did this patient most likely receive? 1) Dexamethasone 2) Potassium chloride 3) Aminoglutethimide 4) Spironolactone (Aldactone) 14. A patient is being evaluated for hyperaldosteronism. What should the nurse expect to assess in this patient? 1) Headache 2) Thin, friable skin 3) Dependent edema 4) Fat maldistribution 15. A patient with hypercortisolism has significant fluid retention. Which nursing action would be most appropriate for this patient? 1) Monitor blood glucose level
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2) Turn and reposition every two hours 3) Elevate the head of the bed 45 degrees 4) Administer medications that interfere with production/secretion of cortisol 16. The nurse is preparing discharge teaching for a patient with hypercortisolism. What should the nurse emphasize to this patient? 1) Increase fluids 2) Increase activity 3) Restrict salt intake 4) Increase salt intake 17. A patient with no predisposing risk factors develops ventricular fibrillation. For which health problem should the patient be evaluated? 1) Hypercortisolism 2) Pheochromocytoma 3) Hyperaldosteronism 4) Cushing’s syndrome 18. A patient is diagnosed with pheochromocytoma. Which manifestation should the nurse expect as a result of catecholamine secretion? 1) Bradycardia 2) Hypotension 3) Hypoglycemia 4) Widening pulse pressure 19. A patient is having a vanillylmandelic acid (VMA) urine test. What food should the nurse instruct the patient to avoid before undergoing this test?NURSINGTB.COM 1) Red meat 2) Chocolate 3) Whole grains 4) Green vegetables 20. A patient is diagnosed with a unilateral pheochromocytoma. For which treatment should the nurse prepare this patient? 1) Adrenalectomy 2) Smooth muscle relaxants 3) Beta-adrenergic blocking agents 4) Alpha-adrenergic blocking agents 21. A patient is scheduled for a bilateral adrenalectomy. For which health problem should the nurse prepare this patient? 1) Hypoglycemia 2) Hypercortisolism 3) Hyperaldosteronism 4) Adrenal insufficiency 22. The nurse notes that a patient with pheochromocytoma is prescribed sodium nitroprusside (Nipride). What is the purpose of this medication? 1) Decrease the secretion of catecholamines 2) Increase chronotropic and inotropic effects 3) Limit the development of tachyarrhythmias 4) Reduce blood pressure through vasodilation
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Multiple Response Identify one or more choices that best complete the statement or answer the question. 23. A patient is admitted to determine the cause for adrenal insufficiency. What body structures should the nurse expect to be examined in this patient? Select all that apply. 1) Ovaries 2) Thyroid 3) Hypothalamus 4) Adrenal glands 5) Anterior pituitary gland 24. The nurse is reviewing the medical history of a patient with adrenal insufficiency. What should the nurse identify as possible causes for the disorder in this patient? Select all that apply. 1) Cancer 2) Trauma 3) Infection 4) Medications 5) Autoimmune disorder 25. The nurse is visiting the home of a patient with adrenal insufficiency. Which observation indicates that the patient needs to be seen by the health-care provider immediately? Select all that apply. 1) Fatigue 2) Poor skin turgor 3) Skin hyperpigmentation 4) Dry mucous membranes NURSINGTB.COM 5) Blood pressure 90/50 mm Hg 26. A patient is admitted with hypertension and low potassium level. What information in the medical record indicates that this patient has Conn’s syndrome? Select all that apply. 1) Age 35 2) Caucasian 3) Male gender 4) Female gender 5) African American 27. The nurse is caring for a female patient with Cushing’s syndrome. What should the nurse expect to assess in this patient? Select all that apply. 1) Leg cramps 2) Amenorrhea 3) Breast atrophy 4) Menstrual pain 5) Deepening of the voice 28. The nurse is reviewing patient data. Which information suggests this patient has pheochromocytoma? Select all that apply. 1) Headache 2) Palpitations 3) Weight gain 4) Hypertension 5) Hyperglycemia
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Chapter 42: Coordinating Care for Patients With Adrenal Disorders Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Adrenal cortex insufficiency Chapter page reference: 886 Heading: Adrenal Cortical Insufficiency > Pathophysiology Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate 1 2 3 4
Feedback Adrenal insufficiency may be caused by decreased secretion of glucocorticoids and mineralocorticoids from the adrenal cortex. The hormones secreted by the adrenal medulla do not affect the development of adrenal insufficiency. Increased secretion of hormones from the anterior pituitary gland does not cause adrenal insufficiency. The pathophysiology of adrenN a lUinRsuSf I f icNieGncTyBm.aC y O b eMrelated to decreased secretion of corticotropin-releasing hormone (CRH) and decreased secretion of ACTH, both from the anterior pituitary gland.
PTS: 1 CON: Metabolism 2. ANS: 4 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Adrenal cortex insufficiency Chapter page reference: 887 Heading: Adrenal Cortical Insufficiency > Clinical Manifestations Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate
1 2 3
Feedback The darker skin does not mean that hormones from the hypothalamus are low. The darker skin does not mean that the cells of the adrenal glands are being destroyed. The darker skin does not mean that the patient has increased levels of cortisol and aldosterone.
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4
As the circulating levels of cortisol and aldosterone fall, the hypothalamus and anterior pituitary gland increase secretion of CRH and ACTH, respectively. Because melanocyte-stimulating hormone (MSH) and ACTH share a progenitor (ancestor) hormone, there is an associated increase in secretion of MSH, leading to a darkened, bronzed hyperpigmentation that accompanies the increased secretion of ACTH.
PTS: 1 CON: Metabolism 3. ANS: 2 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of adrenal disorders Chapter page reference: 887 Heading: Adrenal Cortical Insufficiency > Medical Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate Feedback 1 The level should not be drawn at midnight. 2 Direct measurement of serum cortisol levels is collected in the morning because of changes in levels associated with daily activities. Cortisol levels are highest in the morning (between 6 a.m. and 8 a.m.). 3 Drawing the level at noon would provide incorrect results. 4 Drawin g the level at 10 pm woNuU ldRpS roIviNd eG iT ncBo. rrec C Ot rMesults. PTS: 1 CON: Metabolism 4. ANS: 3 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of adrenal disorders Chapter page reference: 887 Heading: Adrenal Cortical Insufficiency > Medical Management Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate
1 2 3 4
Feedback There is no description of what cancer of the adrenal glands would appear like on an MRI. Stenosis of the adrenal glands would not occur. Adrenal gland enlargement is often observed with infectious processes. Shrinking of the adrenal gland is associated with autoimmune destruction.
PTS: 1 CON: Metabolism 5. ANS: 1 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders
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Chapter learning objective: Discussing the medical management of: Adrenal cortex insufficiency Chapter page reference: 888 Heading: Adrenal Cortical Insufficiency > Medical Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Metabolism; Medication Difficulty: Moderate Feedback 1 In patients presenting with hyperkalemia, treatment with potassium binding or excreting agents such as Kayexalate are indicated. 2 Hydrocortisone is part of routine treatment for adrenal insufficiency. 3 Dexamethasone is part of routine treatment for adrenal insufficiency. 4 IV fluids and glucose are part of routine treatment for adrenal insufficiency. PTS: 1 CON: Metabolism | Medication 6. ANS: 4 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Explaining the presentation and management of adrenal crisis Chapter page reference: 888 Heading: Adrenal Cortical Insufficiency > Medical Management > Complications Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Metabolism; Medication NURSINGTB.COM Difficulty: Moderate
1 2 3 4
Feedback The patient is at risk for hypoglycemia because of the lack of mineralocorticoid and glucocorticoid. Insulin would make the hypoglycemia worse. The patient is at risk for hyperkalemia because of the lack of mineralocorticoid and glucocorticoid. Potassium chloride would make the hyperkalemia worse. The patient is at risk for hypoglycemia. An infusion of Dextrose 5% would be more appropriate. Risk factors for adrenal crisis are seen in patients who have underlying adrenal hypofunction and who undergo stressful events such as trauma, surgery, and infections. Patients with primary adrenal insufficiency require additional doses of glucocorticoid during periods of stress such as surgery, trauma, or infection.
PTS: 1 CON: Metabolism | Medication 7. ANS: 3 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with adrenal disorders Chapter page reference: 888 Heading: Adrenal Cortical Insufficiency > Nursing Management > Assessment and Analysis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing]
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Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 There is no evidence that the patient has an infection. 2 There is no evidence that the patient is experiencing inflammation. 3 Muscular weakness is related to hyperkalemia. 4 The patient’s sodium level will be low. PTS: 1 CON: Metabolism | Assessment 8. ANS: 1 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with adrenal disorders Chapter page reference: 888 Heading: Adrenal Cortical Insufficiency > Nursing Management > Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 Fluid losses lead to hemoconcentration that may increase hematocrit levels. 2 Cortisol levels of less than 13 mcg/dL suggest adrenal insufficiency. 3 A serum sodium of 134 mEq/L is within normal limits. 4 A serum potassium level of 4.8N m UERqS/LINis GwTithBin.nCoOrmMal limits. PTS: 1 CON: Metabolism | Assessment 9. ANS: 4 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with adrenal disorders Chapter page reference: 889 Heading: Adrenal Cortical Insufficiency > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Promoting Health Difficulty: Moderate
1 2
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Feedback Wearing the medical alert bracelet reduces time to definitive treatment in an emergency situation. It is important that the patient (and family) is able to detect early signs of adrenal insufficiency because it can deteriorate to adrenal crisis, which is a life-threatening emergency. Adrenal cortex replacement is required to maintain fluid balance and normal glucose levels. Over-replacement of glucocorticoids results in adverse effects including weight gain.
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PTS: 1 CON: Metabolism | Promoting Health 10. ANS: 1 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Describing the epidemiology of adrenal disorders Chapter page reference: 889 Heading: Adrenal Cortical Hyperfunction > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Metabolism Difficulty: Easy Feedback 1 Excessive secretion of glucocorticoids causes Cushing’s syndrome. 2 Excessive secretion of aldosterone causes Conn’s syndrome. 3 Decreased glucocorticoid level causes Addison’s disease. 4 Decreased aldosterone secretion causes Addison’s disease. PTS: 1 CON: Metabolism 11. ANS: 4 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Adrenal cortex hyperfunction Chapter page reference: 890 Heading: Adrenal Cortical Hyperfunction > Clinical Manifestation NU RSING TB. CO Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 Muscle wasting is an expected finding with adrenal cortical hyperfunction. 2 Elevated blood glucose level is an expected finding with adrenal cortical hyperfunction. 3 Abnormal fat distribution is an expected finding with adrenal cortical hyperfunction. 4 Cardiac irregularities such as the appearance of U waves are secondary to hypokalemia. PTS: 1 CON: Metabolism | Assessment 12. ANS: 3 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of adrenal disorders Chapter page reference: 890 Heading: Adrenal Cortical Hyperfunction > Diagnosis of Hypercortisolism Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate Feedback
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1 2 3 4
Serum sodium would not be prescribed first to diagnose hypercortisolism. Serum potassium would not be prescribed first to diagnose hypercortisolism. Measurement of urinary free cortisol is used as an initial screening tool because it measures urine cortisol over a 24-hour period. Fasting blood glucose would not be prescribed first to diagnose hypercortisolism.
PTS: 1 CON: Metabolism 13. ANS: 3 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Discussing the medical management of: Adrenal cortex hyperfunction Chapter page reference: 890 Heading: Adrenal Cortical Hyperfunction > Medical Management of Hypercortisolism Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Medication Difficulty: Moderate
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Feedback Dexamethasone is used to treat Cushing’s syndrome. Potassium chloride is used to treat hyperaldosteronism. Aminoglutethimide is an example of a medication that interferes with cortisol production in the adrenal cortex. The nurse must monitor for signs of adrenal suppression, including hypoglycemia and hypernatremia. Spironolactone (Aldacton e) isNuse URd StoItrNeaGt ThyBper .Caldo O Msteron ism.
PTS: 1 CON: Metabolism | Medication 14. ANS: 1 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with adrenal disorders Chapter page reference: 891 Heading: Adrenal Cortical Hyperfunction > Nursing Management > Assessment and Analysis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate 1 2 3 4
Feedback Patients with hyperaldosteronism present with headache. Common findings in patients with hypercortisolism include thin, friable skin. Common findings in patients with hypercortisolism include dependent edema. Common findings in patients with hypercortisolism include fat maldistribution.
PTS: 1 CON: Metabolism | Assessment 15. ANS: 2 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders
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Chapter learning objective: Developing a comprehensive plan of nursing care for patients with adrenal disorders Chapter page reference: 892 Heading: Adrenal Cortical Hyperfunction > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate 1 2
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Feedback Serum glucose levels rise secondary to increased secretion of glucocorticoid. Turn patient frequently and protect skin from injury. Thinning of skin along with increased friability of skin accompanied by fluid retention increase the chances of skin injury due to pressure or friction. Head of bed elevated 45 degrees. This decreases the work of breathing that may develop secondary to fluid retention. Administer medications that interfere with production/secretion of cortisol. This will decrease the secretion of cortisol.
PTS: 1 CON: Metabolism 16. ANS: 3 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with adrenal disorders NURSINGTB.COM Chapter page reference: 892 Heading: Adrenal Cortical Hyperfunction > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism; Promoting Health Difficulty: Moderate 1 2 3 4
Feedback Increasing fluids can increase hypertension. There is no evidence that the patient should increase activity. Excessive salt intake may further exacerbate fluid retention. Increasing salt intake could exacerbate fluid retention.
PTS: 1 CON: Metabolism | Promoting Health 17. ANS: 2 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Describing the epidemiology of adrenal disorders Chapter page reference: 892 Heading: Pheochromocytoma > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism
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Difficulty: Moderate
1 2 3 4
Feedback Life-threatening cardiac arrhythmias are not seen in hypercortisolism. Because of excessive catecholamine (epinephrine and norepinephrine) secretion, pheochromocytoma may precipitate life-threatening cardiac arrhythmias. Life-threatening cardiac arrhythmias are not seen in hyperaldosteronism. Life-threatening cardiac arrhythmias are not seen in Cushing’s syndrome.
PTS: 1 CON: Metabolism 18. ANS: 4 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Pheochromocytoma Chapter page reference: 892 Heading: Pheochromocytoma > Pathophysiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate 1 2 3 4
Feedback The release of the epinephrine and norepinephrine is typically paradoxical, rather than continuous, and leads to increaNsed U RhSeaIrtNrat G e.T B.COM The release of the epinephrine and norepinephrine is typically paradoxical, rather than continuous, and leads to a rise in systolic blood pressure. Catecholamine release also stimulates gluconeogenesis resulting in hyperglycemia. The release of the epinephrine and norepinephrine is typically paradoxical, rather than continuous, and leads to widening pulse pressure.
PTS: 1 CON: Metabolism 19. ANS: 2 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of adrenal disorders Chapter page reference: 893 Heading: Pheochromocytoma > Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate 1 2 3
Feedback The patient does not need to avoid red meat before this test. The patient should be instructed to avoid chocolate because it is high in amines and can lead to a false elevation of VMA. The patient does not need to avoid whole grains before this test.
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4
The patient does not need to avoid green vegetables before this test.
PTS: 1 CON: Metabolism 20. ANS: 1 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Discussing the medical management of: Pheochromocytoma Chapter page reference: 893 Heading: Pheochromocytoma > Surgical Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism; Perioperative Difficulty: Moderate
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Feedback Adrenalectomy is the definitive treatment for pheochromocytoma. Pharmacological management focuses on lowering the blood pressure using smooth muscle relaxants. Pharmacological management focuses on lowering the blood pressure using betaadrenergic blocking agents. Pharmacological management focuses on lowering the blood pressure using alphaadrenergic blocking agents.
PTS: 1 CON: Metabolism | Perioperative 21. ANS: 4 NURSINGTB.COM Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Discussing the medical management of: Pheochromocytoma Chapter page reference: 893 Heading: Pheochromocytoma > Surgical Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism; Perioperative Difficulty: Moderate 1 2 3 4
Feedback Immediately after surgery the patient may experience hypoglycemia; however, because of long-term cortisol replacement the patient will be at risk for hyperglycemia. The patient is not at risk for developing hypercortisolism. The patient is not at risk for developing hyperaldosteronism. Patients who undergo bilateral adrenalectomy are at risk for adrenal insufficiency for the remainder of their lives.
PTS: 1 CON: Metabolism | Perioperative 22. ANS: 4 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with adrenal disorders Chapter page reference: 894
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Heading: Pheochromocytoma > Nursing Management > Actions Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Medication Difficulty: Moderate
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Feedback Bedrest decreases secretion of catecholamines. Beta-adrenergic agents lead to increased chronotropic (rate) and inotropic (force) effects on the heart. Cardiac monitoring will help detect tachyarrhythmias. Sodium nitroprusside (Nipride) quickly decreases blood pressure through direct action of blood vessels leading to peripheral vasodilation.
PTS: 1
CON: Metabolism | Medication
MULTIPLE RESPONSE 23. ANS: 3, 4, 5 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Describing the epidemiology of adrenal disorders Chapter page reference: 886 Heading: Adrenal Cortical Insufficiency > Epidemiology Integrated Processes: Nursing ProcesN s:UARssSesIs N mG e nTt B.COM Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Metabolism Difficulty: Easy
1. 2. 3. 4. 5.
Feedback The ovaries are not examined as a cause for adrenal insufficiency. The thyroid gland does not impact adrenal insufficiency. Adrenal insufficiency may result from dysfunction of the hypothalamus. Adrenal insufficiency may result from destruction of the adrenal glands or Addison’s disease. Adrenal insufficiency may result from decreased secretion of adrenocorticotropic hormone (ACTH) from the anterior pituitary gland.
PTS: 1 CON: Metabolism 24. ANS: 1, 2, 3, 5 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Describing the epidemiology of adrenal disorders Chapter page reference: 886 Heading: Adrenal Cortical Insufficiency > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism
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Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Causes of primary adrenal insufficiency include cancer. Causes of primary adrenal insufficiency include traumatic processes that lead to direct insults to the adrenal cortex. Causes of primary adrenal insufficiency include infection. Medications are not identified as causing adrenal insufficiency. Causes of primary adrenal insufficiency include autoimmune disorders.
PTS: 1 CON: Metabolism 25. ANS: 2, 4, 5 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Adrenal cortex insufficiency Chapter page reference: 887 Heading: Adrenal Cortical Insufficiency > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Hard
1. 2. 3. 4. 5.
Feedback Fatigue is a manifestatiN onUoRf S adIren N GalTinBsu.f fCicOieMncy; however, it is not life-threatenin g. Poor skin turgor is an indication of dehydration, which could be life-threatening. Skin hyperpigmentation is a manifestation of adrenal insufficiency; however, it is not lifethreatening. Dry mucous membranes indicate dehydration, which could be life-threatening. A low blood pressure is an indication of hypotension, which could be life-threatening.
PTS: 1 CON: Metabolism 26. ANS: 4, 5 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Describing the epidemiology of adrenal disorders Chapter page reference: 889 Heading: Adrenal Cortical Hyperfunction > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Metabolism Difficulty: Easy
1. 2. 3.
Feedback Age is not identified as a risk factor for Conn’s syndrome. The incidence of hyperaldosteronism is significantly greater in African Americans than in Caucasians. There is an autosomal dominant pattern of inheritance for primary hyperaldosteronism, with females more at risk than males.
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4. 5.
There is an autosomal dominant pattern of inheritance for primary hyperaldosteronism, with females more at risk than males. The incidence of hyperaldosteronism is significantly greater in African Americans than in Caucasians.
PTS: 1 CON: Metabolism 27. ANS: 2, 3, 5 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Adrenal cortex hyperfunction Chapter page reference: 890 Heading: Adrenal Cortical Hyperfunction > Clinical Manifestation Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application [Applying] Concept: Metabolism; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Leg cramping is not a manifestation of Cushing’s syndrome. In female patients, clinical manifestations include amenorrhea. In female patients, clinical manifestations include breast atrophy. Menstrual pain is not specifically linked to Cushing’s syndrome. In female patients, clinical manifestations include vocal changes (deepening).
NURSINGTB.COM PTS: 1 CON: Metabolism | Assessment 28. ANS: 1, 2, 4, 5 Chapter number and title: 42, Coordinating Care for Patients With Adrenal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Pheochromocytoma Chapter page reference: 893 Heading: Pheochromocytoma > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate
1. 2. 3. 4. 5. PTS: 1
Feedback Clinical manifestations of pheochromocytoma include headache. Clinical manifestations of pheochromocytoma include palpitations. Clinical manifestations of pheochromocytoma do not include weight gain. Clinical manifestations of pheochromocytoma include hypertension. Clinical manifestations of pheochromocytoma include hyperglycemia. CON: Metabolism | Assessment
Chapter 43: Coordinating Care for Patients With Thyroid and Parathyroid Disorders
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Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse notes that a patient is diagnosed with Hashimoto’s thyroiditis. What is the most likely cause of this patient’s health problem? 1) Congenital 2) Iodine deficiency 3) Tyrosine deficiency 4) Autoimmune response 2. A patient with hypothyroidism asks why the neck has become so large. What should the nurse respond to this patient? 1) “The growth is cancer.” 2) “The sluggish thyroid caused fat to be deposited around the neck.” 3) “The growth is the body’s attempt to wall off the infection in your thyroid.” 4) “The gland got larger because it was trying to make more thyroid hormone.” 3. A patient with hypothyroidism is prescribed levothyroxine (Synthroid). At which time should the nurse schedule this medication to be administered? 1) 0800 hours 2) 1200 hours 3) 1700 hours 4) 2300 hours 4. The nurse notices that a patient with hypothyroidism has a husky voice. To what should the nurse attribute this finding? 1) Chronic fatigue NURSINGTB.COM 2) Enlarged thyroid gland 3) Edema of the tongue and larynx 4) Dry mucous membranes from dehydration 5. The nurse is evaluating care provided to a patient with hypothyroidism. Which finding indicates that additional care is needed? 1) Skin warm and supple 2) Heart rate 72 and regular 3) Blood pressure 118/68 mm Hg 4) Weight increase 2 kg over a month 6. A patient is being evaluated for hyperthyroidism. What is the most common cause for this disorder? 1) Cancer 2) Toxic medications 3) Radiation exposure 4) Autoimmune disorder 7. The nurse is preparing to assess a patient with exophthalmos. On which body system should the nurse focus during this assessment? 1) Sensory 2) Hematological 3) Gastrointestinal 4) Musculoskeletal
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8. A patient with hyperthyroidism is prescribed propylthiouracil (PTU). What should the nurse include in the teaching plan when explaining the mechanism of this medication? 1) Diverts iodine pathways 2) Causes formation of thyroid antibodies 3) Decreases the vascularity of the thyroid gland 4) Blocks iodine from binding with thyroglobulin 9. A patient is recovering from a thyroidectomy. Which observation needs to be reported immediately to the health-care provider? 1) Changes in voice tone 2) Hypoactive bowel sounds 3) Blood pressure 138/70 mm H 4) Complaints of postoperative pain 10. A patient with hyperthyroidism is placed on seizure precautions as a result of which observation? 1) Hyponatremia 2) Exophthalmos 3) Rapid heart rate 4) Increased T3 and T4 levels 11. The nurse is preparing discharge instructions for a patient being treated medically for hyperthyroidism. What should the nurse emphasize to protect the patient’s eyes? 1) Use artificial tears 2) Wear sunglasses at all times 3) Wear eye shields at all times 4) Tape the eyes closed at bedtime
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12. A patient recovering from surgery to treat thyroid cancer continues to lose weight. Which health-care professional should be consulted to help with this patient’s problem? 1) Surgeon 2) Dietician 3) Pharmacist 4) Radiologist 13. A patient spontaneously develops manifestations of hypoparathyroidism. What should be considered as the reason for this health problem? 1) Diabetes mellitus 2) Thyroid hypertrophy 3) Low intake of calcium-rich foods 4) Congenital absence of parathyroid glands 14. The nurse is explaining the mechanism of hypoparathyroidism. Which electrolyte should the nurse explain as being the most significant with regard to this disorder? 1) Sodium 2) Calcium 3) Potassium 4) Cholesterol 15. During an assessment the nurse suspects that a patient is experiencing hypoparathyroidism. What finding caused the nurse to make this clinical determination? 1) Low heart rate 2) Muscle weakness
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3) Respiratory rate 20 and shallow 4) Hand spasm when measuring blood pressure 16. A patient is being evaluated for hypoparathyroidism. Which laboratory value would help confirm this diagnosis? 1) Elevated serum phosphate 2) Elevated serum magnesium 3) Decreased serum potassium 4) Serum albumin within normal limits 17. The nurse is assessing a patient with suspected hypoparathyroidism. Which finding should the nurse identify as needing further investigation? 1) Heart rate 88 bpm 2) Respiratory rate 16 3) Temperature 99.2 °F 4) Blood pressure 88/50 mm Hg 18. The nurse is preparing medications for a patient with hypoparathyroidism. What should be administered with a calcium supplement? 1) Lithium 2) Synthroid 3) Vitamin D 4) Proplythiouracil (PTU) 19. A patient is diagnosed with secondary hyperparathyroidism. Which additional health problem is this patient most likely being treated for? 1) Diabetes insipidus NURSINGTB.COM 2) Hyperaldosteronism 3) Chronic renal failure 4) Parathyroid adenoma 20. A patient with chronic renal failure is diagnosed with hyperparathyroidism. Which treatment approach should the nurse expect to be prescribed for this patient? 1) Increased oral fluid intake 2) Oral thiazide diuretics twice a day 3) High-volume normal saline infusions 4) Discontinue calcium and vitamin D supplements 21. A patient with hyperparathyroidism is experiencing flank pain. For which health problem should this patient be assessed? 1) Renal calculi 2) Muscle spasms 3) Adrenal gland dysfunction 4) Elevated phosphorous level 22. The nurse is evaluating teaching provided to a patient with hyperparathyroidism. Which statement indicates that teaching has been effective? 1) “I should expect to have a poor appetite.” 2) “I should eat raw vegetables and fruits every day.” 3) “I should expect to have muscle cramping and pain.” 4) “I should consume diary products with breakfast and lunch.”
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Multiple Response Identify one or more choices that best complete the statement or answer the question. 23. The nurse is preparing to assess a patient with hypothyroidism. What findings should the nurse expect? Select all that apply. 1) Fatigue 2) Weight gain 3) Increased sleep 4) Decreased energy 5) Increased appetite 24. The nurse suspects that patient with hypothyroidism is experiencing myxedema. What findings caused the nurse to come to this conclusion? Select all that apply. 1) Constipation 2) Thick, silky hair 3) Dry, coarse skin 4) Decreased heart rate 5) Generalized nonpitting edema 25. A patient is diagnosed with hypothyroidism. What laboratory levels were used to make this diagnosis? Select all that apply. 1) T3 2) T4 3) GH 4) TSH NURSINGTB.COM 5) FSH 26. A patient with hypothyroidism is recovering from orthopedic surgery. Which findings suggest that this patient is developing myxedema coma? Select all that apply. 1) Hypoxia 2) Slow heart rate 3) Low body temperature 4) Elevated blood pressure 5) Retaining carbon dioxide 27. After performing an assessment, the nurse suspects that a patient is experiencing hyperthyroidism. What findings caused the nurse to come to this conclusion? Select all that apply. 1) Anorexia 2) Heart rate 112 bpm 3) Hyperactive bowel sounds 4) Thinning hair noted on the head 5) Weight loss 10 lbs. over the last month 28. The nurse suspects that a patient is experiencing thyroid storm. What actions should the nurse take to support this patient? Select all that apply. 1) Position on a cooling blanket 2) Monitor intravenous fluid infusion 3) Administer antiemetics as prescribed 4) Administer dexamethasone as prescribed 5) Administer beta-adrenergic blockers as prescribed
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Chapter 43: Coordinating Care for Patients With Thyroid and Parathyroid Disorders Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Describing the epidemiology of thyroid and parathyroid disorders Chapter page reference: 897 Heading: Hypothyroidism > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Metabolism Difficulty: Easy Feedback 1 One cause of primary hypothyroidism is a congenital thyroid disorder; however, this does not cause Hashimoto’s thyroiditis. 2 Hypothyroidism can be caused by an iodine deficiency; however, this is rare because of iodized salt. 3 Hypothyroidism can be caused by a tyrosine deficiency; however, this is rare because of iodized salt. 4 Hashimoto’s thyroiditis is the most common type of hypothyroidism and is caused by an autoimmune response that leads to destruction of the thyroid gland by immunological processes. NURSINGTB.COM PTS: 1 CON: Metabolism 2. ANS: 4 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Describing the epidemiology of thyroid and parathyroid disorders Chapter page reference: 897 Heading: Hypothyroidism > Epidemiology Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism Difficulty: Moderate Feedback 1 A goiter is not cancer. 2 A goiter is not fat deposits. 3 A goiter does not develop because of an infection of the thyroid gland. 4 Hypothyroidism is a major cause of goiter and develops secondary to thyroid gland hypertrophy in an attempt to produce normal amounts of T3 and T4. PTS: 1 CON: Metabolism 3. ANS: 1 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Discussing the medical management of: Hypothyroidism
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Chapter page reference: 899 Heading: Hypothyroidism > Medical Management > Diagnosis Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Metabolism; Medication Difficulty: Moderate
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Feedback Because thyroid hormone affects metabolism, the medication is to be taken in the morning. This medication should be taken in the morning. This medication should be taken in the morning. This medication should be taken in the morning.
PTS: 1 CON: Metabolism | Medication 4. ANS: 3 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with thyroid and parathyroid disorders Chapter page reference: 900 Heading: Hypothyroidism > Nursing Management > Assessment and Analysis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] NURSINGTB.COM Concept: Metabolism Difficulty: Moderate
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Feedback The husky voice is not caused by chronic fatigue. The husky voice is not caused by an enlarged thyroid gland. Edema of the tongue and around the larynx results in changes in speech resulting in a husky tone. The husky voice is not caused by dry mucous membranes or dehydration.
PTS: 1 CON: Metabolism 5. ANS: 4 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with thyroid and parathyroid disorders Chapter page reference: 901 Heading: Hypothyroidism > Nursing Management > Evaluating Care Outcomes Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate Feedback
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1 2 3 4
Normal skin turgor and texture are indicative of thyroid health in this patient population. Vital signs within normal limits indicates thyroid health. Vital signs within normal limits indicates thyroid health. Stable weight indicates thyroid health. A weight gain indicates a sluggish thyroid in this patient population.
PTS: 1 CON: Metabolism 6. ANS: 4 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Describing the epidemiology of thyroid and parathyroid disorders Chapter page reference: 901 Heading: Hyperthyroidism > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Knowledge [Remembering] Concept: Metabolism Difficulty: Easy Feedback 1 Cancer is not identified as a common cause for hyperthyroidism. 2 Toxic medications are not identified as common causes for hyperthyroidism. 3 Radiation exposure is not identified as a common cause for hyperthyroidism. 4 Graves’s disease is the most common cause of hyperthyroidism and is an autoimmune disorder involving antibodies (thyroid-stimulating immunoglobulins) that bind to the thyroid gland, resultin g in the N enUlaRrgSe I men NGt of T Bth.eCthOyMro id gland and subsequent hypersecretion of thyroid hormone. PTS: 1 CON: Metabolism 7. ANS: 1 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Hyperthyroidism Chapter page reference: 901 Heading: Hyperthyroidism > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Metabolism; Sensory Perception Difficulty: Moderate 1
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Feedback Protrusion of the eyeball, exophthalmos is characteristic of hyperthyroidism and results in visual changes. The patient’s vision, which is a part of the sensory system, should be the focus of the assessment. Exophthalmos is not associated with a hematological problem. Exophthalmos is not associated with a gastrointestinal problem. Exophthalmos is not associated with a musculoskeletal problem.
PTS: 1
CON: Metabolism | Sensory Perception
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8. ANS: 1 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Discussing the medical management of: Hyperthyroidism Chapter page reference: 903 Heading: Hyperthyroidism > Medical Management Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Metabolism; Medication Difficulty: Moderate Feedback 1 Propylthiouracil (PTU) inhibits the synthesis of thyroid hormone by diverting iodine pathways. 2 Lithium carbonate (Lithonate) can cause thyroid antibodies. 3 Iodine decreases the vascularity of the thyroid gland. 4 Methimazole (Tapazole) blocks the combination of iodine with a protein called thyroglobulin. PTS: 1 CON: Metabolism | Medication 9. ANS: 1 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Discussing the medical management of: Hyperthyroidism Chapter page reference: 903 Heading: Hyperthyroidism > Surgical Management Integrated Processes: Communication and Documentation NURSINGTB.COM Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Perioperative Difficulty: Moderate 1
2 3 4
Feedback Assessing for damage to the laryngeal nerve is also a priority in the postoperative period following thyroidectomy. Changes in voice quality, particularly hoarseness or a husky tone, may be indicative of laryngeal nerve damage. Hypoactive bowel sounds could be caused by general anesthesia. Blood pressure of 138/70 mm Hg could be within normal limits for this patient. Postoperative pain would be expected in the perioperative period.
PTS: 1 CON: Metabolism | Perioperative 10. ANS: 1 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with thyroid and parathyroid disorders Chapter page reference: 904 Heading: Hyperthyroidism > Nursing Management > Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Fluid and Electrolyte Balance
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Difficulty: Moderate Feedback 1 Increased risk for seizure activity related to hyponatremia. 2 Exophthalmos does not increase the risk for seizures. 3 A rapid heart rate is a manifestation of hypermetabolism but will not directly cause seizures. 4 Increased T3 and T4 levels are diagnostic for hyperthyroidism; however, they do not directly cause seizures. PTS: 1 CON: Metabolism | Fluid and Electrolyte Balance 11. ANS: 1 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with thyroid and parathyroid disorders Chapter page reference: 905 Heading: Hyperthyroidism > Nursing Management > Actions Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism; Sensory Perception; Promoting Health Difficulty: Moderate Feedback 1 Eye lubricant decreases possible eye dryness and potential for corneal irritation secondary to incomplete eyelid closure. 2 Sunglasses do not need to be w NoUrnRaSt alIlNtim GTeBs. .COM 3 Wearing eye shields at all times severely reduces this patient’s vision and would not be recommended. 4 The eyes should not be taped shut. PTS: 1 CON: Metabolism | Sensory Perception | Promoting Health 12. ANS: 2 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Coordinating the interprofessional plan of care for the patient undergoing treatment for thyroid cancer Chapter page reference: 905 Heading: Thyroid Cancer Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism; Collaboration Difficulty: Easy Feedback 1 The surgeon would not be able to help with the patient’s weight loss. 2 The dietician should be consulted to help with the patient’s eating plan to stop weight loss. 3 The pharmacist would focus on the patient’s medications. 4 The radiologist would not be able to help with the patient’s weight loss.
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PTS: 1 CON: Metabolism | Collaboration 13. ANS: 1 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Describing the epidemiology of thyroid and parathyroid disorders Chapter page reference: 906 Heading: Hypoparathyroidism > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Metabolism Difficulty: Easy Feedback 1 Autoimmune disease is suspected in patients with spontaneous presentation of hypoparathyroidism with no identifiable cause. In these cases, antiparathyroid antibodies have been detected in patients with other autoimmune disorders such as diabetes mellitus. 2 Thyroid hypertrophy would cause hyperthyroidism. 3 A low intake of calcium-rich foods does not cause hypoparathyroidism. 4 The patient would have experienced symptoms upon birth if the parathyroid glands were congenitally absent. PTS: 1 CON: Metabolism 14. ANS: 2 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: NURSINGTB.COM Hypoparathyroidism Chapter page reference: 906 Heading: Hypoparathyroidism > Pathophysiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Metabolism; Fluid and Electrolyte Balance Difficulty: Easy Feedback 1 Hypoparathyroidism is not caused by an imbalance of sodium. 2 Hypocalcemia is the primary disorder associated with hypoparathyroidism. 3 Hypoparathyroidism is not caused by an imbalance of potassium. 4 Cholesterol is a lipid and not an electrolyte. PTS: 1 CON: Metabolism | Fluid and Electrolyte Balance 15. ANS: 4 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Hypoparathyroidism Chapter page reference: 907 Heading: Hypoparathyroidism > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing]
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Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 A low heart rate is not associated with hypoparathyroidism. 2 Muscle weakness is not associated with hypoparathyroidism. 3 A respiratory rate of 20 and shallow is not associated with hypoparathyroidism. 4 A hand spasm when measuring blood pressure indicates Trousseau’s sign. PTS: 1 CON: Metabolism | Assessment 16. ANS: 1 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of thyroid and parathyroid disorders Chapter page reference: 907 Heading: Hypoparathyroidism > Medical Management Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 Diagnostic results consistent with hypoparathyroidism include high serum phosphate levels. 2 Serum magnesium levels are often evaluated to rule out hypomagnesemia as the cause of hypoparath yroidism, as lowNsU erR um SImNa gGnTesBiu.mCleOvMels inhibit synthesis of PTH. 3 Serum potassium is not used to diagnose hypoparathyroidism. 4 Serum albumin levels are monitored because the majority of serum calcium is plasma protein bound; however, in hypoparathyroidism the serum albumin level will be low. PTS: 1 CON: Metabolism | Assessment 17. ANS: 4 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with thyroid and parathyroid disorders Chapter page reference: 908 Heading: Hypoparathyroidism > Nursing Management > Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate 1 2 3 4
Feedback Heart rate of 88 bpm is within normal limits. A respiratory rate of 16 is within normal limits. A temperature of 99.2 °F does not indicate hypoparathyroidism. Hypotension may occur secondary to decreased myocardial contractility and cardiac dysrhythmias.
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PTS: 1 CON: Metabolism | Assessment 18. ANS: 3 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with thyroid and parathyroid disorders Chapter page reference: 908 Heading: Hypoparathyroidism > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Metabolism; Medication Difficulty: Moderate Feedback 1 Lithium can be used to treat hyperthyroidism. 2 Synthroid is used to treat hypothyroidism. 3 Vitamin D is needed for calcium absorption from the bowel. 4 Proplythiouracil (PTU) is used to treat hyperthyroidism. PTS: 1 CON: Metabolism | Medication 19. ANS: 3 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Describing the epidemiology of thyroid and parathyroid disorders Chapter page reference: 908 Heading: Hyperparathyroidism > Epidemiology NURSINGTB.COM Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Metabolism Difficulty: Easy
1 2 3 4
Feedback Hyperparathyroidism is not associated with diabetes insipidus. Hyperparathyroidism is not associated with hyperaldosteronism. Secondary disorders are most often observed in patients with chronic renal failure. Parathyroid adenomas account for 85% of the cases of primary hyperparathyroidism.
PTS: 1 CON: Metabolism 20. ANS: 4 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Discussing the medical management of: Hyperparathyroidism Chapter page reference: 909 Heading: Hyperparathyroidism > Medical Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Fluid and Electrolyte Balance Difficulty: Difficult
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1 2 3 4
Feedback The patient has chronic renal failure and will most likely have a fluid restriction. Thiazide diuretics increase reabsorption of calcium in the kidney. The patient has chronic renal failure and will most likely have a fluid restriction. Patients with hyperparathyroidism are also taught to decrease consumption of calciumcontaining antacids and vitamin D. Calcium and vitamin D supplements will most likely be discontinued.
PTS: 1 CON: Metabolism | Fluid and Electrolyte Balance 21. ANS: 1 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with thyroid and parathyroid disorders Chapter page reference: 910 Heading: Hyperparathyroidism > Nursing Management > Actions Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate Feedback 1 Elevated serum calcium levels caused by hyperparathyroidism can lead to renal calculi. Manifestations of renal calculi include flank pain. 2 Muscle spasms are not typically associated with flank pain. 3 Adrenal gland dysfunction do es N Unot RStyIp Nicall G Ty Bca.uCseOflMank pain. 4 Elevated phosphorous levels do not cause flank pain. PTS: 1 CON: Metabolism 22. ANS: 2 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with thyroid and parathyroid disorders Chapter page reference: 910 Heading: Hyperparathyroidism > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Promoting Health Difficulty: Moderate Feedback 1 Anorexia is a manifestation of hyperparathyroidism. 2 The patient should be instructed to increase roughage to reduce constipation caused by an elevated calcium level. 3 Muscle cramping and pain are manifestations of hyperparathyroidism. 4 The patient should be instructed to restrict the intake of calcium-rich foods. PTS: 1
CON: Metabolism | Promoting Health
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MULTIPLE RESPONSE 23. ANS: 1, 2, 3, 4 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Hypothyroidism Chapter page reference: 899 Heading: Hypothyroidism > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application [Applying] Concept: Metabolism; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback The hypometabolic state is characterized by fatigue. The hypometabolic state is characterized by weight gain. The hypometabolic state is characterized by increased sleep. The hypometabolic state is characterized by decreased energy. The hypometabolic state is characterized by decreased appetite.
PTS: 1 CON: Metabolism | Assessment 24. ANS: 1, 3, 4, 5 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: NURSINGTB.COM Hypothyroidism Chapter page reference: 900 Heading: Hypothyroidism > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Decreased gastrointestinal activity results in constipation. Hair becomes thin and fragile, and hair loss occurs. Skin changes may result over time secondary to cold intolerance, and a lack of sweating may leave the skin dry and coarse. Cardiac alterations secondary to myxedematous changes include decreased pulse. The increased deposition of glycosaminoglycans causes an osmotic edema and a fluid collection that is associated with a generalized nonpitting edema.
PTS: 1 CON: Metabolism | Assessment 25. ANS: 1, 2, 4 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of thyroid and parathyroid disorders Chapter page reference: 899
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Heading: Hypothyroidism > Medical Management Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback The diagnosis of hypothyroidism is confirmed through analysis of laboratory data, including T3. The diagnosis of hypothyroidism is confirmed through analysis of laboratory data, including T4. Growth hormone is not used to diagnose hypothyroidism. The diagnosis of hypothyroidism is confirmed through analysis of laboratory data, including TSH. Follicle-stimulating hormone is not used to diagnose hypothyroidism.
PTS: 1 CON: Metabolism | Assessment 26. ANS: 1, 2, 3, 5 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Discussing the medical management of: Hypothyroidism Chapter page reference: 899 Heading: Hypothyroidism > Medical Management > Complications Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential NURSINGTB.CO Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Assessment; Perioperative Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback The most severe type of hypothyroidism is myxedema coma and is characterized by hypoxia. Because of significant decreases in cardiac function, the patient is bradycardic. The most severe type of hypothyroidism is myxedema coma and is characterized by hypothermia. Because of significant decreases in cardiac function, the patient is hypotensive. The most severe type of hypothyroidism is myxedema coma and is characterized by carbon dioxide retention.
PTS: 1 CON: Metabolism | Assessment | Perioperative 27. ANS: 2, 3, 4, 5 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Hyperthyroidism Chapter page reference: 901 Heading: Hyperthyroidism > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Metabolism; Assessment
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Increased appetite and not anorexia is associated with hyperthyroidism. Clinical manifestations of hyperthyroidism include elevated heart rate. Clinical manifestations of hyperthyroidism include increased gastric activity. Clinical manifestations of hyperthyroidism include hair loss. Clinical manifestations of hyperthyroidism include weight loss.
PTS: 1 CON: Metabolism | Assessment 28. ANS: 1, 2, 4, 5 Chapter number and title: 43, Coordinating Care for Patients With Thyroid and Parathyroid Disorders Chapter learning objective: Discussing the medical management of: Hyperthyroidism Chapter page reference: 902 Heading: Hyperthyroidism > Complications Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Metabolism; Thermo-regulation; Perfusion; Nursing Difficulty: Moderate
1. 2. 3. 4. 5. PTS: 1
Feedback Cooling blankets may be used to treat hyperthermia. Fluid resuscitation is a priority in a thyroid storm. Antiemetics are not indiN c aU teR d S inIaNthGyT roBid.sC toO rmM. Glucocorticoids, of which dexamethasone is one, may be administered to block the conversion of T4 to T3 and decrease the release of TS from the anterior pituitary gland. For management of tachycardia, beta-adrenergic blockers may be administered. CON: Metabolism | Thermo-regulation | Perfusion | Nursing
Chapter 44: Coordinating Care for Patients With Diabetes Mellitus Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A middle-aged patient is surprised to learn of the diagnosis of type 1 diabetes mellitus. What should the nurse respond? 1) “It is odd since it is usually a disease of childhood.” 2) “You probably developed it because of an infection.” 3) “Type 1 diabetes mellitus can occur at any stage of life.” 4) “It usually means that another disease process is present.” 2. The nurse is reviewing type 1 diabetes mellitus with a group of patients newly diagnosed with the disorder. What should the nurse explain as the major cause for the disorder? 1) Autoimmune process 2) Cancer of the pancreas 3) Alteration in lipid and protein utilization
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4) Malfunction of carbohydrate metabolism 3. The nurse notices that a patient who has been drinking large volumes of water and eating large meals throughout the day continues to lose weight. Which health problem should the nurse suspect this patient is experiencing? 1) Hypercortisolism 2) Hyperaldosteronism 3) Type 1 diabetes mellitus 4) Type 2 diabetes mellitus 4. A patient with type 1 diabetes mellitus is scheduled for a hemoglobin A1c level. What should the nurse emphasize to the patient to prepare for this test? 1) Schedule the test for first thing in the morning 2) Have the test drawn at any time during the day 3) Avoid eating and drinking anything after midnight the day before the test 4) Restrict the intake of red meat for three days before having the test 5. The nurse is reviewing the results of patient’s recent hemoglobin A1c level drawn to evaluate type 1 diabetes management. Which result indicates that treatment has been successful? 1) > or = 8% 2) < or = 6.5% 3) > 110 mg/dL 4) > 140 mg/dL 6. A patient is prescribed Regular insulin 5 units subcutaneous injection now. Which syringe should the nurse use for this dose if all are readily available? 1) U-30 NURSINGTB.COM 2) U-50 3) U-100 4) U-500 7. A patient with type 1 diabetes mellitus will be self-monitoring blood glucose levels at home. What is the minimum number of measurements that this patient should make each day? 1) 1 2) 3 3) 4 4) 8 8. A patient with type 1 diabetes mellitus has not taken insulin for several days. Which observation indicates that diabetic ketoacidosis (DKA) could be developing? 1) Slow heart rate 2) Deep rapid respirations 3) Decreased urine output 4) Increased blood pressure 9. A patient experiencing diabetic ketoacidosis (DKA) is receiving a normal saline infusion and intravenous insulin. What additional medication should the nurse expect to be prescribed for this patient? 1) Diuretic 2) Laxative 3) Antibiotic 4) Potassium
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10. A patient with type 1 diabetes mellitus develops symptoms of hypoglycemia only when the blood glucose level drops to 40 mg/dL. What should be done to reverse this condition? 1) Raise glycemic targets 2) Cut insulin dose in half 3) Add an extra snack to the meal plan 4) Eliminate the evening dose of insulin 11. A patient with type 1 diabetes mellitus is experiencing elevated blood glucose levels in the morning. Which action should be taken to determine the reason for this elevation? 1) Check urine for glucose level 2) Restrict oral fluids after 1800 hours 3) Measure blood glucose at 0200 hours 4) Limit carbohydrate intake to 45 grams with evening meal 12. An older patient with type 1 diabetes mellitus has poor oral intake. What should be considered to ensure adequate blood glucose control? 1) Hold all prandial doses 2) Consider increasing longer-acting insulin 3) Increase the frequency of correctional doses 4) Administer prandial and correctional insulin together 13. The nurse is evaluating teaching provided to a patient with type 1 diabetes mellitus. Which patient observation indicates that medication teaching has been effective? 1) Uses a 1 mL syringe to measure insulin dose 2) Places a new injection an inch away from previous injection site 3) Inserts the needle at a 25-degree angle prior to injecting the medication Bi.n aCl OinMjection in the morning 4) Provides an injection in the thigN h U a fR te S r aIn NabGdT om 14. Which statement best describes the pathophysiology of type 2 diabetes mellitus? 1) An absolute lack of insulin is present 2) The cells resist glucose from entering 3) Pancreatic cells stop producing insulin 4) An autoimmune disorder damages pancreatic cells 15. A patient with type 2 diabetes mellitus is prescribed a glucagon-like peptide-1 agonist. What clinical symptom should the nurse instruct the patient to expect when taking this medication? 1) Nausea 2) Diarrhea 3) Dry mouth 4) Decreased appetite 16. A patient is newly diagnosed with type 2 diabetes mellitus. Which medication classification should the nurse expect to be prescribed for this patient? 1) Biguanides 2) Meglitinides 3) Sulfonylureas 4) Thiazolidinediones 17. A patient with type 1 diabetes mellitus is preparing to play tennis. What should be done first before engaging in this physical activity? 1) Drink 1 liter of fluid 2) Measure blood glucose level
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3) Eat one serving of carbohydrate 4) Take a dose of prescribed medication 18. A patient with type 2 diabetes mellitus is being evaluated for hyperosmolar hyperglycemic state (HHS). Which finding would be consistent with this medical diagnosis? 1) pH 7.31 2) Abdominal pain 3) Blood glucose 250 mg/dL 4) Serum bicarbonate 28 mEq/L 19. The nurse suspects that a patient with type 2 diabetes mellitus is experiencing autonomic neuropathy. What did the nurse assess to make this clinical determination? 1) Bloating 2) Foot pain 3) Tingling of the fingers 4) Numbness of the lower legs 20. During a home visit the nurse is concerned that a patient with type 2 diabetes mellitus would benefit from additional teaching. What did the nurse observe to make this clinical decision? 1) Exercising with a treadmill 2) Walking barefoot in the back yard 3) Eating one-half apple and cheese for a snack 4) Stated a weight loss of 2 lbs. over the last month 21. The nurse is caring for a patient with type 2 diabetes mellitus. Why should the nurse assess capillary refill in this patient? 1) Evaluate for diabetic neuropathy NURSINGTB.COM 2) Determine if foot care is being done 3) Estimate current blood glucose level 4) Assess for microvascular complications 22. The nurse is evaluating care provided to a patient with type 2 diabetes mellitus. Which data indicates that the patient is managing the disease process effectively? 1) Hemoglobin A1c level 8.2% 2) Weight gain of 3 lbs. over the last 2 months 3) Reddened area noted on the sole of the left foot 4) Eye doctor appointment scheduled for the next week Multiple Response Identify one or more choices that best complete the statement or answer the question. 23. The nurse suspects that a patient has undiagnosed type 1 diabetes mellitus. What findings did the nurse use to make this clinical decision? Select all that apply. 1) Weight gain 2) Blurred vision 3) Extreme hunger 4) Excessive thirst 5) Voluminous urine output 24. A patient is having testing to diagnose type 1 diabetes mellitus. Which diagnostic tests might be prescribed for this patient? Select all that apply.
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1) 2) 3) 4) 5)
Hemoglobin A1c 2-hr postprandial Serum albumin level Fasting blood glucose Random blood glucose
25. A medication regimen is being planned for a patient newly diagnosed with type 1 diabetes mellitus. For which reasons should the nurse instruct the patient to self-administer doses of insulin? Select all that apply. 1) Basal 2) Prandial 3) Deficient 4) Excessive 5) Correctional 26. The nurse is concerned that a patient is at risk for developing type 2 diabetes mellitus. What assessment findings caused the nurse to have this concern? Select all that apply. 1) Central obesity 2) Sedentary lifestyle 3) Body mass index 29 4) Blood pressure 140/90 mm Hg 5) Fasting blood glucose 76 mg/dL 27. The nurse is reviewing data collected on a patient demonstrating signs of type 2 diabetes mellitus. Which additional findings strongly suggest that this patient has type 2 of this disorder? Select all that apply. 1) Fatigue 2) Muscle cramps 3) Visual disturbances NURSINGTB.COM 4) Poor wound healing 5) Recurrent infections Numeric Response 28. A patient with type 2 diabetes mellitus is prescribed 45 grams of carbohydrates for breakfast and 60 grams of carbohydrates for lunch and dinner. Additional 30 grams of carbohydrates are to be eaten as snacks. How many servings of carbohydrates is this patient to eat every day? Record your answer as a whole number.
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Chapter 44: Coordinating Care for Patients With Diabetes Mellitus Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Discussing the epidemiology of diabetes mellitus Chapter page reference: 914 Heading: Type 1 Diabetes Mellitus > Epidemiology Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Metabolism Difficulty: Easy 1 2 3 4
Feedback Type 1 diabetes can occur at any stage of life. Type 1 diabetes can develop in response to a virus infection; however, the nurse has no way of knowing why the patient developed the illness. Type 1 diabetes can occur at any stage of life. Type 1 diabetes does not mean that another disease process is present or occurring in the patient.
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PTS: 1 CON: Metabolism 2. ANS: 1 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Describing the pathophysiology of type 1 and type 2 diabetes mellitus Chapter page reference: 914 Heading: Type 1 Diabetes Mellitus > Pathophysiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Metabolism; Promoting Health Difficulty: Easy
1
2 3 4
Feedback Type 1 diabetes is typically triggered by an autoimmune process in which the insulinproducing beta cells of the pancreas are destroyed, resulting in an absolute lack of insulin. If part of the pancreas is removed for cancer, the patient can develop type 1 diabetes mellitus. Type 1 diabetes is not caused by an alteration in lipid and protein utilization. Type 1 diabetes is not caused by a malfunction in carbohydrate metabolism.
PTS: 1 3. ANS: 3
CON: Metabolism | Promoting Health
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Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Correlating clinical manifestations of type 1 and type 2 diabetes mellitus to the pathophysiology of each disorder Chapter page reference: 915 Heading: Type 1 Diabetes Mellitus > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 Hypercortisolism does not cause thirst, hunger, and weight loss. 2 Hyperaldosteronism does not cause thirst, hunger, and weight loss. 3 Despite an increased appetite leading to consumption of large amounts of food, the continual breakdown of fats and proteins leads to weight loss and fatigue. 4 Weight loss is not typically associated with type 2 diabetes mellitus. Extreme hunger may not be present with type 2 diabetes mellitus. PTS: 1 CON: Metabolism | Assessment 4. ANS: 2 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Describing the diagnostic studies used to diagnose and monitor diabetes mellitus Chapter page reference: 915 Heading: Type 1 Diabetes Mellitus > Medical Management > Diagnosis Integrated Processes: Teaching and Learning NURSINGTB.COM Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Metabolism Difficulty: Moderate Feedback 1 The test can be done at any time of the day. 2 The test can be done at any time of the day. 3 The test does not require fasting. 4 Eating does not affect the result. PTS: 1 CON: Metabolism 5. ANS: 2 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Describing the diagnostic studies used to diagnose and monitor diabetes mellitus Chapter page reference: 916 Heading: Type 1 Diabetes Mellitus > Medical Management > Pharmacological Interventions Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate
1
Feedback A hemoglobin A1c level greater than or equal to 8% indicates poor glycemic control.
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2 3 4
A hemoglobin A1c result less than or equal to 6.5% indicates good glycemic control. Hemoglobin A1c is not reported in mg/dL. The value of being less than 110 mg/dL is the ideal fasting blood glucose level. Hemoglobin A1c is not reported in mg/dL. The value of less than 140 mg/dL would be ideal for the 2-hour postprandial test.
PTS: 1 CON: Metabolism 6. ANS: 1 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Comparing indications, administration, actions, and nursing considerations for insulin and oral hypoglycemic agents Chapter page reference: 917 Heading: Type 1 Diabetes Mellitus > Medical Management > Treatment Plans Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Metabolism; Medication Difficulty: Moderate Feedback 1 The patient should choose the insulin syringe size according to the insulin dosage. Using the U-30 syringe allows a more accurate measurement of insulin to be administered. 2 The patient should choose the insulin syringe size according to the insulin dosage. This syringe could be used if the U-30 syringe is not available. 3 The patient should choose the NinUsuRliS nI syNriG n gTe Bsi.zeCaOccMo rd in g to the insulin dosage. This syringe might be difficult to correctly measure 5 units of insulin since 1 mL of medication is equal to 100 units of insulin. 4 The patient should choose the insulin syringe size according to the insulin dosage. A U500 syringe should only be used for insulin doses. PTS: 1 CON: Metabolism | Medication 7. ANS: 3 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Comparing indications, administration, actions, and nursing considerations for insulin and oral hypoglycemic agents Chapter page reference: 919 Heading: Type 1 Diabetes Mellitus > Medical Management > Self–Blood Glucose Monitoring Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Metabolism Difficulty: Moderate
1 2 3
Feedback One measurement would not be sufficient to achieve tight glycemic control. Three measurements would not provide a total picture of glycemic control. Generally, patients with type 1 DM are advised to check their blood glucose a minimum of before meals and at bedtime or 4 times a day.
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4
Eight measurements might be needed if another health problem affecting blood glucose levels is occurring with the patient.
PTS: 1 CON: Metabolism 8. ANS: 2 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Explaining complications associated with type 1 and type 2 diabetes mellitus Chapter page reference: 920 Heading: Type 1 Diabetes Mellitus > Medical Management > Complications Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate
1 2 3 4
Feedback The heart rate would be rapid because of dehydration. The patient develops Kussmaul’s respirations, which are rapid, deep respirations that occur as a compensatory mechanism for the acidosis. The urine output would be increased because of osmotic diuresis. The blood pressure would be low because of dehydration.
PTS: 1 CON: Metabolism 9. ANS: 4 Chapter number and title: 44, CoordiN n aUtinRgSCIaN reGfoTrBP. a tC ie nOtsM With Diabetes Mellitu s Chapter learning objective: Explaining complications associated with type 1 and type 2 diabetes mellitus Chapter page reference: 921 Heading: Type 1 Diabetes Mellitus > Medical Management > Safety Alert Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Metabolism; Medication Difficulty: Moderate 1 2 3 4
Feedback The patient will not need a diuretic because of osmotic diuresis occurring with the DKA. A laxative will not be needed. The patient will have abdominal pain; however, a laxative is not indicated. Antibiotics are not routinely prescribed in the treatment of DKA. Care must be taken to monitor potassium levels prior to treating the hyperglycemia with insulin. As insulin is administered to decrease hyperglycemia, potassium will also move back into the cell, worsening hypokalemia. If hypokalemia is present, potassium replacement is a priority.
PTS: 1 CON: Metabolism | Medication 10. ANS: 1 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Explaining complications associated with type 1 and type 2 diabetes mellitus
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Chapter page reference: 922 Heading: Type 1 Diabetes Mellitus > Medical Management > Complications > Hypoglycemia Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Metabolism Difficulty: Moderate Feedback 1 Individuals with hypoglycemia unawareness should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks to partially reverse hypoglycemia unawareness and reduce risk of further episodes. 2 Cutting the insulin dose will not reverse hypoglycemia unawareness. 3 Adding an extra snack to the meal plan will not reverse hypoglycemia unawareness. 4 Eliminating a dose of insulin will not reverse hypoglycemia unawareness. PTS: 1 CON: Metabolism 11. ANS: 3 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Correlating rationales for nursing interventions to the underlying pathophysiological processes Chapter page reference: 922 Heading: Type 1 Diabetes Mellitus > Medical Management > Complications > Dawn Phenomenon and Somogyi Effect Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [ApplyiN ngU] RSINGTB.CO Concept: Metabolism Difficulty: Moderate Feedback 1 Checking urine for glucose will not help determine the reason for elevated blood glucose levels in the morning. 2 Restricting oral fluids after 1800 hours will not help determine the reason for elevated blood glucose levels in the morning. 3 In order to determine what is causing the increased blood glucose levels in the morning, the patient needs to check blood glucose levels in the early morning hours, 2 or 3 a.m., for several nights. 4 Limiting carbohydrate intake to 45 grams with the evening meal will not help determine the reason for elevated blood glucose levels in the morning. PTS: 1 CON: Metabolism 12. ANS: 4 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations based upon the disease process Chapter page reference: 923 Heading: Type 1 Diabetes Mellitus > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying]
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Concept: Metabolism; Medication Difficulty: Moderate Feedback 1 Holding prandial doses would not be appropriate. 2 Increasing longer-acting insulin could cause early morning hypoglycemia. 3 Increasing the frequency of correctional doses would not be appropriate since the patient has poor oral intake. 4 In patients with questionable or minimal oral intake, prandial and correctional insulins may be administered together after meals after adequate carbohydrate intake has been confirmed. PTS: 1 CON: Metabolism | Medication 13. ANS: 2 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Teaching self-care strategies to patients in relation to management of diabetes mellitus and pharmacological management Chapter page reference: 923 Heading: Type 1 Diabetes Mellitus > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Metabolism; Medication Difficulty: Moderate
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Insulin syringes should be used to measure insulin doses. Rotating sites within one area rather than moving from area to area helps decrease absorption variability from day to day. This can be done by injecting a new shot at least an inch away from the last injection site. The needle should be injected at a 90-degree angle. A 45-degree angle can be used if the patient is very thin. Rotating sites does help reduce lipohypertrophy; however, absorption will be variable between injections if another body part and not a similar area is used.
PTS: 1 CON: Metabolism | Medication 14. ANS: 2 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Describing the pathophysiology of type 1 and type 2 diabetes mellitus Chapter page reference: 925 Heading: Type 2 Diabetes Mellitus > Pathophysiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Metabolism Difficulty: Moderate Feedback 1 An absolute lack of insulin describes type 1 diabetes mellitus.
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Type 2 diabetes mellitus involves defects at the cell membrane that prevent the normal action of insulin. Even though insulin is present, the cell “resists” its effect in transporting glucose into the cell. Pancreatic cells stop producing insulin in type 1 diabetes mellitus. Type 1 diabetes mellitus is considered an autoimmune disorder that damages pancreatic cells.
PTS: 1 CON: Metabolism 15. ANS: 4 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Comparing indications, administration, actions, and nursing considerations for insulin and oral hypoglycemic agents Chapter page reference: 927 Heading: Type 2 Diabetes Mellitus > Medical Management > Treatment Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Metabolism; Medication Difficulty: Moderate Feedback 1 Nausea is not identified as an adverse effect of this medication. 2 Diarrhea is not identified as an adverse effect of this medication. 3 A dry mouth is not identified as an adverse effect of this medication. 4 Glucagon-like peptide-1 agonists are injected subcutaneously twice a day, an hour before breakfast and an hour bNefUo re RSd inIne N Gr. TTBhe.y CloOwMer glucose levels by slowing glucose absorption from the intestine, increasing insulin secretion when blood glucose levels are high and lowering high glucagon levels sometimes found in diabetics after meals. A side benefit of GLP-1 agonists is the action of decreasing appetite by attaching to an appetite receptor on the hypothalamus, ultimately helping with weight loss. PTS: 1 CON: Metabolism | Medication 16. ANS: 1 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Comparing indications, administration, actions, and nursing considerations for insulin and oral hypoglycemic agents Chapter page reference: 926 Heading: Type 2 Diabetes Mellitus > Medical Management > Treatment Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Metabolism; Medication Difficulty: Moderate Feedback 1 Intervention at the time of diagnosis with metformin (glyburide) in combination with lifestyle changes such as diet and exercise is common. Metformin is a biguanide. 2 Meglitinides are not identified as being prescribed first upon diagnosis. 3 Sulfonylureas are not identified as being prescribed first upon diagnosis. 4 Thiazolidinediones are not identified as being prescribed first upon diagnosis.
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PTS: 1 CON: Metabolism | Medication 17. ANS: 2 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations based upon the disease process Chapter page reference: 929 Heading: Type 2 Diabetes Mellitus > Medical Management > Physical Activity Recommendations Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Metabolism Difficulty: Moderate 1 2
3 4
Feedback Although adequate hydration is important, it is not required for this patient. In individuals taking insulin, physical activity can cause hypoglycemia if medication dose or carbohydrate intake is not adjusted. Carbohydrate should be ingested if preexercise blood glucose levels are less than 100 mg/dL. The blood glucose needs to be measured before ingesting a carbohydrate. A carbohydrate should be ingested only if the blood glucose level is less than 100 mg/dL. An additional dose of medication could cause hypoglycemia and should not be done.
PTS: 1 CON: Metabolis m NU RSINGTB.COM 18. ANS: 4 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Explaining complications associated with type 1 and type 2 diabetes mellitus Chapter page reference: 930 Heading: Type 2 Diabetes Mellitus > Medical Management > Complications Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 A low pH is associated with diabetic ketoacidosis (DKA). 2 Abdominal pain is associated with DKA. 3 Blood glucose level around 250 mg/dL is associated with DKA. 4 An elevated serum bicarbonate level is associated with HHS. PTS: 1 CON: Metabolism | Assessment 19. ANS: 1 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Explaining complications associated with type 1 and type 2 diabetes mellitus Chapter page reference: 931 Heading: Type 2 Diabetes Mellitus > Medical Management > Complications Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential
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Cognitive level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 Autonomic neuropathy results when there is damage to the nerves of the autonomic nervous system. Common manifestations include diabetic gastroparesis, which results when the nerves that enervate the stomach are damaged, leading to delayed or erratic emptying of stomach contents into the intestine. Clinical manifestations include symptoms such as bloating. 2 Diabetic peripheral neuropathy results when the nerves to the feet and hands are damaged. Clinical manifestations include pain. 3 Diabetic peripheral neuropathy results when the nerves to the feet and hands are damaged. Clinical manifestations include tingling. 4 Diabetic peripheral neuropathy results when the nerves to the feet and hands are damaged. Clinical manifestations include numbness. PTS: 1 CON: Metabolism | Assessment 20. ANS: 2 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Teaching self-care strategies to patients in relation to management of diabetes mellitus and pharmacological management Chapter page reference: 932 Heading: Type 2 Diabetes Mellitus > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [AnalyzingN ] URSINGTB.CO Concept: Metabolism Difficulty: Moderate Feedback 1 Exercise would be encouraged. 2 The patient with type 2 diabetes mellitus should never walk barefoot. 3 The snack of apple and cheese would be balanced and appropriate for this patient. 4 A weight loss of 2 lbs. in one month would be appropriate for this patient. PTS: 1 CON: Metabolism 21. ANS: 4 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Correlating rationales for nursing interventions to the underlying pathophysiological processes Chapter page reference: 931 Heading: Type 2 Diabetes Mellitus > Nursing Management > Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 Capillary refill is not assessed to evaluate for diabetic neuropathy. 2 Capillary refill is not done to determine if foot care is being done.
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Capillary refill will not estimate the patient’s current blood glucose level. Decreased perfusion secondary to microvascular changes may manifest as delayed capillary refill.
PTS: 1 CON: Metabolism | Assessment 22. ANS: 4 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Teaching self-care strategies to patients in relation to management of diabetes mellitus and pharmacological management Chapter page reference: 932 Heading: Type 2 Diabetes Mellitus > Nursing Management > Evaluating Care Outcomes Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate Feedback 1 A hemoglobin A1c level of 8.2% indicates blood glucose levels have been elevated over the previous 6 to 8 weeks. This is not effectively managing the disease process. 2 A weight gain of 3 lbs. does not indicate effective management of the disease process. 3 A reddened area on the foot indicates that foot care is not being done. This is not effective management of the disease process. 4 Taking action to detect and prevent complications by seeing an eye doctor indicates effective management of the disease process.
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CON: Metabolism | Assessment
MULTIPLE RESPONSE 23. ANS: 3, 4, 5 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Correlating clinical manifestations of type 1 and type 2 diabetes mellitus to the pathophysiology of each disorder Chapter page reference: 915 Heading: Type 1 Diabetes Mellitus > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Weight gain is not a manifestation of type 1 diabetes mellitus. Blurred vision can occur when blood glucose levels are too low or too high; however, this is not used to diagnose type 1 diabetes mellitus. Extreme hunger or polyphagia is a manifestation of type 1 diabetes mellitus. Excessive thirst or polydipsia is a manifestation of type 1 diabetes mellitus. Voluminous urine output or polyuria is a manifestation of type 1 diabetes mellitus.
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PTS: 1 CON: Metabolism | Assessment 24. ANS: 1, 2, 4, 5 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Describing the diagnostic studies used to diagnose and monitor diabetes mellitus Chapter page reference: 915 Heading: Type 1 Diabetes Mellitus > Medical Management > Diagnosis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Metabolism; Assessment Difficulty: Easy
1. 2.
3. 4.
5.
Feedback The hemoglobin A1c gives an accurate indication of long-term, time-averaged glucose levels over the 6 to 8 weeks prior to the HgbA1c blood draw. 2-hr postprandial (after meals) or the oral glucose tolerance test measures blood glucose levels 1 and 2 hours after consuming a high-glucose beverage. The diagnostic value is based on the blood glucose level 2 hours after consumption. Serum albumin level measures protein in the body. It is not used to help diagnose type 1 diabetes mellitus. Fasting blood glucose measures the glucose level after no caloric intake for at least 8 hours. Normally, insulin is released, moving that glucose into the cells, preventing hyperglycemia. Without adequate insulin, hyperglycemia results. A random blood glucose level of greater than or equal to 200 mg/dL in a patient with classic symptoms of hyperglyceNmUiaRoSr I hyNpG erT glB yc.e C miOc M crisis may be indicative of diabetes mellitu s.
PTS: 1 CON: Metabolism | Assessment 25. ANS: 1, 2, 5 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Comparing indications, administration, actions, and nursing considerations for insulin and oral hypoglycemic agents Chapter page reference: 917 Heading: Type 1 Diabetes Mellitus > Medical Management > Treatment Plans Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Metabolism; Medication Difficulty: Moderate
1. 2. 3. 4. 5. PTS: 1
Feedback An approach using a combination of long- or intermediate-acting insulin once or twice a day to provide basal insulin is most effective in maintaining tight glycemic control. Insulin at mealtimes to cover the intake of carbohydrates is considered prandial insulin. Deficient is not a type of insulin coverage. Excessive is not a type of insulin coverage. Correctional insulin is used to compensate for blood glucose elevations. CON: Metabolism | Medication
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26. ANS: 1, 2, 3, 4 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Discussing the epidemiology of diabetes mellitus Chapter page reference: 925 Heading: Type 2 Diabetes Mellitus > Epidemiology > Risk Factors Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback A manifestation of metabolic syndrome is central obesity, which increases the risk of developing type 2 diabetes mellitus. A sedentary lifestyle increases the risk of developing type 2 diabetes mellitus. A body mass index over 26 increases the risk of developing type 2 diabetes mellitus. Elevated blood pressure increases the risk of developing type 2 diabetes mellitus. A fasting blood glucose below 100 mg/dL does not increase the risk of developing type 2 diabetes mellitus.
PTS: 1 CON: Metabolism | Assessment 27. ANS: 1, 3, 4, 5 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Correlating clinical manifestations of type 1 and type 2 diabetes mellitus to the pathophysiology of each disorder NURSINGTB.COM Chapter page reference: 925 Heading: Type 2 Diabetes Mellitus > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Metabolism; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback In addition to the 3 “Ps” of type 1 diabetes, polyuria, polydipsia, polyphagia, other common clinical manifestations include fatigue. Muscle cramps are not identified as a manifestation of type 2 diabetes mellitus. In addition to the 3 “Ps” of type 1 diabetes, polyuria, polydipsia, polyphagia, other common clinical manifestations include visual disturbances. In addition to the 3 “Ps” of type 1 diabetes, polyuria, polydipsia, polyphagia, other common clinical manifestations include poor wound healing. In addition to the 3 “Ps” of type 1 diabetes, polyuria, polydipsia, polyphagia, other common clinical manifestations include recurrent infections.
PTS: 1
CON: Metabolism | Assessment
NUMERIC RESPONSE
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28. ANS: 13 Chapter number and title: 44, Coordinating Care for Patients With Diabetes Mellitus Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations based upon the disease process Chapter page reference: 928 Heading: Type 2 Diabetes Mellitus > Medical Management > Carbohydrate Guidelines Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Basic Care and Comfort Cognitive level: Application [Applying] Concept: Metabolism Difficulty: Easy Feedback: To determine the number of carbohydrate servings, first add up the total number of carbohydrate grams to eat each day and then divide by 15. For this patient this calculation would be 45 + 60 + 60 + 30 = 195; 195/15 = 13. The patient should consume 13 servings of carbohydrates per day. PTS: 1
CON: Metabolism
Chapter 45: Assessment of Visual Function Multiple Choice Identify the choice that best completes the statement or answers the question.
NUR S INGT B. C O M
1. The school nurse is reviewing the structu re s of the e ye w it h a group of middle school students. Which structure should the nurse emphasize as the first line of defense against eye infections? 1) Iris 2) Fovea 3) Cornea 4) Conjunctivae 2. A patient notices a change in the ability to focus the eyes. Which structure should the nurse suspect is causing this change? 1) Lens 2) Macula 3) Optic disk 4) Optic nerve 3. A patient is diagnosed with amblyopia. On which eye structure should the nurse focus when explaining this health problem to the patient? 1) Pupil 2) Retina 3) Sclera 4) Orbital muscles 4. An older patient reports a vision change of seeing dark spots. Which structure is causing this patient’s health concern? 1) Sclera 2) Macula
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3) Vitreous humor 4) Retinal blood vessels 5. During morning care the nurse cleanses a patient’s eyes. Which structure will cause the eyes to blink? 1) Eyelids 2) Eyelashes 3) Lacrimal sacs 4) Lacrimal glands 6. The nurse determines that a patient’s rods are functioning as expected. What color did the patient see that caused the nurse to come to this conclusion? 1) Red 2) Blue 3) Gray 4) Green 7. The nurse notes that a patient has difficulty seeing objects that are near. Which term should the nurse use when documenting this finding? 1) Myopia 2) Hyperopia 3) Emmetropia 4) Astigmatism 8. A patient’s eyes are dilated. Which term should the nurse use to document this finding? 1) Miosis 2) Myopia 3) Mydriasis NURSINGTB.COM 4) Hyperopia 9. The nurse is preparing to assess a patient’s near vision. Which tool should the nurse use for this assessment? 1) Jaegar card 2) Snellen chart 3) Ishihara chart 4) Confrontation test 10. The nurse notes that a patient’s left pupil constricts when the right pupil is exposed to a bright light. What response did the nurse observe? 1) Ocular movements 2) Corneal light reflex 3) Pupillary light reflex 4) Consensual light reflex 11. During an ophthalmologic examination a patient’s red reflex was absent from the left eye. What risk is increased in the patient because of this finding? 1) Injury 2) Impaired comfort 3) Ineffective coping 4) Ineffective protection 12. A patient is demonstrating manifestations of a detached retina. For which diagnostic test should the nurse prepare this patient? 1) MRI
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2) CT scan 3) Ultrasound 4) Radioisotope scan 13. A patient with eye pain is scheduled for slit-lamp testing. What should the nurse instruct the patient to do before this test? 1) Remove contact lenses before the test 2) Take nothing by mouth for four hours before the test 3) Take an over-the-counter analgesic before the test 4) Restrict intake to less than two cups of fluid before the test 14. A patient is scheduled for intraocular pressure testing. What teaching should the nurse provide the patient about this test? 1) Eye shields will need to be worn after the test 2) Avoid consuming alcohol for 12 hours before the test 3) Eye drops will be needed for several hours after the test 4) Take nothing by mouth after midnight the morning of the test 15. A patient is being prepared for corneal staining. Which health problem is this patient most likely experiencing? 1) Cataracts 2) Glaucoma 3) Detached retina 4) Corneal abrasions 16. The nurse is preparing a patient for fluorescein angiography. What should the nurse emphasize about care at home after the test? NURSINGTB.COM 1) Increase oral intake of water after the test 2) Avoid lifting and sneezing for three days after the test 3) Remind that the skin may be yellow for a week after the test 4) Teach to notify the health-care provider if the urine turns green after the test 17. A patient asks why sunglasses need to be worn when out of doors. What health problem should the nurse say is reduced when responding to this patient? 1) Cataracts 2) Glaucoma 3) Detached retina 4) Corneal abrasions 18. A 57-year-old patient asks how frequent eye examinations should be completed. What should the nurse respond to this patient? 1) “It depends upon your age and health status.” 2) “Everyone should have an eye exam every year.” 3) “Most people need an examination every five years.” 4) “If you have a chronic illness, an exam is needed every six months.” 19. A middle-aged adult is concerned about needing reading glasses. On which eye structure should the nurse focus when explaining this age-related change to the patient? 1) Lens 2) Pupil 3) Retina 4) Vitreous humor
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20. An older patient is concerned because the eyes are dry and feel gritty. What should the nurse respond to this patient’s concern? 1) “This is because the eyelids lose elasticity with aging.” 2) “This is because the arteries in the eyes narrow with aging.” 3) “This is an emergency and needs to be treated immediately.” 4) “This is because the tear glands and conjunctiva don’t lubricate the eye as well with aging.” Multiple Response Identify one or more choices that best complete the statement or answer the question. 21. A sharp object that was impaled into a patient’s right eye has punctured the uvea. Which eye structures are at risk because of this injury? Select all that apply. 1) Iris 2) Sclera 3) Retina 4) Choroid 5) Ciliary body 22. The nurse is preparing a tool to teach preoperative patients about the eye. What should the nurse include about the functions of the ciliary body? Select all that apply. 1) Maintains lens zonules 2) Produces aqueous humor 3) Allows for accommodation 4) Supplies blood to the retina NURSINGTB.COM 5) Changes the shape of the lens 23. The nurse is assessing a patient’s eye function. On which cranial nerves should the nurse focus during this assessment? Select all that apply. 1) CN II 2) CN III 3) CN IV 4) CN V 5) CN VI 24. The nurse is preparing to assess a patient’s eyes. Which eye functions are responsible for maintaining clear images of objects? Select all that apply. 1) Myopia 2) Refraction 3) Convergence 4) Pupillary constriction 5) Accommodation Completion Complete each statement. 25. The nurse is reviewing the mechanism of vision with a group of patients planning to have LASIK surgery. In which order should the nurse explain this process? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234)
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1) Light hits the lens 2) Light enters the pupil 3) Lens focuses light rays on retina 4) Ciliary muscles change lens shape 5) Retina changes light to nerve signals
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Chapter 45: Assessment of Visual Function Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Identifying key anatomical components of the visual system Chapter page reference: 937 Heading: Overview of Anatomy and Physiology > Internal Structures Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Sensory Perception; Promoting Health Difficulty: Moderate 1
2 3 4
Feedback The iris, or the colored portion of the eye, is actually a ring of muscle fibers located behind the cornea and in front of the lens. The iris contracts and expands, opening and closing the pupil in response to the amount of light present, thus helping to protect the sensitive retina. The fovea is the central part of the macula that provides the sharpest vision. The cornea is the transparent dome that sits on top of the iris. The fovea contains no RoSstIpNowGeTrfBul.lC blood vessels and is the first aN n dUm e nO s M in the optical system of the eye. Conjunctivae function to lubricate the front portion of the eye as well as the eyelids. This clear thin membrane is the first line of protection for the eye against infection.
PTS: 1 CON: Sensory Perception | Promoting Health 2. ANS: 1 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Identifying key anatomical components of the visual system Chapter page reference: 937 Heading: Overview of Anatomy and Physiology > Internal Structures Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Easy
1 2 3 4
Feedback The lens are responsible for keeping images in focus on the retina. The macula is the most sensitive part of the retina and provides vision for fine work and reading. The optic disk is the spot on the retina where the optic nerve leaves the eye. The optic nerve carries visual signals from the eye to the brain.
PTS: 1
CON: Sensory Perception
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3. ANS: 4 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Identifying key anatomical components of the visual system Chapter page reference: 937 Heading: Overview of Anatomy and Physiology > Internal Structures Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Sensory Perception; Promoting Health Difficulty: Easy
1 2 3 4
Feedback The pupil is the hole in the center of the iris that allows light to pass. Muscles in the iris control the size of the pupil. The retina is the portion of the eye that converts light rays into electrical signals and then sends them to the brain via the optic nerve. The sclera is the white tough covering that functions as the outer layer of the eyeball. The orbital muscles include the six muscles that control eye movements. Weakness or dysfunction of these muscles can lead to amblyopia or a lazy eye.
PTS: 1 CON: Sensory Perception | Promoting Health 4. ANS: 3 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Discussing changes in visual function associated with aging Chapter page reference: 937 NURSINGTB.COM Heading: Overview of Anatomy and Physiology > Internal Structures Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Sensory Perception; Assessment Difficulty: Easy 1
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Feedback The sclera is the white tough covering that functions as the outer layer of the eyeball. The sclera is also covered by a clear mucous membrane consisting of cells and an underlying basement membrane of conjunctival tissue. Tiny red lines (blood vessels) are often visible; these blood vessels transport blood to the sclera. Discoloration of the sclera can provide clues to the patient’s current health status. The center area of the retina is called the macula. Vitreous humor is the clear, jellylike fluid found in the back portion of the eye that helps maintain the shape of the eye. With age, the vitreous humor changes from a geltype substance to a liquid and gradually shrinks, separating from the retina. This normal sign of aging can cause people to start seeing “floaters” and dark spots in their vision. Retinal blood vessels provide nourishment and oxygen to the eye. Abnormalities in these vessels can lead to vision loss in conditions such as diabetic neuropathy and macular degeneration.
PTS: 1 5. ANS: 2
CON: Sensory Perception | Assessment
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Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Identifying key anatomical components of the visual system Chapter page reference: 938 Heading: Overview of Anatomy and Physiology > External Structures Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Easy 1
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Feedback Eyelids function to protect and lubricate the eyes. Oil-producing glands line the inner edge of the eyelid; these oils mix with tears upon blinking, keeping the eyes moist and clean. Touching the eyelashes triggers the eyelids to blink. Lacrimal sacs are the channels that drain tears and other debris from the eye. Lacrimal glands function to lubricate and prevent dehydration of the cornea.
PTS: 1 CON: Sensory Perception 6. ANS: 3 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Discussing the function of the visual system Chapter page reference: 938 Heading: Overview of Visual Function Integrated Processes: Nursing Process: Assessment NaUinRteSnaInNceGTB.COM Client Need: Health Promotion and M Cognitive level: Comprehension [Understanding] Concept: Sensory Perception; Assessment Difficulty: Easy Feedback 1 Red is a type of cone that allows for color vision. 2 Blue is a type of cone that allows for color vision. 3 Rods allow differentiation between black, white, and gray. 4 Green is a type of cone that allows for color vision. PTS: 1 CON: Sensory Perception | Assessment 7. ANS: 2 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Discussing the function of the visual system Chapter page reference: 938 Heading: Overview of Visual Function Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Comprehension [Understanding] Concept: Sensory Perception; Assessment; Communication Difficulty: Easy
1
Feedback Myopia is difficulty seeing objects that are far away.
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2 3 4
Hyperopia is difficulty seeing objects that are near. Emmetropia is the term for perfect vision. Astigmatism results from a misshaped cornea. Patients with astigmatism have difficulty seeing fine details either close up or from a distance.
PTS: 1 CON: Sensory Perception | Assessment | Communication 8. ANS: 3 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Discussing the function of the visual system Chapter page reference: 938 Heading: Overview of Visual Function Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Comprehension [Understanding] Concept: Sensory Perception; Assessment; Communication Difficulty: Easy Feedback 1 Miosis is constriction of the pupil. 2 Myopia is difficulty seeing objects that are far away. 3 Mydriasis is dilation of the pupil. 4 Hyperopia is difficulty seeing objects that are near. PTS: 1 CON: Sensory Perception | Assessment | Communication 9. ANS: 1 Chapter number and title: 45, Assessm NeUnRt oSfIVNisGuaTl BFu.nCctOioMn Chapter learning objective: Describing the procedure for completing a history and physical assessment of visual function Chapter page reference: 941 Heading: Assessment > Vision Testing Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Sensory Perception; Assessment Difficulty: Easy 1 2 3 4
Feedback The Rosenbaum Pocket Vision Screener or Jaeger card assesses for near vision. The Snellen Chart is used to evaluate distance vision. An Ishihara Chart is used to assess color vision. The confrontation test determines the degree of peripheral vision.
PTS: 1 CON: Sensory Perception | Assessment 10. ANS: 4 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of visual function Chapter page reference: 943 Heading: Assessment > Vision Testing Integrated Processes: Nursing Process: Assessment
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Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Sensory Perception; Assessment Difficulty: Easy
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Feedback Assessment of the six ocular movements is done to check eye alignment and coordination. The patient is asked to follow the movement of a penlight with the eyes only. The corneal light reflex provides information about the alignment of the eyes. When there are no alignment problems with the eyes, the light reflex is in approximately the same position in both pupils. Pupillary light reflex is the normal, expected constriction of the pupil observed when exposed to bright light. A consensual light reflex is the simultaneous constriction of the other pupil when one is exposed to bright light.
PTS: 1 CON: Sensory Perception | Assessment 11. ANS: 1 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to the visual system Chapter page reference: 943 Heading: Assessment > Diagnostic Studies Integrated Processes: Nursing Process: Analysis NeGntT/SBa. Client Need: Safe and Effective CareNEUnvRirSoI nm feC tyOanMd Infection Control Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Assessment; Safety Difficulty: Difficult
1 2 3 4
Feedback Absence of the red reflex could indicate opacity of the lens or cloudiness of the vitreous. This will affect the patient’s vision, which increases the risk for injury. There is no evidence to support that the absence of the red reflex could increase the patient’s risk for comfort. There is no evidence to support that the absence of the red reflex could increase the patient’s risk for impaired coping. There is no evidence to support that the absence of the red reflex could increase the patient’s risk for ineffective protection.
PTS: 1 CON: Sensory Perception | Assessment | Safety 12. ANS: 3 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Correlating relevant diagnostic examinations to visual function Chapter page reference: 944 Heading: Assessment > Diagnostic Studies Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying]
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Concept: Sensory Perception Difficulty: Moderate
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Feedback An MRI scan is used most frequently to discover tumors, infection, chronic disease, fractures, changes in the optic nerve, and enlarged eye muscles. Computerized Tomography (CT) scans may be ordered to help diagnose diseases of the eye in the following areas: blood vessels, eye muscles, optic nerve, presence of abscess in or around the eye, fractures of the eye socket, and presence of a foreign body in the eye or the eye socket. An ultrasound is commonly prescribed to diagnose a detached retina. Radioisotope scanning is often done to identify tumors and ocular melanomas that are difficult to visualize in some of the less-invasive testing modalities.
PTS: 1 CON: Sensory Perception 13. ANS: 1 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Correlating relevant diagnostic examinations to visual function Chapter page reference: 944 Heading: Assessment > Diagnostic Studies Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate
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Feedback The patient is required to remove contact lenses prior to the start of the examination. The patient does not need to be NPO before the test. Over-the-counter pain medication does not need to be taken before this test. A fluid restriction is not required before this test.
PTS: 1 CON: Sensory Perception 14. ANS: 2 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Correlating relevant diagnostic examinations to visual function Chapter page reference: 944 Heading: Assessment > Diagnostic Studies Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate
1 2 3
Feedback Eye shields do not need to be worn after this test. The patient should be instructed that the test is most accurate when no alcoholic beverages are consumed for at least 12 hours prior to the test. Eye drops will not be needed after this test.
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The test is most accurate when no more than two cups of liquid are consumed four hours before the test. NPO after midnight is not necessary.
PTS: 1 CON: Sensory Perception 15. ANS: 4 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Correlating relevant diagnostic examinations to visual function Chapter page reference: 944 Heading: Assessment > Diagnostic Studies Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception Difficulty: Moderate
1 2 3 4
Feedback Corneal staining is not used to diagnose cataracts. Corneal staining is not used to diagnose glaucoma. Corneal staining is not used to diagnose a detached retina. Corneal staining is performed to detect scratches or abrasions on the cornea.
PTS: 1 CON: Sensory Perception 16. ANS: 1 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: ExplaininNgUnR u rSsiI n gNcGo nTsB id. e rC a tO ioM n s for diagnostic studies relevant to the visual system Chapter page reference: 945 Heading: Assessment > Diagnostic Studies Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate
1 2 3 4
Feedback Instructions to increase intake of water after the test is important to help flush the infused dye out the body. There are no restrictions on activity or sneezing after the test. The patient may have slightly yellow skin for a few hours after the test. The patient may have green-colored urine after the test caused by excretion of the dye. The health-care provider does not need to be notified if this occurs.
PTS: 1 CON: Sensory Perception 17. ANS: 1 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Describing methods to prevent eye trauma and pathology Chapter page reference: 945 Heading: Eye Protection Integrated Processes: Teaching and Learning
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Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Promoting Health Difficulty: Moderate
1 2 3 4
Feedback Sunglasses are an important piece of equipment. It is now known that there is an association between excessive exposure to UV-B light and early formation of cataracts. Sunlight does not cause the development of glaucoma. Sunlight does not cause the development of a detached retina. Sunlight does not cause the development of corneal abrasions.
PTS: 1 CON: Sensory Perception | Promoting Health 18. ANS: 1 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Describing methods to prevent eye trauma and pathology Chapter page reference: 945 Heading: Eye Protection Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Promoting Health Difficulty: Moderate Feedback 1 Eye examinations are recommN enUdR edSaIt dNiffe G TreBnt. iCntOerMv als depending on the patient’s age and health status. 2 Eye exams are not needed by everyone every year. 3 It is not true that most people need an eye examination every five years. 4 For a chronic illness eye examinations are recommended annually. PTS: 1 CON: Sensory Perception | Promoting Health 19. ANS: 1 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Discussing changes in visual function associated with aging Chapter page reference: 946 Heading: Age-Related Changes Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Sensory Perception; Promoting Health Difficulty: Moderate Feedback 1 Loss of lens elasticity is another expected change in the eye that occurs around the age of 45. The loss of elasticity of the lens makes it harder for the lens to bend in order to focus on closely held objects. This loss of lens accommodation is known as presbyopia and makes “reading glasses” necessary for people in this age group and older. 2 The pupil becomes smaller and less reactive to light with aging; however, this has nothing to do with the need for reading glasses.
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Arteries and veins of the retina become narrower with age, thus reducing blood flow yielding a less responsive light reflex. However, this has nothing to do with the need for reading glasses. Deposits in the vitreous humor, often referred to as “floaters,” may become evident in advancing years; however, this has nothing to do with the need for reading glasses.
PTS: 1 CON: Sensory Perception | Promoting Health 20. ANS: 4 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Discussing changes in visual function associated with aging Chapter page reference: 946 Heading: Age-Related Changes Integrated Processes: Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Sensory Perception; Promoting Health Difficulty: Moderate
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Feedback The loss of eyelid elasticity causes ptosis, which may affect visual fields. It has nothing to do with dry eyes. Narrowing of the arteries in the eyes with aging affects the light reflex and has nothing to do with eye dryness. Dry eyes is not an emergency. There is no need for immediate treatment. Tear glands and conjunctiva mNayU lo Rse SIthNeGabTiBlit.y toCOefficien M t ly lubricate the eye and therefore produce “dry eye” with aging.
PTS: 1
CON: Sensory Perception | Promoting Health
MULTIPLE RESPONSE 21. ANS: 1, 4, 5 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Identifying key anatomical components of the visual system Chapter page reference: 936 Heading: Overview of Anatomy and Physiology > Internal Structures Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Easy
1. 2. 3. 4. 5.
Feedback The middle layer of the eye is the uvea and contains the iris. The sclera is the external layer of the eye. The retina is the innermost layer of the eye. The middle layer of the eye is the uvea and contains the choroid. The middle layer of the eye is the uvea and contains the ciliary body.
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PTS: 1 CON: Sensory Perception 22. ANS: 1, 2, 3 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Identifying key anatomical components of the visual system Chapter page reference: 937 Heading: Overview of Anatomy and Physiology > Internal Structures Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Perioperative Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Maintenance of lens zonules is a function of the ciliary body. Production of aqueous humor is a function of the ciliary body. Accommodation is a function of the ciliary body. The choroid supplies blood to the retina. The ciliary muscles change the shape of the lens.
PTS: 1 CON: Sensory Perception | Perioperative 23. ANS: 1, 2, 3, 5 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Identifying key anatomical components of the visual system Chapter page reference: 938 NURSINGTB.COM Heading: Overview of Anatomy and Physiology > Cranial Nerves Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Sensory Perception; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback CN II Optic transports visual information from the retina to the brain and is responsible for vision. CN III Oculomotor controls pupil constriction as well as eyelid and eyeball movement. CN IV Trochlear innervates the superior oblique muscles and allows eye movement in a downward and lateral motion. CN V Trigeminal does not play a role in eye function. CN VI Abducens controls lateral movement of the eye.
PTS: 1 CON: Sensory Perception | Assessment 24. ANS: 2, 3, 4, 5 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Discussing the function of the visual system Chapter page reference: 938 Heading: Overview of Vision Function Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance
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Cognitive level: Application [Applying] Concept: Sensory Perception; Assessment Difficulty: Moderate
1. 2. 3. 4. 5. PTS: 1
Feedback Myopia results from an eyeball that is too long or when the cornea has too much curve present. Refraction is a function of the eye that allows for clear images of objects. Convergence is a function of the eye that allows for clear images of objects. Pupillary constriction is a function of the eye that allows for clear images of objects. Accommodation is a function of the eye that allows for clear images of objects. CON: Sensory Perception | Assessment
COMPLETION 25. ANS: 21345 Chapter number and title: 45, Assessment of Visual Function Chapter learning objective: Discussing the function of the visual system Chapter page reference: 938 Heading: Overview of Vision Function Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [ApplyiN n gU] RSINGTB.COM Concept: Sensory Perception; Health Promotion Difficulty: Moderate Feedback: Vision is controlled by the interaction of light and nerve impulses transmitted to the nervous system. As light enters the pupil, it hits the lens. The lens then focuses light rays on the back of the eyeball that is known as the retina. The ciliary muscles attached to the lens change the shape of the lens depending on whether the focus is near or far away. The presence of light on the retina causes it to change the light into nerve signals for the brain to interpret. PTS: 1
CON: Sensory Perception | Health Promotion
Chapter 46: Coordinating Care for Patients With Visual Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. While reviewing collected data the nurse notes that a patient has been newly diagnosed with myopia. What information in the patient’s history might have contributed to this refractive error? 1) Has 3 children 2) Smokes 1 PPD of cigarettes 3) Raises homegrown tomatoes 4) Worked for 30 years as a tailor
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2. The nurse is planning care for a patient with an astigmatism. What action should the nurse take to reduce this patient’s headaches and blurred vision? 1) Encourage to wear corrective lenses while awake 2) Apply cool compresses to the eyes every four to six hours 3) Recommend removing corrective lenses every few hours 4) Instruct to gently massage out eye canthus several times a day 3. The nurse suspects that a patient has undiagnosed hyperopia. What did the nurse assess to come to this conclusion? 1) Squints, has headaches, and blurred vision 2) Sees distance objects better than those near 3) Sees near objects better than those at a distance 4) Unable to focus on objects held close to the face 4. A patient has watery eye discharge affecting both eyes. Which health problem should the nurse suspect this patient is experiencing? 1) Cataracts 2) Eye trauma 3) Conjunctivitis 4) Corneal abrasions 5. The nurse is evaluating teaching provided to a patient with bacterial conjunctivitis. Which patient statement indicates that additional teaching is required? 1) “I should place my towel in the bathroom.” 2) “I should wash my hands frequently during the day.” 3) “I should complete all of my prescribed medications.” 4) “I should make a follow-up app N o iU n tR mS e nIt N a sGdT ireBc . tedC.”O M 6. A patient is diagnosed with a corneal abrasion. Which diagnostic test was used to confirm this diagnosis? 1) MRI 2) CT scan 3) Ultrasound 4) Fluorescein stain 7. A patient seeks treatment for a corneal abrasion that occurred the previous week. What should the nurse expect to be prescribed to reduce this patient’s risk of developing a complication? 1) Tetanus vaccination 2) Topical steroid drops 3) Systemic pain medication 4) Topical antihistamine drops 8. The nurse suspects that a patient is developing a cataract. What finding did the nurse use to make this clinical decision? 1) Itching of both eyes 2) Tearing of both eyes 3) Redness of the sclera 4) Double vision in one eye 9. A patient contemplating cataract surgery asks if there are any risk factors. How should the nurse respond? 1) Blindness 2) Detached retina 3) Corneal abrasion
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4) Macular degeneration 10. The nurse is caring for a patient recovering from cataract removal surgery. Which action should the nurse take to reduce intraocular pressure (IOP)? 1) Restrict fluids 2) Position on the operative side 3) Administer mydriatic eye drops 4) Elevate the head of the bed 45 degrees 11. During a vision test, the nurse notes that a patient has decreased peripheral vision of both eyes. Which health problem should the nurse suspect that this patient is experiencing? 1) Secondary glaucoma 2) Acute angle glaucoma 3) Normal-tension glaucoma 4) Primary open-angle glaucoma 12. The nurse notes that a patient is diagnosed with primary open-angle glaucoma. What diagnostic test would have been used to diagnose this health problem? 1) MRI 2) CT scan 3) Tonometry 4) Ultrasound 13. The nurse is visiting the home of a patient recovering from laser trabeculoplasty. Which observation made by the nurse increases this patient’s risk of developing a postoperative complication? 1) Takes a daily laxative 2) Picks up a 3-year-old grandchild NURSINGTB.COM 3) Washes hands before applying eye drops 4) Applies pressure to the lacrimal duct after applying eye drops 14. The nurse is reviewing teaching provided to a patient with glaucoma. Which patient statement indicates that teaching has been effective? 1) “I should consider surgery to cure this disorder.” 2) “I should use the eye drops when my vision blurs.” 3) “I should cut down on eating salty and high-fat foods.” 4) “I should call my doctor before taking any over-the-counter medications.” 15. The nurse notes that a patient known to the community clinic was unable to recognize the health-care provider. What health problem should the nurse suspect is occurring with this patient? 1) Cataracts 2) Glaucoma 3) Corneal abrasions 4) Macular degeneration 16. A patient has been experiencing a gradual loss of central vision. Which tool should the nurse use when assessing this patient? 1) Jaeger card 2) Amsler grid 3) Snellen chart 4) Ishihara chart
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17. A patient with macular degeneration is being treated with verteporfin (Visudyne). What should the nurse emphasize in the patient teaching in order to reduce the risk of complications from this treatment? 1) Apply lotion to the skin for two weeks after the treatment 2) Increase the intake of water for three days after the treatment 3) Avoid indoor and outdoor light for five days after treatment 4) Wear sunglasses when going out of doors for one week after treatment 18. It is documented in the medical record that a patient has a rhegmatogenous detached retina. How should this diagnosis be explained to the patient? 1) Eye trauma causes the retinal to detach from the retinal pigment epithelium (RPE). 2) Eye inflammation causes vitreous fluid leaks into the area under the retina. 3) Vitreous fluid moves under the retina and separates the retina from the pigmented cell layer. 4) Scar tissue on the retina causes the retina to separate from the retinal pigment epithelium (RPE). 19. A patient is demonstrating signs of a detached retina. What is the reason this occurred? 1) Blood vessels in the eye spasm 2) Inner layers of the retina separate 3) Overgrowth of vessels damages vision 4) Drainage of vitreous humor is blocked 20. A patient comes into the emergency department with manifestations of retinal detachment. What should the nurse do to minimize this patient’s eye movements? 1) Provide a sedative 2) Loosely cover both eyes 3) Elevate the head of the bed 45 dN e gUreRe S s INGTB.COM 4) Apply an eye patch over the affected eye 21. During a softball game a child was hit in the eye with a bat. What common manifestation should the nurse expect when assessing this patient? 1) Edema 2) Blood-tinged tears 3) Loss of central vision 4) Loss of peripheral vision 22. The nurse is evaluating teaching provided to a patient recovering from eye trauma. Which statement indicates that additional teaching is required? 1) “I have to wear the eye patch.” 2) “I can play ball again this weekend.” 3) “I need to see the doctor in a few days.” 4) “I should call the doctor if my sight changes.” Multiple Response Identify one or more choices that best complete the statement or answer the question. 23. A patient with myopia asks what can be done to correct the disorder. Which procedures should the nurse review with this patient? Select all that apply. 1) LASIK 2) Radical keratotomy 3) Thermal keratoplasty
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4) Phakic intraocular lens 5) Photorefractive keratotomy 24. A patient is diagnosed with bacterial conjunctivitis. What should the nurse expect to assess in this patient? Select all that apply. 1) Tearing 2) Red sclera 3) Puffy eyelids 4) Purulent eye discharge 5) Matting of the eyelashes 25. A patient is diagnosed with viral conjunctivitis. What should the nurse expect to be prescribed for this patient? Select all that apply. 1) Eye lubricants 2) Cold compresses 3) Topical steroid drops 4) Ocular decongestants 5) Topical antihistamine drops 26. The nurse suspects that a patient is experiencing a corneal abrasion. What did the nurse assess to come to this conclusion? Select all that apply. 1) Tearing 2) Eye pain 3) Squinting 4) Photophobia 5) Purulent drainage
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27. The nurse is preparing information about cataracts for a community health fair. What should the nurse include about risk factors for the disorder? Select all that apply. 1) Obesity 2) Age over 60 3) Family history 4) Alcohol intake 5) Chronic health problems 28. The nurse is preparing a tool about macular degeneration that will be posted during a health fair. Which modifiable risk factors should the nurse include in this tool? Select all that apply. 1) Race 2) Gender 3) Obesity 4) Smoking 5) High blood pressure
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Chapter 46: Coordinating Care for Patients With Visual Disorders Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Describing the epidemiology of visual disorders Chapter page reference: 949 Heading: Visual Acuity Disorders > Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Assessment Difficulty: Moderate
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Feedback The number of children does not impact the development of myopia. Smoking is not a risk factor for the development of myopia. Gardening is not a risk factor for the development of myopia. A risk factor for the development of myopia is doing excessive amounts of close work such as tailoring.
PTS: 1
CON: Sensory Perception | Assessment
2. ANS: 1 NURSINGTB.COM Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with eye disorders Chapter page reference: 953 Heading: Visual Acuity Disorders > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Comfort Difficulty: Moderate
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Feedback Wearing corrective lenses while awake will prevent blurred vision and reduce the frequency of headaches. Cool compresses are not identified as treatment for astigmatism. Removing corrective lenses will cause blurred vision and increase the chance of headaches. Massage of the outer canthus is not identified as a treatment for astigmatism.
PTS: 1 CON: Sensory Perception | Comfort 3. ANS: 2 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Visual acuity disorders
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Chapter page reference: 951 Heading: Visual Acuity Disorders > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Assessment Difficulty: Moderate
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Feedback Astigmatism results in visual changes where objects that are near and distant occur blurry. Other clinical manifestations include squinting, headaches, and blurry vision. Hyperopia occurs when a person can see distant objects more clearly than near objects. Blurred vision of near objects is the symptom associated with this disorder. Myopia causes a person to see near objects more clearly than objects at a distance. The result of this distortion is blurred vision for distant objects. Presbyopia, an expected change in vision around midlife, results in the inability to focus on objects held close to the face
PTS: 1 CON: Sensory Perception | Assessment 4. ANS: 3 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Explaining the pathophysiological processes of visual disorders Chapter page reference: 954 Heading: Conjunctivitis > Pathophysiology Integrated Processes: Nursing Process: Assessment NURSINGTB.COM Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Assessment Difficulty: Moderate
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Feedback Watery eye discharge is not a manifestation of cataracts. More information is required before determining if the patient is experiencing eye trauma. Conjunctivitis is described as an inflammation of the conjunctivae of the eye. There are many types of conjunctivitis, and most people in their lifetime will have the unpleasant experience of at least one of them. Diagnosis of conjunctivitis is made on history, clinical presentation, and physical findings. Corneal abrasions may cause eye tearing, but more information is needed to make this clinical determination.
PTS: 1 CON: Sensory Perception | Assessment 5. ANS: 1 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Developing a teaching plan for a patient with eye disorders Chapter page reference: 956 Heading: Conjunctivitis > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment/Safety and Infection Control
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Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Promoting Health Difficulty: Moderate
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Feedback Towels should be isolated from other family members to prevent possible transmission to another person. Clean hands are essential to prevent the transmission of conditions from one eye to another or from one person to another; conjunctivitis is considered extremely contagious. Completion of all prescribed medication as ordered is needed to prevent reoccurrence or incomplete healing. Incomplete treatments can lead to an even deeper infection in the eye. It is essential that patients keep follow-up appointments with their practitioner to verify the healing process and to monitor for any possible visual loss.
PTS: 1 CON: Sensory Perception | Promoting Health 6. ANS: 4 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected disorders of the eye Chapter page reference: 957 Heading: Corneal Abrasions > Medical Management Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential NURSINGTB.CO Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Assessment Difficulty: Moderate
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Feedback An MRI is not used to diagnose a corneal abrasion. A CT scan is not used to diagnose a corneal abrasion. Ultrasound is not used to diagnose a corneal abrasion. Examination for a corneal abrasion includes corneal staining with fluorescein stain, and visualization under a Wood lamp to confirm diagnosis of the abrasion.
PTS: 1 CON: Sensory Perception | Assessment 7. ANS: 1 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Describing complications associated with selected disorders of the eye Chapter page reference: 957 Heading: Corneal Abrasions > Medical Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Sensory Perception; Medication Difficulty: Moderate Feedback
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1
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Tetanus vaccination should be verified and administered if the patient is not considered up-to-date because any open surface of the body can provide a port of entry for Clostridium tetani to enter. Topical steroid drops are not used to treat or prevent a complication from a corneal abrasion. Systemic pain medications may be used for pain caused by a corneal abrasion; however, they will not prevent a complication from developing. Topical antihistamine drops are not used to treat or prevent a complication from a corneal abrasion.
PTS: 1 CON: Sensory Perception | Medication 8. ANS: 4 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Cataracts Chapter page reference: 959 Heading: Cataracts > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Assessment Difficulty: Moderate
1 2 3 4
Feedback Itching eyes is not a manifestation of cataracts. Eye tearing is not a manifestatNioU nR ofScIatN arG acTtsB. .COM Reddened sclera is not a manifestation of cataracts. Double vision in one eye is a manifestation of cataracts.
PTS: 1 CON: Sensory Perception | Assessment 9. ANS: 2 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Discussing the medical management of selected disorders of the eye Chapter page reference: 959 Heading: Cataracts > Surgical Management Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Perioperative Difficulty: Easy Feedback 1 2 3 4
Cataract removal does not increase the risk of blindness. Cataract removal increases the risk of retinal detachment. Cataract removal is not associated with a corneal abrasion. Cataract removal does not increase the risk of macular degeneration.
PTS: 1 CON: Sensory Perception | Perioperative 10. ANS: 4 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders
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Chapter learning objective: Developing a comprehensive plan of nursing care for patients with eye disorders Chapter page reference: 960 Heading: Cataracts > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Perioperative Difficulty: Easy
1 2 3 4
Feedback Fluids do not need to be restricted after cataract surgery. This does not decrease intraocular pressure. Positioning on the operative side would increase IOP. Mydriatic eye drops dilate the pupil and would be provided preoperatively. These drops do not affect IOP. Elevating the head of the bed 30 to 45 degrees promotes drainage and prevents any increase in IOP.
PTS: 1 CON: Sensory Perception | Perioperative 11. ANS: 4 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Glaucoma Chapter page reference: 962 Heading: Glaucoma > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/N PhUyR sioSlI ogN icG alTABd. apCtaOtiM on Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Assessment Difficulty: Easy
1
2
3
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Feedback Secondary glaucoma usually results from an eye injury, inflammation, tumor, or advanced cases of cataracts, or diabetes. Medications such as steroids, when used chronically, are also noted to cause this type of glaucoma. Acute angle glaucoma is characterized by severe eye pain, nausea and vomiting, sudden onset of visual disturbance (often in low light), blurred vision, halo vision, and reddening of the eye. Normal-tension glaucoma (also referred to as low-tension glaucoma) is a condition where optic nerve damage and vision loss occur despite having a normal IOP between 10 and 21 mm Hg. In primary open-angle glaucoma, clinical manifestations include gradual loss of peripheral vision, usually in both eyes.
PTS: 1 CON: Sensory Perception | Assessment 12. ANS: 3 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected disorders of the eye Chapter page reference: 962
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Heading: Glaucoma > Medical Management Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Sensory Perception; Assessment Difficulty: Easy
1 2 3 4
Feedback An MRI would not detect glaucoma. A CT scan would not detect glaucoma. Tonometry measures the pressures within the eyes and is usually conducted during a routine eye examination. An ultrasound would not detect glaucoma.
PTS: 1 CON: Sensory Perception | Assessment 13. ANS: 2 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Describing complications associated with selected disorders of the eye Chapter page reference: 964 Heading: Glaucoma > Nursing Management > Teaching Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Perioperative Difficulty: Moderate
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Feedback Straining at a bowel movement is contraindicated and can increase the chance of postoperative bleeding within the eye. A laxative would avoid this potential complication. Lifting heavy objects such as a grandchild increases intraocular pressure, which should be avoided after having this surgery. Washing hands before applying eye drops reduces the risk of a postoperative infection. Applying pressure to the lacrimal duct after applying eye drops reduces the risk of systemic absorption of the medication.
PTS: 1 CON: Sensory Perception | Perioperative 14. ANS: 4 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Developing a teaching plan for a patient with eye disorders Chapter page reference: 964 Heading: Glaucoma > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Promoting Health Difficulty: Moderate Feedback
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1 2 3 4
There is no surgery to cure glaucoma. The eye drops should be used as prescribed and not only with blurred vision. Dietary changes will not affect glaucoma. The patient should be instructed to not take any medication, over-the-counter or prescription, without contacting the eye care practitioner first.
PTS: 1 CON: Sensory Perception | Promoting Health 15. ANS: 4 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Macular degeneration Chapter page reference: 966 Heading: Macular Degeneration > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Assessment Difficulty: Moderate
1 2 3 4
Feedback Cataracts will not cause the patient to be unable to recognize faces. Glaucoma will not cause the patient to be unable to recognize faces. Corneal abrasions will not cause the patient to be unable to recognize faces. Dry macular degeneration causes a gradual blurring of the central vision, and the patient may have difficulty recNogn URizSinIg NfaGceTs.B .COM
PTS: 1 CON: Sensory Perception | Assessment 16. ANS: 2 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected disorders of the eye Chapter page reference: 966 Heading: Macular Degeneration > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Assessment Difficulty: Moderate 1 2 3 4
Feedback The Jaeger card assesses near vision. The Amsler grid is used to determine if a matrix of black lines appear straight or are wavy, which could indicate macular degeneration. The Snellen chart is used to assess for visual acuity. The Ishihara chart is used to assess color vision.
PTS: 1 17. ANS: 3
CON: Sensory Perception | Assessment
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Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Describing complications associated with selected disorders of the eye Chapter page reference: 967 Heading: Macular Degeneration > Medical Management > Photodynamic Therapy Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate 1 2 3
4
Feedback This treatment does not affect the skin. Increased fluid intake is not required after this treatment. It is important to instruct the patient that he or she must avoid exposing skin/eyes to direct sunlight or bright indoor light for five days after treatment with verteporfin (Visudyne) because the medication is activated by light. The patient should avoid indoor and outdoor bright light for five days. Sunglasses would not be needed since bright light is avoided.
PTS: 1 CON: Sensory Perception 18. ANS: 3 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Retinal detachment Chapter page reference: 968 NURSINGTB.COM Heading: Retinal Detachment > Pathophysiology Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate 1 2 3
4
Feedback Exudative retinal detachment can occur with eye trauma. Exudative retinal detachment can occur with eye inflammation. Rhegmatogenous is the most common form of retinal detachment and occurs when a tear or break in the retina allows vitreous fluid to move under the retina and separate it from the pigmented cell layer that nourishes the retina. Tractional is the least common type of detachment and occurs when scar tissue on the retina’s surface contracts and causes the retina to separate from the RPE.
PTS: 1 CON: Sensory Perception 19. ANS: 2 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Explaining the pathophysiological processes of visual disorders Chapter page reference: 968 Heading: Retinal Detachment > Pathophysiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential
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Cognitive level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Easy
1 2 3 4
Feedback Retinal detachment is not caused by vessel spasms. Retinal detachment occurs when there is a separation of the inner layers of the retina from the underlying retinal pigment epithelium (RPE; choroid). Retinal detachment is not caused by overgrowth of vessels. Retinal detachment is not caused by blocking the drainage of vitreous humor.
PTS: 1 CON: Sensory Perception 20. ANS: 2 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with eye disorders Chapter page reference: 970 Heading: Retinal Detachment > Nursing Management > Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate
1 2 3 4
Feedback A sedative might help with anxi NUetRy;Sh oIwNeGveTr,Bit.wCilOl nMot minimize eye movements. Movement of either eye can exacerbate internal eye injury. Because eyes move together, both eyes must be covered to minimize injury. Elevating the head of the bed helps decrease intraocular pressure; however, this is not a problem with retinal detachment. A single eye patch is not recommended. Both eyes should be covered.
PTS: 1 CON: Sensory Perception 21. ANS: 1 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Eye trauma Chapter page reference: 972 Heading: Eye Trauma > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Trauma Difficulty: Moderate
1 2 3 4
Feedback Common manifestations of eye trauma include edema around the eye. Blood-tinged tears are not a common manifestation of eye trauma. Loss of central vision occurs with macular degeneration. Loss of peripheral vision occurs with glaucoma.
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PTS: 1 CON: Sensory Perception | Trauma 22. ANS: 2 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Developing a teaching plan for a patient with eye disorders Chapter page reference: 973 Heading: Eye Trauma > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Trauma; Promoting Health Difficulty: Moderate
1 2 3 4
Feedback The patient should be instructed about wearing an eye patch if indicated for the injury. The patient’s activity will most likely be restricted until the injury heals and vision is restored. The patient will need to follow up with the health-care provider at regular intervals. The patient should notify the health-care professional with any vision changes during the recovery period.
PTS: 1
CON: Sensory Perception | Trauma | Promoting Health
MULTIPLE RESPONSE
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23. ANS: 1, 2, 4, 5 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Discussing the medical management of selected disorders of the eye Chapter page reference: 951 Heading: Visual Acuity Disorders > Surgical Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Perioperative Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback LASIK is identified as a treatment for myopia. Radical keratotomy is identified as a treatment for myopia. Thermal keratoplasty is identified as a treatment for hyperopia. Phakic intraocular lens is another form of treatment to correct myopia. This treatment is usually reserved for patients who are unsuitable for LASIK or other vision corrective surgeries. Photorefractive keratotomy is identified as a treatment for myopia.
PTS: 1 CON: Sensory Perception | Perioperative 24. ANS: 4, 5 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders
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Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Conjunctivitis Chapter page reference: 954 Heading: Conjunctivitis > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Application [Applying] Concept: Sensory Perception; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Tearing is associated with allergic conjunctivitis. Red sclera is associated with allergic conjunctivitis. Puffy eyelids are associated with allergic conjunctivitis. Purulent eye discharge is associated with bacterial conjunctivitis. Matting of the eyelashes is associated with bacterial conjunctivitis.
PTS: 1 CON: Sensory Perception | Assessment 25. ANS: 1, 2, 4 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Discussing the medical management of selected disorders of the eye Chapter page reference: 954 Heading: Conjunctivitis > Medical Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity/Reduction of Risk Potential NURSINGTB.CO Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback The treatment for viral conjunctivitis includes eye lubricants. The treatment for viral conjunctivitis includes cold compresses to the eye for pain relief and decrease in swelling/irritation. The treatment for allergic conjunctivitis includes topical steroid drops instilled directly to the eye to decrease inflammation and block the release of histamine. The treatment for viral conjunctivitis includes ocular decongestants to help reduce swelling and inflammation. The treatment for allergic conjunctivitis includes topically antihistamine drops to decrease itching.
PTS: 1 CON: Sensory Perception 26. ANS: 1, 2, 3, 4 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Corneal abrasions Chapter page reference: 956 Heading: Corneal Abrasions > Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity/Reduction of Risk Potential
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Cognitive level: Application [Applying] Concept: Sensory Perception; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback The most common clinical manifestations of corneal abrasions include tearing. The most common clinical manifestations of corneal abrasions include eye pain. The most common clinical manifestations of corneal abrasions include squinting. The most common clinical manifestations of corneal abrasions include photophobia. Purulent drainage is a manifestation of bacterial conjunctivitis.
PTS: 1 CON: Sensory Perception | Assessment 27. ANS: 1, 2, 3, 5 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Describing the epidemiology of visual disorders Chapter page reference: 958 Heading: Cataracts > Epidemiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Sensory Perception; Promoting Health Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Obesity may predisposeNa nU iRndi deC veOloMp men t of cataracts. Svi Idu N GalTtoB. Cataracts are more common after age 60 but can occur at any time. Those with family members who had cataracts are more likely to develop them at some point in their life. Alcohol intake is not identified as a risk factor for cataracts. Chronic medical conditions such as diabetes, autoimmune disorders, hypertension, and other eye problems are considered to be at higher risk for cataract development.
PTS: 1 CON: Sensory Perception | Promoting Health 28. ANS: 3, 4, 5 Chapter number and title: 46, Coordinating Care for Patients With Visual Disorders Chapter learning objective: Describing the epidemiology of visual disorders Chapter page reference: 965 Heading: Macular Degeneration > Epidemiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Sensory Perception; Promoting Health Difficulty: Moderate
1. 2. 3.
Feedback Nonmodifiable risk factors for macular degeneration include race. Nonmodifiable risk factors for macular degeneration include gender. Modifiable risk factors for macular degeneration include obesity.
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4. 5. PTS: 1
Modifiable risk factors for macular degeneration include smoking. Modifiable risk factors for macular degeneration include high blood pressure. CON: Sensory Perception | Promoting Health
Chapter 47: Assessment of Auditory Function Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The school nurse is preparing a poster for students focusing on the structures of the ear. What information should be included about the Eustachian tube? 1) It is the most visible part of the ear 2) It is lined with glands that secrete cerumen 3) It connects the middle ear with the nasopharynx 4) It holds the sensory organs for equilibrium and hearing 2. A patient is being evaluated for a hearing disorder. How should the nurse explain the semicircular canals? 1) Contain glands that make cerumen 2) Is the smallest bone in the human body 3) Cartilage containing fluid and hair cells 4) Separates the external from the middle ear 3. A patient is diagnosed with a bone conduction hearing disorder. Which bones are responsible for transmitting NURSINGTB.COM sound for bone conduction? 1) Skull 2) Maxilla 3) Mastoid 4) Mandible 4. A patient is experiencing extreme vertigo. Which part of the ear is malfunctioning? 1) Pinnae 2) Malleus 3) Labyrinth 4) Organs of Corti 5. Which observation made by the nurse indicates that the patient might be experiencing a hearing disorder? 1) Answers most questions incorrectly 2) Sits with the hands folded in the lap 3) Looks at the nurse’s face when talking 4) Takes a few extra seconds before responding 6. During an assessment the nurse determines that a patient is at risk for a perforated eardrum. What information caused the nurse to have this concern? 1) Flushes the ears with warm water 2) Uses a hair pin to remove ear wax 3) Cleanses the outer ear areas with a wash cloth 4) Places cotton balls in the ears before swimming
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7. The nurse is preparing to use an otoscope to examine an adult patient’s external ear structures. What should the nurse do to ensure the ear canal is straight? 1) Pull the pinna down 2) Pull the pinna up and back 3) Hold the otoscope upright 4) Tilt the patient’s head toward the nurse 8. During a hearing assessment the nurse has the patient cover one ear and asks the patient to repeat a few words spoken near the uncovered ear. Which assessment technique is the nurse using? 1) Voice test 2) Watch test 3) Weber test 4) Tympanic test 9. A patient is scheduled for an audiometry examination. What should the nurse explain as being the purpose of this test? 1) Determines hearing acuity 2) Measures cranial nerve function 3) Identifies if the middle ear is inflamed 4) Analyzes brain interpretation of sound 10. A patient is experiencing “fullness” in the ears. Which diagnostic test should be anticipated for this patient? 1) MRI 2) CT scan 3) Tympanometry 4) Electronystagmography
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11. A patient with a hearing disorder just underwent a CT scan with contrast. What should the nurse emphasize to the patient after the test? 1) Increase oral fluids 2) Avoid caffeinated beverages 3) Take nothing by mouth for three hours 4) Avoid over-the-counter analgesics 12. A patient is directed to schedule an MRI to help diagnose a new onset of unilateral deafness. For which health reason should this diagnostic procedure be delayed? 1) Patient has a pacemaker 2) Patient takes metformin 3) Patient has claustrophobia 4) Patient is allergic to iodine 13. A patient is experiencing a new onset of reduced hearing. Which medication should the nurse suspect is causing this patient’s disorder? 1) Prilosec 2) Gentamycin 3) Dexamethasone 4) Calcium supplement 14. During an assessment the nurse becomes concerned that a patient is at risk for a hearing loss. What information caused the nurse to have this concern? 1) Age 35 years 2) Lives with spouse and two children
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3) Works for a lawn and garden service 4) Has a ranch-style home in the country 15. The mother of an adolescent is frustrated because the teen appears to be “deaf.” What observation made by the nurse might suggest a potential risk to hearing for this teen? 1) Use of earbuds 2) Time spent on the computer 3) Number of followers on Twitter 4) Frequency of posting on Facebook 16. A patient who swims twice a week has been experiencing frequent ear infections. What should the nurse suggest to this patient? 1) Use waterproof earplugs 2) Place cotton in the ears before swimming 3) Instill castor oil into the ears before swimming 4) Flush the ears with hydrogen peroxide after swimming 17. An older patient has an impaction of cerumen in both ears. What should the nurse explain as the reason for this occurrence? 1) Poor diet 2) Drier cerumen 3) Reduced fluid intake 4) Stiffening of blood vessels 18. The ear-nose-and-throat health-care professional documents that a patient has a stiff tympanic membrane. What should this information indicate to the nurse? 1) Antibiotics should be prescribed NURSINGTB.COM 2) Progressive hearing loss will occur 3) Middle ear changes affect the patient’s hearing 4) Special care is required to protect the ears when showering 19. A middle-aged patient avoids eating out in restaurants because of the inability to hear dining partners talk. What should the nurse realize that this patient is describing? 1) Presbycusis 2) Mixed hearing loss 3) Conductive hearing loss 4) Sensorineural hearing loss 20. The nurse notices that an older patient takes a few extra seconds to respond to conversation. What should the nurse realize is causing this to occur? 1) Presbycusis 2) Use of NSAIDs for pain 3) Nerve damage from medication 4) Increased auditory reaction time Multiple Response Identify one or more choices that best complete the statement or answer the question. 21. A patient is diagnosed with a middle ear infection. What structures are affected by this infection? Select all that apply. 1) Cochlea
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2) 3) 4) 5)
Bony labyrinth Eustachian tube Mastoid process Tympanic membrane
22. The nurse notes that a patient has Level III Usher’s syndrome. What should the nurse expect when assessing this patient? Select all that apply. 1) Deafness 2) Unilateral hearing loss 3) Variable vestibular dysfunction 4) Profound sensorineural hearing loss 5) Progressive sensorineural hearing loss 23. A patient is scheduled for an electronystagmography. What should the nurse instruct the patient to prepare for this test? Select all that apply. 1) Bring eyeglasses to the test 2) Report an allergy to iodine or shellfish 3) Drinking fluids after the test will occur slowly 4) Take nothing by mouth for three hours before the test 5) Avoid caffeine products for 24 hours prior to the test 24. The nurse is preparing a teaching tool on hearing for a community fair. Which medication classifications should the nurse identify as potentially causing hearing problems? Select all that apply. 1) Diuretics 2) Antibiotics 3) Vasodilators 4) Chemotherapy agents NURSINGTB.COM 5) Nonsteroidal anti-inflammatory drugs (NSAIDs) Completion Complete each statement. 25. The nurse is explaining the mechanism of hearing through sound conduction to a group of high school students. In which order should the nurse explain this process? Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Sound enters the pinna 2) Vibrations enter the cochlea 3) Vibrations cause the ossicles to move 4) Vibrations travel through nerves to the brain 5) Sound travels to the tympanic membrane
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Chapter 47: Assessment of Auditory Function Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Identifying key anatomical components of the auditory system Chapter page reference: 978 Heading: Overview of Anatomy and Physiology > Anatomy Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Sensory Perception; Promoting Health Difficulty: Easy 1 2 3 4
Feedback The pinnae are the most visible part of the ear. External auditory canals are lined with glands that secrete cerumen. The Eustachian tube connects the middle ear with the nasopharynx. Bony labyrinth is the structure that holds the sensory organs for equilibrium and hearing.
PTS: 1 CON: SensoryNPUeR rcS epItiN onG| TPB ro. mC o tO inMg Health 2. ANS: 3 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Identifying key anatomical components of the auditory system Chapter page reference: 978 Heading: Overview of Anatomy and Physiology > Anatomy Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Easy
1 2 3 4
Feedback The ear canal contains glands that make cerumen. The stapes is located in the middle ear and are the smallest bones in the human body. Semicircular canals are tubes composed of cartilage that contain both fluid and hair cells. The tympanic membrane separates the external ear from the middle ear.
PTS: 1 CON: Sensory Perception 3. ANS: 1 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Identifying key anatomical components of the auditory system Chapter page reference: 978
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Heading: Overview of Anatomy and Physiology > Auditory Function Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Easy
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Feedback Bone conduction transmission of sound occurs when the skull bones transport vibrations directly to the inner ear and then to the auditory nerve. The maxilla is not used to transmit sound. The mastoid bones are commonly used to test bone conduction. The mandible is not used to transmit sound.
PTS: 1 CON: Sensory Perception 4. ANS: 3 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Identifying key anatomical components of the auditory system Chapter page reference: 978 Heading: Overview of Anatomy and Physiology > Auditory Function Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Easy NURSINGTB.COM 1 2 3 4
Feedback The primary function of the pinnae is to collect sounds. The function of the malleus is to transmit sound vibrations from the eardrum to the incus. Inflammation of the labyrinth causes the wrong information to be sent to the brain, thus resulting in a staggering gait and a spinning, whirling sensation known as vertigo. Organs of Corti contain hair cells, and as the hairs bend, they change vibrations into electrical impulses that are then carried by cranial nerve VIII to the brain.
PTS: 1 CON: Sensory Perception 5. ANS: 1 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of the auditory system Chapter page reference: 978 Heading: Assessment of the Auditory System > History Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception Difficulty: Moderate Feedback
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1 2 3 4
One sign of a hearing disorder is answering questions incorrectly on a consistent basis. Sitting with the hands folded in the lap is not a sign of a hearing disorder. Looking at the nurse’s face when talking is not a sign of a hearing disorder. Taking a few extra seconds before responding is not a sign of a hearing disorder.
PTS: 1 CON: Sensory Perception 6. ANS: 2 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Describing methods to prevent ear trauma Chapter page reference: 979 Heading: Assessment of the Auditory System > Personal Hygiene Integrated Processes: Nursing Process–Assessment Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Analysis [Analyzing] Concept: Sensory Perception Difficulty: Moderate
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Feedback Flushing the ears with warm water will not encourage a perforated eardrum. Inserting foreign objects can cause tissue injury to the sides of the canal and can also cause cerumen to be moved. Movement of the cerumen by a foreign object places the patient at risk for cerumen impaction, causing changes in hearing, as well as rupture of the eardrum. Cleansing the outer ears with a wash cloth will not harm the eardrum. Placing cotton balls in the earsNbUefRo S re Isw NiGmTmBin.g Cp rOo Mtects the eardrum.
PTS: 1 CON: Sensory Perception 7. ANS: 2 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of the auditory system Chapter page reference: 980 Heading: Assessment of the Auditory System > Examination With an Otoscope Integrated Processes: Nursing Process–Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Sensory Perception; Assessment Difficulty: Moderate
1 2 3 4
Feedback The pinna is pulled down in an infant or child under 3 years of age. The pinna is pulled up and back in the adult. The otoscope should be held upside down. The patient’s head should be tilted away from the examiner.
PTS: 1 CON: Sensory Perception | Assessment 8. ANS: 1 Chapter number and title: 47, Assessment of Auditory Function
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Chapter learning objective: Describing the procedure for completing a history and physical assessment of the auditory system Chapter page reference: 981 Heading: Auditory Assessment Integrated Processes: Nursing Process–Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Sensory Perception; Assessment Difficulty: Easy
1 2 3 4
Feedback For the voice test, the practitioner whispers a short statement of four words or fewer into the patient’s uncovered ear and asks the patient to repeat the words. For the watch test, the watch is held about five inches from each ear, and the practitioner verifies whether a patient is able to hear the ticking. For the Weber test, a tuning fork is used. Tympanic is not a type of test.
PTS: 1 CON: Sensory Perception | Assessment 9. ANS: 1 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Correlating relevant diagnostic examinations to auditory function Chapter page reference: 982 Heading: Auditory Assessment > Diagnostic Testing > Audiometry Integrated Processes: Nursing Process–Planning NURSINGTB.COM Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Sensory Perception; Assessment Difficulty: Easy
1 2 3 4
Feedback Hearing acuity is measured through audiometry. Audiometry does not measure cranial nerve function. Audiometry does not diagnose middle ear status. Audiometry does not determine the brain’s ability to interpret sound.
PTS: 1 CON: Sensory Perception | Assessment 10. ANS: 3 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Correlating relevant diagnostic examinations to auditory function Chapter page reference: 982 Heading: Auditory Assessment > Diagnostic Testing > Tympanometry Integrated Processes: Nursing Process–Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Assessment Difficulty: Easy Feedback
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4
MRI provides detailed views of the inner ear structures. CT scan provides detailed views of the inner ear structure. Tympanometry is performed to assess the mobility of the eardrum and structures of the middle ear because these changes are consistent with presence of fluid in the middle ear. The electronystagmography (ENG) test is done to detect both central and peripheral diseases of the vestibular system (the system in the inner ear that is responsible for maintaining balance and orientation in space) in the ear.
PTS: 1 CON: Sensory Perception | Assessment 11. ANS: 1 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to the auditory system Chapter page reference: 983 Heading: Auditory Assessment > Patient Teaching Prior to Computed Tomography Scan Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate Feedback 1 Drinking plenty of fluids after the CT scan if IV dye is used helps the body excrete the IV dye. 2 There is no reason for the patien NUt toRSavIoNidGcTafBfe.inCatOedMbev erages. 3 There is no reason for the patient to be NPO for three hours after a CT scan. 4 There is no reason for the patient to avoid over-the-counter analgesics after the test. PTS: 1 CON: Sensory Perception 12. ANS: 1 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to the auditory system Chapter page reference: 983 Heading: Auditory Assessment > Patient Teaching Prior to the Magnetic Resonance Imaging Scan Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Sensory Perception Difficulty: Easy 1 2 3 4
Feedback Patients with pacemakers should check with their practitioner before having any MRI procedure. Metformin would be an issue if the patient were having a CT scan. Sedatives can be prescribed for patients with claustrophobia. Dye is not used during an MRI. The patient’s allergy to iodine is not an issue.
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PTS: 1 CON: Sensory Perception 13. ANS: 2 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Identifying ototoxic medications Chapter page reference: 983 Heading: Ototoxic Medications Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Medication Difficulty: Moderate
1 2 3 4
Feedback Prilosec is a medication for gastroesophageal reflux disease and is not considered at high risk for causing hearing loss. Some antibiotics can affect hearing. This medication should be investigated as causing hearing loss. Dexamethasone is a glucocorticoid, which is not identified as possibly causing a hearing loss. Calcium supplements are not identified as possibly causing a hearing loss.
PTS: 1 CON: Sensory Perception | Medication 14. ANS: 3 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Describing methods to prevent ear trauma NURSINGTB.COM Chapter page reference: 984 Heading: Hearing Protection Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Assessment Difficulty: Moderate
1 2 3 4
Feedback Advancing age is a risk factor for a hearing loss. Marital status and children are not risk factors for a hearing loss. Occupations that place the patient in the presence of loud noises such as those used in a lawn and garden service is a risk factor for a hearing loss. Living in the country would not increase the patient’s risk for a hearing loss.
PTS: 1 CON: Sensory Perception | Assessment 15. ANS: 1 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Describing methods to prevent ear trauma Chapter page reference: 983 Heading: Hearing Protection Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing]
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Concept: Sensory Perception; Assessment Difficulty: Easy
1
2 3 4
Feedback The frequent use of “earbuds” for listening to music and other sounds can pose a serious risk to the ear structures if used well beyond recommended volume levels because damage may be done to sensitive hair cells or other structures within the ear. Time spent on the computer will not necessarily adversely affect hearing. The number of followers on Twitter will not have any effect on hearing. The frequency of posting on Facebook will not have any effect on hearing.
PTS: 1 CON: Sensory Perception | Assessment 16. ANS: 1 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Describing methods to prevent ear trauma Chapter page reference: 984 Heading: Hearing Protection Integrated Processes: Nursing Process–Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Easy 1 2 3 4
Feedback Waterproof earplugs would heNlpUpRreSv en I Nt tGheTdBeve .CloOp Mment of future ear infections caused by swimming. Cotton in the ears would trap water and could encourage the development of an ear infection. There is no evidence that castor oil in the ears prevents an ear infection. Hydrogen peroxide is caustic and could damage the ear canal. This should not be recommended.
PTS: 1 CON: Sensory Perception 17. ANS: 2 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Discussing changes in hearing associated with aging Chapter page reference: 985 Heading: Age-Related Changes Integrated Processes: Nursing Process–Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Easy
1 2
Feedback Drier cerumen is not related to diet. Atrophy of the apocrine glands that produce cerumen causes the cerumen to become drier.
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Drier cerumen is not related to fluid intake. Drier cerumen is not related to blood vessel integrity.
PTS: 1 CON: Sensory Perception 18. ANS: 3 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Discussing changes in hearing associated with aging Chapter page reference: 985 Heading: Age-Related Changes Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception Difficulty: Easy 1 2 3 4
Feedback Antibiotics are not required because of a stiff tympanic membrane. There is no evidence to suggest that progressive hearing loss will occur. In the middle ear, membrane changes that include stiffening of the tympanic membrane will affect hearing. Special care to protect the ears should occur at all times and not just because the patient’s tympanic membrane is stiffer.
PTS: 1 CON: Sensory Perception 19. ANS: 1 NURSINGTB.COM Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Discussing changes in hearing associated with aging Chapter page reference: 985 Heading: Age-Related Changes Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception Difficulty: Moderate 1 2 3 4
Feedback Presbycusis is a type of hearing loss that occurs with older adults. Localization of sound, especially in the presence of background noises, is impaired The patient is not describing mixed hearing loss. The patient is not describing conductive hearing loss. The patient is not describing sensorineural hearing loss.
PTS: 1 CON: Sensory Perception 20. ANS: 4 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Discussing changes in hearing associated with aging Chapter page reference: 985 Heading: Age-Related Changes
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Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception Difficulty: Moderate
1 2 3 4
Feedback Presbycusis is a type of hearing loss that occurs with older adults. This loss is gradual and is caused by nerve degeneration in the inner ear or auditory nerve. There is no evidence to support that the patient uses NSAIDs. There is no information to support that the patient is taking ototoxic medications. Patients aged 70 years or older may also have an increased auditory reaction time that results in it taking longer for the elderly patient to process and respond to sensory input.
PTS: 1
CON: Sensory Perception
MULTIPLE RESPONSE 21. ANS: 3, 5 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Identifying key anatomical components of the auditory system Chapter page reference: 977 Heading: Overview of Anatomy and Physiology > Anatomy Integrated Processes: Nursing Process–Assessment NeGn Tt/SBa. Client Need: Safe and Effective CareNEUn R v iS roI nm f eC tyOa M n d Infection Control Cognitive level: Comprehension [Understanding] Concept: Sensory Perception; Infection Difficulty: Easy
1. 2. 3. 4. 5.
Feedback The cochlea is a structure of the inner ear. The bony labyrinth is a structure of the inner ear. The Eustachian tube is a structure of the middle ear. The mastoid process is a structure of the external ear. The tympanic membrane is a structure of the middle ear.
PTS: 1 CON: Sensory Perception | Infection 22. ANS: 3, 5 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of the auditory system Chapter page reference: 980 Heading: Assessment of the Auditory System > Genetics Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate
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1. 2. 3. 4. 5.
Feedback Deafness is associated with neurofibromatosis type 2. Unilateral hearing loss is associated with Waardenburg syndrome. Variable vestibular function is associated with Type III Usher’s syndrome. Profound sensorineural hearing loss is associated with Type I Usher’s syndrome. Progressive sensorineural loss is associated with Type III Usher’s syndrome.
PTS: 1 CON: Sensory Perception 23. ANS: 1, 3, 4, 5 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to the auditory system Chapter page reference: 982 Heading: Auditory Assessment > Electronystagmography Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Patients who normally wear eyeglasses should bring them to the test with them. Eyeglasses assist the patient in vision during the testing. This test does not use coNn tra URstSmIeNdiGu mTBso.aCn OalMlergy to iodine or shellfish is not reported. Patients should be informed that reintroduction of fluids after this test will be gradual to prevent the occurrence of nausea and vomiting. The patient should be NPO for at least three hours prior to the test. Patients may experience nausea and vomiting with this test; NPO status may help to decrease this sensation. The patient should refrain from ingestion of caffeine for at least 24 hours prior to the test. Caffeine can cause stimulation of the central nervous system and therefore possibly influence testing results.
PTS: 1 CON: Sensory Perception 24. ANS: 1, 2, 4, 5 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Identifying ototoxic medications Chapter page reference: 983 Heading: Ototoxic Medications Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Sensory Perception; Medication; Promoting Health Difficulty: Moderate
1. 2. 3.
Feedback The most common categories of medications that pose ototoxic risks include diuretics. The most common categories of medications that pose ototoxic risks include antibiotics. Vasodilators are not identified as posing ototoxic risks.
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4. 5. PTS: 1
The most common categories of medications that pose ototoxic risks include chemotherapy agents. The most common categories of medications that pose ototoxic risks include NSAIDs. CON: Sensory Perception | Medication | Promoting Health
COMPLETION 25. ANS: 15324 Chapter number and title: 47, Assessment of Auditory Function Chapter learning objective: Discussing the function of the auditory system Chapter page reference: 978 Heading: Overview of Anatomy and Physiology > Auditory Function Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Sensory Perception; Promoting Health Difficulty: Moderate Feedback: Sound is gathered by the pinna, and the waves enter the ear traveling through the auditory canal until they reach the tympanic membrane (eardrum). The sound waves set up vibrations in the eardrum. The vibrations of the eardrum cause the auditory ossicles in the middle ear to move back and forth. The cochlea receives the sound vibrations next. Finally, the sound stimulus travels to the vestibulocochlear nerve (acoustic or auditory nerve), cranial nerve VIIIN, U anR dS teI rmNinGaTte B s . in C thOe Mcereb ral cortex. PTS: 1
CON: Sensory Perception | Promoting Health
Chapter 48: Coordinating Care for Patients With Hearing Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. During a home visit the nurse suspects that someone in the family has hearing loss. What did the nurse observe to come to this conclusion? 1) Television volume on loud 2) Patient sitting in the kitchen 3) Music playing in the background 4) Family member cooking at the stove 2. A patient with a hearing loss is wearing headphones as a part of a diagnostic test. What test is being completed with this patient? 1) Tympanometry 2) Pure-tone threshold 3) MRI with gadolinium 4) Speech reception threshold
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3. A patient is scheduled for a cochlear implant. Which patient statement indicates that teaching about this surgery has been effective? 1) “This implant will not restore my hearing.” 2) “I will be able to hear perfectly after this surgery.” 3) “This surgery will drain fluid from my middle ear.” 4) “This surgery will rebuild my damaged tympanic membrane.” 4. The nurse is planning care for a patient recovering from a tympanoplasty. Which action should the nurse include to ensure the ear packing stays intact? 1) Increase fluid intake 2) Administer tobramycin 3) Maintain nothing by mouth status 4) Position flat with the operative side up 5. A patient who swims several times a week asks why the ears are becoming frequently infected. What should the nurse explain to this patient? 1) “The pool water is entering your Eustachian tubes.” 2) “The pool water has microorganisms that are entering your ears.” 3) “The pool water is drying out your ears causing skin breakdown.” 4) “The pool water has chlorine that is killing all of the good bacteria.” 6. A patient with external otitis has a ruptured tympanic membrane. Which medication should the nurse expect to be prescribed for this patient? 1) Tobramycin 2) Fluoroquinolone 3) 2.0% Acetic acid (Vosol) 4) 90% to 95% isopropyl alcohol NURSINGTB.COM 7. A patient with external otitis rates pain as 8 on a scale of 0 to 10. What should the nurse do to improve this patient’s comfort? 1) Apply warm, dry heat to the ear 2) Apply a cool compress to the ear 3) Position supine with the affected ear down 4) Obtain an order for an opioid pain medication 8. During a well-child visit the nurse suspects that a two-year-old is experiencing otitis media. What finding did the nurse use to make this clinical determination? 1) Drowsiness 2) Tugging at the ear 3) Tearing of the eyes 4) Clear mucous from the nose 9. A patient with a low-grade fever is diagnosed with otitis media. Which medication should the nurse expect to be prescribed as a priority for this patient? 1) Cefixime (Suprax) 2) Ibuprofen (Motrin) 3) Acetaminophen (Tylenol) 4) Normal saline nose drops 10. A patient being treated for otitis media is experiencing reduced hearing and dizziness. Which complication should the nurse suspect is occurring with this patient? 1) Petrositis
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2) Meningitis 3) Mastoiditis 4) Labyrinthitis 11. A patient seeking medical attention for “buzzing in the ears” asks why the blood pressure is being measured. How should the nurse respond to this patient? 1) “Blood pressure measurement is done on every patient.” 2) “The ear buzzing means your blood vessels are constricted.” 3) “Elevated blood pressure makes the buzzing more noticeable.” 4) “The blood pressure is used to determine what medication you will need.” 12. A patient asks what can be done to stop the “noises” in the ears. What should the nurse ask to determine if the patient is experiencing tinnitus? 1) “What does the noise sound like?” 2) “How often do the noises occur?” 3) “What are the noises saying to you?” 4) “Do the noises occur mostly at night?” 13. A patient with tinnitus is prescribed diphenhydramine. What should the nurse explain to the patient about this medication? 1) “This is an antibiotic that will cure the problem.” 2) “This is a decongestant to help reduce the symptoms.” 3) “This is an anticonvulsant that will stop the aura of the noises.” 4) “This is a vitamin supplement that will improve blood flow to the ears.” 14. A middle-aged patient is experiencing tinnitus. What should the nurse suggest to help determine the reason for this health problem? NURSINGTB.COM 1) Increase the intake of fresh fruit 2) Write down when the noises occur 3) Sleep a few extra hours each night 4) Reduce fluid intake after 1800 hours 15. After an assessment the nurse suspects a patient is experiencing vertigo. Which data caused the nurse to come to this conclusion? 1) Nasal congestion 2) Spinning sensation at rest 3) Feeling of fullness in the ears 4) Mucopurulent drainage from the nose 16. During a home visit the nurse notes that a patient continues to experience vertigo. On what should the nurse focus care during this visit? 1) Safety 2) Nutrition 3) Perfusion 4) Fluid balance 17. The nurse is evaluating teaching provided to a patient with vertigo. Which observation indicates that teaching has been effective? 1) Sips a cup of coffee 2) Changes positions slowly 3) Prepares canned soup for lunch 4) Drinks diet soda during the day
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18. The nurse is reviewing data in a patient’s medical record. Which information increases the patient’s risk for developing Ménière’s disease? 1) Follows a gluten-free diet 2) Allergic to house dust and pet dander 3) Works as a computer science technician 4) Treated for a pinched nerve in the lower back 19. A patient with Ménière’s disease is admitted for intravenous fluid administration. What additional manifestation is seen in this disease process? 1) Muscle cramps 2) Drop in blood pressure 3) Capillary glucose 90 mg/dL 4) Uncontrollable eye movements 20. A patient with Ménière’s disease is experiencing severe nausea and vomiting. Which medication should the nurse expect to be prescribed for this patient? 1) Diazepam (Valium) 2) Meclizine (Antivert) 3) Promethazine (Phenergan) 4) Dimenhydrinate (Dramamine) 21. A patient with severe Ménière’s disease is considering a labyrinthectomy. What should the nurse emphasize as a complication of this procedure? 1) Long-term tinnitus 2) Chronic otitis media 3) Rupture of the tympanic membrN anUe RSINGTB.COM 4) Complete hearing loss of the affected ear 22. The nurse suspects that patient is experiencing undiagnosed Ménière’s disease. Which assessment finding supports the nurse’s clinical decision? 1) Facial pain 2) Nasal drainage 3) Positive Romberg test 4) Decreased deep tendon reflexes Multiple Response Identify one or more choices that best complete the statement or answer the question. 23. The nurse is preparing teaching materials for a group of senior citizens. What information should the nurse include as risk factors for hearing loss? Select all that apply. 1) Diet 2) Heredity 3) Medications 4) Recreational noise 5) Occupational noise 24. A patient seeks medical attention for ear pain. What findings indicate that this patient is experiencing external otitis? Select all that apply. 1) Edema of the ear canal 2) External ear tender to touch
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3) Pain when moving the auricle 4) Purulent drainage from the ear 5) Swelling around the external ear 25. The nurse is preparing information to share during a community health fair. What should the nurse include about risk factors for the development of otitis media? Select all that apply. 1) Chronic illnesses 2) Exposed to smoking 3) Genetic predisposition 4) Flat Eustachian tube in children 5) Current upper respiratory infection 26. The nurse is preparing to assess a patient experiencing tinnitus. What should the nurse include in this assessment? Select all that apply. 1) Current age 2) Nutritional status 3) Presence of earwax 4) Current medications 5) Exposure to loud noises 27. A patient is diagnosed with peripheral inner ear disorder causing vertigo. On which areas should the nurse focus when assessing this patient? Select all that apply. 1) Pinna 2) CN VIII 3) Inner ear 4) Nasopharynx 5) Tympanic membrane NURSINGTB.COM Numeric Response 28. A patient with vertigo is prescribed prochlorperazine (Compro) 10 mg intramuscularly four times a day. A vial containing 250 mg/10 mL of the medication is delivered by the pharmacy. How many mL of the medication should the nurse provide for each dose? Record your answer to the nearest tenth decimal point.
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Chapter 48: Coordinating Care for Patients With Hearing Disorders Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Hearing loss Chapter page reference: 988 Heading: Hearing Loss > Clinical Manifestations Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Easy
1 2 3 4
Feedback Manifestations of increasing difficulty in hearing include turning up the volume on electronics such as televisions and radios. The patient sitting in the kitchen does not indicate a hearing loss. More information is needed about music playing in the background because the volume of the music is not addressed. A family member’s actions doNnU otRiS n dIicN atG e T aB he. arC inOg Mloss.
PTS: 1 CON: Sensory Perception 2. ANS: 2 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected disorders of the ear Chapter page reference: 989 Heading: Hearing Loss > Medical Management > Diagnostic Tests Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Easy
1 2
3
Feedback Tympanometry is a test that measures the impedance of the middle ear to the acoustic energy. Pure-tone threshold is an audiological test conducted with air and bone conduction assessment to quantify hearing loss. To complete this test, the patient wears headphones. Standard MRI with gadolinium enhancement is usually performed with patients who present with an abnormal neurological examination and/or when a cerebellopontineangle lesion is suspected.
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4
Speech reception threshold is used to measure the intensity at which speech is recognized by a patient. This test is used to determine the softest level at which the patient is able to recognize speech.
PTS: 1 CON: Sensory Perception 3. ANS: 1 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Discussing the medical management of selected disorders of the ear Chapter page reference: 990 Heading: Hearing Loss > Medical Management > Treatment Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Perioperative Difficulty: Medium
1 2 3 4
Feedback The cochlear implant does not restore normal hearing. The cochlear implant does not restore normal hearing. A myringotomy drains fluid from the middle ear. A myringoplasty reconstructs the eardrum.
PTS: 1 CON: Sensory Perception | Perioperative 4. ANS: 4 Chapter number and title: 48, CoordiN n aUtinRgSCIaN reGfoTrBP. a tC ie nOtsM With Hearing Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with ear disorders Chapter page reference: 991 Heading: Hearing Loss > Nursing Management > Action Integrated Processes: Nursing Process–Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Perioperative Difficulty: Medium
1 2 3 4
Feedback Increasing the fluid intake may decrease the thickening of the earwax. Tobramycin is an identified ototoxic medication and should be questioned. There is no need to keep the patient NPO. The patient should be positioned flat, turned on the side with the operative side facing up after tympanoplasty. This decreases the chance of packing being displaced.
PTS: 1 CON: Sensory Perception | Perioperative 5. ANS: 3 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Explaining the pathophysiological process of hearing disorders Chapter page reference: 993 Heading: External Otitis > Pathophysiology Integrated Processes: Nursing Process–Implementation
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Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Infection Difficulty: Medium
1 2 3
4
Feedback The pool water is not entering the patient’s Eustachian tubes. The pool water is not causing the patient’s ear infections. External otitis develops in swimmers as a result of excessive water exposure yielding a decrease in cerumen. The decrease in cerumen can lead to drying of the external auditory canal resulting in potential skin breakdown, providing an excellent entry port for bacterial or fungal infections. The pool water is not killing off the patient’s good bacteria.
PTS: 1 CON: Sensory Perception | Infection 6. ANS: 2 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Discussing the medical management of selected disorders of the ear Chapter page reference: 993 Heading: External Otitis > Medical Management Integrated Processes: Nursing Process–Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Sensory Perception; Infection; Medication Difficulty: Medium
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Feedback Tobramycin is used for an acute bacterial infection; however, it is not identified as being safe for a ruptured tympanic membrane. Fluoroquinolone is the only medication approved with tympanic membrane rupture. 2.0% Acetic acid (Vosol) is not identified as being safe for a ruptured tympanic membrane. 90% to 95% isopropyl alcohol is not identified as being safe for a ruptured tympanic membrane.
PTS: 1 CON: Sensory Perception | Infection | Medication 7. ANS: 1 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with ear disorders Chapter page reference: 994 Heading: External Otitis > Nursing Management > Actions Integrated Processes: Nursing Process –Implementation Client Need: Physiological Integrity/Basic Care and Comfort Cognitive level: Application [Applying] Concept: Sensory Perception; Infection; Comfort Difficulty: Medium
1
Feedback Dry, warm heat may provide some comfort when applied to the ear directly.
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2 3 4
Dry heat is preferred over a cool compress. Sitting or semi-sitting with the affected ear on a soft object provides comfort. Supine with the affected ear down may increase pain. Pain relief is usually accomplished by over-the-counter (OTC) medications. An opioid is not required.
PTS: 1 CON: Sensory Perception | Infection | Comfort 8. ANS: 2 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Otitis media Chapter page reference: 996 Heading: Otitis Media > Clinical Manifestations Integrated Processes: Nursing Process–Assessment Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Application [Applying] Concept: Sensory Perception; Infection; Assessment Difficulty: Easy
1 2 3 4
Feedback Drowsiness is not a clinical manifestation of otitis media. Tugging or pulling at the ear is a clinical manifestation of otitis media seen in children. Eye tearing is not a clinical manifestation of otitis media. Clear mucous draining from the nose is not a clinical manifestation of otitis media.
NURSINGTB.COM PTS: 1 CON: Sensory Perception | Infection | Assessment 9. ANS: 1 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Discussing the medical management of selected disorders of the ear Chapter page reference: 996 Heading: Otitis Media > Medical Management Integrated Processes: Nursing Process–Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Sensory Perception; Infection; Medication Difficulty: Moderate
1 2 3 4
Feedback Cefixime (Suprax) is an antibiotic. Oral antimicrobial therapy is the most effective treatment for acute otitis media. Ibuprofen (Motrin) can be used as an antipyretic and analgesic; however, this would not be the priority. Acetaminophen (Tylenol) can be used as an antipyretic and analgesic; however, this would not be the priority. Normal saline nose drops would be used for nasal congestion; however, there is no information to support that the patient is experiencing nasal congestion.
PTS: 1
CON: Sensory Perception | Infection | Medication
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10. ANS: 4 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Describing complications associated with selected disorders of the ear Chapter page reference: 996 Heading: Otitis Media > Medical Management > Complications Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Infection Difficulty: Moderate
1 2 3 4
Feedback Petrositis develops when there is inflammation of the temporal bone that penetrates deep into the ear. Meningitis is an inflammation of the meninges, which is the outer covering of the brain. Mastoiditis is the spread of infection to the mastoid bone that causes an inflammation of the mastoid air cells of the temporal bone. Labyrinthitis is an inflammatory disorder of the inner ear labyrinth that occurs as a complication of otitis media, which results in a disturbance in balance and hearing. This complication may be unilateral or bilateral.
PTS: 1 CON: Sensory Perception | Infection 11. ANS: 3 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Explaining the pathophysiological process of hearing disorders NURSINGTB.COM Chapter page reference: 1000 Heading: Tinnitus > Pathophysiology Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate
1 2 3 4
Feedback Blood pressure measurement might be done on every patient; however, this does address the patient’s problem. Ear buzzing does not necessarily mean that the patient’s blood vessels are constricted. Elevated blood pressure and factors contributing to elevated blood pressure, such as stress, alcohol consumption, and caffeine, make tinnitus more noticeable. The blood pressure measurement for tinnitus is not used to determine the medications that should be prescribed.
PTS: 1 CON: Sensory Perception 12. ANS: 1 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Tinnitus Chapter page reference: 999 Heading: Tinnitus > Clinical Manifestations Integrated Processes: Nursing Process–Assessment
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Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception Difficulty: Moderate
1
2 3 4
Feedback The nurse should ask the patient to describe the noises. The most common bothersome sensations of sound described by patients, when no sound is actually present, include ringing, buzzing, roaring, clicking, whistling, and hissing sounds in the ear. These sounds may be present consistently or intermittently. Asking how often the noises occur will not help determine if the patient is experiencing tinnitus. Asking what the noises are saying to the patient would help determine if the patient is experiencing a mental health disorder. Asking if the noises occur at night is a closed-ended question and would not provide the best information to determine if the patient is experiencing tinnitus.
PTS: 1 CON: Sensory Perception 13. ANS: 2 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Discussing the medical management of selected disorders of the ear Chapter page reference: 1000 Heading: Tinnitus > Medical Management Integrated Processes: Nursing Process–Implementation Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies NURSINGTB.CO Cognitive level: Application [Applying] Concept: Sensory Perception; Medication Difficulty: Moderate
1 2 3 4
Feedback Antibiotics are not prescribed for tinnitus. Antibiotics will not cure the disorder. Decongestants might be prescribed for tinnitus to reduce the symptoms. Anticonvulsants have been used to reduce the symptoms. Tinnitus is not identified as being an aura before a seizure. Vitamin supplements have been shown to reduce the symptoms; however, there is no information to support that the supplement will improve the blood flow to the ears.
PTS: 1 CON: Sensory Perception | Medication 14. ANS: 2 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Developing a teaching plan for a patient with an ear disorder Chapter page reference: 1001 Heading: Tinnitus > Nursing Management > Teaching Integrated Processes: Nursing Process–Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Assessment Difficulty: Moderate
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1 2
3 4
Feedback Lack of fresh fruit is not identified as a risk factor for tinnitus. Instructing patients to keep a diary of clinical manifestations may help to identify a causative agent. This diary should include date/time/symptoms experienced to see if an identifiable trend is present. Lack of sleep is not identified as a risk factor for tinnitus. Excess fluid is not identified as a risk factor for tinnitus.
PTS: 1 CON: Sensory Perception | Assessment 15. ANS: 2 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of
vertigo Chapter page reference: 1002 Heading: Vertigo > Pathophysiology Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Assessment Difficulty: Moderate
1 2 3 4
Feedback Nasal congestion is not a clinical manifestation of vertigo. Clinical manifestations of vertigo include a spinning sensation at rest. Feeling of fullness in the ears N isUn R o tSa IclNinGicT a lBm.a C n iO f eM s tation of vertigo. Mucopurulent drainage from the nose is not a clinical manifestation of vertigo.
PTS: 1 CON: Sensory Perception | Assessment 16. ANS: 1 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Describing complications associated with selected disorders of the ear Chapter page reference: 1002 Heading: Vertigo > Medical Management > Complications Integrated Processes: Nursing Process–Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Safety Difficulty: Moderate
1 2 3 4
Feedback Injuries from falls in the patient with vertigo are not uncommon and may be of particular concern to elderly patients, who can suffer catastrophic effects from a fall. Nutrition is not an issue with vertigo. Perfusion is not an issue with vertigo. Fluid balance is not an issue with vertigo.
PTS: 1 17. ANS: 2
CON: Sensory Perception | Safety
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Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Developing a teaching plan for a patient with an ear disorder Chapter page reference: 1003 Heading: Vertigo > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Safety; Promoting Health Difficulty: Moderate
1 2
3
4
Feedback Avoiding caffeine is most likely associated to the stimulant effects of caffeine. The patient would need more teaching for this observation. Instructions to plan slow, methodical position changes help to decrease vertigo in patients. Decreasing vertigo symptoms with changes of position may also decrease the patient’s risk of falling. Decreasing salt intake probably decreases tinnitus based upon its impact on fluid retention and blood pressure. Limiting salt intake is particularly important in the patient with hypertension who experiences tinnitus. The patient would need more teaching about the sodium content of canned foods. Aspartame may have a toxic effect on the inner ear and brain. The patient would need more teaching about the intake of diet soda.
PTS: 1 CON: Sensory Perception | Safety | Promoting Health 18. ANS: 2 NURSINGTB.COM Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Describing the epidemiology of hearing disorders Chapter page reference: 1003 Heading: Ménière’s Disease > Epidemiology Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception Difficulty: Moderate 1 2 3 4
Feedback A gluten-free diet is not a risk factor for Ménière’s disease. Risk factors for Ménière’s disease include allergies. Vocation is not identified as a risk factor for Ménière’s disease. Lower spinal cord disorders are not identified as risk factors for Ménière’s disease.
PTS: 1 CON: Sensory Perception 19. ANS: 4 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of
Meniere’s disease Chapter page reference: 1004 Heading: Ménière’s Disease > Clinical Manifestations Integrated Processes: Nursing Process–Assessment
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Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception Difficulty: Moderate
1 2 3 4
Feedback Muscle cramps are not associated with Ménière’s disease. Hypotension is not a manifestation of Ménière’s disease. Blood glucose level is not typically assessed in Ménière’s disease. Uncontrollable eye movements are manifestations of Ménière’s disease.
PTS: 1 CON: Sensory Perception 20. ANS: 3 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Discussing the medical management of selected disorders of the ear Chapter page reference: 1005 Heading: Ménière’s Disease > Medical Management Integrated Processes: Nursing Process–Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Sensory Perception; Medication Difficulty: Moderate 1 2 3 4
Feedback Diazepam (Valium) depressesNaU ll le Rve SIlsNoGf tTheBc.ent C OraMl nervous system and thereby decreases symptoms. Meclizine (Antivert) decreases excitability of the inner ear labyrinth and blocks conduction of the inner ear vestibular cerebellar pathways. Promethazine (Phenergan) blocks histamine at the site to decrease symptoms of nausea and vomiting. Dimenhydrinate (Dramamine) decreases the exaggerated sense of motion.
PTS: 1 CON: Sensory Perception | Medication 21. ANS: 4 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Describing complications associated with selected disorders of the ear Chapter page reference: 1005 Heading: Ménière’s Disease > Surgical Management Integrated Processes: Nursing Process–Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Perioperative Difficulty: Moderate
1 2 3
Feedback Tinnitus is not a complication after a labyrinthectomy. Chronic otitis media is not a complication after a labyrinthectomy. Tympanic membrane rupture is not a complication after a labyrinthectomy.
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4
A more radical surgery reserved for very severe cases includes removal of part of the inner ear called a labyrinthectomy. Although this surgery also improves the vertigo symptoms, complete hearing loss in the ear on the affected side is a result of the procedure.
PTS: 1 CON: Sensory Perception | Perioperative 22. ANS: 3 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with ear disorders Chapter page reference: 1006 Heading: Ménière’s Disease > Nursing Management > Assessment Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Sensory Perception; Assessment Difficulty: Moderate
4
Feedback Facial pain is not associated with Ménière’s disease. Nasal drainage is not a primary symptom of Ménière’s disease. In Ménière’s disease, patients may exhibit a positive Romberg test on examination (meaning they have a disturbance in balance) and may also have nystagmus. Changes in deep tendon reflexes do not occur in Ménière’s disease.
PTS:
1
1 2 3
CON: SensoryNPUeR rcS epItioNnG| TAB ss.esCs m OeMn t
MULTIPLE RESPONSE 23. ANS: 2, 3, 4, 5 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Describing the epidemiology of hearing disorders Chapter page reference: 988 Heading: Hearing Loss > Epidemiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Sensory Perception; Promoting Health Difficulty: Easy
1. 2. 3. 4. 5.
Feedback Diet is not identified as placing a person at higher risk for developing hearing loss. Heredity is identified as placing a person at higher risk for developing hearing loss. Medications are identified as placing a person at higher risk for developing hearing loss. Recreational noise is identified as placing a person at higher risk for developing hearing loss. Occupational noise is identified as placing a person at higher risk for developing hearing loss.
PTS: 1 24. ANS: 1, 2, 3, 5
CON: Sensory Perception | Promoting Health
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Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: External otitis Chapter page reference: 993 Heading: External Otitis > Clinical Manifestations Integrated Processes: Nursing Process–Assessment Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Comprehension [Understanding] Concept: Sensory Perception; Infection; Assessment Difficulty: Easy
1. 2. 3. 4. 5.
Feedback Common clinical manifestations of external otitis include edema of the ear canal. Common clinical manifestations of external otitis include external ear is tender to touch. Common clinical manifestations of external otitis include pain when moving the auricle of the ear. Common clinical manifestations of external otitis include scant drainage from the ear. Common clinical manifestations of external otitis include swelling around the external ear.
PTS: 1 CON: Sensory Perception | Infection | Assessment 25. ANS: 2, 3, 4, 5 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Describing the epidemiology of hearing disorders Chapter page reference: 995 Heading: Otitis Media > Epidemiology NURSINGTB.COM Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Sensory Perception; Infection; Promoting Health Difficulty: Easy
1. 2. 3. 4.
5.
Feedback Chronic illnesses is not an identified risk factor for otitis media. Smoking can cause chronic inflammation to the airways, increasing a person’s risk of developing otitis media. Patients with family members who have an identified genetic predisposition for otitis media are at greater risk of developing this disorder. The Eustachian tube is more flat in children or other congenital features can accentuate infection. This flattening of the Eustachian tube prevents drainage and makes fluid in the ear more likely to stagnate or to accumulate. Inflammation from an upper respiratory infection can cause narrowing of passages in the ear, predisposing the patient to fluid accumulation and infection.
PTS: 1 CON: Sensory Perception | Infection | Promoting Health 26. ANS: 1, 3, 4, 5 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Describing the epidemiology of hearing disorders Chapter page reference: 998 Heading: Tinnitus > Epidemiology
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Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Advanced age is a risk factor for the development of tinnitus. Nutritional status is not identified as a risk factor for the development of tinnitus. Earwax blockage is identified as a risk factor for tinnitus. Certain medications such as salicylates, NSAIDs, and some antihypertensives, antidepressants, and chemotherapeutic agents can increase the risk of developing tinnitus. Exposure to loud noises can increase the patient’s risk of developing tinnitus.
PTS: 1 CON: Sensory Perception | Assessment 27. ANS: 2, 3 Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Explaining the pathophysiological process of hearing disorders Chapter page reference: 1002 Heading: Vertigo > Pathophysiology Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Sensory Perception; Assessment Difficulty: Moderate NURSINGTB.COM 1. 2. 3. 4. 5.
Feedback The pinna is part of the outer ear. Disorders of the inner ear and CN VIII are termed peripheral disorders. Disorders of the inner ear and CN VIII are termed peripheral disorders. The nasopharynx is not a part of the inner ear. The tympanic membrane separates the external from the middle ear.
PTS: 1
CON: Sensory Perception | Assessment
NUMERIC RESPONSE 28. ANS: 0.4 mL Chapter number and title: 48, Coordinating Care for Patients With Hearing Disorders Chapter learning objective: Discussing the medical management of selected disorders of the ear Chapter page reference: 1002 Heading: Vertigo > Medical Management > Treatment Integrated Processes: Nursing Process–Implementation Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Sensory Perception; Medication Difficulty: Moderate
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Feedback: First determine the amount of medication in each mL by dividing 250 mg/10 mL = 25 mg. Then divide the dose prescribed by the dose available or 10 mg/25 mg x 1 mL = 0.4 mL. The patient should receive 0.4 mL of medication in each dose. PTS: 1
CON: Sensory Perception | Medication
Chapter 49: Assessment of Integumentary Function Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is preparing information on the integumentary system for a group of high school students. Which layer of the skin should the nurse explain that plays an initial role in immunity? 1) Dermis 2) Hypodermis 3) Innermost layer of the epidermis 4) Outermost layer of the epidermis 2. A patient is concerned about hair loss. What should the nurse explain about the relationship between hair and the skin? 1) Hair follicles are anchored and protrude through the dermis. 2) Hair follicles are anchored and protrude through the epidermis. 3) Hair follicles are anchored in the dermis and protrude through the epidermis. 4) Hair follicles are anchored in theNhUyR p oSdI erNmG isTa B n d.pC roOtrM u de through the dermis. 3. The nurse notes that a male patient is bald. What is the status of the hair follicles on the head of this patient? 1) Dead 2) In the resting phase 3) Awaiting keratinization 4) Pausing in the growth cycle 4. A patient asks why it takes so long for fingernails to grow. How should the nurse respond to this patient? 1) “Nail growth speeds up as a person ages.” 2) “Nails have a slow but continuous growth process.” 3) “Slow nail growth is associated with vitamin deficiencies.” 4) “This could mean you have an undiagnosed disease process.” 5. The nurse is caring for a patient with a major burn on the right arm. Which function of the skin is most affected by this injury? 1) Sensation 2) Excretion 3) Protection 4) Metabolism 6. An older patient says that sunlight has always been avoided because of the risk for developing skin cancer. Which function of the skin has been most affected by this patient’s practice? 1) Sensation 2) Protection 3) Vitamin D metabolism
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4) Temperature regulation 7. The nurse notes that a patient’s skin and hair are dry. Which function of the skin is most likely malfunctioning? 1) Sensation 2) Excretion 3) Protection 4) Metabolism 8. The nurse notes that a patient’s fingertips are blue in color. What should this finding indicate to the nurse? 1) Anemia 2) Liver disease 3) Hemosiderin 4) Poor perfusion 9. The nurse notes that a patient has irregularly shaped areas on the skin that are rough and thick. What health problem should the nurse suspect is causing this patient’s skin condition? 1) Eczema 2) Drug rash 3) Open vesicles 4) Chronic dermatitis 10. The nurse notes that a patient has longitudinal red lines in the finger nails. What health problem should the nurse suspect is causing this problem? 1) Lymphedema 2) Respiratory failure 3) Bacterial endocarditis NURSINGTB.COM 4) Inflammatory bowel disease 11. An older patient is experiencing dry skin that is itchy and burns. Which age-related change should the nurse consider is causing this patient’s symptoms? 1) Xerosis 2) Eczema 3) Psoriasis 4) Herpes zoster 12. An older patient asks why a wound is taking so long to heal. What explanation should the nurse provide to this patient? 1) “There is less protein in the skin with aging.” 2) “The tissue between the skin cells is weaker.” 3) “The amount of blood flow to the skin is slower with aging.” 4) “The number of immune cells in the skin reduces with aging.” 13. The nurse notes that an older patient complains of always feeling cold. Which age-related change to the skin could be causing this in the patient? 1) Fewer protein stores 2) Decreased subcutaneous tissue 3) Reduced levels of immune cells 4) Slower blood flow to the skin layers 14. An older patient has areas of psoriasis on the arms and legs. What should the nurse expect to be prescribed for this patient?
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1) 2) 3) 4)
Topical steroids Topical Benadryl Lidocaine patches Systemic antibiotics
15. The nurse needs to send a specimen for a wound culture. What should the nurse do prior to obtaining the specimen? 1) Apply clean gloves 2) Flush the wound bed with sterile saline 3) Cleanse the wound with antimicrobial solution 4) Keep the wound open to air for several minutes 16. The nurse instructs a patient on care required after a punch biopsy. Which patient statement indicates that teaching has been effective? 1) “I should avoid showering for several days.” 2) “I should change the bandage on the site once a day.” 3) “I should call the doctor if there is any blood on the dressing.” 4) “I should call the doctor if the site is not healed in a few days.” 17. The results of a patient’s biopsy indicate a malignant growth. What should the nurse anticipate being prescribed for this patient? 1) Systemic medication 2) Additional diagnostic testing 3) Topical antibiotic medication 4) Surgical removal of the lesion 18. The nurse notes that a patient with a N skU inRrS a sI h N h aGs T a nBe.leC vaOteMd white blood cell count. What should this information suggest to the nurse? 1) An infection is present. 2) Protein status is questionable. 3) Infection is altering blood flow. 4) Infection has reached the blood stream. 19. A patient is suspected as having a fungal infection. What should the nurse have available during the evaluation of this skin area? 1) Sterile water 2) Potassium chloride 3) Sterile normal saline 4) Potassium hydroxide 20. A patient recovering from a punch biopsy calls the community clinic because the site is red, warm, and painful. What should the nurse direct this patient to do? 1) Take an over-the-counter analgesic 2) Clean the site with hydrogen peroxide 3) Go immediately to the emergency department 4) Remove the dressing and flush with sterile saline Multiple Response Identify one or more choices that best complete the statement or answer the question.
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21. The nurse is preparing information for high school students about the skin. What should the nurse include about the function of the glands in the skin? Select all that apply. 1) Eccrine sweat glands serve to cool the body. 2) Apocrine sweat glands contribute to body odor. 3) The glands create strength and elastic recoil to the skin. 4) They support temperature regulation through dilation and constriction. 5) Sebaceous glands produce a substance that moisturizes the hair and skin. 22. The nurse notes that a patient’s skin is dry, discolored, and easily torn. Which medications should the nurse consider as causing this patient’s skin condition? Select all that apply. 1) Steroids 2) Furosemide 3) Amiodarone 4) Warfarin sodium 5) Nonsteroidal anti-inflammatory drugs (NSAIDs) 23. The nurse suspects that a patient’s disrupted skin integrity has a chemical basis. What could have caused this patient’s health problem? Select all that apply. 1) Urine 2) Stool 3) Adhesives 4) Immobility 5) Gastric fluids 24. “Possible viral skin infection” is documented in a patient’s medical record. Which infections should the nurse consider as causing the patient’s skin problem? Select all that apply. 1) Rubella NURSINGTB.COM 2) Measles 3) Cellulitis 4) Folliculitis 5) Herpes simplex 25. A patient is to undergo a punch biopsy of a lesion. What should the nurse anticipate when assisting in the collection of this specimen? Select all that apply. 1) A sterile blade will be used. 2) The site may need stitches. 3) Local anesthesia will be provided. 4) The entire lesion may be removed. 5) The sample includes epidermis, dermis, and subcutaneous tissue.
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Chapter 49: Assessment of Integumentary Function Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Identifying key anatomical components of the integumentary system Chapter page reference: 1011 Heading: Overview of Anatomy, Physiology, and Function > Epidermis Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Skin Integrity; Health Promotion Difficulty: Moderate
1
2 3 4
Feedback The dermis is beneath the epidermis and contains blood vessels, nerves, immune system cells including macrophages and mast cells, dermal proteins including collagen and elastin, hair follicles, and sweat and sebaceous glands. The hypodermis contains adipose tissue, connective tissue, nerves, and blood supply. The innermost level of the epidermis contains dendritic structures called Langerhans cells, which are the outermost cells of the immune system. The outermost skin layer is called the epidermis and protects the body by forming a barrier that resists pathogen inN vaUsR io S n INGTB.COM
PTS: 1 CON: Skin Integrity | Health Promotion 2. ANS: 3 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Identifying key anatomical components of the integumentary system Chapter page reference: 1011 Heading: Overview of Anatomy, Physiology, and Function > Hair Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering] Concept: Skin Integrity; Health Promotion Difficulty: Easy
1 2 3 4
Feedback Hair follicles are anchored in the dermis, then protrude into the epidermis. Hair follicles are anchored in the dermis, then protrude into the epidermis. Hair follicles are anchored in the dermis, then protrude into the epidermis. Hair follicles are anchored in the dermis, then protrude into the epidermis.
PTS: 1 CON: Skin Integrity | Health Promotion 3. ANS: 1 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Identifying key anatomical components of the integumentary system
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Chapter page reference: 1012 Heading: Overview of Anatomy, Physiology, and Function > Hair Integrated Processes: Nursing Process–Assessment Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering] Concept: Skin Integrity; Health Promotion Difficulty: Easy
1 2 3 4
Feedback Complete death of a hair follicle results in baldness. In the resting phase the hair follicle holds onto the hair shaft which minimizes hair loss. Keratinization occurs during the hair growth cycle, which is absent when the hair follicles are dead. A pause in the growth cycle is the resting phase; however, this is not occurring because the patient’s hair follicles are dead.
PTS: 1 CON: Skin Integrity | Health Promotion 4. ANS: 2 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Identifying key anatomical components of the integumentary system Chapter page reference: 1012 Heading: Overview of Anatomy, Physiology, and Function > Nails Integrated Processes: Nursing Process–Implementation Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering] Concept: Skin Integrity; Health PromNoU tioRnSINGTB.COM Difficulty: Easy
1 2 3 4
Feedback Nail growth does not speed up as a person ages. Nails have a slow but continuous growth process. Slow nail growth is normal. This does not mean the patient has a vitamin deficiency. Slow nail growth is normal. This does not mean the patient has an undiagnosed disease process.
PTS: 1 CON: Skin Integrity | Health Promotion 5. ANS: 3 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Discussing the function of the integumentary system Chapter page reference: 1010 Heading: Overview of Anatomy, Physiology, and Function Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Skin Integrity Difficulty: Moderate Feedback 1 Sensation is controlled in the dermis, the location of many nerve receptors that communicate with the central nervous system.
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2 3 4
The role of the skin in excretion relates to losses of fluid through the sweat glands, the evaporation of water through the skin. Providing protection from the external environment as well as to underlying structures and organs, the skin is essential to homeostasis. Vitamin D metabolism is another major function of the skin, as the epidermis is the major source of vitamin D for the body. Activated in the epidermis by ultraviolet light, vitamin D enters the circulation and works in the gastrointestinal system to facilitate calcium absorption.
PTS: 1 CON: Skin Integrity 6. ANS: 3 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Discussing the function of the integumentary system Chapter page reference: 1010 Heading: Overview of Anatomy, Physiology, and Function Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Skin Integrity Difficulty: Moderate Feedback 1 Sensation is controlled in the dermis, the location of many nerve receptors that communicate with the central nervous system. 2 Providing protection from the external environment as well as to underlying structures and organs, the skin is essentiaNl U toRhS om IeNoGstas T Bis..COM 3 Vitamin D metabolism is another major function of the skin, as the epidermis is the major source of vitamin D for the body. Activated in the epidermis by ultraviolet light, vitamin D enters the circulation and works in the gastrointestinal system to facilitate calcium absorption. 4 Supporting temperature regulation, the skin plays a role through facilitating heat loss or heat conservation through the skin. PTS: 1 CON: Skin Integrity 7. ANS: 2 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Discussing the function of the integumentary system Chapter page reference: 1011 Heading: Overview of Anatomy, Physiology, and Function Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Skin Integrity Difficulty: Moderate Feedback 1 Sensation is controlled in the dermis, the location of many nerve receptors that communicate with the central nervous system.
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2
3 4
Eccrine sweat glands cover most of the body’s surface and apocrine sweat glands are present in hair follicles of the armpits and genitalia. Sebaceous glands produce sebum, which exits from the hair follicle. Sebum is a lipid-rich substance that moisturizes hair and skin. Providing protection from the external environment as well as to underlying structures and organs, the skin is essential to homeostasis. Vitamin D metabolism is another major function of the skin, as the epidermis is the major source of vitamin D for the body. Activated in the epidermis by ultraviolet light, vitamin D enters the circulation and works in the gastrointestinal system to facilitate calcium absorption.
PTS: 1 CON: Skin Integrity 8. ANS: 4 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of integumentary function Chapter page reference: 1017 Heading: Assessment > Color Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Skin Integrity; Assessment Difficulty: Moderate
NURSINGTB.COM 1 2 3 4
Generalized pallor would indicate anemia. Yellow skin and mucous membranes are seen in liver disease. Hemosiderin discolors the skin brown and is caused by RBC trapped in dermal layers. Cyanosis indicates poor perfusion.
PTS: 1 CON: Skin Integrity | Assessment 9. ANS: 4 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of integumentary function Chapter page reference: 1023 Heading: Assessment > Lesions Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Skin Integrity; Assessment Difficulty: Moderate
1 2 3 4
Feedback Eczema could cause dried exudate from a wound bed. A drug rash would cause the skin to flake. An open vesicle would be red and moist. Lichenification is an irregular shape that causes the epidermis to become rough and thick. This can be caused by chronic dermatitis.
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PTS: 1 CON: Skin Integrity | Assessment 10. ANS: 3 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of integumentary function Chapter page reference: 1028 Heading: Assessment > Nails > Color Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Skin Integrity; Assessment Difficulty: Moderate 1 2 3 4
Feedback Yellow nails are associated with lymphedema. Cyanotic nails are associated with respiratory failure. Longitudinal red lines are associated with bacterial endocarditis, White or opaque nails are associated with inflammatory bowel disease.
PTS: 1 CON: Skin Integrity | Assessment 11. ANS: 1 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Discussing changes in integumentary appearance and function associated with aging NURSINGTB.COM Chapter page reference: 1031 Heading: Age-Related Skin Changes Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Skin Integrity; Assessment Difficulty: Moderate Feedback 1 In xerosis the skin appears rough dry and is often described as itching or pruritus and burning, 2 Eczema is reddened skin that has weeping, crusting, scales, and severe pruritus. 3 Psoriasis is thick, flaky, silvery skin that appears as circumferential red patches. 4 Herpes zoster appears as blistering and erythema along a dermatome. PTS: 1 CON: Skin Integrity | Assessment 12. ANS: 3 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Discussing changes in integumentary appearance and function associated with aging Chapter page reference: 1031 Heading: Age-Related Skin Changes Integrated Processes: Nursing Process–Implementation Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Application [Applying]
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Concept: Skin Integrity Difficulty: Moderate Feedback 1 2 3 4
With aging, less collagen and elastin weakens the tensile strength of the skin. With aging, flattening of the rete ridges weakens the strength of the epidermal-dermal junction. With aging, the vascularity of the dermis decreases, which causes slower healing rates. With aging, fewer immune cells impacts the ability to recognize and respond to invading organisms. This will not impact wound healing.
PTS: 1 CON: Skin Integrity 13. ANS: 2 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Discussing changes in integumentary appearance and function associated with aging Chapter page reference: 1031 Heading: Age-Related Skin Changes Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Skin Integrity Difficulty: Moderate Feedback Fewer protein stores would caNu U seRthSeIskNinGtT oB be.w 1 CeOakMer. 2 Temperature regulation becomes less efficient because of decreased subcutaneous tissue. 3 Reduced levels of immune cells increase the risk of skin infections. 4 Slower blood flow to the skin layers will slow wound healing. PTS: 1 CON: Skin Integrity 14. ANS: 1 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Discussing changes in integumentary appearance and function associated with aging Chapter page reference: 1031 Heading: Age-Related Skin Changes Integrated Processes: Nursing Process–Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Skin Integrity; Medication Difficulty: Moderate Feedback 1 Topical steroids are used to treat psoriasis. 2 Topical Benadryl would be used to reduce itching associated with an allergic skin reaction. 3 Lidocaine patches would be used to reduce the pain associated with herpes zoster lesions.
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4
Systemic antibiotics would not be indicated for psoriasis but may be used for a bacterial skin infection.
PTS: 1 CON: Skin Integrity | Medication 15. ANS: 2 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to integumentary function Chapter page reference: 1033 Heading: Diagnostic Studies and Nursing Considerations > Culturing and Laboratory Studies > Tissue Culturing Integrated Processes: Nursing Process–Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Moderate
1 2 3 4
Feedback A wound culture is obtained using sterile technique. The wound should be flushed with normal saline to remove surface residue. The wound should be cleansed with a non-antiseptic solution. Keeping the wound open to air could dry the wound bed and affect the amount of specimen obtained.
PTS: 1 CON: Skin Inte Ngr URitySINGTB.COM 16. ANS: 2 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to integumentary function Chapter page reference: 1035 Heading: Diagnostic Studies and Nursing Considerations > Culturing and Laboratory Studies > Skin Biopsy > Nursing Implications Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Skin Integrity Difficulty: Moderate 1 2 3 4
Feedback Showering is permitted the day after the biopsy. The bandage should be changed daily. A small amount of red drainage is normal and does not need to be reported to the health-care provider. It may take one to two weeks for the site to heal. The health-care provider does not need to be notified if the site has not healed in a few days.
PTS: 1 CON: Skin Integrity 17. ANS: 4 Chapter number and title: 49, Assessment of Integumentary Function
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Chapter learning objective: Correlating relevant diagnostic examinations to integumentary function Chapter page reference: 1035 Heading: Diagnostic Studies and Nursing Considerations > Culturing and Laboratory Studies > Skin Biopsy > Significance of Abnormal Values Integrated Processes: Nursing Process–Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Moderate 1 2 3 4
Feedback Systemic medication may be prescribed for a fungal infection. Additional diagnostic testing may be prescribed for an inflammatory lesion. Topical antibiotic medication may be prescribed for a bacterial infection. For a malignant growth treatment involves surgical removal of the lesion as well as removal of 5–6 mm of healthy tissue surrounding the lesion to ensure safe margins.
PTS: 1 CON: Skin Integrity 18. ANS: 1 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Correlating relevant diagnostic examinations to integumentary function Chapter page reference: 1033 Heading: Diagnostic Studies and Nursing Considerations > Culturing and Laboratory Studies > Laboratory Studies Integrated Processes: Nursing Process–Planning NURSINGTB.COM Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Skin Integrity Difficulty: Moderate
1 2 3 4
Feedback A complete blood count is used to evaluate for an infection. Protein status is evaluated through a serum albumin level. Doppler ultrasound will determine if the infection is altering the blood flow. Blood cultures are used to determine if an infection has entered the circulatory system.
PTS: 1 CON: Skin Integrity 19. ANS: 4 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to integumentary function Chapter page reference: 1034 Heading: Diagnostic Studies and Nursing Considerations > Culturing and Laboratory Studies > Laboratory Studies > Fungal Infection Integrated Processes: Nursing Process–Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Moderate
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1 2 3 4
Feedback Sterile water is not used during the diagnostic evaluation of a fungal specimen. Potassium chloride is not used during the diagnostic evaluation of a fungal specimen. Sterile normal saline is not used during the diagnostic evaluation of a fungal specimen. During diagnostic evaluation of a fungal specimen, a potassium hydroxide (KOH) preparation is most frequently used because it partially dissolves the keratin protein so that the fungal cells become perceptible in the specimen.
PTS: 1 CON: Skin Integrity 20. ANS: 2 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to integumentary function Chapter page reference: 1035 Heading: Diagnostic Studies and Nursing Considerations > Culturing and Laboratory Studies > Skin Biopsy > Nursing Implications Integrated Processes: Nursing Process–Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Moderate
1 2 3 4
Feedback The site needs to be cleansed. N AU n R ovSer-t INheG-cToBun.teCr OanMalgesic may not be sufficient. If erythema, edema, increased pain, or drainage develops, clean the site with hydrogen peroxide. The patient does not need emergency care at this time. The site should be flushed with hydrogen peroxide. Sterile normal saline would not help remove any pathogens in the biopsy site.
PTS: 1
CON: Skin Integrity
MULTIPLE RESPONSE 21. ANS: 1, 2, 5 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Discussing the function of the integumentary system Chapter page reference: 1012 Heading: Overview of Anatomy, Physiology, and Function > Dermis Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering] Concept: Skin Integrity; Health Promotion Difficulty: Easy Feedback
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1. 2. 3. 4. 5.
Eccrine sweat glands cover most of the body’s surface. They produce a water-and-salt mixture that evaporates to cool the body. Apocrine sweat glands are present in hair follicles of the armpits and genitalia. Secretions from these glands contribute to body odor. Dermal proteins create tensile strength elastic recoil in the skin. Blood vessels support temperature regulation via dilation and constriction. Sebaceous glands produce sebum, which exits from the hair follicle. Sebum is a lipid -rich substance that moisturizes hair and skin.
PTS: 1 CON: Skin Integrity | Health Promotion 22. ANS: 1, 3, 4, 5 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of integumentary function Chapter page reference: 1014 Heading: Assessment > Personal History: Medications Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Skin Integrity; Assessment; Medications Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Medications that may disrupt skin integrity include steroids. Furosemide is not identiN fiU edRasS aIm NeGdTicatB.io nC thOatM may disrupt skin integrity . Medications that may disrupt skin integrity include amiodarone. Medications that may disrupt skin integrity include warfarin sodium. Medications that may disrupt skin integrity include NSAIDs.
PTS: 1 CON: Skin Integrity | Assessment | Medications 23. ANS: 1, 2, 5 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of integumentary function Chapter page reference: 1018 Heading: Physical Assessment > Integrity Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Skin Integrity; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Urine is a chemical factor that disrupts the skin integrity. Stool is a chemical factor that disrupts the skin integrity. Adhesives are mechanical factors that disrupt the skin integrity. Immobility is a mechanical factor that disrupts the skin integrity. Gastric fluids are a chemical factor that disrupts the skin integrity.
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PTS: 1 CON: Skin Integrity | Assessment 24. ANS: 1, 2, 5 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Correlating relevant diagnostic examinations to integumentary function Chapter page reference: 1033 Heading: Diagnostic Studies and Nursing Considerations > Culturing and Laboratory Studies > Significance of Abnormal Values Integrated Processes: Nursing Process–Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Skin Integrity Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Rubella is a viral infection. Measles is a viral infection. Cellulitis is a bacterial infection. Folliculitis is a bacterial infection. Herpes simplex is a viral infection.
PTS: 1 CON: Skin Integrity 25. ANS: 2, 3, 5 Chapter number and title: 49, Assessment of Integumentary Function Chapter learning objective: Correlating relevant diagnostic examinations to integumentary function NURSINGTB.COM Chapter page reference: 1034 Heading: Diagnostic Studies and Nursing Considerations > Culturing and Laboratory Studies > Skin Biopsy Integrated Processes: Nursing Process–Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Moderate 1. 2. 3. 4. 5. PTS: 1
Feedback A sterile blade is used for a shave biopsy. Minimal stitching may be required for a punch biopsy. Local anesthesia will be provided for a punch biopsy. The entire lesion may be removed for an excisional biopsy. The sample includes the epidermis, dermis, and subcutaneous tissue in a punch biopsy. CON: Skin Integrity
Chapter 50: Coordinating Care for Patients With Skin Disorders Multiple Choice Identify the choice that best completes the statement or answers the question.
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1. A patient seeks medical care for a carbuncle. What treatment should the nurse expect to be prescribed as a priority for this patient? 1) Moist heat 2) Incision and drainage 3) Topical mupirocin ointment 4) Clindamycin and peroxide wash 2. A patient has a leg wound that has beige exudate and a fishy odor. For which microorganism should the nurse plan care for this patient? 1) Proteus 2) Pseudomonas 3) Streptococcus 4) Staphylococcus 3. A patient is demonstrating signs of a herpes simplex virus infection. Which diagnostic test should be prescribed to confirm this diagnosis? 1) Pap smear 2) Tzanck’s smear 3) Sedimentation rate 4) HSV-1 antibody testing 4. A patient is diagnosed with herpes simplex viral encephalitis. Which medication should the nurse prepare to administer to this patient? 1) Acyclovir 2) Famciclovir 3) Valacyclovir 4) Parenteral acyclovir NURSINGTB.COM 5. A patient is experiencing scaly, patchy skin changes on the upper back, chest, and arms. In some areas the skin is either red, dark in color, or lighter in color. Which type of fungal infection is this patient most likely experiencing? 1) Intertrigo 2) Tinea corporis 3) Tinea unguium 4) Tinea versicolor 6. A patient is diagnosed with tinea corporis. Which medication should the nurse expect to be prescribed to treat this infection? 1) Topical miconazole 2) Topical terbinafine (Lamisil) 3) Topical butenafine (Lotrimin) 4) Topical selenium sulfide 1% (Selsun Blue) 7. During an assessment the nurse notes skin changes on the patient’s elbows and knees. Which findings support that these changes are plaque psoriasis? 1) Red raised areas with inconsistent borders 2) Thick red plaques covered with silvery scales 3) Large reddened areas of weeping and maceration 4) Small raised and reddened areas with fluid-filled pustules 8. A patient with psoriasis is prescribed salicylic acid. What should the nurse explain to the patient about this treatment?
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1) 2) 3) 4)
Prevents formation of new lesions Decreases scaling and softens plaques Suppresses cell division and decreases inflammation Diminishes proliferation of keratinocytes and decrease inflammation
9. The nurse instructs a patient on medications prescribed to treat psoriasis. Which patient statement indicates that additional teaching is required? 1) “This medication will cure the disease.” 2) “This medication can stain my skin and clothes.” 3) “This medication can cause my skin to get irritated.” 4) “The condition can get worse if I stop this medication.” 10. A patient is prescribed phototherapy as treatment for psoriasis. Which patient statement indicates that teaching about this treatment has been effective? 1) “I should expect my skin to feel painful from the treatments.” 2) “I should expect my skin to become red from the treatments.” 3) “I should not have a treatment if my skin gets red or is blistered.” 4) “I should expect occasional blisters and drainage from the treatments.” 11. The nurse notes that a patient has several lacerations over the coccyx area. What finding most likely caused these lesions? 1) Heat 2) Pressure 3) Shearing 4) Moisture 12. The nurse notes that a patient’s wounNdUisRwSe eIpNinGg TanBd.e dCeOmMatous. In which phase of healing is this wound? 1) Maturation 2) Hemostasis 3) Proliferative 4) Inflammatory 13. A patient has a secondary closure surgical wound. What was most likely used to close this wound? 1) Tape 2) Grafts 3) Staples 4) Sutures 14. A patient has a blood-filled blister surrounded by tissue that is painful, mushy, and warm to the touch. How should the nurse classify this skin presentation? 1) Stage III ulcer 2) Stage IV ulcer 3) Unstageable 4) Suspected tissue injury 15. A patient with a pressure ulcer is prescribed a zinc supplement. What should the nurse explain to the patient about this supplement? 1) It helps strengthen capillaries. 2) It helps with immune function. 3) It is needed for protein synthesis. 4) It aids with red blood cell formation.
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16. A patient with a sacral stage III pressure ulcer has an elevated temperature. What diagnostic test would help determine if this patient is developing osteomyelitis? 1) CT scan 2) Bone biopsy 3) Venous Doppler 4) Serum electrolytes 17. The nurse is preparing an educational tool to teach high school students about skin cancer. What should the nurse highlight as being the most common precancerous lesion? 1) Basal cell 2) Melanoma 3) Squamous cell 4) Actinic keratoses 18. A patient is diagnosed with basal cell carcinoma. What should the nurse expect to assess in this patient? 1) Translucent papule 2) Reddish brown plaque 3) Crusted ulcerated plaque 4) Asymmetric black lesion 19. The nurse is caring for a patient with a squamous cell lesion. For which treatment should the nurse prepare this patient? 1) Radiotherapy 2) Mohs’ surgery 3) Photodynamic therapy 4) Curettage and electrodessication
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20. The nurse is teaching at a community fair about ways to reduce the risk of skin cancer. What should the nurse emphasize in this presentation? 1) Wear clothing with UV protection 2) Use sunscreen with an SPF of at least 15 3) Examine the body every six months for lesions 4) Spend time in the sun between the hours of 1000 and 1600 21. A patient is admitted for reconstructive surgery. For which reason should the nurse consider that this surgery is needed? 1) Cancer 2) Face lift 3) Rhinoplasty 4) Breast augmentation 22. A patient recovering from reconstructive surgery is experiencing unrelenting postoperative pain. What should the nurse consider is occurring with this patient? 1) Infection 2) Fluid imbalance 3) Electrolyte imbalance 4) Attention-seeking behavior Multiple Response Identify one or more choices that best complete the statement or answer the question.
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23. After reviewing the visit schedule, the home-care nurse prepares for patients who might have a community acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infection. What skin conditions caused the nurse to take this action? Select all that apply. 1) Abscess 2) Eczema 3) Cellulitis 4) Impetigo 5) Folliculitis 24. The nurse is concerned that a patient is developing a complicated soft tissue bacterial infection. What assessment findings caused the nurse to come to this conclusion? Select all that apply. 1) Pain 2) Fever 3) Tachycardia 4) Muscle atrophy 5) Low blood pressure 25. The nurse suspects that a patient is experiencing a recurrent herpes simplex virus infection. What assessment findings were used to make this decision? Select all that apply. 1) Fever 2) Anorexia 3) Areas of redness 4) Tingling sensation 5) Fluid-filled vesicles 26. The nurse determines that a patient’s abdominal wound is in the proliferative phase of healing. What is occurring during this phase? Select aN ll U thR a tSaI ppNlyG. TB.COM 1) Granulation 2) Angiogenesis 3) Epithelialization 4) Collagen synthesis 5) Reorganization of collagen 27. A patient’s leg wound is not healing as quickly as expected. What should the nurse do to determine the reason for the patient’s poor healing? Select all that apply. 1) Obtain a referral for a dietician 2) Elevate the extremity on a pillow 3) Increase the frequency of dressing changes 4) Encourage increased independent movement 5) Obtain an order for prealbumin and albumin levels Numeric Response 28. The nurse sends 10 samples of body sites to assess an intensive care patient’s Candida colonization index. Seven of the samples came back as being positive. What is this patient’s colonization index? Record your answer to the nearest tenth decimal point. _
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Chapter 50: Coordinating Care for Patients With Skin Disorders Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Discussing the medical management of: Bacterial skin infections Chapter page reference: 1041 Heading: Bacterial Skin Infections > Medical Management Integrated Processes: Nursing Process–Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Moderate
1 2 3 4
Feedback Moist heat is used to treat folliculitis or furuncles. Treatment of a carbuncle includes incision and drainage. Topical mupirocin ointment is used to treat impetigo and a furuncle. Clindamycin and peroxide wash is used to treat folliculitis caused by MRSA.
PTS: 1 CON: Skin Integrity 2. ANS: 1 NURSINGTB.COM Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with skin disorders Chapter page reference: 1045 Heading: Bacterial Skin Infections > Nursing Management > Assessment Integrated Processes: Nursing Process–Planning Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Application [Applying] Concept: Skin Integrity; Infection Difficulty: Moderate
1 2 3 4
Feedback Beige pus and fishy odor is associated with a Proteus infection. Greenish-blue drainage with a fruity odor is associated with a Pseudomonas infection. No specific drainage is identified for a Streptococcus infection. Creamy yellow pus is associated with a Staphylococcus infection.
PTS: 1 CON: Skin Integrity | Infection 3. ANS: 4 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of skin disorders Chapter page reference: 1047 Heading: Herpes Simplex Virus > Medical Management > Diagnosis Integrated Processes: Nursing Process–Planning
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Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Application [Applying] Concept: Skin Integrity; Infection Difficulty: Moderate
1 2 3 4
Feedback Pap smear is a nonspecific method of diagnosing herpes simplex virus. Tzanck’s smear is a nonspecific method of diagnosing herpes simplex virus. Sedimentation rate is used to determine inflammation. Serological type-specific glycoprotein G–based assays obtained from capillary or serum blood samples accurately diagnose herpes simplex virus.
PTS: 1 CON: Skin Integrity | Infection 4. ANS: 4 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Discussing the medical management of: Herpes simplex Chapter page reference: 1047 Heading: Herpes Simplex Virus > Medical Management > Treatment Integrated Processes: Nursing Process–Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Skin Integrity; Infection; Medication Difficulty: Moderate
NURSINGTB.COM 1 2 3 4
The bioavailability of acyclovir is less through the oral route. Famciclovir is helpful in the treatment of herpes simplex virus; however, it not recommended for encephalitis. Valacyclovir is helpful in the treatment of herpes simplex virus; however, it is not recommended for encephalitis. Because the bioavailability of IV acyclovir is greater than the oral route, IV acyclovir is utilized for patients with severe disease or those who encounter complications of HSV such as encephalitis.
PTS: 1 CON: Skin Integrity | Infection | Medication 5. ANS: 4 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Fungal infections Chapter page reference: 1052 Heading: Fungal Infections > Pathophysiology and Clinical Manifestations Integrated Processes: Nursing Process–Assessment Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Comprehension [Understanding] Concept: Skin Integrity; Infection Difficulty: Easy Feedback
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1
2 3 4
Intertrigo is a fungal infection that is found in the skinfolds and is worsened by heat, moisture, and lack of air. The infection causes maceration, skin erosion, erythema, itching, and burning. Tinea corporis is a fungal infection that causes annual patches or plaques on the body. Tinea unguium is a fungal infection that affects the nails, causing yellow, brittle, thick nails with subungual hyperkeratosis. Tinea versicolor is a fungal infection that occurs on the upper chest, back, and upper arms that creates scaly patches of different colors that are either red, dark in color, or absent of color.
PTS: 1 CON: Skin Integrity | Infection 6. ANS: 1 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Fungal infections Chapter page reference: 1050 Heading: Fungal Infections > Medical Management Integrated Processes: Nursing Process–Planning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Skin Integrity; Infection; Medication Difficulty: Moderate
1 2 3 4
Feedback Treatment for tinea corporis inNc lu Ude RSs toINpiGcaTl m Bic.on C OazMo le. Treatment for tinea cruris includes topical terbinafine (Lamisil). Treatment for tinea faciei includes topical butenafine (Lotrimin). Treatment for tinea versicolor includes topical selenium sulfide 1% (Selsun Blue).
PTS: 1 CON: Skin Integrity | Infection | Medication 7. ANS: 2 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Psoriasis Chapter page reference: 1057 Heading: Psoriasis > Pathophysiology and Clinical Manifestations Integrated Processes: Nursing Process–Assessment Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Application [Applying] Concept: Skin Integrity; Infection Difficulty: Moderate
1
Feedback Red raised areas with inconsistent borders does not describe plaque psoriasis.
2
Patients with plaque psoriasis present with well-circumscribed, thick, reddened papules or plaques often covered with silvery scaling flakes.
3 4
Large reddened areas of weeping and maceration does not describe plaque psoriasis. Small raised and reddened areas with fluid filled pustules does not describe plaque psoriasis.
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PTS: 1 CON: Skin Integrity | Infection 8. ANS: 2 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Discussing the medical management of: Psoriasis Chapter page reference: 1058 Heading: Psoriasis > Medical Management > Treatment Integrated Processes: Teaching Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Skin Integrity; Infection; Medication Difficulty: Moderate
1 2 3 4
Feedback Corticosteroids prevent the formation of new lesions. Salicylic acid decreases scaling and softens plaques. Coal tar suppresses cell division and decreases inflammation. Retinoids (vitamin A) diminish proliferation of keratinocytes and decrease inflammation.
PTS: 1 CON: Skin Integrity | Infection | Medication 9. ANS: 1 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with skin disorders Chapter page reference: 1059 NURSINGTB.COM Heading: Psoriasis > Nursing Management > Actions Integrated Processes: Teaching Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Skin Integrity; Infection; Medication Difficulty: Moderate 1 2 3 4
Feedback Medications may not cure psoriasis; however, they do minimize symptoms and may minimize exacerbations. Some topical medications cause staining of the skin, hair, nails, and clothing. Retinoids can cause skin irritation. The disease can worsen after discontinuing strong topical corticosteroids.
PTS: 1 CON: Skin Integrity | Infection | Medication 10. ANS: 3 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with skin disorders Chapter page reference: 1060 Heading: Psoriasis > Nursing Management > Teaching Integrated Processes: Teaching Learning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing]
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Concept: Skin Integrity; Infection Difficulty: Moderate
1 2 3 4
Feedback Phototherapy should be held if the skin becomes painful. Phototherapy should be held if the skin becomes reddened. Phototherapy should be held if the skin becomes red or blistered. Phototherapy should be held if the skin develops blisters with drainage.
PTS: 1 CON: Skin Integrity | Infection 11. ANS: 3 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Discussing the epidemiology of disorders of the skin Chapter page reference: 1060 Heading: Skin Trauma > Epidemiology Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Skin Integrity Difficulty: Easy
1 2 3 4
Feedback Heat does not cause a laceration. Pressure could cause an ulcer. A laceration is a break in the sN kiU nR caSu I seN d G byThBig.hCshOeM arin g forces that exert a diagonal force on the skin causing damage. Moisture would cause maceration.
PTS: 1 CON: Skin Integrity 12. ANS: 4 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Describing the process and stages of wound healing Chapter page reference: 1062 Heading: Skin Trauma > Pathophysiology and Clinical Manifestations Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Skin Integrity Difficulty: Easy 1 2 3 4
Feedback In the maturation phase there is less fluid within the wound and collagen fibers reorganize. In the hemostasis phase of healing platelets and clotting factors are activated. In the proliferative phase of healing granulation tissue forms and the wound contracts. In the inflammatory phase of healing fluid escapes into the wound and causes edema.
PTS: 1
CON: Skin Integrity
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13. ANS: 2 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Discussing the medical management of: Skin Trauma Chapter page reference: 1068 Heading: Skin Trauma > Surgical Management Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Skin Integrity Difficulty: Easy
1 2 3 4
Feedback Tape is used to close a primary closure wound. Grafts are used to close a secondary closure wound. Staples are used to close a primary closure wound. Sutures are used to close a primary closure wound.
PTS: 1 CON: Skin Integrity 14. ANS: 4 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Pressure ulcers Chapter page reference: 1074 Heading: Pressure Ulcers > Pathophysiology and Clinical Manifestations Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/N ReUdR ucStiI onNoGf T RB isk.PCoO teM ntial Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Moderate
1
2
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Feedback A stage III pressure ulcer has full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. A stage IV pressure ulcer has full thickness loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. It often includes undermining and tunneling. An unstageable wound has full thickness tissue loss where the base of the ulcer is covered in slough or eschar in the wound bed. A suspected deep tissue injury is a purple or maroon localized area of discolored, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.
PTS: 1 CON: Skin Integrity 15. ANS: 3 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Discussing the medical management of: Pressure ulcers Chapter page reference: 1079
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Heading: Pressure Ulcers > Medical Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity/Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Skin Integrity; Medication Difficulty: Moderate
1 2 3 4
Feedback Ascorbic acid (vitamin C) strengthens capillaries. Ascorbic acid (vitamin C) improves immune function. Zinc helps with collagen formation and protein synthesis. Copper helps with red blood cell formation.
PTS: 1 CON: Skin Integrity | Medication 16. ANS: 1 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Describing complications associated with skin disorders Chapter page reference: 1082 Heading: Pressure Ulcers > Medical Management > Complications Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Skin Integrity Difficulty: Moderate
1 2 3 4
NURSINGTB.COM Feedback If osteomyelitis is suspected, evaluation with a CT scan is recommended. A bone biopsy is not recommended to diagnose osteomyelitis. A venous Doppler is not used to diagnose osteomyelitis. Serum electrolytes are not used to diagnose osteomyelitis.
PTS: 1 CON: Skin Integrity 17. ANS: 4 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Discussing the epidemiology of disorders of the skin Chapter page reference: 1084 Heading: Skin Cancer > Epidemiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Skin Integrity Difficulty: Easy
1 2 3
Feedback Basal cell carcinomas are the most common form of cancer occurring in human beings. Melanoma is currently the most common cancer affecting women aged 25 to 29 and the second most common cancer diagnosed in women aged 30 to 34. Squamous cell carcinoma is mostly attributed to cumulative exposure to UVB rays over an extended period of time and is a cancer that arises from epidermal squamous cells.
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4
Actinic keratoses are atypical keratinocytes found in the epidermis and represent the most common form of precancerous lesions.
PTS: 1 CON: Skin Integrity 18. ANS: 1 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Skin cancer Chapter page reference: 1085 Heading: Skin Cancer > Pathophysiology and Clinical Manifestations Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Physiological Adaptation Cognitive level: Application [Applying] Concept: Skin Integrity; Cellular Regulation Difficulty: Moderate
1 2 3 4
Feedback Basal cell carcinoma can present as a translucent papule. Actinic keratoses can present as a reddish brown plaque. Squamous cell carcinoma can present as a crusted ulcerated plaque. Melanoma can present as an asymmetric black lesion.
PTS: 1 CON: Skin Integrity | Cellular Regulation 19. ANS: 2 Chapter number and title: 50, CoordiN n aUtinRgSCIaN reGfoTrBP. a tC ie nOtsM With Skin Disorders Chapter learning objective: Discussing the medical management of: Skin cancer Chapter page reference: 1086 Heading: Skin Cancer > Medical Management Integrated Processes: Nursing Process–Planning Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Skin Integrity; Cellular Regulation; Perioperative Difficulty: Moderate
1
2 3
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Feedback Radiotherapy is appropriate for use in patients who are poor surgical candidates because of their health or the site and extent of the tumor. In cases of aggressive squamous cell carcinoma, radiotherapy is an additional treatment following surgical excision Mohs’ micrographic surgery is considered the “gold standard” for the treatment of nonmelanoma skin cancers. Photodynamic therapy is advantageous for patients who are poor surgical candidates because of other comorbidities or for those who have large or multiple lesions that can be treated at one time. Curettage and electrodessication is appropriate for low-risk, smaller lesions.
PTS: 1 CON: Skin Integrity | Cellular Regulation | Perioperative 20. ANS: 1 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders
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Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with skin disorders Chapter page reference: 1088 Heading: Skin Cancer > Nursing Management > Teaching Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Skin Integrity; Cellular Regulation; Promoting Health Difficulty: Moderate 1 2 3 4
Feedback Clothing with UV protection or dark clothing is recommended to protect as much of the skin as possible. A sunscreen with an SPF of at least 30 is recommended. The body should be examined every month. Time in the sun should be avoided between the hours of 10 am and 4 pm when UV rays are strongest.
PTS: 1 CON: Skin Integrity | Cellular Regulation | Promoting Health 21. ANS: 1 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Discussing the epidemiology of disorders of the skin Chapter page reference: 1088 Heading: Reconstructive Surgery > Epidemiology Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/N ReUdR ucStiI onNoGf T RB isk.PCoO teM ntial Cognitive level: Comprehension [Understanding] Concept: Skin Integrity; Cellular Regulation; Perioperative Difficulty: Easy
1 2 3 4
Feedback The most common reconstructive surgeries performed by a plastic surgeon in 2014 were for cancer reconstruction. Reconstructive surgery is not identified as being highly used for a face lift. Reconstructive surgery is not identified as being highly used for a rhinoplasty. Reconstructive surgery is not identified as being highly used for breast augmentation.
PTS: 1 CON: Skin Integrity | Cellular Regulation | Perioperative 22. ANS: 1 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with skin disorders Chapter page reference: 1089 Heading: Reconstructive Surgery > Nursing Management > Assessment Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Skin Integrity; Perioperative; Comfort Difficulty: Moderate
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1 2 3 4
Feedback Uncontrollable pain may indicate complications, including infection. Fluid imbalance does not cause uncontrollable pain. Electrolyte imbalance does not cause uncontrollable pain. Pain is whatever the patient says it is. It is highly unlikely that a postoperative patient is stating the existence of pain because of attention-seeking behavior.
PTS: 1
CON: Skin Integrity | Perioperative | Comfort
MULTIPLE RESPONSE 23. ANS: 1, 3, 4, 5 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Discussing the epidemiology of disorders of the skin Chapter page reference: 1039 Heading: Bacterial Skin Infections > Epidemiology Integrated Processes: Nursing Process–Planning Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Approximately 80% of CA-MRSA cases are uncomplicated skin and soft tissue infections in the form of an abscess, cNeU lluRlS itiI s,NfoGlT l icBu. liC t isO, M or impetigo. Eczema is not associated with CA-MRSA. Approximately 80% of CA-MRSA cases are uncomplicated skin and soft tissue infections in the form of cellulitis, folliculitis, impetigo, or an abscess. Approximately 80% of CA-MRSA cases are uncomplicated skin and soft tissue infections in the form of impetigo, cellulitis, folliculitis, or an abscess. Approximately 80% of CA-MRSA cases are uncomplicated skin and soft tissue infections in the form of folliculitis, cellulitis, impetigo, or an abscess.
PTS: 1 CON: Skin Integrity 24. ANS: 1, 2, 3, 5 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Bacterial skin infections Chapter page reference: 1042 Heading: Bacterial Skin Infections > Pathophysiology and Clinical Manifestations Integrated Processes: Nursing Process–Assessment Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Analysis [Analyzing] Concept: Skin Integrity Difficulty: Moderate
1.
Feedback Moderate pain is a manifestation of a complicated soft tissue bacterial infection.
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2. 3. 4. 5.
Fever is a manifestation of a complicated soft tissue bacterial infection. Tachycardia is a manifestation of a complicated soft tissue bacterial infection. Muscle atrophy is not a manifestation of a complicated soft tissue bacterial infection. Hypotension is a manifestation of a complicated soft tissue bacterial infection.
PTS: 1 CON: Skin Integrity 25. ANS: 3, 4, 5 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Herpes simplex Chapter page reference: 1046 Heading: Herpes Simplex Virus > Pathophysiology and Clinical Manifestations Integrated Processes: Nursing Process–Assessment Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Analysis [Analyzing] Concept: Skin Integrity; Infection Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Fever is a manifestation of a primary herpes simplex virus infection. Anorexia is a manifestation of a primary herpes simplex virus infection. Areas of redness are manifestations of a recurrent herpes simplex virus infection. Tingling sensation is a manifestation of a recurrent herpes simplex virus infection. Fluid-filled vesicles are manifestations of a recurrent herpes simplex virus infection.
NURSINGTB.COM PTS: 1 CON: Skin Integrity | Infection 26. ANS: 1, 2, 3, 4 Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Describing the process and stages of wound healing Chapter page reference: 1062 Heading: Skin Trauma > Pathophysiology and Clinical Manifestations Integrated Processes: Nursing Process–Assessment Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Skin Integrity Difficulty: Easy
1. 2. 3. 4. 5. PTS: 1 27. ANS: 1, 5
Feedback As the capillary bed is laid down, the wound fills with granulation tissue and appears beefy red, shiny, and granular. Endothelial cells are activated to initiate angiogenesis, which increases blood supply to the new tissue. Keratinocytes help with epithelialization during this phase. Macrophages synthesis collagen during this phase. The reorganization of collagen occurs during the maturation phase. CON: Skin Integrity
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Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with skin disorders Chapter page reference: 1069 Heading: Skin Trauma > Nursing Implications > Assessment Integrated Processes: Nursing Process–Implementation Client Need: Physiological Integrity/Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Nutritional status affects wound healing. A referral to a dietician may be needed. Elevating the limb on a pillow will not enhance wound healing. Increasing the frequency of dressing changes could damage fragile granulation tissue. Increased activity will not necessarily improve wound healing, Nutritional status affects wound healing. Prealbumin and albumin levels provide data about overall nutritional status.
PTS: 1
CON: Skin Integrity
NUMERIC RESPONSE 28. ANS: 0.7 NURSINGTB.COM Chapter number and title: 50, Coordinating Care for Patients With Skin Disorders Chapter learning objective: Describing complications associated with skin disorders Chapter page reference: 1055 Heading: Fungal Infections > Complications Integrated Processes: Nursing Process–Assessment Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Application [Applying] Concept: Skin Integrity; Infection Difficulty: Easy Feedback: The Candida colonization index requires the acquisition of surveillance cultures from
multiple patient body sites a few times per week up to daily while the patient is in the ICU. The Candida colonization index is the ratio of the number of body sites that grow the same species of Candida divided by the number of body sites tested. For this patient the number of sites that were positive were 7 divided by 10 samples = 0.7. The patient’s index is 0.7. PTS: 1
CON: Skin Integrity | Infection
Chapter 51: Coordinating Care for Patients With Burns Multiple Choice Identify the choice that best completes the statement or answers the question.
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1. A victim of a house fire is brought to the emergency department for burn treatment. What assessment finding indicates that the patient may have an inhalation injury? 1) Coughing 2) Soot on the face 3) Singed facial hair 4) Heart rate 98 bpm 2. The nurse is caring for a patient with 50% total body surface area burns. Which finding indicates that burn shock is resolving? 1) Heart rate 112 bpm 2) Respirations 24 per minute 3) Blood pressure 90/60 mm Hg 4) Urine output 800 mL over 2 hours 3. A victim of a car fire is confused, dizzy, and nauseated. What diagnostic test should be done to determine if this patient is experiencing carbon monoxide poisoning? 1) Chest x-ray 2) Bronchoscopy 3) Pulse oximeter 4) Carboxyhemoglobin level 4. A patient is admitted for a suspected inhalation injury. What should the nurse emphasize when caring for this patient? 1) Increase oral fluids 2) Turn in bed every two hours 3) Monitor strict intake and outputNURSINGTB.COM 4) Deep breathing and coughing every hour 5. The nurse is caring for a patient who sustained electrical burns. Why should the nurse monitor this patient for compartment syndrome? 1) Potential for undiagnosed injuries 2) Injuries from being thrown bruise soft tissue 3) Electrical current alters integrity of blood vessels 4) Fluid seeps from intravascular spaces into the interstitium 6. The nurse is preparing an educational tool to instruct community members on burn prevention. What should the nurse include as the most common injury in children under age 5? 1) Scald 2) Flame 3) Chemical 4) Carbon monoxide poisoning 7. A patient with 55% total body surface area burned received two-thirds of the required fluid resuscitation. For which potential problem should the nurse prepare to provide care to this patient? 1) Increased zone of stasis 2) Increased zone of hyperemia 3) Increased zone of coagulation 4) Decreased zone of coagulation 8. A patient comes into the emergency room seeking treatment for radiation burns. What should be considered prior to providing care to this patient?
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1) 2) 3) 4)
Pathway of flow through the body Duration of contact with the agent Type, dose, and length of exposure Temperature to which the skin is heated
9. It is documented that a patient has superficial partial-thickness burns over both anterior lower arms. What should the nurse expect when assessing this patient? 1) Dry with no blisters 2) Waxy appearance and cherry red in color 3) Dry leathery appearance and pale or brown in color 4) Open or closed blisters, mild edema, easily blanches 10. A patient has full-thickness burns over 30% of total body surface area. Which intervention will least likely provide comfort initially to this patient? 1) Elevate injured extremities 2) Medicate for pain around the clock 3) Apply medicated ointment to all areas 4) Elevate the head of the bed 30 degrees 11. A patient with several deep partial-thickness burns asks how long it will take for the burn to heal. What should the nurse respond to this patient? 1) “More than two weeks.” 2) “Within one to two weeks.” 3) “Within 24 to 72 hours.” 4) “You will need skin grafts.” 12. The nurse is assistin g with the secondNaU ryRsuSrI veNyGo fT aBp.atCieO ntMwith 50% total body surface area electrical burns. Which test would be a priority for this patient? 1) Chest x-ray 2) Bronchoscopy 3) CT scan of the head 4) 12-lead electrocardiogram 13. The nurse is caring for a patient with 45% total body surface area thermal burns. Which laboratory value change would be expected? 1) Increased pH 2) Increased sodium 3) Increased potassium 4) Decreased hematocrit 14. A patient recovering from deep and full thickness burns is nauseated. Which medication should the nurse provide to help this patient? 1) Ranitidine (Zantac) 2) Esomeprazole (Nexium) 3) Metoclopramide (Reglan) 4) Polyethylene glycol (Miralax) 15. The nurse is evaluating care provided to a patient with burns during the emergent phase. Which data indicates that additional fluid resuscitation is required? 1) Blood pH 7.39 2) Heart rate 112 bpm 3) Blood pressure 110/60 mm Hg
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4) Central venous pressure 2 mm Hg 16. A patient with deep partial-thickness wounds is receiving enzymatic debridement. What assessment made by the nurse would indicate that wound care treatment has been successful? 1) Gray wound bed 2) Separation of eschar 3) Development of eschar 4) Presence of purulent exudate 17. A patient recovering from full-thickness burns rates pain as a 9 on a scale of 0 to 10 when hydrotherapy is performed. For which type of pain should this patient be treated? 1) Referred 2) Procedural 3) Background 4) Breakthrough 18. The nurse is caring for a patient with 70% total body surface area chemical burns. Which approach should the nurse anticipate to meet this patient’s nutritional needs? 1) Parenteral nutrition 2) Duodenal tube feedings 3) Nasogastric tube feedings 4) Six small high-calorie meals per day 19. A patient recovering from 25% total body surface area burns has a low-grade fever. What should the nurse do to reduce this patient’s risk of developing an infection? 1) Follow contact precautions 2) Implement protective isolation NURSINGTB.COM 3) Use sterile technique for all dressing changes 4) Administer prophylactic antibiotics as prescribed 20. The nurse is evaluating nutritional teaching provided to a patient recovering from 24% total body surface area burns. Which information indicates that teaching has been effective? 1) Weight loss 3 kg 2) Serum protein level 7.1 g/dL 3) Serum albumin level 2.8 g/dL 4) +1 pitting edema of lower extremities 21. A patient with 35% total body surface area burns is in the rehabilitative phase of care. Which approach should be used to reduce the risk of developing contractures? 1) Apply splints 2) Physical therapy two hours a day 3) Passive range of motion exercises 4) Occupational therapy one hour every other day 22. A patient is ending the first year of recovery after having burns to both legs. Which observation indicates that the patient needs to be encouraged to wear the pressure garment? 1) Skin warm and moist 2) Pedal pulses present but faint 3) Scattered areas of scarring noted 4) Nonpitting edema of both ankles
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23. An 11-year-old child received burns over both upper and lower arms, both hands, anterior upper and lower legs, anterior chest, and the neck. Using the following as a guide, what is this child’s total body surface area burned?
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Text Figure 51.8 1) 2) 3) 4)
30 % 42 % 57 % 65 %
Multiple Response Identify one or more choices that best complete the statement or answer the question.
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24. The nurse is caring for a patient who sustained chemical burns. What would have caused these injuries? Select all that apply. 1) Lime 2) Gasoline 3) Bleach 4) Fabric softener 5) Hydrofluoric acid 25. The school nurse is preparing material for National Fire Prevention week. What information should be added to the classroom posters? Select all that apply. 1) Never leave a burning candle unattended. 2) Set heating pads on “low” when sleeping. 3) Keep a flashlight and telephone near the bed. 4) Check smoke alarm batteries every six months. 5) Never use the oven as a method to warm the home. 26. A patient is diagnosed with several superficial partial-thickness burns. What treatment would be indicated for this patient? Select all that apply. 1) Apply bacitracin ointment 2) Cover with a nonadherent bandage 3) Apply mafenide acetate 10% cream 4) Wash with antiseptic soap and warm water 5) Apply collagenase and cover with roll gauze 27. A patient has been recovering for 18 months from burns that affected 60% total body surface area. For which problems should the nurse anticipate providing continuing care to this patient? Select all that apply. 1) Anxiety NURSINGTB.COM 2) Depression 3) Spiritual distress 4) Body image disorder 5) Post-traumatic stress disorder (PTSD) Numeric Response 28. A patient weighing 187 lbs. has 38% total body surface area burns. Using the Parkland formula, how much fluid should this patient receive over the first eight hours after the burn occurred? Record your answer as a whole number.
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Chapter 51: Coordinating Care for Patients With Burns Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Discussing the epidemiology of burn injuries Chapter page reference: 1102 Heading: Systemic Effects of Major Burn Injuries>Respiratory Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Skin Integrity; Oxygenation Difficulty: Moderate 1 2 3 4
Feedback Coughing does not indicate an inhalation injury. Soot on the face does not indicate an inhalation injury. Patients with an inhalation injury may present with singed facial hair. A heart rate of 98 bpm does not indicate that the patient has an inhalation injury
PTS: 1 CON: Skin Integrity | Oxygenation 2. ANS: 4 NURSINGTB.COM Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Explaining the pathophysiological processes associated with burn injuries Chapter page reference: 1102 Heading: Systemic Effects of Major Burn Injuries>Cardiovascular Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Skin Integrity; Perfusion Difficulty: Moderate
1 2 3 4
Feedback Tachycardia is a manifestation of burn shock. Tachypnea is a manifestation of burn shock. Hypotension is a manifestation of burn shock. In the postburn shock phase, which begins 24 to 48 hours after injury, the capillaries begin to regain integrity. Burn shock slowly begins to resolve, and the fluid gradually returns to the intravascular space. Urinary output continues to increase secondary to patient diuresis.
PTS: 1 CON: Skin Integrity | Perfusion 3. ANS: 4 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Discussing the appropriate diagnostic examinations for patients with burn injuries
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Chapter page reference: 1105 Heading: Special Considerations in the Burn Patient>Carbon Monoxide Poisoning Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Skin Integrity; Oxygenation Difficulty: Moderate
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Feedback A chest x-ray will not diagnose carbon monoxide poisoning. A bronchoscopy will not diagnose carbon monoxide poisoning. In cases of suspected carbon monoxide poisoning, oxygen measurement by pulse oximeter is useless because the determination between the oxygen and carbon monoxide molecules saturating the hemoglobin is not possible. Because carbon monoxide binds to the hemoglobin molecule with an affinity 200 times greater than that of oxygen, tissue hypoxia results when carbon monoxide levels are above normal. Carboxyhemoglobin levels will detect the amount of carbon monoxide in the patient.
PTS: 1 CON: Skin Integrity | Oxygenation 4. ANS: 4 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestylebased considerations for patients with burn injuries Chapter page reference: 1107 NURSINGTB.COM Heading: Special Considerations in the Burn Patient>Management of Inhalation Injuries>Nursing Management>Actions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Skin Integrity; Oxygenation Difficulty: Moderate 1 2 3 4
Feedback The intake of oral fluids will depend upon the integrity of the patient’s throat. The patient might be nothing by mouth until the extent of the inhalation injury is known. Turning in bed every two hours is essential to reduce the hazards of immobility; however, it is not as important as deep breathing and coughing. Monitoring strict intake and output would be more important for a patient with burns. An inhalation injury will not necessarily impact cardiac output and fluid balance. Deep breathing and coughing should be done every hour to assist with airway clearance and mobilization of secretions.
PTS: 1 CON: Skin Integrity | Oxygenation 5. ANS: 4 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Explaining the pathophysiological processes associated with burn injuries Chapter page reference: 1107 Heading: Special Considerations in the Burn Patient>Electrical Injuries
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Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Skin Integrity; Perfusion Difficulty: Moderate
1 2 3 4
Feedback Monitoring for compartment syndrome is not because of the potential for undiagnosed injuries. Monitoring for compartment syndrome is not because of soft tissue injuries from being thrown. Monitoring for compartment syndrome is not because the electrical current has altered the integrity of blood vessels. Pulses are closely monitored in all affected extremities for the first 48 hours postinjury in order to assess for the potential development of compartment syndrome. As fluid seeps from the intravascular spaces into the interstitium, pressure within the tissues continues to rise and confines swelling inside muscle compartments.
PTS: 1 CON: Skin Integrity | Oxygenation 6. ANS: 1 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Discussing the epidemiology of burn injuries Chapter page reference: 1093 Heading: Incidence and Epidemiology Integrated Processes: Teaching and Learning NURSINGTB.COM Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Skin Integrity; Promoting Health Difficulty: Easy
1 2 3 4
Feedback Scald injuries are most prevalent in children under the age of 5. Flame injuries are common in all age groups. Chemical injuries are not the most prevalent in children under the age of 5. Carbon monoxide poisoning is not the most prevalent in children under the age of 5.
PTS: 1 CON: Skin Integrity | Promoting Health 7. ANS: 3 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Describing classifications of burn injuries Chapter page reference: 1101 Heading: Pathophysiology>Classifications>Anatomical Changes Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Moderate Feedback
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1 2 3
4
Without sufficient fluid resuscitation, the zone of stasis would convert to another zone. Inadequate fluid resuscitation would not impact the zone of hyperemia. The zone of stasis immediately surrounds the zone of coagulation and is characterized by damaged cells and impaired circulation. It is this area of the burn that is most at risk for conversion if the patient does not receive adequate resuscitation. Improper resuscitation or under-resuscitation may cause the burn to become deeper because of limited blood flow, causing the zone of stasis to convert into the zone of coagulation. Inadequate fluid resuscitation would make the zone of coagulation greater.
PTS: 1 CON: Skin Integrity 8. ANS: 3 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Describing classifications of burn injuries Chapter page reference: 1095 Heading: Pathophysiology>Classifications>Burn Etiology>Radiation Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Moderate 1 2 3 4
Feedback Pathway of flow through the body would be essential for an electrical burn. Duration of contact would be essential for a chemical burn. The severity of a radiation burN nU isRdS epIenNdG enTt B up.onC th OeM type, dose, and length of exposure. The temperature to which the skin is heated is applicable for a thermal burn.
PTS: 1 CON: Skin Integrity 9. ANS: 4 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Correlating the pathophysiological changes to clinical manifestations seen in patients with superficial, partial-thickness, and full-thickness burns Chapter page reference: 1096 Heading: Pathophysiology>Classifications>Burn Depth Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Moderate
1 2 3 4
Feedback A superficial burn is dry with blisters. Deep-partial thickness burns have a waxy appearance and are cherry red. Full-thickness burns are dry, leathery, pale and white, brown, or black in color. A superficial partial-thickness burn has blisters that may be closed or open and weeping; pink or red; mild edema; and blanches easily.
PTS: 1
CON: Skin Integrity
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10. ANS: 2 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Correlating the pathophysiological changes to clinical manifestations seen in patients with superficial, partial-thickness, and full-thickness burns Chapter page reference: 1098 Heading: Pathophysiology>Classifications>Burn Depth>Full-Thickness Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Analysis [Analyzing] Concept: Skin Integrity Difficulty: Moderate
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Feedback Elevating the injured extremity would provide comfort. A full-thickness burn involves destruction of the epidermis, the dermis, and portions of the subcutaneous tissue. All epidermal and dermal structures are destroyed including hair follicles, sweat glands, and nerve endings. As a result of the extensive damage to the nerve endings, full-thickness burns are insensate to palpation and often are not painful. Pain medication would be least likely to provide comfort to this patient initially. Applying medicated ointment to the injuries would provide comfort. Elevating the head of the bed would ease respiratory effort.
PTS: 1 CON: Skin Integrity 11. ANS: 1 NURSINGTB.COM Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Correlating the pathophysiological changes to clinical manifestations seen in patients with superficial, partial-thickness, and full-thickness burns Chapter page reference: 1097 Heading: Pathophysiology>Classifications>Burn Depth>Deep Partial Thickness Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Moderate
1 2 3 4
Feedback The majority of deep partial-thickness burns take more than two weeks to heal. Superficial partial-thickness burns usually heal in one to two weeks with minimal to no scarring. Superficial burns typically resolve in 24 to 72 hours. Full-thickness burns do not heal spontaneously and require skin grafting.
PTS: 1 CON: Skin Integrity 12. ANS: 4 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Discussing the appropriate diagnostic examinations for patients with burn injuries Chapter page reference: 1110 Heading: Management of Burn Injuries>Emergent Phase
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Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Moderate
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Feedback A chest x-ray is a basic diagnostic test done on all burn victims; however, it is not specific to a patient with electrical burns. A bronchoscopy is not indicated for electrical burns. A CT scan of the head is not indicated for electrical burns. A 12-lead electrocardiogram is indicated for an electrical injury.
PTS: 1 CON: Skin Integrity 13. ANS: 3 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Discussing the appropriate diagnostic examinations for patients with burn injuries Chapter page reference: 1112 Heading: Management of Burn Injuries>Emergent Phase>Diagnostic Studies Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Skin Integrity Difficulty: Moderate
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NURSINGTB.COM Feedback Acidosis or a decreased pH can occur because of a loss of bicarbonate ions. Decreased sodium is expected because large amounts of sodium are lost to third spacing, wound draining, and shifting into cells as potassium is released. Hyperkalemia is expected because of massive cellular trauma causing the release of potassium into extracellular fluid. An elevated hematocrit is expected because plasma is lost to extravascular spaces, leaving the remaining blood very viscous.
PTS: 1 CON: Skin Integrity 14. ANS: 3 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Explaining the medical and surgical management of patients with burn injuries Chapter page reference: 1113 Heading: Management of Burn Injuries>Emergent Phase>Medications Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Skin Integrity; Medication Difficulty: Moderate 1 2
Feedback Ranitidine (Zantac) decreases stomach acid and risk of gastric ulceration. Esomeprazole (Nexium) decreases stomach acid and risk of ulceration.
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3 4
Metoclopramide (Reglan) promotes stomach emptying and decreases nausea. Polyethylene glycol (Miralax) is a laxative used for constipation.
PTS: 1 CON: Skin Integrity | Medication 15. ANS: 4 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Explaining the medical and surgical management of patients with burn injuries Chapter page reference: 1111 Heading: Management of Burn Injuries>Emergent Phase>Fluid Resuscitation Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Skin Integrity; Medication Difficulty: Hard
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Feedback Indications of adequate fluid resuscitation include a blood pH between 7.35-7.45. Indications of adequate fluid resuscitation include a heart rate less than 120 bpm. Indications of adequate fluid resuscitation include a blood pressure greater than 100 mm Hg. Indications of adequate fluid resuscitation include a central venous pressure between 5 10 mm Hg. A pressure of 2 mm Hg indicates fluid volume deficit. More fluid would be indicated.
PTS: 1 CON: Skin Inte Ngr URityS|IMNeGd iTcaBtion . COM 16. ANS: 2 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Developing comprehensive plans of care for patients with burn injuries Chapter page reference: 1116 Heading: Management of Burn Injuries>Intermediate Phase>Mechanical and Enzymatic Debridement Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Skin Integrity Difficulty: Hard
1 2 3 4
Feedback A gray wound bed indicates inadequate blood flow and dead tissue. Enzymatic debridement involves the application of a proteolytic ointment that hastens eschar separation. Eschar would develop at the time of the burn. Purulent exudate indicates an infection.
PTS: 1 CON: Skin Integrity 17. ANS: 2 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Developing comprehensive plans of care for patients with burn injuries Chapter page reference: 1119 Heading: Management of Burn Injuries>Intermediate Phase>Pain Management
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Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Skin Integrity; Comfort Difficulty: Easy
1 2 3 4
Feedback The burn patient is not likely to experience referred pain. Procedural pain is associated with therapeutic activities such as wound care and physical therapy. Background pain is the underlying pain from the primary injury that is continuous and ongoing. Breakthrough pain is pain related to specific episodes associated with activities of daily living (ADLs), such as walking.
PTS: 1 CON: Skin Integrity | Comfort 18. ANS: 2 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Developing comprehensive plans of care for patients with burn injuries Chapter page reference: 1120 Heading: Management of Burn Injuries>Intermediate Phase>Nutritional Support Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Skin Integrity; Nutrition NURSINGTB.COM Difficulty: Moderate
1 2
3
4
Feedback Total parenteral nutrition is not often utilized among burn patients because of its complication rates, including an increased risk for infection and hyperglycemia. In large burn injuries, longer nutritional support is required, and placement of a duodenal feeding tube is often recommended to help prevent aspiration and allow for feeding up to and during procedures. Nutritional supplementation is most often achieved through the placement of a nasogastric tube, where feedings can be given continuously or intermittently in the form of a bolus. However, the patient has a large TBSA burned. Another approach would be more appropriate. Once a person has sustained a burn of approximately 20% or greater, it is difficult to consume the amount of calories and protein needed for wound healing.
PTS: 1 CON: Skin Integrity | Nutrition 19. ANS: 1 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Developing comprehensive plans of care for patients with burn injuries Chapter page reference: 1120 Heading: Management of Burn Injuries>Intermediate Phase>Prevention of Infection Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Application [Applying]
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Concept: Skin Integrity; Infection Difficulty: Moderate
1
2 3 4
Feedback Cross-contamination among burn patients is common, and as a result, isolation guidelines are widespread practices among burn centers. Contact precautions may be used when entering all patient rooms. Protective isolation is not required. Wound care is a clean procedure. Prophylactic antibiotics are not recommended because of the potential of breeding antibiotic-resistant pathogens, and instead treatment is based on positive culture results.
PTS: 1 CON: Skin Integrity | Infection 20. ANS: 2 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestylebased considerations for patients with burn injuries Chapter page reference: 1121 Heading: Management of Burn Injuries>Intermediate Phase>Nursing Interventions>Teaching> Evaluating Care Outcomes Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Analysis [Analyzing] Concept: Skin Integrity; Nutrition Difficulty: Moderate
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Feedback Stable body weight is an indication of nutritional status. A weight loss would mean additional teaching is required. A normal serum protein level is 6.4 to 8.3 g/dL. A normal serum albumin level is 3.5 to 5.0 g/dL. A value of 2.8 g/dL indicates additional teaching is required. Adequate albumin also supports oncotic pressure that promotes fluid remaining in the intravascular space. Edema could indicate an inadequate protein level.
PTS: 1 CON: Skin Integrity | Nutrition 21. ANS: 1 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestylebased considerations for patients with burn injuries Chapter page reference: 1122 Heading: Management of Burn Injuries>Rehabilitative Phase Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Skin Integrity; Mobility Difficulty: Moderate Feedback
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Splinting is the most common method used to help prevent the formation of contractures. Physical therapy two hours every day is not recommended as a method to prevent contractures. Passive range of motion is not recommended as a method to prevent contractures. Occupational therapy is not recommended as a method to prevent contractures.
PTS: 1 CON: Skin Integrity | Mobility 22. ANS: 3 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestylebased considerations for patients with burn injuries Chapter page reference: 1122 Heading: Management of Burn Injuries>Rehabilitative Phase Integrated Processes: Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Skin Integrity; Self Difficulty: Moderate Feedback 1 Warm and moist skin would not indicate that the pressure garment is not being worn. 2 Faint pedal pulses would indicate sluggish perfusion. 3 Specialty pressure garments are intended to provide continuous and uniform pressure over the area of burn to prevent hypertrophic scarring. These garments are to be worn 23 hours a day for up to a yearNoUr m RSorIe NafGterT iBnj.urCy OinMso me patients. The presence of scarring indicates the garment has not been worn consistently. 4 Nonpitting edema of both ankles would not be associated with the pressure garment. PTS: 1 CON: Skin Integrity | Self 23. ANS: 4 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Describing classifications of burn injuries Chapter page reference: 1100 Heading: Pathophysiology>Classifications>Total Body Surface Area Percentage>Lund and Browder Classification Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Easy Feedback: Select the percentage burn column for 10-14-year-old. The neck is 2; the anterior trunk is 13; the right upper arm is 4; the right lower arm is 3; the left upper arm is 4; the left lower arm is 3; the right hand is 2.5; the left hand is 2.5; the right thigh is 9; the left thigh is 9; the right lower leg is 6.5; and the left lower leg is 6.5. The total body surface area burned is 65%. The other answer choices are miscalculations or incorrect use of the graphic provided. PTS: 1
CON: Skin Integrity
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MULTIPLE RESPONSE 24. ANS: 1, 2, 3, 5 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Explaining the pathophysiological processes associated with burn injuries Chapter page reference: 1195 Heading: Pathophysiology>Chemical Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment/Safety and Infection Control Cognitive level: Comprehension [Understanding] Concept: Skin Integrity Difficulty: Easy
1. 2. 3. 4. 5.
Feedback Lime can cause a chemical burn. Gasoline can cause a chemical burn. Bleach can cause a chemical burn. Fabric softener is not identified as causing a chemical burn. Hydrofluoric acid can cause a chemical burn.
PTS: 1 CON: Skin Integrity 25. ANS: 1, 3, 4, 5 Chapter number and title: 51, Coordinating Care for Patients With Burns Ch ap ter learn in g objective: DiscussinNgUthRe SepIiN d eGmTioBlo.gyCoOf Mbu rn in ju ries Chapter page reference: 1094 Heading: Incidence and Epidemiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Skin Integrity; Promoting Health Difficulty: Easy
1. 2. 3. 4. 5.
Feedback To prevent fires, never leave a burning candle unattended. To prevent fires, never use a heating pad during sleep. To respond to a fire, keep a flashlight and telephone near the bed. To prevent fires, check smoke alarm batteries every 6 months. To prevent fires, never use the oven as a method to warm the home.
PTS: 1 CON: Skin Integrity | Promoting Health 26. ANS: 1, 2, 4 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Explaining the medical and surgical management of patients with burn injuries Chapter page reference: 1098 Heading: Pathophysiology>Classifications>Burn Depth Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation
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Cognitive level: Application [Applying] Concept: Skin Integrity Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Care of a superficial partial-thickness burn includes applying bacitracin ointment. Care of a superficial partial-thickness burn includes covering with nonadherent bandage. Mafenide acetate 10% cream is used to treat full-thickness burns. A superficial partial-thickness burn is to be washed with antiseptic soap and warm water. An enzymatic cream like collagenase is used for full-thickness burn wound care.
PTS: 1 CON: Skin Integrity 27. ANS: 1, 2, 4, 5 Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Developing comprehensive plans of care for patients with burn injuries Chapter page reference: 1121 Heading: Management of Burn Injuries>Rehabilitative Phase Integrated Processes: Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Skin Integrity; Grief and Loss; Mood; Self; Stress Difficulty: Moderate
1. 2. 3. 4.
5.
Feedback The burn patient may enNduUreR m San I Ny GpsTych B.o lCogOical M and emotional challenges throughout his or her lengthy course of treatment and recovery. The patient may experience anxiety. The burn patient may endure many psychological and emotional challenges throughout his or her lengthy course of treatment and recovery. The patient may experience depression. Spiritual distress is not specifically identified as a potential problem for a patient recovering from burns. The burn patient may endure many psychological and emotional challenges throughout his or her lengthy course of treatment and recovery. The patient may experience body image disorder. The burn patient may endure many psychological and emotional challenges throughout his or her lengthy course of treatment and recovery. The patient may experience post-traumatic stress disorder (PTSD).
PTS: 1
CON: Skin Integrity | Grief and Loss | Mood | Self | Stress
NUMERIC RESPONSE 28. ANS: 6460 mL Chapter number and title: 51, Coordinating Care for Patients With Burns Chapter learning objective: Explaining the medical and surgical management of patients with burn injuries Chapter page reference: 1110 Heading: Management of Burn Injuries>Fluid Resuscitation Integrated Processes: Nursing Process: Planning
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Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Skin Integrity; Medication Difficulty: Moderate Feedback: First calculate the patient’s weight in kg by dividing the weight in lbs. by 2.2 or 187/2.2 = 85 kg. Next use the formula 4 mL x kg of body weight x TBSA % to calculate the total fluid amount needed. For this patient that would be 4 mL x 85 x 38 = 12,920 mL. Since one-half of the total fluid amount should be provided in the first 8 hours, divide the total amount of fluid by 2 or 12,920/2 = 6460 mL. The patient should receive 6460 mL of fluid in the first 8 hours after the burn injury. PTS: 1
CON: Skin Integrity | Medication
Chapter 52: Assessment of Musculoskeletal Function Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is preparing information about bone health for a community fair. What part of the bone should the nurse identify as containing living bone cells? 1) Nerves 2) Collagen 3) Osteoblasts 4) Blood vessels
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2. A patient has a muscle that has been torn from the bone. Which structure has been injured in this patient? 1) Fascia 2) Tendon 3) Cartilage 4) Ligament 3. A patient is experiencing bursitis of the hip. What physical finding should the nurse expect to assess in this patient? 1) Muscle edema 2) Shortened limb 3) Hip contracture 4) Pain with movement 4. The nurse is preparing teaching material on the musculoskeletal system. What should the nurse include about the function of short bones? 1) Produces blood cells 2) Controls movement of the body 3) Provides stability with little movement 4) Controls contraction of organs and blood vessels 5. The nurse is assessing a patient’s vertebral column. What term best describes the function of the joints between the vertebrae? 1) Meiosis 2) Diarthrosis 3) Synarthrosis
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4) Amphiarthrosis 6. A patient has a low level of thyroid stimulating hormone (TSH). How will this affect the musculoskeletal system? 1) Reduces bone growth 2) Initiates the growth of bone 3) Slows the rate of bone destruction 4) Promotes the number of osteoblasts 7. The nurse notes that a patient has muscular and skeletal balance. What should this observation indicate to the nurse? 1) Joints are stressed. 2) Muscles are damaged. 3) Body organs are aligned. 4) Bones are compensating. 8. The nurse is assessing a patient’s musculoskeletal status. Which observation indicates that the gait is normal? 1) Base is as wide as the patient’s hips. 2) Symmetrical arm swing occurs with each step. 3) Foot is on the ground for 40% of the stance phase. 4) Foot is off of the ground for 60% of the swing phase. 9. The nurse is evaluating a patient’s musculoskeletal system. Which approach should be used to determine joint mobility? 1) Gait 2) Posture 3) Range of motion NURSINGTB.COM 4) Palpation of muscle tone 10. The nurse notes that a patient has full range of motion against gravity but not resistance. How should the nurse document this finding? 1) Fair 2) Poor 3) Good 4) Normal 11. A patient is scheduled for a CT scan of the left femur. What should the nurse expect the findings of this diagnostic test to reveal? 1) Fractures 2) Disk disease 3) Osteomyelitis 4) Ligamentous tears 12. The nurse notes that patient is scheduled for an arthrogram. What is the purpose of this test? 1) Evaluate healing of a bone fracture 2) Visualize joint soft tissue structures 3) Identify the location of a bone tumor 4) Determine the cause for muscle weakness 13. A patient’s bone density results are -2.7. For which potential health problem should the nurse instruct this patient? 1) Pain
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2) Fractures 3) Contractures 4) Muscle atrophy 14. A patient’s bone scan results showed a 3 cm cold spot area on the right fibula. What does this finding indicate? 1) Cancer 2) Bone infection 3) Healing fracture 4) Bone metabolism disease 15. A patient has loose bone fragments within the knee. Which diagnostic test should be considered to remove these fragments? 1) Bone scan 2) Arthroscopy 3) Arthrocentesis 4) Electromyography 16. A patient is recovering from an arthrocentesis of the right knee. What should the nurse instruct the patient regarding care at home? 1) Elevate the extremity 2) Ambulate with crutches 3) Avoid all weight bearing for three to five days 4) Apply ice to the wound for the first 24 hours 17. The nurse notes that a 55-year-old female patient’s bone density test has changed from -1.2 to a current level of -2.5. What could be the reason forNthUisRcS h aInN geG? TB.COM 1) Immobility 2) Loss of estrogen 3) Chronic diseases 4) Poor nutritional status 18. An older patient is diagnosed with a fractured hip joint. What should the nurse consider as the reason for this fracture? 1) Mineral deposits 2) Decreased joint fluid 3) Thinner joint cartilage 4) Loss of fluid in tendons 19. An older patient is experiencing arthritis in major joints. What could be the reason for the development of this disorder? 1) Decreased cartilage 2) Decline in muscle mass 3) Less fluid in joint spaces 4) Loss of fluid in ligaments 20. An older patient asks what can be done to prevent bone fractures. What should the nurse suggest to this patient? 1) Limit exposure to the sun 2) Increase the intake of water 3) Increase frequency of rest periods 4) Engage in weight-bearing exercise
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Multiple Response Identify one or more choices that best complete the statement or answer the question. 21. The nurse is preparing educational material for the parents of children recovering from fractures. What should the nurse include as the parts of long bones? Select all that apply. 1) Diaphysis 2) Epiphysis 3) Ligaments 4) Periosteum 5) Endosteum 22. The nurse is assessing a patient’s musculoskeletal system. Which observation indicates that the muscles are functioning appropriately? Select all that apply. 1) Limb bends at a joint. 2) A body part is raised. 3) Action occurs automatically. 4) Arm moves in a circle around the shoulder. 5) Limb moves away from the midline of the body. 23. The nurse is preparing to conduct a physical assessment of a patient’s musculoskeletal system. Which techniques should the nurse use for this assessment? Select all that apply. 1) Palpation 2) Inspection 3) Evaluation 4) Percussion NURSINGTB.COM 5) Auscultation 24. A patient is scheduled for an MRI of the pelvis. What should the nurse include when preparing this patient for the test? Select all that apply. 1) Insert a urinary catheter 2) Assess for metal implants 3) Remove all medication patches 4) Ensure all metal jewelry and hair items are removed 5) Maintain nothing by mouth status for eight hours before the test 25. A patient is scheduled for electromyography. What teaching should the nurse provide to prepare the patient for this test? Select all that apply. 1) Shower before the test. 2) Apply lotion for better electrode contact. 3) Slight pain might occur with needle insertion. 4) Slight bruising may occur at the site of electrodes. 5) Avoid caffeinated food items two to three hours before the test.
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Chapter 52: Assessment of Musculoskeletal Function Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Identifying key anatomical components of the musculoskeletal system Chapter page reference: 1128 Heading: Overview of Anatomy and Physiology>Bones Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Mobility; Nutrition; Promoting Health Difficulty: Moderate Feedback 1 The portion of the bone that contains living tissue includes the nerves. 2 The portion of the bone that contains living tissue includes collagen. 3 The living cells contain osteoblasts or the cells that help form bone. 4 The portion of the bone that contains living tissue includes the blood vessels. PTS: 1 CON: Mobility | Nutrition | Promoting Health 2. ANS: 2 Chapter number and title: 52, Assessment of Musculoskeletal Function NURSINGTB.CO Chapter learning objective: Identifying key anatomical components of the musculoskeletal system Chapter page reference: 1130 Heading: Overview of Anatomy and Physiology>Muscles Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Mobility Difficulty: Easy Feedback 1 Fascia is a layer of interconnected fibers of connective tissue with elastic properties that encloses, stabilizes, and separates muscles and internal organs. 2 Skeletal muscle consists of bundles of muscle fibers called fasciculi and are attached to a bone by a fibrous cord known as a tendon. 3 Cartilage is an avascular structure that receives its necessary nutrients from the synovial fluid as it is circulated during joint movement. 4 Ligaments are fibrous connective tissues present at joints to help provide stability to the joint. PTS: 1 CON: Mobility 3. ANS: 4 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Identifying key anatomical components of the musculoskeletal system Chapter page reference: 1132 Heading: Overview of Anatomy and Physiology>Joints
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Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility Difficulty: Moderate Feedback 1 Bursitis does not cause muscle edema. 2 Bursitis does not cause limb shortening. 3 Bursitis does not cause hip contracture. 4 A bursa is a fluid-filled sac lined with synovial tissue. It acts as a cushion between tendons, skin, or ligaments and bones to facilitate the friction-free movement between soft and hard bone. PTS: 1 CON: Mobility 4. ANS: 3 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Discussing the function of the musculoskeletal system Chapter page reference: 1128 Heading: Overview of Anatomy and Physiology>Bones Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Mobility; Promoting Health Difficulty: Moderate
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Spongy bone forms an open network that is filled with bone marrow, which functions to produce essential blood cells of the body. The main function of skeletal muscles is conscious or voluntary control of movement of the body or its parts. The primary function of short bones is to provide stability with little movement. Smooth muscles are under control of the autonomic nervous system, which controls contractions of organs and blood vessels automatically.
PTS: 1 CON: Mobility | Promoting Health 5. ANS: 4 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Discussing the function of the musculoskeletal system Chapter page reference: 1132 Heading: Overview of Anatomy and Physiology>Joints Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Mobility; Assessment Difficulty: Moderate Feedback 1 Meiosis is a form of cell division. 2 Diarthrosis describes a joint that permits a variety of movements. An example is the shoulder. 3 Synarthrosis describes a joint that limits movement such as the skull sutures.
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4
Amphiarthrosis describes a joint that permits slight movement like between the vertebrae.
PTS: 1 CON: Mobility | Assessment 6. ANS: 1 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Discussing the function of the musculoskeletal system Chapter page reference: 1130 Heading: Overview of Anatomy and Physiology>Hormonal Influences Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Mobility Difficulty: Moderate
1 2 3 4
Feedback TSH inhibits the activity of osteoclasts and reduces bone growth. Growth hormone initiates the growth of bone until adult size is achieved. Estrogen induces a chemical in osteoclasts that causes them to self-destruct and slows the rate of bone destruction. Parathyroid hormone promotes the activity and number of osteoblasts.
PTS: 1 CON: Mobility 7. ANS: 3 Chapter number and title: 52, Assessm NeUnRt oSfIMNuGscTu lBo.skCelOetMa l Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of musculoskeletal function Chapter page reference: 1134 Heading: Assessment>Physical Assessment>Posture Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Analysis [Analyzing] Concept: Mobility; Assessment Difficulty: Easy Feedback 1 Poor posture causes compensation on joints. 2 Poor posture can cause muscle damage. 3 Good posture supports the body organs. 4 Poor posture causes the bones to compensate. PTS: 1 CON: Mobility | Assessment 8. ANS: 2 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of musculoskeletal function Chapter page reference: 1134 Heading: Assessment>Physical Assessment>Gait Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance
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Cognitive level: Analysis [Analyzing] Concept: Mobility; Assessment Difficulty: Easy Feedback 1 The base should be as wide as the shoulder width of the patient. 2 A symmetrical arm swing should also be noted during assessment and observation of a patient’s gait status. 3 The stance phase, 60% of the cycle, is when the foot is on the ground. 4 The swing phase is defined as the time when the foot is not on the ground. This should be 40% of the time. PTS: 1 CON: Mobility | Assessment 9. ANS: 3 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of musculoskeletal function Chapter page reference: 1134 Heading: Assessment>Physical Assessment>Joint Mobility Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Mobility; Assessment Difficulty: Easy Feedback 1 Gait does not evaluate the mobNilUityR of SIallN joGTinBts.. COM 2 Posture does not evaluate the mobility of all joints. 3 Range of motion is used to evaluate joint mobility. 4 Palpation of muscle tone does not evaluate joint mobility. PTS: 1 CON: Mobility | Assessment 10. ANS: 1 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of musculoskeletal function Chapter page reference: 1135 Heading: Assessment>Physical Assessment>Muscle Tone and Strength Integrated Processes: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Mobility; Assessment; Communication Difficulty: Easy Feedback 1 Fair would be full range of motion against gravity but not resistance. 2 Poor would be full passive range of motion but not against gravity or resistance. 3 Good would be full range of motion against some resistance. 4 Normal would be full range of motion against full resistance. PTS: 1
CON: Mobility | Assessment | Communication
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11. ANS: 1 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Correlating relevant diagnostic examinations to musculoskeletal function Chapter page reference: 1136 Heading: Diagnostic Studies>Imaging Studies>Computerized Tomography Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Mobility; Assessment Difficulty: Easy
1 2 3 4
Feedback Computed tomography scans are done to diagnose muscle and bone disorders including fractures. MRI is used to diagnose disk disease. MRI is used to diagnose osteomyelitis. MRI is used to diagnose ligamentous tears.
PTS: 1 CON: Mobility | Assessment 12. ANS: 2 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Correlating relevant diagnostic examinations to musculoskeletal function Chapter page reference: 1137 Heading: Diagnostic Studies>Imaging Studies>Arthrogram Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity N –U ReRdS ucItiN onGoTf B R. iskCPOoM tential Cognitive level: Comprehension [Understanding] Concept: Mobility Difficulty: Easy
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Feedback An arthrogram is not used to evaluate healing of a bone fracture. An arthrogram allows for visualization of soft tissue structures of a joint. An arthrogram is not used to identify the location of a bone tumor. An arthrogram is not used to determine the cause for muscle weakness.
PTS: 1 CON: Mobility 13. ANS: 2 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to musculoskeletal function Chapter page reference: 1137 Heading: Diagnostic Studies>Imaging Studies>Bone Mineral Density Studies Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility; Fluid and Electrolyte Balance Difficulty: Moderate
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1 2 3 4
Feedback A bone density score of -2.5 does not increase the patient’s risk of pain. A bone density score of -2.5 and below indicates the presence of osteoporosis and increases the patient’s risk of fractures. A bone density score of -2.5 does not increase the patient’s risk of contractures. A bone density score of -2.5 does not increase the patient’s risk of muscle atrophy.
PTS: 1 CON: Mobility | Fluid and Electrolyte Balance 14. ANS: 1 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Correlating relevant diagnostic examinations to musculoskeletal function Chapter page reference: 1137 Heading: Diagnostic Studies>Imaging Studies>Bone Scan Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Mobility Difficulty: Easy
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Feedback Areas of “cold” spots define areas with a lack of blood supply to the bone and may indicate the presence of cancer. “Hot spots” are areas where the tracer accumulates in the bone. These spots are often attributed to bone infection. “Hot spots” are areas where thNe U trac u la.teCsOinMthe bone. These spots are often R SerIaNccGumTB attributed to fractures that are healing. “Hot spots” are areas where the tracer accumulates in the bone. These spots are often attributed to diseases of bone metabolism.
PTS: 1 CON: Mobility 15. ANS: 2 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Correlating relevant diagnostic examinations to musculoskeletal function Chapter page reference: 1138 Heading: Diagnostic Studies>Imaging Studies>Arthroscopic Examination Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Mobility Difficulty: Easy
1 2 3 4
Feedback A bone scan is a diagnostic scan to find damage to bones, disease (such as cancer), infection, or trauma. Arthroscopy is used to diagnose, repair, and remove loose or foreign materials in the joint. Arthrocentesis is a clinical procedure where fluid is aspirated from a joint. Electromyography (EMG) is a diagnostic test that assesses the health of motor neurons and muscle.
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PTS: 1 CON: Mobility 16. ANS: 4 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to musculoskeletal function Chapter page reference: 1138 Heading: Diagnostic Studies>Imaging Studies>Arthrocentesis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility Difficulty: Moderate
1 2 3 4
Feedback After an arthrocentesis the extremity does not need to be elevated. After an arthrocentesis the patient does not need to use crutches. After an arthrocentesis the patient does not need to avoid weight bearing for three to five days. Postprocedure instructions after an arthrocentesis include applying ice to the wound for the first 24 hours post procedure.
PTS: 1 CON: Mobility 17. ANS: 2 Chapter number and title: 52, Assessment of Musculoskeletal Function NURSINGTB.CO Chapter learning objective: Discussing changes in the musculoskeletal function associated with aging Chapter page reference: 1139 Heading: Aging Bones and Muscles Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Mobility; Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 There is not enough information to determine if the patient has been immobile. Immobility can cause bone demineralization; however, that is not identified as a reason for an older person to lose bone density. 2 The loss of bone density accelerates in women after menopause because of loss of estrogen. 3 Chronic diseases are not identified as reasons for the loss of bone density. 4 Poor nutritional status can contribute to bone demineralization; however, that is not identified as a reason for an older person to lose bone density. PTS: 1 CON: Mobility | Fluid and Electrolyte Balance 18. ANS: 3 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Discussing changes in the musculoskeletal function associated with aging Chapter page reference: 1139 Heading: Aging Bones and Muscles
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Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Mobility Difficulty: Moderate Feedback 1 Minerals may also deposit in and around some joints, which is known as calcification. 2 Joints become stiffer and less flexible as fluid often decreases in the joint spaces. 3 The joint cartilage decreases in mass because of a decrease in bone mineral content, making them thinner and more likely to fracture. 4 Connective tissues within ligaments and tendons lose water content and become more rigid. PTS: 1 CON: Mobility 19. ANS: 2 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Discussing changes in the musculoskeletal function associated with aging Chapter page reference: 1139 Heading: Aging Bones and Muscles Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Mobility Difficulty: Moderate
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The joint cartilage decreases in mass because of a decrease in bone mineral content, making them thinner and more likely to fracture. Muscle fibers gradually decrease in size, number, and contractility starting around age 30. This identified loss of strength places more stress on an individual’s joints and predisposes to the development of arthritis. Joints become stiffer and less flexible as fluid often decreases in the joint spaces. Connective tissues within ligaments lose water content and become more rigid.
PTS: 1 CON: Mobility 20. ANS: 4 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Discussing changes in the musculoskeletal function associated with aging Chapter page reference: 1139 Heading: Aging Bones and Muscles Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Mobility; Promoting Health Difficulty: Moderate 1 2
Feedback Sun exposure helps to synthesize vitamin D. This would not prevent bone fractures. Water is not identified as a method to reduce bone fractures.
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3 4
Rest and immobility encourages bone demineralization, which could potentiate fractures. Regular weight-bearing exercise is necessary to maintain a healthy, functional musculoskeletal system.
PTS: 1
CON: Mobility | Promoting Health
MULTIPLE RESPONSE 21. ANS: 1, 2, 4, 5 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Identifying key anatomical components of the musculoskeletal system Chapter page reference: 1129 Heading: Overview of Anatomy and Physiology>Bones Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Mobility; Promoting Health Difficulty: Moderate
1.
2. 3. 4.
5.
Feedback Diaphysis is the shaft, which is made up of the long portion of the bone. It is constructed of a thick compact bone that surrounds the medulla cavity in adults. The medulla cavity contains fat known as the yellow marrow. Epiphysis is known as thNeUe nRdSpIo rNtiG o nToBf . thC e O b oMne. A thin layer of compact bone forms the exterior portion of the bone, and the interior of this portion of the bone contains spongy bone. Ligaments are fibrous connective tissues present at joints to help provide stability to the joint. Periosteum is the tough outer surface of the bone. It consists of connective tissue, primarily of bone-forming cells known as osteoblasts. This portion of the bone also provides an insertion or anchoring point for tendons and ligaments. Endosteum is the internal bone surface that is covered with a delicate connective tissue membrane.
PTS: 1 CON: Mobility | Promoting Health 22. ANS: 1, 2, 4, 5 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Discussing the function of the musculoskeletal system Chapter page reference: 1130 Heading: Overview of Anatomy and Physiology>Muscles Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Mobility; Assessment Difficulty: Moderate
1.
Feedback The main function of skeletal muscles is conscious or voluntary control of movement of the body or its parts. These movements include flexion (bending a limb at a joint).
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2. 3. 4.
5.
The main function of skeletal muscles is conscious or voluntary control of movement of the body or its parts. These movements include elevation or raising a body part. Automaticity is a function of cardiac muscle. The main function of skeletal muscles is conscious or voluntary control of movement of the body or its parts. These movements include circumduction (moving the arm in a circle around the shoulder). The main function of skeletal muscles is conscious or voluntary control of movement of the body or its parts. These movements include abduction (moving a limb away from the midline of the body).
PTS: 1 CON: Mobility | Assessment 23. ANS: 1, 2 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of musculoskeletal function Chapter page reference: 1133 Heading: Assessment>Physical Assessment Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Mobility; Assessment Difficulty: Easy
1. 2. 3. 4. 5.
Feedback Palpation is an importanN t pUaR rtSo fI the NGpThyBs.icCalOexMamination to assess muscle tone and strength, range of motion, sensation, skin temperature, and quality of pulses. A physical examination begins with a general inspection of the posture, gait, joint mobility, and skin. Evaluation is a step in the nursing process. Percussion is not a technique used when assessing the musculoskeletal system. Auscultation is not a technique used when assessing the musculoskeletal system.
PTS: 1 CON: Mobility | Assessment 24. ANS: 2, 3, 4, 5 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to musculoskeletal function Chapter page reference: 1136 Heading: Diagnostic Studies>Imaging Studies>Magnetic Resonance Imaging Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility Difficulty: Moderate
1. 2.
Feedback A urinary catheter is not required for an MRI. Metal implants might contraindicate the use of an MRI as a diagnostic test. This needs to be reported.
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3. 4. 5.
Medication patches can cause burns at the site and should be removed prior to the MRI. Metal jewelry and hair items should be removed prior to the MRI. External metal items may interfere with the magnetic imaging. For an MRI of the pelvis the patient should be NPO for eight hours before the test.
PTS: 1 CON: Mobility 25. ANS: 1, 3, 4, 5 Chapter number and title: 52, Assessment of Musculoskeletal Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to musculoskeletal function Chapter page reference: 1138 Heading: Diagnostic Studies>Imaging Studies>Electromyography Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility Difficulty: Moderate
1. 2. 3. 4. 5.
PTS: 1
Feedback The patient should be instructed to shower before the test. Lotion should not be applied to the skin. Lotion interferes with electrode contact. The patient should be instructed that slight pain might occur when the needles are inserted. The patient should be informed that slight bruising might occur where the electrodes were placed. The patient should be inN stru U Rcted S ItoN aGvToiBd .caCffOeiMnated food items for two to three hours before the test. CON: Mobility
Chapter 53: Coordinating Care for Patients With Musculoskeletal Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A patient with Duchenne muscular dystrophy has significant muscle damage. What is the primary reason for this destruction? 1) High body fat 2) Lack of dystrophin 3) Breakdown of collagen 4) Decreased body protein 2. The nurse is reviewing orders written for a patient with muscular dystrophy. Which medication should the nurse expect to be prescribed for this patient? 1) Cortisol 2) Furosemide 3) Gabapentin 4) Acetaminophen 3. A patient with osteoporosis asks why the health problem developed. What nursing response would be appropriate for this patient?
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1) 2) 3) 4)
Osteoclasts break down bone with acids and enzymes. Osteoclastic activity is greater than osteoblastic activity. Osteoblastic activity is greater than osteoclastic activity. Osteoblasts synthesize and add minerals to the bony matrix.
4. A patient is suspected of having osteoporosis. Which diagnostic test should the nurse expect to be prescribed for this patient? 1) MRI 2) CT scan 3) Bone scan 4) DEXA scan 5. A patient is prescribed alendronate (Fosamax). What instruction should the nurse provide to the patient about this medication? 1) Take at bedtime 2) Take with a full meal 3) Take on an empty stomach 4) Take two hours after breakfast 6. A patient is diagnosed with Paget’s disease. What finding should the nurse expect when assessing this patient? 1) Pain 2) Edema 3) Hypotension 4) Abdominal cramps 7. A patient with Paget’s disease is presN crUibRedSaIbNisGp hToBsp.h oCnOa tMe medication. Which additional medication should the nurse expect to be prescribed for this patient? 1) Anticholinergic 2) Thiazide diuretic 3) Antihypertensive 4) Calcium with vitamin D 8. A patient recovering from total knee replacement surgery develops osteomyelitis. What teaching should the nurse prepare as a priority for this patient? 1) Antibiotic therapy 2) Pain management 3) Debridement of the wound 4) Removal of the knee prosthesis 9. The nurse is evaluating dietary teaching provided to a patient recovering from osteomyelitis. Which meal choice indicates that additional teaching is required? 1) Green salad, meat loaf, brown rice, and broccoli 2) Caesar’s salad, pork loin slices, sauerkraut, baked potato, and sautéed carrots 3) Tossed salad, spaghetti with marinara sauce, Italian bread, and creamed spinach 4) Iceberg lettuce wedge, baked chicken breast, parsley red potatoes, and green beans 10. A middle-aged person with scoliosis asks why exercises are prescribed when the pain is already severe. How should the nurse respond to this patient? 1) “Exercise will stop the pain caused by the deformity.” 2) “Pain medication should not be needed for people with scoliosis.” 3) “Exercise can reverse and prevent the progression of the spinal deformity.”
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4) “Exercise helps with weight management, which is a major reason for the problem.” 11. A patient with severe hip pain is diagnosed with osteoarthritis (OA). What information should the nurse provide to the patient about this disease process? 1) “OA causes an overgrowth of cartilage in the joints.” 2) “OA causes joint fluid to become bluish-white in color.” 3) “OA causes a decrease in joint fluid that affects the cartilage.” 4) “OA causes a build of fluid in the joints, hindering movement.” 12. The blood pressure of a patient recovering from total hip replacement surgery is dropping. What should the nurse suspect is occurring with this patient? 1) Blood loss 2) Pain medication overdose 3) Development of a deep vein thrombosis 4) Development of a postoperative infection 13. A patient recovering from total hip replacement surgery is having difficulty with position changes and ambulation. Which member of the interdisciplinary team should be consulted to address this patient’s issues? 1) Orthopedic nurse 2) Physical therapist 3) Orthopedic surgeon 4) Occupational therapist 14. The manager notes that several nurses have been seen in employee health for low back pain over the last month. What type of education should the manager plan to help reduce the incidence of this health problem? 1) Safety 2) Body mechanics NURSINGTB.COM 3) Coordinating care 4) Stress management 15. The nurse is preparing material about back pain for a community health fair. What should be included as a reason why this pain occurs most frequently in the lumbar region of the spine? 1) It contains peripheral nerves. 2) It is the most rigid area of the spine. 3) It is the most flexible area of the spine. 4) It anchors the weight of the lower body. 16. A patient is experiencing severe lower back pain that radiates down the leg causing weakness. Which diagnostic test should be considered after an MRI? 1) CT scan 2) Bone scan 3) Spinal x-ray 4) Electromyography 17. A patient is seeking medical treatment for chronic low back pain. Which approach will help speed this patient’s recovery? 1) Regular exercise 2) Spinal injections 3) Nonsteroidal anti-inflammatory agents (NSAIDs) 4) Transcutaneous electrical nerve stimulation (TENS)
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18. A patient with bone cancer is admitted for treatment. What finding should the nurse expect to observe when assessing this patient? 1) Limp 2) Muscle atrophy 3) Skin discoloration 4) Dependent edema 19. A patient is diagnosed with a primary bone tumor. Which treatment should the nurse expect to be prescribed first for this patient? 1) Surgery 2) Amputation 3) Radiotherapy 4) Chemotherapy 20. The nurse is planning care for a patient with osteosarcoma. What should be done before encouraging the patient to increase activity? 1) Assess for pain 2) Assess heart rate 3) Measure blood pressure 4) Provide assistive devices 21. A patient recovering from surgery for bone cancer is scheduled for postoperative radiation treatments. What should the nurse emphasize when providing teaching before a treatment? 1) Apply lotion to the skin 2) Examine the condition of the skin 3) Coat the skin with protective cream NU 4) Lightly dust the skin with talcum p oRwSdeIr NGTB.COM Multiple Response Identify one or more choices that best complete the statement or answer the question. 22. The nurse is assigned to care for a patient with muscular dystrophy. What should the nurse expect to assess in this patient? Select all that apply. 1) Nausea and vomiting 2) Alteration in cardiac rhythm 3) Progressive muscle weakening 4) Reduction in respiratory excursion 5) Wasting of voluntary muscle groups 23. The nurse is reviewing orders written for a patient with Paget’s disease. Which medications should the nurse expect to be prescribed? Select all that apply. 1) Etidronate (Didronel) 2) Ibandronate (Boniva) 3) Risedronate (Actonel) 4) Calcitonin (Miacalcin) 5) Zoledronic acid (Zoledronate) 24. The nurse suspects that a home care patient recovering from hip replacement surgery is developing osteomyelitis. What findings caused the nurse to come to this conclusion? Select all that apply. 1) Fever 2) Bone deformity
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3) Pain unrelieved by rest 4) Progressive muscle weakness 5) Tenderness and warmth at the surgical site 25. A middle-aged person is surprised to learn of the development of scoliosis. What factors in the patient’s history increased the risk for this health problem? Select all that apply. 1) Body mass index 31.4 2) Plays tennis twice a week 3) Smokes 1 PPD of cigarettes 4) Cares for two aging parents 5) Employed as a factory worker 26. The nurse suspects a patient has scoliosis. What observations caused the nurse to make this decision? Select all that apply. 1) Even gait 2) Uneven waist 3) Different arm lengths 4) Lateral curve of the spine 5) Uneven hem line at the knees 27. The nurse is planning care for a patient with osteoarthritis (OA). On what should the nurse focus when preparing teaching material for this patient? Select all that apply. 1) Weight management 2) Nonsteroidal therapy 3) Activity modification 4) Joint replacement surgery 5) Glucosamine and chondroitin NURSINGTB.COM 28. A patient is diagnosed with metastatic bone cancer. Which laboratory value should the nurse expect to see elevated for this patient? Select all that apply. 1) Serum calcium 2) Serum alkaline phosphatase 3) Lactate dehydrogenase (LD) 4) Erythrocyte sedimentation rate (ESR) 5) Serum aspartate aminotransferase (AST)
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Chapter 53: Coordinating Care for Patients With Musculoskeletal Disorders Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Muscular dystrophies Chapter page reference: 1144 Heading: Muscular Dystrophies>Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Mobility Difficulty: Moderate 1 2
3 4
Feedback In Duchenne muscular dystrophy, muscle damage is not because of high body fat. With progressive deterioration and weakness to the facial, limb, respiratory, and cardiac muscles, the ultimate result is muscular damage. This is due primarily to the lack of the key protein (dystrophin) to maintain the integrity of the muscle fibers as well as the ability to repair muscle tissue as it breaks down and/or deteriorates. In Duchenne muscular dystrophy, muscle damage is not because of the breakdown of NURSINGTB.COM collagen. In Duchenne muscular dystrophy, muscle damage is not because of decreased body protein.
PTS: 1 CON: Mobility 2. ANS: 1 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Discussing the medical management of: Muscular dystrophies Chapter page reference: 1147 Heading: Muscular Dystrophies>Medical Management>Treatment Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Mobility; Medication Difficulty: Moderate
1
2 3 4
Feedback There is no specific cure or pharmacological intervention. Glucocorticoid therapy is frequently the medication of choice in conjunction with supportive and collaborative care. Cortisol is a glucocorticoid. Furosemide is a diuretic. This is not prescribed as treatment for muscular dystrophy. Gabapentin is an anticonvulsant often prescribed for peripheral neuropathic pain. This is not prescribed as treatment for muscular dystrophy. Acetaminophen is a NSAID and is not prescribed as treatment for muscular dystrophy.
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PTS: 1 CON: Mobility | Medication 3. ANS: 2 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Osteoporosis Chapter page reference: 1149 Heading: Osteoporosis>Pathophysiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Mobility; Fluid and Electrolyte Balance Difficulty: Moderate 1 2
3 4
Feedback Osteoclasts breaking down bone with acids and enzymes is part of the process of building new bone. Bone loss osteopenia occurs when bone resorption or osteoclastic activity is greater than bone rebuilding or osteoblastic activity, which ultimately results in a decreased bone mineral density (BMD). Osteoblastic activity is less than osteoclastic activity. Osteoblasts rebuild bone by synthesis and mineralization of the new bony matrix within the bone cavity.
PTS: 1 CON: Mobility | Fluid a n d Electr ol y te Balance N URSI N G TB.C O M 4. ANS: 4 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses for musculoskeletal disorders Chapter page reference: 1150 Heading: Osteoporosis>Medical Management>Diagnosis Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility; Fluid and Electrolyte Balance Difficulty: Easy
1 2 3 4
Feedback An MRI is not used to diagnose osteoporosis. A CT scan is not used to diagnose osteoporosis. A bone scan is not used to diagnose osteoporosis. The gold standard assessment for osteoporosis is bone mineral density measurements. They are obtained through a dual-energy x-ray absorptiometry (DEXA) scan.
PTS: 1 CON: Mobility | Fluid and Electrolyte Balance 5. ANS: 3 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Discussing the medical management of: Osteoporosis Chapter page reference: 1151
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Heading: Osteoporosis>Medical Management>Medications Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Mobility; Fluid and Electrolyte Balance; Medication Difficulty: Moderate
1 2 3 4
Feedback Alendronate (Fosamax) should not be taken at bedtime. Alendronate (Fosamax) is not to be taken with a full meal. Alendronate (Fosamax) should be taken on an empty stomach. Alendronate (Fosamax) is not to be taken two hours after breakfast.
PTS: 1 CON: Mobility | Fluid and Electrolyte Balance | Medication 6. ANS: 1 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Paget’s disease Chapter page reference: 1153 Heading: Paget’s Disease>Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Mobility Difficulty: Easy NURSINGTB.COM Feedback 1 One of the main clinical characteristics of Paget’s disease is pain in the affected bony site. 2 Edema is not a main clinical characteristic of Paget’s disease. 3 Hypotension is not a main clinical characteristic of Paget’s disease. 4 Abdominal cramps are not associated with Paget’s disease. PTS: 1 CON: Mobility 7. ANS: 4 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with musculoskeletal disorders Chapter page reference: 1155 Heading: Paget’s Disease>Nursing Medical Management>Actions Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Mobility; Medication Difficulty: Moderate
1 2 3
Feedback Anticholinergic medications are not used in the treatment of Paget’s disease. Thiazide diuretics are not used in the treatment of Paget’s disease. Antihypertensives are not used in the treatment of Paget’s disease.
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4
Calcium levels may be lowered with treatment with bisphosphonates. Supplemental calcium is suggested as well as vitamin D to facilitate GI absorption of calcium.
PTS: 1 CON: Mobility | Medication 8. ANS: 4 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Discussing the medical management of: Osteomyelitis Chapter page reference: 1158 Heading: Osteomyelitis>Surgical Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility; Infection; Perioperative Difficulty: Moderate
1 2
3
4
Feedback Antibiotics will be prescribed; however, teaching about this medication can be instructed at any time. The patient will be experiencing pain; however, teaching about pain management would not be a priority. With appropriate surgical and medical therapy, pain should be managed and decrease. Surgical intervention with débridement is required when a patient with osteomyelitis demonstrates failure to respond to antibiotic therapy, evidence of soft tissue abscess or subperiosteal collection, suspected or confirmed joint infection, and/or progressive neurological deficits or spinal in st ab il ity in the case o f vertebral osteomyelitis. Since U R Sorthopedic IN G TB .Chardware, OM this patient’s osteomyelitis isNfrom the hardware needs to be removed. In the event that a patient has known or suspected infected orthopedic hardware, surgical removal is often warranted.
PTS: 1 CON: Mobility | Infection | Perioperative 9. ANS: 3 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Designing a plan of care for patients with musculoskeletal disorders that includes pharmacological, dietary, and lifestyle considerations Chapter page reference: 1158 Heading: Osteomyelitis>Nursing Management>Actions Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Mobility; Infection; Nutrition Difficulty: Difficult
1 2
Feedback Adequate ingestion of vitamin C, zinc, iron, thiamine, folic acid, and protein can help with wound healing and eliminating infection. This meal choice would be adequate. Adequate ingestion of vitamin C, zinc, iron, thiamine, folic acid, and protein can help with wound healing and eliminating infection. This meal choice would be adequate.
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3 4
This meal choice has no protein. It may have adequate zinc and folic acid; however, protein is missing, which is required for wound healing. Adequate ingestion of vitamin C, zinc, iron, thiamine, folic acid, and protein can help with wound healing and eliminating infection. This meal choice would be adequate.
PTS: 1 CON: Mobility | Infection | Nutrition 10. ANS: 3 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Discussing the medical management of: Scoliosis Chapter page reference: 1160 Heading: Scoliosis>Medical Management Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility; Promoting Health Difficulty: Moderate
1 2 3 4
Feedback Exercise is not used as complete pain control. Many people with scoliosis will have some amount of pain. Pain management is a medical strategy for people with scoliosis. Exercise can reverse the signs and symptoms of spinal deformity and prevent further progression within adolescents and adults. Although obesity is a risk factor for the development of scoliosis, exercises are not being prescribed for weight mN anUagReS mI enNt G buTt ra B.thCerOtoMpreven t the progression of the deformity.
PTS: 1 CON: Mobility | Promoting Health 11. ANS: 3 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Total joint replacement Chapter page reference: 1161 Heading: Joint Replacement>Pathophysiology Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Mobility Difficulty: Moderate
1 2 3
4
Feedback OA causes a breakdown of the cartilage in the joints. OA causes joint fluid to change to yellow-brown in color. In OA, there is a decrease in the proteoglycans, which are responsible for the management of the fluid within the joints. The result is a loss of cartilage strength and functionality. OA does not affect the volume of joint fluid.
PTS: 1
CON: Mobility
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12. ANS: 1 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with musculoskeletal disorders Chapter page reference: 1165 Heading: Joint Replacement>Nursing Management>Postoperative Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Mobility; Perfusion Difficulty: Moderate Feedback 1 Hypotension may signal blood loss. 2 A reduction in respiratory rate would be seen in the patient who is overmedicated for pain. 3 Pain, redness, and edema would indicate a deep vein thrombosis. 4 Increased temperature and purulent drainage would indicate a postoperative infection. PTS: 1 CON: Mobility | Perfusion 13. ANS: 2 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Coordinating the interdisciplinary plan of care for the patient undergoing joint replacement surgery Chapter page reference: 1165 Heading: Joint Replacement>Nursing Management>Actions>Postoperative Actions NURSINGTB.CO Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment/Management of Care Cognitive level: Application [Applying] Concept: Mobility; Collaboration Difficulty: Easy Feedback 1 Devices to assist with position changes and ambulation would not be recommended by the orthopedic nurse. 2 Assistive walking devices such as a walker or crutches are recommended by physical therapy. 3 Devices to assist with position changes and ambulation would not be recommended by the orthopedic surgeon. 4 Devices to assist with position changes and ambulation would not be recommended by the occupational therapist. PTS: 1 CON: Mobility | Collaboration 14. ANS: 2 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Describing the epidemiology of musculoskeletal disorders Chapter page reference: 1166 Heading: Low Back Pain>Epidemiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying]
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Concept: Mobility; Promoting Health Difficulty: Easy
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Feedback Education about safety will not reduce the risk for low back pain. Risk factors for low back pain include poor body mechanics, which would be helpful for nurses. Coordinating care is not a risk factor for low back pain. Stress is not a risk factor for low back pain even though stress is a part of the diagnosis for low back pain.
PTS: 1 CON: Mobility | Promoting Health 15. ANS: 3 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Low back pain Chapter page reference: 1166 Heading: Low Back Pain>Pathophysiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Mobility; Promoting Health Difficulty: Easy
NURSINGTB.COM 1 2 3 4
The lumbar region contains nerve roots that are susceptible to injury or disease. The lumbar region is the most flexible area of the spine. The lumbar region is the most flexible area of the spine. The lumbar region supports the weight of the upper body.
PTS: 1 CON: Mobility | Promoting Health 16. ANS: 4 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses for musculoskeletal disorders Chapter page reference: 1167 Heading: Low Back Pain>Medical Management>Diagnosis Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility Difficulty: Easy Feedback 1 A CT scan is indicated when the spinal and neurological levels or exam are clear (normal) and bony pathology is suspected such as a disk rupture, spinal stenosis, or damage to vertebrae. 2 A bone scan may be performed to rule out a pathologic condition or infection. 3 An x-ray can help determine the obvious causes of LBP such as fractures, degenerative changes, curves, and deformities.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4
Electromyography assesses the electrical activity in a nerve to detect muscle weakness.
PTS: 1 CON: Mobility 17. ANS: 1 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Discussing the medical management of: Low back pain Chapter page reference: 1167 Heading: Low Back Pain>Medical Management>Treatment Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility Difficulty: Easy Feedback 1 Regular exercise is an effective way to speed recovery and help strengthen the back and core muscles. 2 Spinal injections ease inflammation. 3 NSAIDs are recommended for pain relief. 4 Transcutaneous electrical nerve stimulation (TENS) stimulates the peripheral nerves via skin surface electrodes. PTS: 1 CON: Mobility 18. ANS: 1 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: CorrelatiN n gUcRliS n iI c aN l G maTnB ife.sC tatOioMns to pathophysiolo gical processes of: Bone cancer Chapter page reference: 1169 Heading: Bone Cancer>Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Mobility; Cellular Regulation Difficulty: Moderate Feedback 1 Pain may cause the patient to limp. 2 Muscle atrophy is not a manifestation of bone cancer. 3 Skin discoloration is not a manifestation of bone cancer. 4 Although swelling is associated with bone cancer, dependent edema does not typically occur. PTS: 1 CON: Mobility | Cellular Regulation 19. ANS: 3 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Discussing the medical management of: Bone cancer Chapter page reference: 1169 Heading: Bone Cancer>Medical Management>Treatment Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying]
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Concept: Mobility; Cellular Regulation Difficulty: Moderate Feedback 1 Surgery may occur after radiotherapy. 2 The goal of therapy is to prevent limb amputation. 3 In the case of primary bone tumors, radiotherapy is used to destroy or to reduce the size of the tumor so that chemotherapy and/or surgical excision can be used for treatment. 4 Chemotherapy may occur after radiotherapy. PTS: 1 CON: Mobility | Cellular Regulation 20. ANS: 1 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with musculoskeletal disorders Chapter page reference: 1170 Heading: Bone Cancer>Nursing Management>Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Mobility; Cellular Regulation; Comfort Difficulty: Moderate Feedback 1 Independence versus dependence is a potential problem for patients with bone cancer. Pain and the disability caused by osteosarcoma may limit the ability to perform activities of daily living indepen NUdeRnStlyI. NGTB.COM 2 Alteration in heart rate is not typically associated with bone cancer. 3 Alteration in blood pressure is not typically associated with bone cancer. 4 Providing assistive devices would support activity; however, the nurse needs to first find out if the patient is able to perform independent activity. PTS: 1 CON: Mobility | Cellular Regulation | Comfort 21. ANS: 2 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Designing a plan of care for patients with musculoskeletal disorders that includes pharmacological, dietary, and lifestyle considerations Chapter page reference: 1170 Heading: Bone Cancer>Nursing Management>Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility; Cellular Regulation; Skin Integrity Difficulty: Moderate Feedback 1 No lotion should be applied to the skin before a radiation treatment. 2 Radiation therapy can cause localized skin irritation, blisters, and burns. The condition of the skin should be known before a treatment. 3 No creams should be applied to the skin before a radiation treatment. 4 No talcum powder should be applied to the skin before a radiation treatment.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1
CON: Mobility | Cellular Regulation | Skin Integrity
MULTIPLE RESPONSE 22. ANS: 3, 5 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Describing the epidemiology of musculoskeletal disorders Chapter page reference: 1144 Heading: Muscular Dystrophies>Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Mobility Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Nausea and vomiting are not primary symptoms of muscular dystrophies. Alterations in cardiac rhythm are not primary symptoms of muscular dystrophies. The primary symptoms of muscular dystrophies are progressive muscle weakening. Reduction in respiratory excursion is not a primary symptom of muscular dystrophy. The primary symptoms of muscular dystrophies are wasting of skeletal or voluntary muscle groups.
PTS: 1 CON: MobilitN y URSINGTB.COM 23. ANS: 2, 3, 5 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Discussing the medical management of: Paget’s disease Chapter page reference: 1154 Heading: Paget’s Disease>Medical Management>Medications Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Mobility; Medication Difficulty: Moderate
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Feedback Etidronate (Didronel) was the first bisphosphonate used with a 50% reduction in disease activity noted. Presently, it is used less, secondary to the fact that the therapeutic doses required for effective management have been linked to side effects such as bone demineralization. Ibandronate (Boniva) is one of six nitrogen-containing bisphosphonates used for the initial treatment of Paget’s disease. Risedronate (Actonel) is one of six nitrogen-containing bisphosphonates used for the initial treatment of Paget’s disease. Calcitonin was the first therapeutic treatment used for Paget’s disease, but long-term management is difficult because of side effects and the need for ongoing subcutaneous injections. Patients also may develop resistance to this medication.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
5.
Zoledronic acid (Zoledronate) is one of six nitrogen-containing bisphosphonates used for the initial treatment of Paget’s disease.
PTS: 1 CON: Mobility | Medication 24. ANS: 1, 3, 5 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Osteomyelitis Chapter page reference: 1157 Heading: Osteomyelitis>Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Mobility; Infection Difficulty: Moderate
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Feedback Clinical manifestations of acute osteomyelitis include fever. Bone deformity is associated with Paget’s disease. Clinical manifestations of acute osteomyelitis include pain relieved by rest. Progressive muscle weakness is associated with muscular dystrophy. Clinical manifestations of acute osteomyelitis include tenderness and warmth at the site.
PTS: 1 CON: Mobility | Infection 25. ANS: 1, 3, 4, 5 NURSINGTB.COM Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Describing the epidemiology of musculoskeletal disorders Chapter page reference: 1159 Heading: Scoliosis>Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Mobility; Assessment Difficulty: Easy
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Feedback Obesity is a risk factor associated with scoliosis. Sedentary lifestyle is a risk factor associated with scoliosis. Smoking is a risk factor associated with scoliosis. Psychologically strenuous work is a risk factor associated with scoliosis. Occupations that require heavy, physical work are risk factors associated with scoliosis.
PTS: 1 CON: Mobility | Assessment 26. ANS: 2, 3, 4, 5 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Scoliosis Chapter page reference: 1159 Heading: Scoliosis>Clinical Manifestations Integrated Processes: Nursing Process: Assessment
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Mobility; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback An uneven gait is identified as a symptom of scoliosis. Uneven waist is a symptom of scoliosis. Different arm lengths is a symptom of scoliosis. Lateral curve of the spine is a symptom of scoliosis. Uneven hemline at the knees could indicate one hip is higher than the other, which is a symptom of scoliosis.
PTS: 1 CON: Mobility | Assessment 27. ANS: 1, 2, 3, 5 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Discussing the medical management of: Total joint replacement Chapter page reference: 1161 Heading: Joint Replacement>Medical Management Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Mobility; Promoting Health Difficulty: Moderate
NURSINGTB.COM
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Feedback The initial medical management prior to joint replacement is focused on weight management. The initial medical management prior to joint replacement is focused on nonsteroidal therapy. The initial medical management prior to joint replacement is focused on activity modification. The National Institute for Health and Care Excellence states that a total hip replacement (THR) or a total knee replacement (TKR) can be considered once self-management, exercise, and analgesia are no longer effective in relieving pain during activities of daily living. The initial medical management prior to joint replacement is focused on the use of joint supplements such as glucosamine and chondroitin.
PTS: 1 CON: Mobility | Promoting Health 28. ANS: 1, 2, 3, 4 Chapter number and title: 53, Coordinating Care for Patients With Musculoskeletal Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses for musculoskeletal disorders Chapter page reference: 1169 Heading: Bone Cancer>Medical Management>Diagnosis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Mobility; Cellular Regulation Difficulty: Moderate Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1. 2.
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PTS: 1
With metastasis from the breast, kidney, or lung to the bone, elevated calcium levels are frequently noted. Serum alkaline phosphatase is frequently elevated with osteosarcomas due to the increased enzyme activity at the level of the muscle, the deterioration of bone, and the inflammatory response. LD is frequently elevated with osteosarcomas due to the increased enzyme activity at the level of the muscle, the deterioration of bone, and the inflammatory response. ESR is frequently elevated with osteosarcomas due to the increased enzyme activity at the level of the muscle, the deterioration of bone, and the inflammatory response. AST is frequently elevated with muscular dystrophy (MD), not metastatic bone cancer. The AST level is monitored to assess for muscle wasting and deterioration in MD. CON: Mobility | Cellular Regulation
Chapter 54: Coordinating Care for Patients With Musculoskeletal Trauma Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A patient is recovering from surgery to repair a third-degree strain. What needs to be emphasized to the patient about postoperative care? 1) Elevate the extremity 2) Rest the extremity for up to 72 hours tiR mS e sIa NdaGyTB.COM 3) Apply ice to the area three to fivNe U 4) Immobilize the extremity for four to six weeks 2. A patient is treated for a second-degree sprain. Which patient statement indicates that teaching about care has been ineffective? 1) “I should apply ice.” 2) “I should elevate my leg.” 3) “I should expect the leg to feel numb.” 4) “I should take pain medication as directed.” 3. A 70-year-old patient is diagnosed with a low energy fracture. What most likely caused this injury to occur? 1) A fall 2) Contact sport 3) Bicycle accident 4) Motor vehicle collision 4. A patient has an injury where one side of the bone is bent and the other is fractured. How should the nurse document this fracture? 1) Spiral 2) Oblique 3) Greenstick 4) Comminuted 5. A patient with Paget’s disease is demonstrating manifestations of a fracture. What diagnostic test should be ordered to confirm if a fracture has occurred? 1) X-ray
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) Bone scan 3) Myelogram 4) Angiogram 6. While playing tennis a patient fell and fractured the right elbow. For which treatment should the nurse prepare this patient? 1) Cast 2) Splint 3) External fixator 4) Pressure dressing 7. A patient recovering from surgery to repair a fractured femur is experiencing extreme pain and pulselessness. What should the nurse expect to be prescribed for this patient? 1) Fasciotomy 2) Limb CT scan 3) Intravenous fluids 4) Anticoagulant therapy 8. A patient recovering from surgery to repair a fractured hip is placed on skin traction. Which finding indicates that the traction is being effective? 1) Strong peripheral pulses 2) Reduction in muscle spasms 3) Improved mobility of the foot 4) Reduction of lower extremity edema 9. A patient with peripheral vascular disease has a non-healing leg wound. Which observation indicates that the patient is at risk for an elective ampuN taU t ioRnS ? INGTB.COM 1) Mutilation of soft tissue 2) Development of gangrene 3) Crushed lower extremity bone 4) Severed blood vessels and nerves 10. A patient recovering from a traumatic amputation is experiencing phantom limb pain. What should the nurse expect to be included in the treatment plan for this patient? 1) Gabapentin 2) Rigid splint 3) Ice compresses 4) Elevate stump on a pillow 11. During a home visit the nurse suspects that a patient recovering from an amputation is not complying with prescribed postoperative care. What observation caused the nurse to make this clinical determination? 1) Suture line pink and slightly edematous 2) Evidence of a developing hip contracture 3) Stump wrapped with a compression bandage 4) Taking opioid medication every 8 to 10 hours 12. A patient seeks medical treatment for a meniscus injury. What assessment finding would suggest a reason this injury occurred? 1) History of chronic joint disease 2) Participation in cycling or golf 3) Intake of sufficient water and protein 4) Use of nonsteroidal anti-inflammatory drugs (NSAIDs)
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
13. A patient sustained a meniscus injury several months ago and did not seek medical attention. What is this patient at risk of developing? 1) Tendonitis 2) Fractured patella 3) Dependent edema 4) Permanent joint damage 14. The nurse suspects that while playing basketball a patient sustained a meniscus tear. What information did the nurse use to make this decision? 1) Knee pops when bent 2) Weak peripheral pulses 3) Reduced muscle tone of the thigh 4) Calf cramping with the knees bent 15. The nurse notes that a patient recovering from surgery to repair a torn meniscus has a blood pressure of 158/90 mm Hg. This finding would suggest that the nurse also assess the patient for which condition? 1) Pain 2) Edema 3) Infection 4) Hemorrhage 16. The nurse is preparing a teaching tool for a community health program. What should the nurse include as a risk factor for the development of carpal tunnel syndrome (CTS)? 1) Male gender 2) Age less than 20 3) Plays musical instruments NURSINGTB.COM 4) Works as a marketing manager 17. The nurse suspects that a patient is developing carpal tunnel syndrome (CTS). What finding caused the nurse to make this clinical determination? 1) Reduced radial pulses 2) Fingers cool to touch 3) Capillary refill > 3 seconds 4) Hand tingling during the night 18. A patient with bilateral carpal tunnel syndrome (CTS) does not want to have surgery. What is this patient at risk for developing? 1) Infection 2) Chronic pain 3) Further nerve injury 4) Hematoma formation 19. The nurse requests an occupational therapy consultation for a patient with bilateral carpal tunnel syndrome. What is the reason for this consultation? 1) Evaluate the work area 2) Instruct on hand exercises 3) Instruct on the use of splints 4) Review the action of NSAIDs 20. The nurse is reviewing postoperative instructions with a patient recovering from carpal tunnel syndrome (CTS) surgery. Which statement indicates that additional teaching would be required?
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1) 2) 3) 4)
“I should take the pain medication as prescribed.” “I should expect my hand to feel numb for a few weeks.” “I should perform hand exercises as directed by the therapist.” “I should stop any activity that causes hand numbness or pain.”
Multiple Response Identify one or more choices that best complete the statement or answer the question. 21. The nurse is reviewing statistics about the frequency of anterior cruciate ligament (ACL) tears. What increases the risk of experiencing this type of injury? Select all that apply. 1) Knee torque 2) Less knee flexibility 3) Practicing ice skating 4) Performing gymnastics 5) Less muscular strength 22. A patient is diagnosed with a third-degree sprain. What should the nurse expect to assess in this patient? Select all that apply. 1) Edema 2) Severe pain 3) Ecchymosis 4) Inability to ambulate 5) Altered ability to ambulate 23. The nurse suspects that a patient with an injured ankle is experiencing neurovascular compromise. What did the nurse assess to come to this conclNusUioRnS ? I S eNleG ctTaB ll .thC a tOaM pp ly. 1) Pain 2) Pressure 3) Paralysis 4) Peristalsis 5) Pulselessness 24. A victim of a motor vehicle crash has a partially severed lowered extremity. What emergency care does this patient need? Select all that apply. 1) Administer antibiotics 2) Prepare for blood transfusions 3) Prepare for emergency surgery 4) Assess for active hemorrhaging 5) Monitor effectiveness of tourniquet 25. A patient is diagnosed with a small meniscus tear of the right knee. What should the nurse expect to be prescribed for this patient? Select all that apply. 1) Ice 2) Limited rest 3) Physical therapy for a month 4) Total immobility for several weeks 5) Use of nonsteroidal anti-inflammatory drugs (NSAIDs)
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Chapter 54: Coordinating Care for Patients With Musculoskeletal Trauma Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Explaining the effective medical management of: Sprains and strains Chapter page reference: 1175 Heading: Strains and Sprains>Medical Management Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility; Perioperative Difficulty: Moderate Feedback 1 Treatment of first- and second-degree strains and sprains includes elevating the extremity. 2 Treatment of first- and second-degree strains and sprains includes resting the extremity. 3 Treatment of first- and second-degree strains and sprains includes applying ice to the extremity. 4 Postoperative treatment for strains and sprains involves immobilization of the affected extremity for four to six weeks. PTS: 1 CON: MobilitN y U | PReS rioIpN erG atT ivB e .COM 2. ANS: 3 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations based on patients with musculoskeletal trauma Chapter page reference: 1176 Heading: Strains and Sprains>Nursing Management>Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Mobility; Promoting Health Difficulty: Moderate Feedback 1 A second-degree sprain is treated with ice. 2 A second-degree sprain is treated with elevation. 3 Numbness could indicate neurovascular compromise and should be reported. 4 A second-degree sprain is treated with pain medication. PTS: 1 CON: Mobility | Promoting Health 3. ANS: 1 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Describing the epidemiology of various types of musculoskeletal trauma Chapter page reference: 1177 Heading: Fractures>Epidemiology
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Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Mobility Difficulty: Easy Feedback 1 Fractures in people 65 or older are generally caused by low-energy trauma such as falls. 2 Contact sports cause high-energy injuries. 3 Bicycle accidents are a type of high-energy trauma. 4 Motor vehicle collisions are a type of high-energy trauma. PTS: 1 CON: Mobility 4. ANS: 3 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Identifying the clinical manifestations to pathophysiological processes of: Fractures Chapter page reference: 1177 Heading: Fractures>Pathophysiology Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility; Communication Difficulty: Easy Feedback 1 A spiral fracture wraps aroundNthe URsShaIf tNoGf tTheBb.oCn eO. M 2 An oblique fracture line occurs usually at a 45-degree angle across the cortex of the bone. 3 A greenstick fracture is an incomplete disruption where one side of the bone is bent and the other is fractured. 4 A comminuted fracture has several disruptions producing shattered bone fragments within the fracture site. PTS: 1 CON: Mobility | Communication 5. ANS: 2 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Describing the diagnostic results used to confirm the specific type of musculoskeletal trauma Chapter page reference: 1177 Heading: Fractures>Management>Diagnosis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility Difficulty: Easy Feedback 1 The patient will need more than an x-ray. 2 If a chronic illness is suspected as having a major role in the injury, a bone scan may be needed to confirm the diagnosis. 3 A myelogram is not used to diagnose a fracture.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4
An angiogram is not used to diagnose a fracture.
PTS: 1 CON: Mobility 6. ANS: 1 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Explaining the effective medical management of: Fractures Chapter page reference: 1179 Heading: Fractures>Management>Treatment Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility Difficulty: Moderate Feedback 1 An elbow fracture is immobilized with a cast. 2 A fractured forearm or clavicle would be immobilized with a splint. 3 A fractured wrist may need to be immobilized with an external fixator. 4 A fractured wrist may be immobilized with a pressure dressing. PTS: 1 CON: Mobility 7. ANS: 1 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Explaining the clinical presentation and management of complications associated with musculoskeletal trauma Chapter page reference: 1181 NURSINGTB.COM Heading: Fractures>Management>Complications Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility Difficulty: Moderate Feedback 1 Once compartment syndrome is suspected, the provider will often remove the cast or perform a fasciotomy to immediately relieve the compartment pressure. 2 A CT scan is not used to relieve the pressure of compartment syndrome. 3 Intravenous fluids would be prescribed to treat rhabdomyolysis. 4 Anticoagulant therapy would be prescribed to treat a deep vein thrombosis. PTS: 1 CON: Mobility 8. ANS: 2 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Explaining the effective medical management of: Fractures Chapter page reference: 1180 Heading: Fractures>Management>Traction Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Mobility Difficulty: Moderate
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1 2 3 4
Feedback Skin traction is not used to improve blood flow. Skin traction is applied to relieve muscle spasms. Skin traction is not used to improve mobility. Skin traction is not used to reduce edema.
PTS: 1 CON: Mobility 9. ANS: 2 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Identifying the clinical manifestations to pathophysiological processes of: Amputations Chapter page reference: 1186 Heading: Amputations>Pathophysiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Mobility; Infection Difficulty: Moderate Feedback 1 Mutilation of soft tissue occurs with a traumatic amputation. 2 Elective amputations are caused by disease that alters perfusion. Cell death causes necrotic tissue to form. The wound acts as a portal for an infection that can lead to gangrene. 3 A traumatic amputation mutilates bones. 4 A traumatic amputation severeNdUbR loS o dIvNesGsT e lB s a.ndC nOeM rves. PTS: 1 CON: Mobility | Infection 10. ANS: 1 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Explaining the clinical presentation and management of complications associated with musculoskeletal trauma Chapter page reference: 1187 Heading: Amputations>Medical Management>Complications Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Mobility; Comfort; Medication Difficulty: Moderate Feedback 1 The administration of antidepressant and anticonvulsant medications such as gabapentin has demonstrated effectiveness in treating phantom limb pain. 2 A rigid splint reduces edema and aids with fitting for a prosthesis. 3 Ice compresses promote vasoconstriction and decrease painful edema. 4 Elevation would encourage the development of contractures and would not help reduce phantom limb pain. PTS: 1 11. ANS: 2
CON: Mobility | Comfort | Medication
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations based on patients with musculoskeletal trauma Chapter page reference: 1188 Heading: Amputations>Nursing Management>Teaching Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Mobility Difficulty: Moderate
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Feedback A pink and slightly edematous suture line would indicate healing. A developing hip contracture indicates that the patient is not complying with postoperative exercises and actions to prevent the development of a contracture. Wrapping the stump with a pressure bandage decreases edema and aids in the correct fitting of the prosthesis. Taking pain medication as prescribed indicates adherence to postoperative teaching and care.
PTS: 1 CON: Mobility 12. ANS: 1 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Describing the epidemiology of various types of musculoskeletal trauma Chapter page reference: 1189 NURSINGTB.COM Heading: Meniscus Injuries>Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility Difficulty: Easy Feedback 1 Chronic joint diseases are risk factors for a meniscus injury. 2 Cycling and golf are not risk factors for a meniscus injury. 3 Oral intake of fluid and protein are not risk factors for a meniscus injury. 4 Use of NSAIDs is not a risk factor for a meniscus injury. PTS: 1 CON: Mobility 13. ANS: 4 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Explaining the clinical presentation and management of complications associated with musculoskeletal trauma Chapter page reference: 1190 Heading: Meniscus Injuries>Medical Management>Complications Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Mobility Difficulty: Easy
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1 2 3 4
Feedback Meniscus tears are not related to tendonitis. Meniscus tears will not cause patellar fractures. Meniscus tears will not cause dependent edema. If left untreated, meniscus tears can lead to permanent joint damage.
PTS: 1 CON: Mobility 14. ANS: 1 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Developing a comprehensive plan of nursing care for patients with musculoskeletal trauma Chapter page reference: 1190 Heading: Meniscus Injuries>Nursing Management>Assessment and Analysis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Mobility; Assessment Difficulty: Moderate Feedback 1 The diagnosis of meniscus injuries is based upon physical examination using either the McMurray’s or Steinman’s test in which the knee is supported and flexed while the lower leg is rotated internally and externally. A positive result is indicated when either test reveals an audible/palpable “click.” 2 Meniscus injuries to not affect peripheral pulses. 3 Meniscus injuries do not affecN t tU hiR ghSI muNsG cleT sBtr. enCgO thM . 4 Calf cramping is not associated with a meniscus injury. PTS: 1 CON: Mobility | Assessment 15. ANS: 1 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations based on patients with musculoskeletal trauma Chapter page reference: 1190 Heading: Meniscus Injuries>Nursing Management>Assessments Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility; Assessment; Perioperative Difficulty: Moderate Feedback 1 Hypertension may indicate increased pain. 2 Edema can cause poor perfusion and reduce peripheral pulses. 3 An elevated temperature indicates an infection. 4 Tachycardia and hypotension may indicate hemorrhage. PTS: 1 CON: Mobility | Assessment | Perioperative 16. ANS: 3 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma
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Chapter learning objective: Describing the epidemiology of various types of musculoskeletal trauma Chapter page reference: 1191 Heading: Carpal Tunnel Syndrome>Epidemiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Mobility; Promoting Health Difficulty: Moderate Feedback 1 Women are four to five times more likely to get CTS than their male counterparts, partially because of the smaller size of the carpal tunnel in women. 2 Risk factors for carpal tunnel syndrome include advancing age. 3 Higher occurrences are noted in patients who have jobs requiring repetitive motions of the hands such as musicians. 4 There is an increased prevalence of CTS among those who work in industrial occupations involving repetitive movement of the hands and wrists. PTS: 1 CON: Mobility | Promoting Health 17. ANS: 4 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Identifying the clinical manifestations to pathophysiological processes of: Carpal tunnel syndrome Chapter page reference: 1191 Heading: Carpal Tunnel Syndrome>Pathophysiology and Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity N –U ReRdS ucItiN onGoTf B R. iskCPOoM tential Cognitive level: Application [Applying] Concept: Mobility; Assessment Difficulty: Moderate
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Feedback CTS does not affect the radial pulse. CTS does not affect temperature of the fingers. CTS does not affect capillary refill. In CTS inflammation compresses the median nerve causing sharp pain, numbness, and tingling of the hand. Symptoms initially occur intermittently at night, then progress if not treated.
PTS: 1 CON: Mobility | Assessment 18. ANS: 2 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Explaining the clinical presentation and management of complications associated with musculoskeletal trauma Chapter page reference: 1192 Heading: Carpal Tunnel Syndrome>Medical Management>Complications Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Mobility
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Difficulty: Easy
1 2 3 4
Feedback Postoperative complications include infection. Untreated CTS can lead to chronic pain. Postoperative complications include further nerve injury. Postoperative complications include hematoma formation.
PTS: 1 CON: Mobility 19. ANS: 1 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations based on patients with musculoskeletal trauma Chapter page reference: 1192 Heading: Carpal Tunnel Syndrome>Nursing Management>Actions Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Mobility; Collaboration Difficulty: Easy
1 2 3 4
Feedback An occupational therapist can evaluate the work area and make recommendations for modifications to eliminate causative factors. A physical therapist would insNtruc URt on SIhNanGdTexe B.rcCisOesM. A physical therapist would instruct on the use of splints. The nurse or pharmacist would review the action of NSAIDs.
PTS: 1 CON: Mobility | Collaboration 20. ANS: 2 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations based on patients with musculoskeletal trauma Chapter page reference: 1192 Heading: Carpal Tunnel Syndrome>Nursing Management>Teaching Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Mobility; Perioperative Difficulty: Moderate
1 2 3 4
Feedback The patient should take postoperative pain medication as prescribed. The patient should report any worsening symptoms to the health-care provider. The patient should perform physical therapy to promote movement, muscle strength, and return to pre-injury functioning. The patient should stop any activity that causes hand numbness or pain and evaluate the environment to reduce the pain from reoccurring.
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PTS: 1
CON: Mobility | Perioperative
MULTIPLE RESPONSE 21. ANS: 1, 2, 4, 5 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Describing the epidemiology of various types of musculoskeletal trauma Chapter page reference: 1174 Heading: Strains and Sprains>Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Mobility Difficulty: Easy
1. 2. 3. 4. 5.
Feedback A great degree of knee torque increases the risk of an ACL injury. Less knee flexibility increases the risk of an ACL injury. The frequency of ankle sprains can be ranked highest among the sport of ice skating. An ACL injury occurs most frequently in sports that involve twisting and jumping like gymnastics. Less muscular strength increases the risk for an ACL injury.
PTS: 1 CON: MobilitN y URSINGTB.COM 22. ANS: 1, 2, 3, 4 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Identifying the clinical manifestations to pathophysiological processes of: Strains and sprains Chapter page reference: 1174 Heading: Strains and Sprains>Pathophysiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Symptoms of a third-degree sprain include edema. Symptoms of a third-degree sprain include severe pain. Symptoms of a third-degree sprain include ecchymosis. Third-degree or severe sprains include the complete tearing of a ligament, which renders the patient unable to ambulate because of joint instability. Symptoms of a second-degree sprain include an altered ability to ambulate.
PTS: 1 CON: Mobility | Assessment 23. ANS: 1, 2, 3, 5 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma
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Chapter learning objective: Developing a comprehensive plan of nursing care for patients with musculoskeletal trauma Chapter page reference: 1176 Heading: Strains and Sprains>Nursing Management>Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility; Assessment Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Symptoms of neurovascular compromise include pain. Symptoms of neurovascular compromise include pressure. Symptoms of neurovascular compromise include paralysis. Peristalsis is not a symptom of neurovascular compromise. Symptoms of neurovascular compromise include pulselessness.
PTS: 1 CON: Mobility | Assessment 24. ANS: 2, 3, 4, 5 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Explaining the effective medical management of: Amputations Chapter page reference: 1186 Heading: Amputations>Medical Management>Safety Alert Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Reduction of Risk Potential NURSINGTB.COM Cognitive level: Application [Applying] Concept: Mobility; Infection; Perioperative Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback Antibiotics are not part of emergency care for a traumatic amputation. To prevent hemorrhagic shock after a traumatic amputation, the patient should be prepared for blood transfusions. The patient with a traumatic amputation should be prepared for emergency surgery. The patient with a traumatic amputation should be assessed for active hemorrhaging. The tourniquet or pressure bandage placed over the site of a traumatic amputation should be assessed for effectiveness.
PTS: 1 CON: Mobility | Infection | Perioperative 25. ANS: 1, 2, 5 Chapter number and title: 54, Coordinating Care for Patients With Musculoskeletal Trauma Chapter learning objective: Explaining the effective medical management of: Meniscus injuries Chapter page reference: 1190 Heading: Meniscus Injuries>Medical Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Mobility Difficulty: Moderate
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1. 2. 3. 4. 5. PTS: 1
Feedback Smaller tears often heal within a few months and are treated with ice. Smaller tears often heal within a few months and are treated with limited rest. Physical therapy would be indicated for a larger meniscus tear requiring surgery. Total immobility and resting of the affected joint is not recommended because it may cause muscle atrophy, stiffness, and further movement problems. Smaller tears often heal within a few months and are treated with NSAIDs. CON: Mobility
Chapter 55: Assessment of Gastrointestinal Function Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which structure of the gastrointestinal (GI) system is found in the right upper quadrant (RUQ) and is the primary site of absorption? 1) Stomach 2) Duodenum 3) Sigmoid 4) Large intestine 2. The patient reports left upper quadranNtU(LRUSQI) N p aGinT. B Ba.seCdOoMn this data, which does the nurse suspect? 1) Ruptured spleen 2) Pneumonia 3) Hepatitis 4) Duodenal ulcer 3. Which organ functions as a main site for metabolizing drugs and may become impaired with the aging process? 1) Stomach 2) Liver 3) Spleen 4) Large intestine 4. The nurse is assessing a patient who is prescribed an anticholinergic agent. Which assessment finding indicates the patient is experiencing an adverse reaction to the drug? 1) GI bleeding 2) Hepatic necrosis 3) Diarrhea 4) Hypoactive bowel sounds 5. The nurse is providing care to a patient who reports diffuse abdominal pain. Upon assessment, the nurse notes absent bowel sounds and abdominal distension. Based on this data, which medical diagnosis does the nurse suspect? 1) Appendicitis 2) Bowel obstruction 3) Cirrhosis
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4) Cholelithiasis 6. The nurse notes a positive shifting dullness during abdominal percussion. Which diagnosis does this assessment data support? 1) Ascites 2) Liver enlargement 3) Pancreatitis 4) An abdominal mass 7. Which action by the nurse is appropriate when determining if bowel sounds are absent during the patient assessment? 1) Palpating the abdomen for two minutes 2) Inspecting the abdomen for 30 seconds 3) Percussing the abdomen for 60 seconds 4) Auscultating the abdomen for five minutes 8. Which is the correct sequence for the abdominal exam? 1) Inspection, palpation, percussion, and auscultation 2) Inspection, percussion, palpation, and auscultation 3) Inspection, auscultation, percussion, and palpation 4) Inspection, auscultation, palpation, and percussion 9. Which sound would the nurse expect to elicit when percussing the liver? 1) Resonance 2) Hyperresonance 3) Dullness 4) Tympany NURSINGTB.COM 10. Which is the normal liver span at the midclavicular line the nurse anticipates when conducting a gastrointestinal assessment? 1) 3 to 6 cm 2) 4 to 8 cm 3) 6 to 12 cm 4) 12 to 16 cm 11. An older adult patient is admitted to the hospital with blunt trauma to the abdomen after an auto accident. Which finding may indicate intra-abdominal bleeding? 1) Borborygmi 2) Everted umbilicus 3) Visible peristaltic waves 4) Bluish tint around the umbilicus 12. Which bowel sound noted by the nurse during the gastrointestinal assessment indicates an early bowel obstruction? 1) Hyperperistaltic 2) Hypoperistaltic 3) Absent 4) Epigastric 13. Which action by the nurse is appropriate when attempting to locate the spleen during the abdominal assessment? 1) Percussing over the 9th to the 11th ribs at the midaxillary line
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2) Performing the scratch test 3) Auscultating for venous hums 4) Palpating for the apical pulse 14. Which structure, located in the right upper quadrant (RUQ) of the abdomen, is assessed by the nurse by palpation and percussion? 1) Spleen 2) Stomach 3) Sigmoid 4) Liver 15. Which structure is located in the left upper quadrant (LUQ) of the abdomen? 1) Liver 2) Spleen 3) Appendix 4) Sigmoid 16. Which structure is located in the right lower quadrant (RLQ) of the abdomen? 1) Liver 2) Stomach 3) Cecum 4) Sigmoid 17. Which is the primary system that is assessed by the nurse during an abdominal assessment? 1) Reproductive 2) Urinary 3) Digestive NURSINGTB.COM 4) Respiratory 18. The nurse is assessing an older adult patient who is experiencing constipation. Which age-related change may contribute to this clinical finding? 1) Increased saliva 2) Increased stomach acid 3) Decreased abdominal fat accumulation 4) Decreased peristalsis 19. The nurse is assessing a patient who is exhibiting pain in the right lower quadrant (RLQ). Based on this data, which diagnosis does the nurse suspect? 1) Cholelithiasis 2) Appendicitis 3) Cholecystitis 4) Pneumonia 20. The nurse is assessing a patient who presents with weight loss. Which assessment question is most appropriate for this patient? 1) “How is your appetite?” 2) “How frequent are your bowel movements?” 3) “When was your last bowel movement?” 4) “What color is your stool?” Multiple Response
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Identify one or more choices that best complete the statement or answer the question. 21. When conducting an abdominal assessment, the nurse notes tender unmovable inguinal nodes that are greater than 1 cm. Which conclusions by the nurse may be appropriate? Select all that apply. 1) Infection 2) Appendicitis 3) Cancer 4) Cholecystitis 5) Lymphoma 22. The nurse is conducting a health history for a patient who presents with abdominal discomfort. Which assessment questions are appropriate? Select all that apply. 1) “Where is the pain?” 2) “Was the onset gradual or sudden?” 3) “When was your last menstrual period?” 4) “How is your appetite?” 5) “What have you had to eat in the last 24 hours?” 23. The nurse is conducting a health history for a patient who presents with weight change. Which assessment questions are appropriate? Select all that apply. 1) “Where is the pain?” 2) “Was the onset gradual or sudden?” 3) “When was your last menstrual period?” 4) “How is your appetite?” 5) “What have you had to eat in the last 24 hours?”
Bh.icCh OstMructu res can be assessed by palpation in the right 24. The nurse is conducting an abdominaNl U a sR seSssImNenGt.TW upper quadrant (RUQ)? Select all that apply. 1) Liver 2) Gallbladder 3) Duodenum 4) Spleen 5) Stomach 25. The nurse is assessing a patient who experienced blunt force trauma to the umbilical region of the abdomen. Which structures may be affected based on this information? Select all that apply. 1) Right kidney 2) Ascending colon 3) Ileum 4) Aorta 5) Spine
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Chapter 55: Assessment of Gastrointestinal Function Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Discussing the function of the gastrointestinal system Chapter page reference: 1196-1213 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Assessment; Digestion; Bowel Elimination Difficulty: Easy Feedback 1 The stomach, found in the left upper quadrant, turns the food bolus into chyme. 2 The duodenum is the primary site for digestion, especially chemical digestion. It is located in the RUQ. 3 The sigmoid colon is found in the left upper quadrant. 4 The large intestine primarily reabsorbs water. PTS: 1 CON: Assessment | Digestion | Bowel Elimination 2. ANS: 1 NURSINGTB.COM Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Identifying key anatomical components of the gastrointestinal system Chapter page reference: 1196-1213 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Assessment Difficulty: Easy
1 2 3 4
Feedback A ruptured spleen would manifest with pain in the LUQ. Pneumonia would manifest with pain in the right upper quadrant (RUQ). Hepatitis would manifest with pain in the right upper quadrant (RUQ). A duodenal ulcer would manifest with pain in the right upper quadrant (RUQ).
PTS: 1 CON: Assessment 3. ANS: 2 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Discussing the function of the gastrointestinal system Chapter page reference: 1196-1213 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
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Cognitive level: Comprehension [Understanding] Concept: Medication Difficulty: Easy
1 2 3 4
Feedback The stomach turns food bolus into chyme. The liver detoxifies a variety of substances such as drugs and alcohol. This function may become impaired with the aging process. The spleen produces and stores red (RBCs) and white (WBCs) blood cells. The large intestine reabsorbs water.
PTS: 1 CON: Medication 4. ANS: 4 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Correlating relevant diagnostic examinations to gastrointestinal function Chapter page reference: 1203-1208 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Digestion; Bowel Elimination; Medication Difficulty: Easy
1 2 3 4
Feedback GI bleeding is an adverse reacN tioUnRaS ssI ocNiaGteT d Bw. i thCaOspMirin, not an anticholin ergic drug. Hepatic necrosis is an adverse reaction associated with toxic levels of acetaminophen, not an anticholinergic drug. Diarrhea is an adverse reaction associated with many drugs, but this is not an adverse reaction associated with an anticholinergic drug. Hypoactive bowel sounds may indicate an adverse drug reaction.
PTS: 1 CON: Digestion | Bowel Elimination | Medication 5. ANS: 2 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Correlating relevant diagnostic examinations to gastrointestinal function Chapter page reference: 1196-1213 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy
1 2
Feedback Appendicitis causes abdominal pain; bowel sounds are absent if the appendix perforates and causes peritonitis. Absent bowel sounds are caused by late bowel obstruction, peritonitis, or paralytic ileus after surgery in which the bowel was manipulated.
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3 4
Cirrhosis may affect liver size. Cholelithiasis causes abdominal pain.
PTS: 1 CON: Digestion 6. ANS: 1 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Correlating relevant diagnostic examinations to gastrointestinal function Chapter page reference: 1196-1213 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Assessment Difficulty: Easy Feedback 1 Shifting dullness indicates abdominal fluid of greater than 500 mL. This finding supports the diagnosis of ascites. 2 Liver enlargement will cause dullness, but it does not shift. 3 Positive shifting dullness is not indicative of pancreatitis. 4 An abdominal mass will cause dullness, but it does not shift. PTS: 1 CON: Assessment 7. ANS: 4 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: DescribinNgUthReSp I roN c eGduTrB e . foC r cOoM mpletin g a history and physical assessment of gastrointestinal function Chapter page reference: 1196-1213 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Assessment Difficulty: Moderate 1 2 3 4
Feedback Palpation is not the technique used to assess bowel sounds. Inspection is not the technique used to assess bowel sounds. Percussion is not the technique used to assess bowel sounds. Bowel sounds occur every 5 to 15 seconds in an average adult patient. The nurse should auscultate the abdomen for 5 minutes before determining that bowel sounds are absent.
PTS: 1 CON: Assessment 8. ANS: 3 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Describing the procedure for completing a history and physical assessment
of gastrointestinal function Chapter page reference: 1196-1213 Heading: Assessment
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Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering] Concept: Assessment Difficulty: Easy Feedback 1 This is not the correct order for an abdominal assessment. 2 This is not the correct order for an abdominal assessment. 3 It is important to auscultate before percussion and palpation because the manipulation that occurs with these techniques may increase the frequency of bowel sounds. 4 This is not the correct order for an abdominal assessment. PTS: 1 CON: Assessment 9. ANS: 3 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Describing the procedure for completing a history and physical assessment
of gastrointestinal function Chapter page reference: 1196-1213 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Assessment Difficulty: Easy Feedback NURSINGTB.COM 1 Resonance is a respiratory percussion sound. 2 Hyperresonance is a respiratory percussion sound. 3 Dullness should be heard over the liver (around the fifth to seventh intercostal space). 4 Tympany is percussed over the stomach or intestines filled with air or gas. PTS: 1 CON: Assessment 10. ANS: 3 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Identifying key anatomical components of the gastrointestinal system Chapter page reference: 1196-1213 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering] Concept: Assessment Difficulty: Easy Feedback 1 2 3 4
The normal liver span at the midclavicular line is not 3 to 6 cm. The normal liver span at the midclavicular line is not 4 to 8 cm. The normal liver span at the midclavicular line is 6 to 12 cm. The normal liver span at the midclavicular line is not 12 to 16 cm.
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PTS: 1 CON: Assessment 11. ANS: 4 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Correlating relevant diagnostic examinations to gastrointestinal function Chapter page reference: 1196-1213 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Assessment Difficulty: Easy 1 2 3 4
Feedback Borborygmi is the term used to describe hyperactive bowel sounds. An everted umbilicus is often a normal finding for pregnant patients. Visible peristaltic waves can be a normal finding for pediatric patients. Bluish discoloration around the umbilicus (Cullen's sign) indicates hemorrhagic pancreatitis or intraperitoneal bleeding.
PTS: 1 CON: Assessment 12. ANS: 1 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Correlating relevant diagnostic examinations to gastrointestinal function Chapter page reference: 1196-1213 Heading: Assessment NURSINGTB.COM Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Assessment; Digestion; Bowel Elimination Difficulty: Easy Feedback 1 Hyperperistalsis can be a sign of early bowel obstruction. 2 Hypoperistalsis is not a sign of an early bowel obstruction. 3 Absent bowel sounds is a not a sign of an early bowel obstruction. 4 Epigastric bowel sounds are not a sign of an early bowel obstruction. PTS: 1 CON: Assessment | Digestion | Bowel Elimination 13. ANS: 1 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Describing the procedure for completing a history and physical assessment
of gastrointestinal function Chapter page reference: 1196-1213 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Assessment Difficulty: Moderate
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1 2 3 4
Feedback Dullness of the normal spleen will be noted around the 9th to the 11th ribs. The scratch test is used to locate the liver. Venous hums indicate liver disease. Palpating the apical pulse is not a procedure used to locate the spleen.
PTS: 1 CON: Assessment 14. ANS: 4 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Describing the procedure for completing a history and physical assessment
of gastrointestinal function Chapter page reference: 1196-1213 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Assessment Difficulty: Easy Feedback 1 The spleen is located in the left upper quadrant. 2 The stomach is located in the left upper quadrant. 3 The sigmoid colon is located in the left lower quadrant. 4 The liver is located in the RUQ. The nurse assesses this organ with palpation and percussion.
NURSINGTB.COM PTS: 1 CON: Assessment 15. ANS: 2 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Identifying key anatomical components of the gastrointestinal system Chapter page reference: 1196-1213 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering] Concept: Assessment Difficulty: Easy Feedback 1 The liver is located in the right upper quadrant. 2 The spleen is located in the LUQ. 3 The appendix is located in the right lower quadrant. 4 The sigmoid is located in the left lower quadrant. PTS: 1 CON: Assessment 16. ANS: 3 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Identifying key anatomical components of the gastrointestinal system Chapter page reference: 1196-1213 Heading: Overview of Anatomy and Physiology
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Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering] Concept: Assessment Difficulty: Easy Feedback 1 The liver is located in the right upper quadrant. 2 The stomach is located in the left upper quadrant. 3 The cecum is located in the RLQ. 4 The sigmoid is located in the left lower quadrant. PTS: 1 CON: Assessment 17. ANS: 3 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Describing the procedure for completing a history and physical assessment
of gastrointestinal function Chapter page reference: 1196-1213 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Assessment; Digestion; Bowel Elimination Difficulty: Easy Feedback 1 The reproductive system is assNe sUseRdSdI u rNinGg TanBa.bC d oOmMinal assessment; however, this is not the primary system the nurse is assessing. 2 The urinary system is assessed during an abdominal assessment; however, this is not the primary system the nurse is assessing. 3 The digestive system is the primary system being assessed during an abdominal examination. 4 The respiratory system is assessed during an abdominal assessment; however, this is not the primary system the nurse is assessing. PTS: 1 CON: Assessment 18. ANS: 4 and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Discussing changes in gastrointestinal function associated with aging Chapter page reference: 1196-1213 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Assessment; Bowel Elimination; Digestion Difficulty: Easy 1
Feedback The older adult patient will experience decreased, not increased, saliva. This finding does not contribute to constipation.
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2 3 4
The older adult patient will experience decreased, not increased, stomach acid. This finding does not contribute to constipation. The older adult patient will experience increased, not decreased, abdominal fat accumulation. This finding does not contribute to constipation. Decreased peristalsis may contribute to constipation for older adult patients.
PTS: 1 CON: Assessment | Bowel Elimination | Digestion 19. ANS: 2 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Correlating relevant diagnostic examinations to gastrointestinal function Chapter page reference: 1196-1213 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Assessment Difficulty: Easy 1 2 3 4
Feedback Pain in the RLQ does not indicate gallstones. Appendicitis manifests with pain in the RLQ. Pain in the RLQ does not indicate gallbladder inflammation. Pneumonia does not manifest with pain in the RLQ.
PTS: 1 CON: Assessm NeUnRt SINGTB.COM 20. ANS: 1 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Describing the procedure for completing a history and physical assessment
of gastrointestinal function Chapter page reference: 1196-1213 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Assessment Difficulty: Moderate
1 2 3 4
Feedback Asking the patient about appetite is appropriate when the patient presents with weight loss. This question is more appropriate for a patient who is experiencing alterations in bowel elimination. This question is more appropriate for a patient who is experiencing alterations in bowel elimination. This question is more appropriate for a patient who is experiencing alterations in bowel elimination.
PTS: 1
CON: Assessment
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MULTIPLE RESPONSE 21. ANS: 1, 3, 5 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Correlating relevant diagnostic examinations to gastrointestinal function Chapter page reference: 1196-1213 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Assessment Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is correct. This finding could indicate infection. This is incorrect. This finding is not indicative of appendicitis. This is correct. This finding could indicate cancer. This is incorrect. This finding is not indicative of cholecystitis. This is correct. This finding could indicate lymphoma.
PTS: 1 CON: Assessment 22. ANS: 1, 2, 3 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: DescribiN ngUR thS e I prNoG ceT dB ur. eC foOr M completing a history and physical assessm ent
of gastrointestinal function Chapter page reference: 1196-1213 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Assessment; Digestion; Bowel Elimination; Comfort Difficulty: Moderate
1. 2. 3. 4. 5.
PTS: 1 23. ANS: 4, 5
Feedback This is correct. This question is appropriate for the patient who presents with abdominal discomfort. It is essential for the nurse to determine the exact location of the pain. This is correct. This question is appropriate for a patient who presents with abdominal pain. The onset may determine the source of the pain. This is correct. Abdominal pain in female patients may indicate reproductive issues; therefore, the nurse should determine the last menstrual period. This is incorrect. This question is more appropriate for a patient who has experienced a change in weight. This is incorrect. This question is more appropriate for a patient who has experienced a change in weight. CON: Assessment | Digestion | Bowel Elimination | Comfort
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Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Describing the procedure for completing a history and physical assessment
of gastrointestinal function Chapter page reference: 1196-1213 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Assessment; Nutrition Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback This is incorrect. This question is more appropriate for a patient who presents with abdominal pain. This is incorrect. This question is more appropriate for a patient who presents with abdominal pain. This is incorrect. This question is more appropriate for a patient who presents with abdominal pain. This is correct. Weight change is assessed by determining the patient’s appetite. This is correct. A 24-hour dietary log is appropriate to further assess a patient who presents with a change in weight.
PTS: 1 CON: Assessment | Nutrition 24. ANS: 1, 2, 3 Chapter number and title: 55, Assessm Nen URt of SIGNasGtrToiBnt.esCtiOnaMl Function Chapter learning objective: Describing the procedure for completing a history and physical assessment
of gastrointestinal function Chapter page reference: 1196-1213 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Assessment; Digestion; Bowel Elimination Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback This is correct. The liver is located in the RUQ and assessed by palpation. This is correct. The gallbladder is located in the RUQ and assessed by palpation. This is correct. The duodenum is located in the RUQ and assessed by palpation. This is incorrect. The spleen is located in the left, not right, upper quadrant. This is incorrect. The stomach is located in the left, not right, upper quadrant.
PTS: 1 CON: Assessment | Digestion | Bowel Elimination 25. ANS: 3, 4, 5 Chapter number and title: 55, Assessment of Gastrointestinal Function Chapter learning objective: Correlating relevant diagnostic examinations to gastrointestinal function Chapter page reference: 1196-1213 Heading: Overview of Anatomy and Physiology
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Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Assessment Difficulty: Easy
1. 2. 3. 4. 5. PTS: 1
Feedback This is incorrect. The right kidney is located in the right lumbar region. This is incorrect. The ascending colon is located in the right lumbar region. This is correct. The ileum is located in the umbilical region. This is correct. The aorta is located in the umbilical region. This is correct. The spine is located in the umbilical region. CON: Assessment
Chapter 56: Coordinating Care for Patients With Oral and Esophageal Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is explaining the alteration in normal function to a patient recently diagnosed with gastroesophageal reflux disease (GERD). Which etiology contributing to GERD will the nurse include in the teaching session? 1) Transient constriction of the lower esophageal sphincter 2) Decreased pressure within the stNom UR a cS h INGTB.COM 3) Incompetent lower esophageal sphincter 4) Prolonged constriction of the upper esophageal sphincter 2. The nurse is providing care to several patients in an outpatient clinic. Which patient is at high risk of developing gastroesophageal reflux disorder (GERD)? 1) A patient who is six weeks pregnant 2) A patient who is morbidly obese 3) A patient who follows a strict vegetarian diet 4) A patient who drinks one glass of wine monthly 3. A patient is admitted to the emergency department reporting a burning pain in the chest of a 7 on a 0 to 10 pain scale. Gastroesophageal reflux disorder (GERD) secondary to hiatal hernia is diagnosed. Based on this data, which is the priority nursing diagnosis? 1) Anxiety 2) Acute Pain 3) Ineffective Health Maintenance 4) Dysfunctional Gastrointestinal Motility 4. A patient is with a history of gastroesophageal reflux disorder (GERD) presents with metabolic alkalosis. Based on the data reviewed in the patient’s history, which medication does the nurse suspect contributed to the current diagnosis? 1) Aluminum hydroxide 2) Omeprazole 3) Ranitidine 4) Metoclopramide
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5. An adult patient with a BMI of 39 who smokes 1 pack of cigarettes per day is diagnosed with erosive esophagitis through upper GI endoscopy. The patient is now refusing all medications and states “I'm not getting hooked on any pills.” What would the nurse recommend for the multidisciplinary collaborative plan? 1) Interview the patient and spouse for a 24-hour recall of usual food content, intake, and meal times. 2) Enlist the patient’s son to elevate the foot of the patient’s bed at home six inches. 3) Offer the patient a surgical consult to reduce the necessity of medication. 4) Omit the pharmacist notification of the Multidisciplinary Team meeting about the patient. 6. The nurse has implemented a care plan for an adult patient with gastroesophageal reflux disorder (GERD). On the next clinic visit, which statement by the patient indicates adherence to the plan of care? 1) “Spandex camisoles are worth heartburn.” 2) “I have switched from margaritas to wine.” 3) “I've lost six pounds because I eat every three hours and never before bed.” 4) “I take a TUMS with the ranitidine to make it work better.” A
7. Which data collected by the nurse during the physical assessment indicates the patient is experiencing stage 1 stomatitis? 1) Redness of mucosa 2) Patchy oral ulceration 3) Oral ulcerations that bleed with minor trauma 4) Tissue necrosis with significant bleeding noted 8. Which data collected by the nurse during the physical assessment indicates the patient is experiencing stage 2 stomatitis? 1) Redness of mucosa NURSINGTB.COM 2) Patchy oral ulceration 3) Oral ulcerations that bleed with minor trauma 4) Tissue necrosis with significant bleeding noted 9. Which data collected by the nurse during the physical assessment indicates the patient is experiencing stage 3 stomatitis? 1) Redness of mucosa 2) Patchy oral ulceration 3) Oral ulcerations that bleed with minor trauma 4) Tissue necrosis with significant bleeding noted 10. Which data collected by the nurse during the physical assessment indicates the patient is experiencing stage 4 stomatitis? 1) Redness of mucosa 2) Patchy oral ulceration 3) Oral ulcerations that bleed with minor trauma 4) Tissue necrosis with significant bleeding noted 11. Which patient activity should the nurse discourage for a patient who is diagnosed with stomatitis? 1) Mouth care after each meal 2) Alcohol-based mouth rinses 3) Soft-bristle toothbrush 4) Regular dental checkups
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12. Which diagnostic test should the nurse anticipate when providing care to a patient who is suspected of having a hiatal hernia? 1) Complete blood count 2) Lower abdominal x-ray 3) Magnetic resonance imaging (MRI) 4) Esophagogastroduodenoscopy (ECG) 13. Which common site of metastasis should the nurse anticipate when providing care to a patient diagnosed with oral cancer? 1) Skin 2) Liver 3) Breast 4) Brain 14. The nurse is providing education to a patient who is diagnosed with oral cancer who is being treated with radiation therapy. Which should the nurse include as a rare but serious complication? 1) Weight loss 2) Hearing loss 3) Skin irritation 4) Laryngeal edema 15. Which common cause for oral trauma should the nurse include in an educational seminar for individuals over the age of 60 years? 1) Falls 2) Athletic activities 3) Physical altercations 4) Automobile accidents NURSINGTB.COM 16. The nurse is providing care to a patient whose mouth is wired shut after oral trauma. Which is a priority when providing this patient’s care? 1) Monitoring for pain 2) Ensuring oxygen is available 3) Having wire cutters available 4) Administering prescribed analgesics 17. Which is the priority nursing diagnosis when providing care for a patient with oral trauma? 1) Risk for bleeding 2) Risk for infection 3) Risk for ineffective airway clearance 4) Risk for imbalanced nutrition, less than body requirements 18. The nurse is providing care to a patient who is suspected of having esophageal cancer. Which diagnostic test should the nurse anticipate for this patient first? 1) Barium swallow 2) Computed tomography 3) Endoscopic ultrasonography 4) Positron emission tomography 19. Which complementary and alternative medicine (CAM) therapy should the nurse suggest for muscular relaxation for a patient who is experiencing pain due to esophageal cancer? 1) Yoga 2) Vibration
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3) Meditation 4) Spirituality 20. The nurse is providing care to a patient who is diagnosed with esophageal cancer. Which assessment finding indicates metastasis to the liver? 1) Emesis 2) Rhonchi 3) Jaundice 4) Dysphagia 21. The nurse is providing care to a patient who ingested bleach. Which diagnosis should the nurse anticipate when planning care for this patient? 1) Oral cancer 2) Oral trauma 3) Esophageal cancer 4) Esophageal trauma 22. Which clinical manifestation associated with the ingestion of bleach causing esophageal trauma does the nurse anticipate for the patient 48 hours after the initial event? 1) Peritonitis 2) Glottic edema 3) Kidney damage 4) Excessive salivation Multiple Response Identify one or more choices that best complete thNeUsR tatSem IeNn Gt oTrBan.sCweOrMthe question. 23. Which should the nurse include in the discharge teaching for a patient who is being discharged after a laparoscopic Nissen fundoplication? Select all that apply. 1) Follow a soft diet for two weeks 2) Avoid foods that are not easy to swallow 3) Take large bites and eat quickly 4) Avoid carbonated beverages 5) No heavy lifting until cleared by surgeon 24. Which should the nurse include in the discharge instruction regarding physical assessment findings that requires the patient to seek emergent care following a laparoscopic Nissen fundoplication? Select all that apply. 1) Feeling full with the ability to burp 2) Thick drainage with a foul odor from incision site 3) Difficulty swallowing 4) Abdomen is soft and tender 5) Watery stool 25. Which are risk factors for the development of hiatal hernia? Select all that apply. 1) Obesity 2) Pregnancy 3) Tobacco use 4) Oral sex 5) Alcohol abuse
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Chapter 56: Coordinating Care for Patients With Oral and Esophageal Disorders Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Describing the epidemiology of disorders of the oral cavity and esophagus Chapter page reference: 1226-1229 Heading: Oral and Esophageal Diseases Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Digestion Difficulty: Moderate Feedback 1 The lower esophageal sphincter is normally constricted except during swallowing. 2 Increased pressure in the stomach can cause acid to reflux into the esophagus. 3 An incompetent lower esophageal sphincter remains open, allowing gastric acid to reflux into the esophagus. 4 The action of the upper esophageal sphincter is not a cause of GERD. PTS: 1 CON: Digestion ANS: 2 2. NURSINGTB.COM Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Describing the epidemiology of disorders of the oral cavity and esophagus Chapter page reference: 1226-1229 Heading: Oral and Esophageal Diseases Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 Pregnancy is an increasing risk factor in the later stages due to pressure on the stomach. 2 Obesity is a risk factor for GERD. 3 A vegetarian diet is not a risk factor for GERD. 4 Rare alcohol consumption is not as strong a risk factor for GERD as morbid obesity. PTS: 1 CON: Digestion 3. ANS: 2 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with oral and esophageal disorders Chapter page reference: 1226-1229 Heading: Oral and Esophageal Diseases Integrated Processes: Nursing Process: Diagnosis Client Need: Safe and Effective Care Environment – Management of Care
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Cognitive level: Analysis [Analyzing] Concept: Digestion Difficulty: Difficult Feedback 1 Anxiety may be decreased by relieving pain. 2 Acute pain management is the priority of nursing care. 3 Dysfunctional gastrointestinal motility and ineffective health maintenance are less urgent. 4 Dysfunctional gastrointestinal motility and ineffective health maintenance are less urgent. PTS: 1 CON: Digestion 4. ANS: 1 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Describing the epidemiology of disorders of the oral cavity and esophagus Chapter page reference: 1226-1229 Heading: Oral and Esophageal Diseases Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Digestion; Medication Difficulty: Easy Feedback 1 Aluminum hydroxide antacids neutralize gastric acid. Overuse of antacids may cause metabolic acidosis. NURSINGTB.COM 2 Omeprazole, ranitidine, and metoclopramide are all GERD medications that do not cause metabolic alkalosis. 3 Omeprazole, ranitidine, and metoclopramide are all GERD medications that do not cause metabolic alkalosis. 4 Omeprazole, ranitidine, and metoclopramide are all GERD medications that do not cause metabolic alkalosis. PTS: 1 CON: Digestion | Medication 5. ANS: 1 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with oral and esophageal disorders Chapter page reference: 1226-1229 Heading: Oral and Esophageal Diseases Integrated Processes: Nursing Process - Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Digestion Difficulty: Moderate
1
Feedback Weight loss and smoking cessation will improve the symptoms of GERD. Determining food types, amounts, and times of consumption can help the patient avoid foods that stimulate acid production and avoid eating prior to lying down.
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2 3 4
The head of the bed should be elevated, and the team should recommend this to the patient rather than enlisting the patient’s son. A surgical consult should come from the primary provider and will not necessarily reduce the need for medication. The pharmacist should be included in the Multidisciplinary Team meeting to give input to strategies to improve the patient's receptivity to medication therapy.
PTS: 1 CON: Digestion 6. ANS: 3 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Discussing the medical management of: Gastroesophageal Reflux Disease Chapter page reference: 1226-1229 Heading: Oral and Esophageal Diseases Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Digestion Difficulty: Difficult Feedback 1 Although the patient knows tight-fitting spandex camisoles can worsen GERD, she is not willing to stop wearing them. 2 Changing from margaritas to wine will not improve GERD. 3 Appropriate patient outcomes are freedom from pain and knowledge of lifestyle changes to manage GERD. Weight loss, small, frequent meals, and avoiding lying down within three hours of ea tin NUgRinSd IicNatGe cTorrBec . tC m OaMnagemen t. 4 Antacids like TUMS should be avoided within one hour before or after an H2-receptor blocker like ranitidine. PTS: 1 CON: Digestion 7. ANS: 1 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Stomatitis Chapter page reference: 1218-1221 Heading: Oral and Esophageal Diseases Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 This data indicates stage 1 stomatitis. 2 This data indicates stage 2 stomatitis. 3 This data indicates stage 3 stomatitis. 4 This data indicates stage 4 stomatitis. PTS: 1 CON: Digestion 8. ANS: 2 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Stomatitis
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Chapter page reference: 1218-1221 Heading: Oral and Esophageal Diseases Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 This data indicates stage 1 stomatitis. 2 This data indicates stage 2 stomatitis. 3 This data indicates stage 3 stomatitis. 4 This data indicates stage 4 stomatitis. PTS: 1 CON: Digestion 9. ANS: 3 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Stomatitis Chapter page reference: 1218-1221 Heading: Oral and Esophageal Diseases Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy
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1 2 3 4
This data indicates stage 1 stomatitis. This data indicates stage 2 stomatitis. This data indicates stage 3 stomatitis. This data indicates stage 4 stomatitis.
PTS: 1 CON: Digestion 10. ANS: 4 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Stomatitis Chapter page reference: 1218-1221 Heading: Oral and Esophageal Diseases Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 This data indicates stage 1 stomatitis. 2 This data indicates stage 2 stomatitis. 3 This data indicates stage 3 stomatitis. 4 This data indicates stage 4 stomatitis. PTS: 1
CON: Digestion
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11. ANS: 2 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with oral and esophageal disorders Chapter page reference: 1218-1221 Heading: Oral and Esophageal Diseases Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Digestion; Comfort Difficulty: Moderate
1 2 3 4
Feedback Mouth care is encouraged after each meal for a patient diagnosed with stomatitis. Alcohol-based mouth rinses are likely to cause pain and inflammation for a patient diagnosed with stomatitis; therefore, this is discouraged by the nurse. The use of a soft-bristle toothbrush is encouraged for a patient diagnosed with stomatitis. Regular dental checkups are encouraged for a patient diagnosed with stomatitis.
PTS: 1 CON: Digestion | Comfort 12. ANS: 4 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected disorders of the oral cavity and esophagus Chapter page reference: 1221-1226 NURSINGTB.COM Heading: Oral and Esophageal Diseases Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 A CBC is not a diagnostic tool for hiatal hernia. 2 An upper, not lower, abdominal x-ray is a diagnostic tool for hiatal hernia. 3 An MRI is not a diagnostic tool for hiatal hernia. 4 An ECG that allows viewing of the esophagus and stomach lining is a diagnostic tool the nurse anticipates when providing care to a patient who is suspected of having hiatal hernia. PTS: 1 CON: Digestion 13. ANS: 2 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Describing complications associated with selected disorders of the oral cavity and esophagus Chapter page reference: 1229-1235 Heading: Oral Cancer Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation
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Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Easy Feedback 1 Oral cancer is not known to metastasize to the skin. 2 Oral cancer is known to metastasize to the lungs, liver, and bones. Liver enzyme tests will be monitored to determine liver involvement for a patient diagnosed with oral cancer. 3 Oral cancer is not known to metastasize to the breast. 4 Oral cancer is not known to metastasize to the brain. PTS: 1 CON: Cellular Regulation 14. ANS: 2 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Developing a teaching plan for a patient with oral or esophageal disorders Chapter page reference: 1229-1235 Heading: Oral Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Easy Feedback 1 Weight loss is a common side effect associated with radiation therapy. 2 Hearing loss is a serious, but rN arU e,Rc oSmIpNlica G TtiBon.aCssOo cMiated with radiation therapy. 3 Skin irritation is a common side effect associated with radiation therapy. 4 Laryngeal edema is a common side effect associated with radiation therapy. PTS: 1 CON: Cellular Regulation 15. ANS: 1 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Describing the epidemiology of disorders of the oral cavity and esophagus Chapter page reference: 1235-1237 Heading: Oral Trauma Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 Falls are the most common cause of oral trauma for patients over the age of 60 years. 2 Athletic activities can cause oral trauma; however, this is not the most common cause for patients over the age of 60 years. 3 Physical altercations can cause oral trauma; however, this is not the most common cause for patients over the age of 60 years 4 Automobile accidents can cause oral trauma; however, this is not the most common cause for patients over the age of 60 years
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PTS: 1 CON: Digestion 16. ANS: 3 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with oral and esophageal disorders Chapter page reference: 1235-1237 Heading: Oral Trauma Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult Feedback 1 While monitoring the patient for pain is important, this is not the priority. 2 While ensuring the availability of oxygen is important, this is not the priority. 3 Patients with jaws wired are at risk for airway compromise, particularly with managing saliva and emesis. Because the patient is unable to open the mouth as a result of the wiring, wire cutters are required to be available with the patient at all times in the event the mouth needs to be opened to clear the airway or perform other lifesaving maneuvers. 4 While administering prescribed analgesics is important, this is not the priority. PTS: 1 CON: Safety 17. ANS: 3 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders NURSINGTB.CO Chapter learning objective: Developing a comprehensive plan of nursing care for patients with oral and esophageal disorders Chapter page reference: 1235-1237 Heading: Oral Trauma Integrated Processes: Nursing Process: Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult Feedback 1 While this is an important nursing diagnosis, this is not the priority based on airway, breathing, and circulation. 2 While this is an important nursing diagnosis, this is not the priority based on airway, breathing, and circulation. 3 This is the priority nursing diagnosis when using airway, breathing, and circulation (ABCs) to plan care. 4 While this is an important nursing diagnosis, this is not the priority based on airway, breathing, and circulation. PTS: 1 CON: Safety 18. ANS: 1 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected disorders of the oral cavity and esophagus
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Chapter page reference: 1237-1242 Heading: Esophageal Cancer Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Digestion Difficulty: Difficult
1 2 3
4
Feedback Barium swallow identifies irregularities in the surface of the wall of the esophagus and is one of the first tests done to diagnose esophageal cancer. Computed tomography scans are used to determine how far the cancer has spread in the esophagus and to assess for spread to the lymph nodes and nearby organs. Endoscopic ultrasonography is performed by placing a small ultrasound probe in the esophagus. The probe produces sound waves that penetrate into normal tissue and abnormal tissue. These sound waves are converted into a picture that shows how much the tissue and nearby lymph nodes are affected by the cancer. Positron emission tomography scans detect areas of metastasis and can even detect small collections of cancer cells that are not detectable with other diagnostic studies.
PTS: 1 CON: Digestion 19. ANS: 2 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with oral and esophageal disorders Chapter page reference: 1237-1242 NURSINGTB.COM Heading: Esophageal Cancer Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Analysis [Analyzing] Concept: Digestion; Comfort Difficulty: Difficult Feedback 1 While yoga is a CAM therapy used for pain for a patient diagnosed with esophageal cancer, this therapy is not specific for muscular relaxation. 2 Vibration and massage are two CAM therapies used for muscular relaxation for a patient diagnosed with esophageal cancer. 3 While meditation is a CAM therapy used for pain for a patient diagnosed with esophageal cancer, this therapy is not specific for muscular relaxation. 4 While spirituality is a CAM therapy used for pain for a patient diagnosed with esophageal cancer, this therapy is not specific for muscular relaxation. PTS: 1 CON: Digestion | Comfort 20. ANS: 3 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Describing complications associated with selected disorders of the oral cavity and esophagus Chapter page reference: 1237-1242 Heading: Esophageal Cancer
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Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 Emesis often occurs for a patient who is being treated with chemotherapy for esophageal cancer; however, this data does not support metastasis to the liver. 2 Rhonchi is a clinical manifestation indicative of aspiration, not metastasis to the liver. 3 Jaundice and elevated liver enzymes are both indicative of metastasis to the liver. 4 Dysphagia often leads to aspiration; however, this is not indicative of metastasis to the liver. PTS: 1 CON: Digestion 21. ANS: 4 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with oral and esophageal disorders Chapter page reference: 1242-1245 Heading: Esophageal Trauma Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy NURSINGTB.COM Feedback 1 Oral cancer is not anticipated for this patient. 2 Oral trauma is not anticipated for this patient. 3 Esophageal cancer is not anticipated for this patient. 4 Esophageal trauma is anticipated for this patient. PTS: 1 CON: Digestion 22. ANS: 3 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Esophageal trauma Chapter page reference: 1242-1245 Heading: Esophageal Trauma Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 Peritonitis is an immediate consequence to bleach ingestion. 2 Glottic edema is an immediate consequence to bleach ingestion. 3 Kidney damage often occurs 24 to 48 hours after the initial bleach ingestion. 4 Excessive salivation is an immediate consequence to bleach ingestion.
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PTS: 1
CON: Digestion
MULTIPLE RESPONSE 23. ANS: 2, 4, 5 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Discussing the medical management of: Gastroesophageal Reflux Disease Chapter page reference: 1224 Heading: Oral and Esophageal Diseases Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Digestion Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback This is incorrect. A soft diet is followed for one, not two, week post procedure. This is correct. Foods that are not easy to swallow should be avoided. This is incorrect. The patient should take small bites and eat slowly. This is correct. Carbonated beverages should be avoided as this activity causes air to be swallowed. This is correct. Heavy lifting should be avoided until cleared by the surgeon post procedure.
PTS: 1 CON: DigestiN o nURSINGTB.COM 24. ANS: 2, 3 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders Chapter learning objective: Discussing the medical management of: Gastroesophageal Reflux Disease Chapter page reference: 1224 Heading: Oral and Esophageal Diseases Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Digestion Difficulty: Moderate
1. 2. 3. 4. 5.
Feedback This is incorrect. Feeling full with the inability to burp or vomit indicates the need for emergent care. This is correct. Thick drainage from the incision site that has a foul odor indicates the need for emergent care. This is correct. Difficulty swallowing indicates the need for emergent care. This is incorrect. An abdomen that feels hard and painful indicates the need for emergent care. This is incorrect. Stools that are black, bloody, or tarry indicate the need for emergent care.
PTS: 1 CON: Digestion 25. ANS: 1, 2, 3 Chapter number and title: 56, Coordinating Care for Patients With Oral and Esophageal Disorders
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Chapter learning objective: Describing the epidemiology of disorders of the oral cavity and esophagus Chapter page reference: 1221-1226 Heading: Oral and Esophageal Diseases Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Knowledge [Remembering] Concept: Digestion Difficulty: Easy
1. 2. 3. 4. 5. PTS: 1
Feedback This is correct. Obesity is a risk factor for developing hiatal hernia. This is correct. Pregnancy is a risk factor for developing hiatal hernia. This is correct. Tobacco use, specifically smoking, is a risk factor for hiatal hernia. This is incorrect. Oral sex that causes the transmission of HPV is a risk factor for oropharyngeal cancer, not hiatal hernia. This is incorrect. Alcohol abuse is a risk factor for oropharyngeal cancer, not hiatal hernia. CON: Digestion
Chapter 57: Coordinating Care for Patients With Stomach Disorders Multiple Choice Identify the choice that best completes the statement or answers the question.
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1. The nurse is providing care to a patient who is hospitalized for complications associated with peptic ulcer disease. Which data supports the patient is experiencing a gastrointestinal bleed? 1) Tarry stools 2) Pain in the right arm 3) Absent bowel sounds 4) Emesis of undigested food 2. The nurse is providing care to a patient who is hospitalized for complications associated with peptic ulcer disease. Which data supports the patient is experiencing penetration to another organ? 1) Tarry stools 2) Pain in the right arm 3) Absent bowel sounds 4) Emesis of undigested food 3. The nurse is providing care to a patient who is hospitalized for complications associated with peptic ulcer disease. Which data supports the patient is experiencing a perforation? 1) Tarry stools 2) Pain in the right arm 3) Absent bowel sounds 4) Emesis of undigested food 4. The nurse is providing care to a patient who is hospitalized for complications associated with peptic ulcer disease. Which data supports the patient is experiencing an obstruction? 1) Tarry stools 2) Pain in the right arm
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3) Absent bowel sounds 4) Emesis of undigested food 5. The nurse is conducting an assessment for a patient who is suspected of having peptic ulcer disease. Which is a risk factor identified in the patient’s health history? 1) Acetaminophen use for pain 2) Hypoparathyroidism 3) Social drinking 4) Sarcoidosis 6. Which assessment data would indicate active bleeding for a patient who is diagnosed with peptic ulcer disease? 1) Absent bowel sounds 2) Coffee-ground emesis 3) Bright red blood in emesis 4) Black tarry stools with a foul odor 7. The nurse is providing care to a patient who is prescribed levofloxacin-based triple therapy for the treatment of peptic ulcer disease. Which drugs should the nurse educate this patient about based on this data? 1) Proton pump inhibitor, levofloxacin, and amoxicillin 2) Proton pump inhibitor, amoxicillin, and clarithromycin 3) Proton pump inhibitor, clarithromycin, and metronidazole 4) Proton pump inhibitor, bismuth subsalicylate, metronidazole, and tetracycline 8. The nurse is providing care to a patient who is prescribed sequential therapy for the treatment of peptic ulcer disease. Which drugs should the nurse educate this patient about based on this data? 1) Proton pump inhibitor, levofloxaNcU inR , aSndI aNm GoTx iBci.llCin OM 2) Proton pump inhibitor, amoxicillin, and clarithromycin 3) Proton pump inhibitor, clarithromycin, and metronidazole 4) Proton pump inhibitor, bismuth subsalicylate, metronidazole, and tetracycline 9. The nurse is providing care to a patient who is diagnosed with acute gastritis. Which assessment data supports this diagnosis? 1) Weight gain 2) Epigastric pain 3) Increased appetite 4) Increased blood pressure 10. Which diagnostic test should the nurse anticipate to detect active infection with H. pylori for a patient diagnosed with gastritis? 1) Guaiac 2) Hematest 3) Hemoccult 4) Urea breathing test 11. Which food should the nurse encourage for a patient, diagnosed with gastritis, when a clear liquid diet is prescribed? 1) Milk 2) Broth 3) Pudding 4) Cream soup
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12. Which food should the nurse encourage for a patient, diagnosed with gastritis, when a heavier liquid diet is prescribed? 1) Milk 2) Broth 3) Gelatin 4) Carbonated beverages 13. Which medication, acting as a physical barrier, does the nurse anticipate for a patient diagnosed with gastritis? 1) Maalox 2) Mylanta 3) Pepcid 4) Carafate 14. The nurse is providing education for a patient who is diagnosed with gastritis. Which statement indicates the need for further education? 1) “I will eat bland, nonspicy foods.” 2) “I will eat smaller, more frequent meals.” 3) “I will take aspirin for headaches from now on.” 4) “I will take an antacid if my symptoms continue.” 15. Which is the priority nursing diagnosis when planning care for this patient who is diagnosed with acute gastritis? 1) Anxiety 2) Acute pain 3) Deficient knowledge 4) Risk for deficient fluid volume NURSINGTB.COM 16. Which principal risk factor should the nurse assess for during the health history in a patient who is suspected of having peptic ulcer disease? 1) Stress 2) Anxiety 3) H. pylori infection 4) Use of acetaminophen 17. Which diagnostic test should the nurse anticipate to rule out anemia when providing care to a patient diagnosed with peptic ulcer disease? 1) Hematocrit 2) Stool antigen 3) White blood cell 4) Fecal occult blood 18. Which diagnostic test should the nurse anticipate to rule out peritonitis when providing care to a patient diagnosed with peptic ulcer disease? 1) Hematocrit 2) Stool antigen 3) White blood cell 4) Fecal occult blood 19. The nurse is providing discharge instructions for a patient diagnosed with peptic ulcer disease. Which statement indicates the need for additional education? 1) “I will avoid spicy foods.”
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2) “I will be sure to eat a large meal before bedtime.” 3) “I will use acetaminophen rather than aspirin for headache.” 4) “I will avoid caffeinated beverages, such as coffee, as this increases symptoms.” 20. The nurse is providing care to a patient who is status post partial gastrectomy for the treatment of gastric carcinoma. Which should the nurse include in the plan of care to decrease the risk of dumping syndrome? 1) Providing smaller meals at more frequent intervals 2) Providing larger meals at less frequent intervals 3) Providing liquids and solids together 4) Providing liquids only 21. Which assessment data collected by the nurse supports the patient’s diagnosis of advanced gastric cancer? 1) Anorexia 2) Indigestion 3) Epigastric pain 4) Palpable epigastric mass 22. Which assessment data collected by the nurse supports the patient’s diagnosis of early gastric cancer? 1) Anorexia 2) Nausea and vomiting 3) Iron-deficiency anemia 4) Palpable epigastric mass Multiple Response Identify one or more choices that best complete the statement or answer the question.
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23. The nurse is providing care to a patient who is diagnosed with peptic ulcer disease. When planning care, which should the nurse include as first-line triple dose therapy for a patient who is allergic to penicillin? Select all that apply. 1) Amoxicillin 2) Metronidazole 3) Clarithromycin 4) Bismuth subsalicylate 5) Proton pump inhibitor 24. The nurse is providing care to a patient who is diagnosed with peptic ulcer disease. When planning care, which should the nurse include as first-line triple dose therapy? Select all that apply. 1) Amoxicillin 2) Metronidazole 3) Clarithromycin 4) Bismuth subsalicylate 5) Proton pump inhibitor 25. The nurse is providing care to a patient who is diagnosed with peptic ulcer disease. When planning care, which should the nurse include as first-line quadruple dose therapy? Select all that apply. 1) Amoxicillin 2) Metronidazole 3) Clarithromycin 4) Bismuth subsalicylate 5) Proton pump inhibitor
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Chapter 57: Coordinating Care for Patients With Stomach Disorders Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Describing complications associated with selected disorders of the stomach Chapter page reference: 1255-1261 Heading: Peptic Ulcer Disease Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 Tarry stools indicate gastrointestinal bleeding. 2 Referred pain, such as that in the arm, is indicative of penetration to another organ. 3 Absent bowel sounds is indicative of perforation. 4 Emesis of undigested food is indicative of obstruction. PTS: 1 CON: Digestion 2. ANS: 2 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders NURSINGTB.CO Chapter learning objective: Describing complications associated with selected disorders of the stomach Chapter page reference: 1255-1261 Heading: Peptic Ulcer Disease Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 Tarry stools indicate gastrointestinal bleeding. 2 Referred pain, such as that in the arm, is indicative of penetration to another organ. 3 Absent bowel sounds is indicative of perforation. 4 Emesis of undigested food is indicative of obstruction. PTS: 1 CON: Digestion 3. ANS: 3 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Describing complications associated with selected disorders of the stomach Chapter page reference: 1255-1261 Heading: Peptic Ulcer Disease Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion
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Difficulty: Easy Feedback 1 Tarry stools indicate gastrointestinal bleeding. 2 Referred pain, such as that in the arm, is indicative of penetration to another organ. 3 Absent bowel sounds is indicative of perforation. 4 Emesis of undigested food is indicative of obstruction. PTS: 1 CON: Digestion 4. ANS: 4 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Describing complications associated with selected disorders of the stomach Chapter page reference: 1255-1261 Heading: Peptic Ulcer Disease Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 Tarry stools indicate gastrointestinal bleeding. 2 Referred pain, such as that in the arm, is indicative of penetration to another organ. 3 Absent bowel sounds is indicative of perforation. 4 Emesis of undigested food is indicative of obstruction. PTS: 1 CON: DigestioNnURSINGTB.COM 5. ANS: 4 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Describing the epidemiology of stomach disorders Chapter page reference: 1255-1261 Heading: Peptic Ulcer Disease Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 NSAID and aspirin, not acetaminophen, use are risk factors for peptic ulcer disease. 2 Hyper-, not hypoparathyroidism, is a risk factor for peptic ulcer disease. 3 Heavy, not social, drinking is a risk factor for peptic ulcer disease. 4 Sarcoidosis is a risk factor for the development of peptic ulcer disease. PTS: 1 CON: Digestion 6. ANS: 3 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Peptic ulcer disease Chapter page reference: 1255-1261 Heading: Peptic Ulcer Disease
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Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 Absent bowel sounds indicates perforation, not active bleeding. 2 Coffee-ground emesis indicates older blood. 3 Bright red blood in the emesis indicates active bleeding. 4 Black tarry stools with a foul odor indicates older blood. PTS: 1 CON: Digestion 7. ANS: 1 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Discussing the medical management of: Peptic ulcer disease Chapter page reference: 1255-1261 Heading: Peptic Ulcer Disease Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Digestion Difficulty: Moderate Feedback 1 These drugs are included in levofloxacin-based triple therapy for peptic ulcer disease. 2 These drugs are included in thN e se URquSent INia lG the TBra.p yC fo O rMpeptic ulcer disease. 3 These drugs are included in triple therapy for peptic ulcer disease when the patient is allergic to penicillin. 4 These drugs are included in quadruple therapy for peptic ulcer disease. PTS: 1 CON: Digestion 8. ANS: 2 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Discussing the medical management of: Peptic ulcer disease Chapter page reference: 1255-1261 Heading: Peptic Ulcer Disease Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Digestion Difficulty: Moderate Feedback 1 These drugs are included in levofloxacin-based triple therapy for peptic ulcer disease. 2 These drugs are included in the sequential therapy for peptic ulcer disease. 3 These drugs are included in triple therapy for peptic ulcer disease when the patient is allergic to penicillin. 4 These drugs are included in quadruple therapy for peptic ulcer disease. PTS: 1
CON: Digestion
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9. ANS: 2 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Gastritis Chapter page reference: 1249-1254 Heading: Gastritis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 Weight loss is a clinical manifestation associated with acute gastritis. 2 Epigastric pain is a clinical manifestation associated with acute gastritis. 3 A decreased, not increased, appetite is a clinical manifestation with acute gastritis. 4 A decreased, not increased, blood pressure is a clinical manifestation of acute gastritis with acute fluid loss. PTS: 1 CON: Digestion 10. ANS: 4 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected disorders of the stomach Chapter page reference: 1249-1254 Heading: Gastritis Integrated Processes: Nursing Process: Planning Client Need: Physiological IntegrityNURSINGTB.COM – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy
1 2 3 4
Feedback Guaiac is anticipated to detect blood in the stool for a patient diagnosed with gastritis. Hematest is anticipated to detect blood in the stool for a patient diagnosed with gastritis. Hemoccult is anticipated to detect blood in the stool for a patient diagnosed with gastritis. A urea breathing test is anticipated to detect active infection with H. pylori for a patient who is diagnosed with gastritis.
PTS: 1 CON: Digestion 11. ANS: 2 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Discussing the medical management of: Gastritis Chapter page reference: 1249-1254 Heading: Gastritis Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Digestion
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Difficulty: Moderate Feedback 1 Milk is a heavier liquid. 2 Broth is a clear liquid. 3 Pudding is a heavier liquid. 4 Cream soup is a heavier liquid. PTS: 1 CON: Digestion 12. ANS: 1 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Discussing the medical management of: Gastritis Chapter page reference: 1249-1254 Heading: Gastritis Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Digestion Difficulty: Moderate
1 2 3 4
Feedback Milk is a heavier liquid. Broth is a clear liquid. Gelatin is a clear liquid. Carbonated beverages are clear liquids.
NURSINGTB.COM PTS: 1 CON: Digestion 13. ANS: 4 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Discussing the medical management of: Gastritis Chapter page reference: 1249-1254 Heading: Gastritis Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 This drug is used to neutralize acid. 2 This drug is used to neutralize acid. 3 This drug is used to decrease the production of gastric acid. 4 Carafate is a drug that acts as a physical barrier protecting the lining of the stomach from gastric acid. PTS: 1 CON: Digestion 14. ANS: 3 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Developing a teaching plan for a patient with stomach disorders Chapter page reference: 1249-1254
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Heading: Gastritis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Digestion Difficulty: Difficult
1 2 3 4
Feedback This statement indicates correct understanding. This statement indicates correct understanding. Aspirin should be avoided for a patient who is diagnosed with gastritis. This statement indicates the need for further education. This statement indicates correct understanding.
PTS: 1 CON: Digestion 15. ANS: 2 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with stomach disorders Chapter page reference: 1249-1254 Heading: Gastritis Integrated Processes: Nursing Process: Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Digestion NURSINGTB.COM Difficulty: Difficult
1 2 3 4
Feedback While anxiety is an important diagnosis, physiological diagnoses take priority over psychosocial diagnoses. Acute pain is a physiological diagnosis that take priority in this situation. While knowledge deficit is an important diagnosis, physiological diagnoses take priority. Risk for diagnoses do not take priority over actual diagnoses.
PTS: 1 CON: Digestion 16. ANS: 3 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Describing the epidemiology of stomach disorders Chapter page reference: 1255-1261 Heading: Peptic Ulcer Disease Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback
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1 2 3 4
Stress is no longer considered a principal risk factor in the development of peptic ulcer disease. Anxiety is no longer considered a principal risk factor in the development of peptic ulcer disease. H. pylori infection is a principal risk factor in the development of peptic ulcer disease. Use of NSAIDs, not acetaminophen, is a principal risk factor in the development of peptic ulcer disease.
PTS: 1 CON: Digestion 17. ANS: 1 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected disorders of the stomach Chapter page reference: 1255-1261 Heading: Peptic Ulcer Disease Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 Hematocrit is used to monitor the patient for anemia. 2 A stool antigen test is a noninvasive test for peptic ulcer disease. 3 A patient’s white blood cell count is used to monitor the patient for peritonitis when diagnosed with peptic ulcer diN seU asRe.SINGTB.COM 4 A fecal occult blood test is used to monitor for blood in the stool when diagnosed with peptic ulcer disease. PTS: 1 CON: Digestion 18. ANS: 3 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected disorders of the stomach Chapter page reference: 1255-1261 Heading: Peptic Ulcer Disease Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 Hematocrit is used to monitor the patient for anemia. 2 A stool antigen test is a noninvasive test for peptic ulcer disease. 3 A patient’s white blood cell count is used to monitor the patient for peritonitis when diagnosed with peptic ulcer disease. 4 A fecal occult blood test is used to monitor for blood in the stool when diagnosed with peptic ulcer disease. PTS: 1
CON: Digestion
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19. ANS: 2 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Developing a teaching plan for a patient with stomach disorders Chapter page reference: 1255-1261 Heading: Peptic Ulcer Disease Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Digestion Difficulty: Difficult Feedback 1 Spicy foods should be avoided; therefore, this statement indicates correct understanding. 2 The patient should avoid eating two hours prior to bedtime; therefore, this statement indicates the need for further education. 3 Aspirin and NSAIDs should be avoided; therefore, this statement indicates correct understanding. 4 Caffeine is known to exacerbate peptic ulcer disease; therefore, this statement indicates correct understanding. PTS: 1 CON: Digestion 20. ANS: 1 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Describing complications associated with selected disorders of the stomach Chapter page reference: 1261-1264 NURSINGTB.COM Heading: Gastric Cancer Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Digestion Difficulty: Moderate Feedback 1 The patient who is status post a partial gastrectomy should be provided small meals at frequent intervals to decrease the risk for dumping syndrome. 2 Larger meals at less frequent intervals is likely to cause dumping syndrome. 3 To decrease the risk for dumping syndrome, the nurse should offer solids and liquids at separate times. 4 A liquid only diet is not known to decrease the risk for dumping syndrome. PTS: 1 CON: Digestion 21. ANS: 4 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Gastric cancer Chapter page reference: 1261-1264 Heading: Gastric Cancer Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding]
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Concept: Digestion Difficulty: Easy Feedback 1 Anorexia is a clinical manifestation with early gastric cancer. 2 Indigestion is a clinical manifestation with early gastric cancer. 3 Epigastric pain is a clinical manifestation with early gastric cancer. 4 A palpable epigastric mass is a clinical manifestation of advanced gastric cancer. PTS: 1 CON: Digestion 22. ANS: 1 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Gastric cancer Chapter page reference: 1261-1264 Heading: Gastric Cancer Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 Anorexia is a clinical manifestation with early gastric cancer. 2 Nausea and vomiting are clinical manifestations of advanced gastric cancer. 3 Iron-deficiency anemia is a clinical manifestation of advanced gastric cancer. 4 A palpable epigastric mass is aNcUliR n iS c aIl m NaGnTifeBs.taCtioOnMof advanced gastric cancer. PTS: 1
CON: Digestion
MULTIPLE RESPONSE 23. ANS: 2, 3, 5 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Discussing the medical management of: Peptic ulcer disease Chapter page reference: 1255-1261 Heading: Peptic Ulcer Disease Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy
1. 2. 3.
Feedback This is incorrect. Amoxicillin is not included in the first-line triple dose therapy for a patient who is allergic to penicillin. This is correct. Metronidazole is included in the first-line triple dose therapy for a patient who is allergic to penicillin. This is correct. Clarithromycin is included in the first-line triple dose therapy for a patient who is allergic to penicillin.
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4. 5.
This is incorrect. Bismuth subsalicylate is included in the first-line quadruple, not triple, dose therapy. This is correct. A proton pump inhibitor is included in the first-line triple dose therapy for a patient who is allergic to penicillin.
PTS: 1 CON: Digestion 24. ANS: 1, 3, 5 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Discussing the medical management of: Peptic ulcer disease Chapter page reference: 1255-1261 Heading: Peptic Ulcer Disease Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is incorrect. Amoxicillin is included in the first-line triple dose therapy for a patient diagnosed with peptic ulcer disease. This is correct. Metronidazole is included in the first-line triple dose therapy only for a patient who is allergic to penicillin and diagnosed with peptic ulcer disease. This is correct. Clarithromycin is included in the first-line triple dose therapy for a patient who is diagnosed with peptic ulcer disease. This is incorrect. BismuN thUsuRbSsaIlicy N GlaTteBis.inc COluMd ed in the first-line quadruple, not triple, dose therapy for a patient diagnosed with peptic ulcer disease. This is correct. A proton pump inhibitor is included in the first-line triple dose therapy for a patient diagnosed with peptic ulcer disease.
PTS: 1 CON: Digestion 25. ANS: 2, 4, 5 Chapter number and title: 57, Coordinating Care for Patients With Stomach Disorders Chapter learning objective: Discussing the medical management of: Peptic ulcer disease Chapter page reference: 1255-1261 Heading: Peptic Ulcer Disease Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy
1. 2. 3.
Feedback This is incorrect. Amoxicillin is included in the first-line triple dose therapy for a patient who is diagnosed with peptic ulcer disease. This is correct. Metronidazole is included in first-line quadruple dose therapy for a patient who is diagnosed with peptic ulcer disease. This is incorrect. Clarithromycin is included in the first-line triple dose therapy for a patient who is diagnosed with peptic ulcer disease.
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4. 5.
PTS: 1
This is incorrect. Bismuth subsalicylate is included in the first-line quadruple dose therapy for a patient diagnosed with peptic ulcer disease. This is correct. A proton pump inhibitor is included in the first-line quadruple dose therapy for a patient diagnosed with peptic ulcer disease. CON: Digestion
Chapter 58: Coordinating Care for Patients With Intestinal Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. An older adult African-American patient with a history of celiac disease presents with abdominal cramps, pain, and diarrhea. The patient denies the use of alcohol, but states, “my favorite foods are steak, cheese, and ice cream.” Based on this data, which condition does the nurse suspect? 1) Acute pancreatitis 2) Appendicitis 3) Lactase deficiency 4) Food poisoning 2. The nurse is speaking with a patient who wants information regarding colorectal cancer. Which statement indicates the patient understood the information presented by the nurse? 1) “The risk of colorectal cancer decreases with age.” 2) “Colorectal cancer can be detected in early stages by measuring the level of the NURSINGTB.COM carcinogenic embryonic antigen (CEA).” 3) “Colorectal cancer occurs more frequently in patients who have a history of ulcerative colitis.” 4) “Colorectal cancer has no symptoms in the early stage, and there are no definitive diagnostic tests.” 3. The nurse provides an educational session for community members about the risk factors for colorectal cancer. Which participant statement indicates the need for further education? 1) “There is a genetic link in the development of colorectal cancer.” 2) “People with other bowel disease are at increased risk for developing this cancer.” 3) “Eating a diet high in red meat reduces the risk for developing this type of cancer.” 4) “Taking aspirin and a multivitamin each day reduces the risk of colorectal cancer.” 4. A nurse discusses medications prescribed to a patient who is diagnosed with Crohn’s disease. Which is the typical prescribed pharmacological option for treatment? 1) Ciprofloxacin (Cipro) 2) Diazepam (Valium) 3) Furosemide (Lasix) 4) Digoxin (Lanoxin) 5. The nurse is interpreting laboratory values for a patient suspected of having ulcerative colitis. Which finding does the nurse anticipate based on the diagnosis? 1) Protein in the urine 2) Increased sedimentation rate 3) Decreased white blood cell count
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4) Antineutrophil cytoplasmic antibodies 6. Which drug prescription should the nurse anticipate for a patient, diagnosed with hemorrhoids, to decrease pain? 1) Zinc oxide 2) Benzocaine 3) Witch hazel 4) Hydrocortisone 7. A patient recovering from surgery to place a permanent colostomy as treatment for colon cancer is concerned that her spouse will no longer find her sexually attractive. Which response by the nurse is the most appropriate? 1) “Tell me more about the concerns you are having.” 2) “Would you like me to speak with your husband for you?” 3) “Do not worry about sex right now. It is more important to focus on recovery.” 4) “I will refer you to a counselor to talk about your concerns.” 8. A patient has just been told that a colectomy and ileostomy are needed to treat a new diagnosis of colon cancer. Which diagnosis should the nurse use to plan this patient’s preoperative nursing care? 1) Knowledge Deficit 2) Risk for Disuse Syndrome 3) Risk for Perioperative–Positioning Injury 4) Anticipatory Grieving 9. The nurse is evaluating care provided to a patient recovering from surgery for colorectal cancer. Which assessment data indicates the need for further intervention by the nurse? 1) Patient has an hourly urine outpuNtUofR 4S5ImNLG . TB.COM 2) Patient performs morning care with assistance. 3) Patient states family members will care for the ostomy at home. 4) Patient tolerates full liquid diet and is requesting solid food. 10. Which drug prescription should the nurse anticipate for a patient, diagnosed with hemorrhoids, to promote skin dryness to relieve inflammation? 1) Zinc oxide 2) Benzocaine 3) Witch hazel 4) Hydrocortisone 11. Which drug prescription should the nurse anticipate for a patient, diagnosed with hemorrhoids, to form a physical barrier on the skin to prevent irritation? 1) Zinc oxide 2) Benzocaine 3) Witch hazel 4) Hydrocortisone 12. The nurse is providing care to a patient who is diagnosed with irritable bowel syndrome (IBS). Which drug prescription should the nurse anticipate to relieve diarrhea? 1) Tegaserod 2) Loperamide 3) Dicyclomine 4) Amitriptyline
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13. The nurse is providing care to a patient who is diagnosed with irritable bowel syndrome (IBS). Which drug prescription should the nurse anticipate to provide pain relief? 1) Tegaserod 2) Loperamide 3) Dicyclomine 4) Amitriptyline 14. The nurse is providing care to a patient who is experiencing five to six loose, nonbloody stools each day. Which diagnosis does the nurse anticipate when planning care for this patient? 1) Diverticulitis 2) Crohn’s disease 3) Ulcerative colitis 4) Colorectal cancer 15. The nurse is providing care to a patient who is experiencing 10 liquid, bloody stools each day. Which diagnosis does the nurse anticipate when planning care for this patient? 1) Diverticulitis 2) Crohn’s disease 3) Ulcerative colitis 4) Colorectal cancer 16. The nurse is providing education to a patient, diagnosed with colorectal cancer, who will be treated with chemotherapy. Which drug action should the nurse include in the teaching session for a patient who is prescribed 5-Fluorouracil? 1) “This drug is cell-cycle specific and interferes with the synthesis of DNA and RNA, causing its death.” 2) “This drug is converted in the tiN ssU u eRtoS5I-N F UG,TwBh . ichCiOnhMib its DNA and RNA synthesis by preventing thymidine production, causing death of rapidly replicating cells.” 3) “This drug is a platinum-based antineoplastic agent that binds to DNA and RNA, miscoding information and/or inhibiting DNA replication, causing cell death.” 4) “This drug is an antiangiogenesis medication that reduces blood flow to the tumor cells, depriving them of nutrients needed for replication.”
3)
17. The nurse is providing education to a patient, diagnosed with colorectal cancer, who will be treated with chemotherapy. Which drug action should the nurse include in the teaching session for a patient who is prescribed capecitabine? 1) “This drug is cell-cycle specific and interferes with the synthesis of DNA and RNA, causing its death.” 2) “This drug is converted in the tissue to 5-FU, which inhibits DNA and RNA synthesis by preventing thymidine production, causing death of rapidly replicating cells.” “This drug is a platinum-based antineoplastic agent that binds to DNA and RNA, miscoding information and/or inhibiting DNA replication, causing cell death.” 4) “This drug is an antiangiogenesis medication that reduces blood flow to the tumor cells, depriving them of nutrients needed for replication.” 18. The nurse is providing education to a patient, diagnosed with colorectal cancer, who will be treated with chemotherapy. Which drug action should the nurse include in the teaching session for a patient who is prescribed oxaliplatin? 1) “This drug is cell-cycle specific and interferes with the synthesis of DNA and RNA, causing its death.”
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2) 3) 4)
“This drug is converted in the tissue to 5-FU, which inhibits DNA and RNA synthesis by preventing thymidine production, causing death of rapidly replicating cells.” “This drug is a platinum-based antineoplastic agent that binds to DNA and RNA, miscoding information and/or inhibiting DNA replication, causing cell death.” “This drug is an antiangiogenesis medication that reduces blood flow to the tumor cells, depriving them of nutrients needed for replication.” 19. The nurse is providing education to a patient, diagnosed with colorectal cancer, who will be treated with chemotherapy. Which drug action should the nurse include in the teaching session for a patient who is prescribed bevacizumab? 1) “This drug is cell-cycle specific and interferes with the synthesis of DNA and RNA, causing its death.” 2) “This drug is converted in the tissue to 5-FU, which inhibits DNA and RNA synthesis by preventing thymidine production, causing death of rapidly replicating cells.” 3) “This drug is a platinum-based antineoplastic agent that binds to DNA and RNA, miscoding information and/or inhibiting DNA replication, causing cell death.” 4) “This drug is an antiangiogenesis medication that reduces blood flow to the tumor cells, depriving them of nutrients needed for replication.” 20. The nurse is providing education to a patient who will receive surgical intervention for the treatment of ulcerative colitis. Which patient statement indicates correct understanding of a proctocolectomy with a permanent ileostomy? 1) “My colon and rectum will be removed, and my anus will be closed.” 2) “My colon will be removed, and my ileum is sutured to the anal canal.” 3) “My colon will be removed while the distal portion of my ileum is used to create a pouch.” NURSINGTB.COM 4) “My colon and rectal mucosa will be removed and a reservoir created using a portion of my ileum.” 21. The nurse is providing education to a patient who will receive surgical intervention for the treatment of ulcerative colitis. Which patient statement indicates correct understanding of an abdominal colectomy with ileoanal anastomosis? 1) “My colon and rectum will be removed, and my anus will be closed.” 2) “My colon will be removed, and my ileum is sutured to the anal canal.” 3) “My colon will be removed while the distal portion of my ileum is used to create a pouch.” 4) “My colon and rectal mucosa will be removed and a reservoir created using a portion of my ileum.” 22. The nurse is providing education to a patient who will receive surgical intervention for the treatment of ulcerative colitis. Which patient statement indicates correct understanding of a proctocolectomy with continent ileostomy? 1) “My colon and rectum will be removed, and my anus will be closed.” 2) “My colon will be removed, and my ileum is sutured to the anal canal.” 3) “My colon will be removed while the distal portion of my ileum is used to create a pouch.” 4) “My colon and rectal mucosa will be removed and a reservoir created using a portion of my ileum.”
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23. The nurse is providing education to a patient who will receive surgical intervention for the treatment of ulcerative colitis. Which patient statement indicates correct understanding of an ileal pouch–anal anastomosis (IPAA) procedure? 1) “My colon and rectum will be removed, and my anus will be closed.” 2) “My colon will be removed, and my ileum is sutured to the anal canal.” 3) “My colon will be removed while the distal portion of my ileum is used to create a pouch.” 4) “My colon and rectal mucosa will be removed and a reservoir created using a portion of my ileum.” 24. The nurse is providing education to a patient who is will undergo diagnostic studies for colorectal cancer. Which patient statement indicates correct understanding regarding a lower-GI series? 1) “A stool sample is collected by my doctor by digital rectal examination.” 2) “After I have expelled most of the contrast, my intestine is filled with air and x-rays are taken.” 3) “Constipation may occur as a result of this procedure, so I will increase my water and fiber intake.” 4) “A flexible tube with a light and camera is inserted into my rectum so that tissue can be biopsied.” 25. The nurse is providing education to a patient who will undergo diagnostic studies for colorectal cancer. Which patient statement indicates correct understanding regarding a double contract barium enema? 1) “A stool sample is collected by my doctor by digital rectal examination.” 2) “After I have expelled most of the contrast, my intestine is filled with air and x-rays are taken.” 3) “Constipation may occur as a result of this procedure, so I will increase my water and fiber NURSINGTB.COM intake.” 4) “A flexible tube with a light and camera is inserted into my rectum so that tissue can be biopsied.” 26. The nurse is providing care to a patient who presents to the emergency department (ED) with blunt abdominal trauma after an automobile accident. Which should the nurse assess for based on the current data? 1) Spleen injury 2) Liver laceration 3) Intestinal obstruction 4) Traumatic brain injury 27. The nurse is providing care to a patient who presents to the emergency department (ED) with an abdominal stab injury. Which should the nurse assess for based on the current data? 1) Spleen injury 2) Liver laceration 3) Intestinal obstruction 4) Traumatic brain injury Multiple Response Identify one or more choices that best complete the statement or answer the question. 28. The nurse is providing care to a patient diagnosed with celiac disease who experiences frequent diarrhea. Based on this data, the nurse anticipates the patient may also experience which associated problems? Select all that apply.
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1) 2) 3) 4) 5)
Skin breakdown Fluid and electrolyte imbalance Hair loss Lifestyle issues Sexual dysfunction
29. The nurse is preparing care for a patient recovering from surgery for colorectal cancer. Which interventions should the nurse use when creating a pain management plan for this patient? Select all that apply. 1) Provide pain medication upon request 2) Assess surgical site for inflammation 3) Assess bowel sounds 4) Administer pain medication after painful procedures 5) Instruct to use a pillow to splint when deep breathing and coughing 30. A nurse is caring for a patient who has had a double-barrel colostomy. Which statement is true regarding the proximal stoma? Select all that apply. 1) Is also called the mucous fistula 2) Diverts feces to the abdominal wall 3) Expels mucus from the distal colon 4) It is a functional stoma 5) Expels mucus from the proximal colon
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Chapter 58: Coordinating Care for Patients With Intestinal Disorders Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Describing the epidemiology of infectious and noninfectious intestinal disorders Chapter page reference: 1274 Heading: Intestinal Disorders Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy
1 2 3 4
Feedback The most common risk factor for pancreatitis is alcohol abuse. Appendicitis usually involves loss of appetite and nausea and/or vomiting soon after abdominal pain begins. Lactose intolerance is more common in Native Americans, Asians, Hispanics, and African-Americans and in those with a history of celiac disease. Food poisoning generally causes some nausea and vomiting.
PTS: 1 CON: DigestiN o nURSINGTB.COM 2. ANS: 3 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Describing the epidemiology of infectious and noninfectious intestinal disorders Chapter page reference: 1287-1296 Heading: Colorectal Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Cellular Regulation Difficulty: Difficult
1 2
3 4
Feedback The risk of colorectal cancer rises with age, and it is the most common cancer after the age of 65. Carcinogenic embryonic antigen (CEA) is not considered a diagnostic test but is used as a tumor marker to follow and manage the disease in patients diagnosed with the disease. The incidence of colorectal cancer is increased in patients with a history of ulcerative colitis, and these patients need diligent screening. Colorectal cancer is asymptomatic in the early stages. Screening tools such as annual fecal occult blood testing and colonoscopy performed every 5-10 years can detect the cancer when it is still in the curable stage.
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PTS: 1 CON: Cellular Regulation 3. ANS: 3 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Describing the epidemiology of infectious and noninfectious intestinal disorders Chapter page reference: 1287-1296 Heading: Colorectal Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Cellular Regulation Difficulty: Difficult Feedback 1 Genetic factors are strongly linked to the risk for colorectal cancer. Family history of the disease increases an individual’s risk for its development. 2 Inflammatory bowel diseases increase the risk of colorectal cancer. 3 The disease is prevalent in people who consume diets high in meat proteins. 4 The use of aspirin and multivitamins may reduce the risk of developing colorectal cancer. PTS: 1 CON: Cellular Regulation 4. ANS: 1 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Discussing the medical management of: Inflammatory bowel syndrome Chapter page reference: 1279 Heading: Intestinal Disorders NURSINGTB.COM Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Bowel Elimination Difficulty: Easy
1
2 3 4
Feedback Metronidazole (Flagyl) and ciprofloxacin (Cipro) have demonstrated effectiveness in the treatment of perianal complications. Antibiotics, such as ampicillin (Marcillin), gentamicin (Garamycin), clindamycin (Cleocin), and metronidazole (Flagyl), are effective during acute exacerbations. This medication is not appropriate for the treatment of Crohn’s disease. This medication is not appropriate for the treatment of Crohn’s disease. This medication is not appropriate for the treatment of Crohn’s disease.
PTS: 1 CON: Bowel Elimination 5. ANS: 2 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected disorders of the intestine. Chapter page reference: 1277-1278 Heading: Intestinal Disorders Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential
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Cognitive level: Comprehension [Understanding] Concept: Bowel Elimination Difficulty: Easy Feedback 1 Protein in the urine is not anticipated for a patient diagnosed with ulcerative colitis. 2 An increased ESR is anticipated for this patient due to inflammation. 3 A decreased white blood cell count is not anticipated for this patient. 4 Antineutrophil cytoplasmic antibodies is not anticipated for a patient diagnosed with ulcerative colitis. PTS: 1 CON: Bowel Elimination 6. ANS: 2 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Discussing the medical management of: Hemorrhoids Chapter page reference: 1270-172 Heading: Intestinal Disorders Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Bowel Elimination Difficulty: Easy Feedback 1 Zinc oxide forms a physical barrier on the skin to prevent irritation of the perianal region. 2 Benzocaine, a local anestheticN , pUroRvS idI esNteGmTpB or.arCy OreMlief from burning, itching, and pain. 3 Witch hazel promotes skin dryness, which helps relieve itching, irritation, and inflammation. 4 Hydrocortisone reduces inflammation. PTS: 1 CON: Bowel Elimination 7. ANS: 1 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care with intestinal disorders Chapter page reference: 1287-1296 Heading: Colorectal Cancer Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 Since the patient has expressed concern to the nurse regarding sexual functioning, the nurse should ask the patient to expand upon why there are concerns. 2 Telling the patient not to worry about the concern and offering to speak to her spouse are not the most appropriate responses at this time. 3 Telling the patient not to worry about the concern and offering to speak to her spouse are not the most appropriate responses at this time.
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4
Although a referral may be needed for the patient at some point, this is not the most appropriate response by the nurse.
PTS: 1 CON: Elimination 8. ANS: 4 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care with intestinal disorders Chapter page reference: 1287-1296 Heading: Colorectal Cancer Integrated Processes: Nursing Process: Diagnosis Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Elimination Difficulty: Moderate Feedback 1 Now is not the time to begin instructions, because the patient will most likely be unable to learn or concentrate on what the nurse is teaching. 2 Disuse syndrome and injury from positioning may be factors after surgery. 3 Disuse syndrome and injury from positioning may be factors after surgery. 4 The patient and family will require support to deal with their emotional response to learning the patient has cancer and will undergo body image-changing surgery. PTS: 1 CON: Elimination 9. ANS: 3 Chapter number and title: 58, CoordiN n aUtinRgSCIaN reGfoTrBP. a tC ie nOtsM With Intestinal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care with intestinal disorders Chapter page reference: 1287-1296 Heading: Colorectal Cancer Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Elimination Difficulty: Easy Feedback 1 Evidence that care has been effective includes an adequate hourly urine output of at least 0.5 mL/kg/hr, ability to perform activities of daily living, and tolerating oral intake. 2 Evidence that care has been effective includes an adequate hourly urine output of at least 0.5 mL/kg/hr, ability to perform activities of daily living, and tolerating oral intake. 3 Not participating in the care of an ostomy and stating that family will provide the care needed are evidence of ineffective coping, an undesirable outcome. 4 Evidence that care has been effective includes an adequate hourly urine output of at least 0.5 mL/kg/hr, ability to perform activities of daily living, and tolerating oral intake. PTS: 1 CON: Elimination 10. ANS: 3 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders
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Chapter learning objective: Discussing the medical management of: Hemorrhoids Chapter page reference: 1270-1272 Heading: Intestinal Disorders Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Bowel Elimination Difficulty: Easy Feedback 1 Zinc oxide forms a physical barrier on the skin to prevent irritation of the perianal region. 2 Benzocaine, a local anesthetic, provides temporary relief from burning, itching, and pain. 3 Witch hazel promotes skin dryness, which helps relieve itching, irritation, and inflammation. 4 Hydrocortisone reduces inflammation. PTS: 1 CON: Bowel Elimination 11. ANS: 1 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Discussing the medical management of: Hemorrhoids Chapter page reference: 1270-1272 Heading: Intestinal Disorders Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [UnN deUrsRtaSnI diN ngG]TB.COM Concept: Bowel Elimination Difficulty: Easy Feedback 1 Zinc oxide forms a physical barrier on the skin to prevent irritation of the perianal region. 2 Benzocaine, a local anesthetic, provides temporary relief from burning, itching, and pain. 3 Witch hazel promotes skin dryness, which helps relieve itching, irritation, and inflammation. 4 Hydrocortisone reduces inflammation. PTS: 1 CON: Bowel Elimination 12. ANS: 3 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Discussing the medical management of: Hemorrhoids Chapter page reference: 1275 Heading: Intestinal Disorders Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Bowel Elimination Difficulty: Easy
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1
2 3 4
Feedback This drug is a serotonergic agent that causes the release of other neurotransmitters and results in increased peristalsis, increased intestinal secretion, and decreased visceral sensitivity. This drug is an antidiarrheal agent that slows bowel transit, enhances water absorption, and strengthens anal sphincter tone, resulting in fewer stools, but does not relieve pain. This drug is an antispasmodic agent that relaxes smooth muscle spasm and GI motility while also inhibiting gastric secretion. This drug is an antidepressant that blocks norepinephrine reuptake and is believed to slow transit time and improve pain tolerance.
PTS: 1 CON: Bowel Elimination 13. ANS: 4 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Discussing the medical management of: Irritable bowel syndrome Chapter page reference: 1275 Heading: Intestinal Disorders Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Bowel Elimination Difficulty: Easy
1
2 3 4
Feedback This drug is a serotonergic ageNntU tR haSt ca INusGesT tBhe.rCelOeaMse of other neurotransmit ters and results in increased peristalsis, increased intestinal secretion, and decreased visceral sensitivity. This drug is an antidiarrheal agent that slows bowel transit, enhances water absorption, and strengthens anal sphincter tone, resulting in fewer stools, but does not relieve pain. This drug is an antispasmodic agent that relaxes smooth muscle spasm and GI motility while also inhibiting gastric secretion. This drug is an antidepressant that blocks norepinephrine reuptake and is believed to slow transit time and improve pain tolerance.
PTS: 1 CON: Bowel Elimination 14. ANS: 2 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Inflammatory bowel disease Chapter page reference: 1277 Heading: Intestinal Disorders Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Bowel Elimination Difficulty: Easy Feedback 1 The assessment data does not support planning care for diverticulitis. 2 Crohn’s disease manifests with five to six loose, nonbloody stools each day.
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3 4
The assessment data does not support planning care for ulcerative colitis. The assessment data does not support planning care for colorectal cancer.
PTS: 1 CON: Bowel Elimination 15. ANS: 3 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Inflammatory bowel disease Chapter page reference: 1277 Heading: Intestinal Disorders Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Bowel Elimination Difficulty: Easy Feedback 1 The assessment data does not support planning care for diverticulitis. 2 Crohn’s disease manifests with five to six loose, nonbloody stools each day. 3 Ulcerative colitis manifests with 10 to 20 loose, bloody stools each day. 4 The assessment data does not support planning care for colorectal cancer. PTS: 1 CON: Bowel Elimination 16. ANS: 1 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: DiscussinNgUthReSmIedNi G c aT l B ma.nC a gOem Men t of: Colorectal cancer Chapter page reference: 1287-1296 Heading: Colorectal Cancer Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate
1 2 3 4
Feedback This is the action of 5-Fluorouracil. This is the action of capecitabine. This is the action of oxaliplatin. This is the action of bevacizumab.
PTS: 1 CON: Cellular Regulation 17. ANS: 2 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Discussing the medical management of: Colorectal cancer Chapter page reference: 1287-1296 Heading: Colorectal Cancer Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Cellular Regulation
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Difficulty: Moderate
1 2 3 4
Feedback This is the action of 5-Fluorouracil. This is the action of capecitabine. This is the action of oxaliplatin. This is the action of bevacizumab.
PTS: 1 CON: Cellular Regulation 18. ANS: 3 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Discussing the medical management of: Colorectal cancer Chapter page reference: 1287-1296 Heading: Colorectal Cancer Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate 1 2 3 4
Feedback This is the action of 5-Fluorouracil. This is the action of capecitabine. This is the action of oxaliplatin. This is the action of bevacizum NaUb .R SINGTB.COM
PTS: 1 CON: Cellular Regulation 19. ANS: 4 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Discussing the medical management of: Colorectal cancer Chapter page reference: 1287-1296 Heading: Colorectal Cancer Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate 1 2 3 4
Feedback This is the action of 5-Fluorouracil. This is the action of capecitabine. This is the action of oxaliplatin. This is the action of bevacizumab.
PTS: 1 CON: Cellular Regulation 20. ANS: 1 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Discussing the medical management of: Inflammatory bowel disease
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Chapter page reference: 1278-1280 Heading: Intestinal Disorders Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Bowel Elimination Difficulty: Difficult
1 2 3 4
Feedback This statement indicates correct understanding of a proctocolectomy with a permanent ileostomy. This statement indicates correct understanding of an abdominal colectomy with ileoanal anastomosis. This statement indicates correct understanding of a proctocolectomy with continent ileostomy, also referred to a Kock pouch. This statement indicates correct understanding of a colectomy, mucosal proctectomy, and ileal pouch-anal canal anastomosis (IPAA). This procedure is performed in two steps.
PTS: 1 CON: Bowel Elimination 21. ANS: 2 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Discussing the medical management of: Inflammatory bowel disease Chapter page reference: 1278-1280 Heading: Intestinal Disorders NURSINGTB.COM Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Bowel Elimination Difficulty: Difficult
1 2 3 4
Feedback This statement indicates correct understanding of a proctocolectomy with a permanent ileostomy. This statement indicates correct understanding of an abdominal colectomy with ileoanal anastomosis. This statement indicates correct understanding of a proctocolectomy with continent ileostomy, also referred to a Kock pouch. This statement indicates correct understanding of a colectomy, mucosal proctectomy, and ileal pouch-anal canal anastomosis (IPAA). This procedure is performed in two steps.
PTS: 1 CON: Bowel Elimination 22. ANS: 3 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Discussing the medical management of: Inflammatory bowel disease Chapter page reference: 1278-1280 Heading: Intestinal Disorders Integrated Processes: Teaching and Learning
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Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Bowel Elimination Difficulty: Difficult
1 2 3 4
Feedback This statement indicates correct understanding of a proctocolectomy with a permanent ileostomy. This statement indicates correct understanding of an abdominal colectomy with ileoanal anastomosis. This statement indicates correct understanding of a proctocolectomy with continent ileostomy, also referred to a Kock pouch. This statement indicates correct understanding of a colectomy, mucosal proctectomy, and ileal pouch-anal canal anastomosis (IPAA). This procedure is performed in two steps.
PTS: 1 CON: Bowel Elimination 23. ANS: 4 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Discussing the medical management of: Inflammatory bowel disease Chapter page reference: 1278-1280 Heading: Intestinal Disorders Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] NURSINGTB.COM Concept: Bowel Elimination Difficulty: Difficult
1 2 3 4
Feedback This statement indicates correct understanding of a proctocolectomy with a permanent ileostomy. This statement indicates correct understanding of an abdominal colectomy with ileoanal anastomosis. This statement indicates correct understanding of a proctocolectomy with continent ileostomy, also referred to a Kock pouch. This statement indicates correct understanding of a colectomy, mucosal proctectomy, and ileal pouch-anal canal anastomosis (IPAA). This procedure is performed in two steps.
PTS: 1 CON: Bowel Elimination 24. ANS: 3 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected disorders of the intestine. Chapter page reference: 1287-1296 Heading: Colorectal Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing]
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Concept: Cellular Regulation Difficulty: Difficult
1 2 3 4
Feedback This statement indicates correct understanding of a fecal occult blood test collected by DRE. This statement indicates correct understanding of a double contrast barium enema. This statement indicates correct understanding of a lower GI series. This statement indicates correct understanding of a colonoscopy.
PTS: 1 CON: Cellular Regulation 25. ANS: 2 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected disorders of the intestine. Chapter page reference: 1287-1296 Heading: Colorectal Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Analysis [Analyzing] Concept: Cellular Regulation Difficulty: Difficult
1 2 3 4
Feedback This statement indicates corre ct NUunRdSerIstNanGd Tin Bg of .CaOfeMcal occult blood test collected by DRE. This statement indicates correct understanding of a double contrast barium enema. This statement indicates correct understanding of a lower GI series. This statement indicates correct understanding of a colonoscopy.
PTS: 1 CON: Cellular Regulation 26. ANS: 1 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Describing complications associated with selected disorders of the intestine Chapter page reference: 1296-1298 Heading: Abdominal Trauma Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Assessment Difficulty: Moderate 1 2 3 4
Feedback Blunt abdominal trauma is likely to cause a spleen injury. Abdominal stab injury is likely to cause a liver laceration. Intestinal obstruction is not likely to occur based on the current data. Traumatic brain injury is not likely to occur based on the current data.
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PTS: 1 CON: Assessment 27. ANS: 2 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Describing complications associated with selected disorders of the intestine Chapter page reference: 1296-1298 Heading: Abdominal Trauma Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Assessment Difficulty: Moderate
1 2 3 4
Feedback Blunt abdominal trauma is likely to cause a spleen injury. Abdominal stab injury is likely to cause a liver laceration. Intestinal obstruction is not likely to occur based on the current data. Traumatic brain injury is not likely to occur based on the current data.
PTS: 1
CON: Assessment
MULTIPLE RESPONSE 28. ANS: 1, 2, 4 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: CorrelatiN n gUcRliS n iI c aN l G maTnB ife.sC tatOioMns to pathophysiolo gical processes of: Irritab le bowel syndrome Chapter page reference: 1274-1276 Heading: Intestinal Disorders Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion; Bowel Elimination Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is correct. Patients with diarrhea may have perianal skin irritation and skin breakdown. This is correct. Diarrhea disturbs the fluid and electrolyte balance and can disrupt normal life activities. This is incorrect. There is no known direct connection between diarrhea and hair loss or sexual dysfunction. This is correct. Diarrhea disturbs the fluid and electrolyte balance and can disrupt normal life activities. This is incorrect. There is no known direct connection between diarrhea and hair loss or sexual dysfunction.
PTS: 1 CON: Digestion | Bowel Elimination 29. ANS: 2, 3, 5 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders
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Chapter learning objective: Developing a comprehensive plan of nursing care with intestinal disorders Chapter page reference: 1287-1296 Heading: Colorectal Cancer Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Cellular Regulation; Comfort Difficulty: Moderate
1.
2. 3. 4. 5.
Feedback This is incorrect. Pain level should be routinely assessed, and pain medication should be provided based upon the assessment and not only when the patient requests medication for pain. This is correct. The surgical site should be routinely assessed for inflammation as a potential source of pain. This is correct. Bowel sounds should be assessed, as a paralytic ileus could cause an increase in pain. This is incorrect. Pain medication should be provided before painful procedures. This is correct. The patient should be instructed to use a pillow to splint the incision when deep breathing and coughing.
PTS: 1 CON: Cellular Regulation | Comfort 30. ANS: 2, 4 Chapter number and title: 58, Coordinating Care for Patients With Intestinal Disorders Chapter learning objective: Discussing the medical management of: Colorectal cancer Chapter page reference: 1280-1283NURSINGTB.COM Heading: Intestinal Disorders Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Bowel Elimination Difficulty: Easy
1. 2. 3. 4. 5.
PTS: 1
Feedback This is incorrect. The distal, not proximal, stoma is synonymous with a mucous fistula. This is correct. The proximal stoma diverts feces to the abdominal wall. This is incorrect. The distal, not proximal, stoma expels mucus from the distal colon. This is correct. The proximal stoma is a functional stoma. This is incorrect. The distal stoma expels mucus from the distal colon. The proximal stoma does not expel mucus from the proximal colon. CON: Bowel Elimination
Chapter 59: Coordinating Care for Patients With Hepatic Disorders Multiple Choice Identify the choice that best completes the statement or answers the question.
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1. A patient is diagnosed with viral hepatitis transmitted by the fecal-oral route. Which conditions may be acquired by this mode of transmission? 1) Hepatitis A (HAV) 2) Hepatitis B (HBV) 3) Hepatitis C (HCV) 4) Hepatitis D (HDV) 2. The nurse is providing information about hepatitis to a high school health occupations class. The students all volunteer examples of how hepatitis is transmitted. Which student statement indicates the need for further education? 1) “Body piercing or tattoo with infected equipment” 2) “Contaminated food or fluids” 3) “Alcoholism or drug overdose” 4) “Bite of an infected mosquito or tick” 3. The nurse is planning education for an adolescent patient recently diagnosed with hepatitis. The patient moved back to the parent’s home. Which recommendation to the patient’s parents will best prevent them from acquiring hepatitis B (HBV)? 1) Refuse to donate blood 2) Avoid contaminated water 3) Obtain postexposure prophylaxis 4) Abstain from alcohol 4. When planning care for a patient with chronic hepatitis, which collaborative discipline will be most helpful in treating continued alcohol use? 1) Social worker NURSINGTB.COM 2) Primary provider 3) Pharmacist 4) Dietitian 5. The multidisciplinary care team is meeting to discuss care for a patient who exhibits symptoms of the prodromal phase of hepatitis. Lab results incluade a positive anti-HAV IgM. The nurse creates an action plan to present to the team. Which intervention is appropriate? 1) Early treatment with lamivudine 2) Referral to the liver transplant team 3) Patient education on acceptable pain medication 4) High-fat, low-calorie, and no-alcohol diet teaching 6. A young adult waiter has been treated for viral hepatitis at a health-care clinic. Which patient outcome indicates the need for additional intervention? 1) Body mass index (BMI) changes from 24 to 21. 2) Return demonstration of hand washing is correctly performed. 3) Social Services notified the Health Department of the occurrence. 4) Patient denies abdominal or epigastric pain. 7. Which medication noted in the patient’s health history interview is a risk factor for developing hepatitis? 1) Aspirin 2) Ibuprofen 3) Acetaminophen 4) Naproxen sodium
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
8. Which patient statement regarding toxins causing hepatitis indicates the need for further education by the nurse? 1) “Exposure to industrial chemicals is a risk factor for hepatitis.” 2) “Exposure to carbon tetrachloride is a risk factor for hepatitis.” 3) “Exposure to phosphorus is a risk factor for hepatitis.” 4) “Exposure to valproic acid is a risk factor for hepatitis.” 9. The nurse is providing care to a patient who is diagnosed with hepatic encephalopathy. Which clinical manifestation supports the documentation of stage 1? 1) Coma 2) Tremors 3) Disorientation 4) Difficulty to awaken 10. The nurse is providing care to a patient who is diagnosed with hepatic encephalopathy. Which clinical manifestation supports the documentation of stage 2? 1) Coma 2) Tremors 3) Disorientation 4) Difficulty to awaken 11. The nurse is providing care to a patient who is diagnosed with hepatic encephalopathy. Which clinical manifestation supports the documentation of stage 3? 1) Coma 2) Tremors 3) Disorientation 4) Difficulty to awaken NURSINGTB.COM 12. The nurse is providing care to a patient who is diagnosed with hepatic encephalopathy. Which clinical manifestation supports the documentation of stage 4? 1) Coma 2) Tremors 3) Disorientation 4) Difficulty to awaken 13. Which laboratory data supports the patient’s diagnosis of liver failure? 1) Decreased AST 2) Elevated albumin 3) Elevated ammonia 4) Decreased total bilirubin 14. Which information should the nurse provide to a patient who will be receiving the hepatitis A vaccine? 1) “The vaccine is considered effective for 15 years or longer.” 2) “You will receive a series of three shots over 6 to 12 months.” 3) “You will receive one shot with a booster 6 to 12 months later.” 4) “The vaccine is recommended for everyone including newborns.” 15. Which information should the nurse include in a teaching session for a patient who is to receive the hepatitis B vaccine? 1) “You will receive three injections over a 6 to 12 month period.” 2) “This vaccine provides protection within two to four weeks of vaccine.” 3) “You will receive one shot followed by a booster 6 to 12 months later.”
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4) “This vaccine is recommended for those who engage in risky behavior, such as illegal injected drug users.” 16. The nurse is providing care to a patient who is diagnosed with hepatic encephalopathy. Which term should the nurse use to document a sweet fecal smell of the breath? 1) Asterixis 2) Euphoria 3) Fetor hepaticus 4) Rigid extremities 17. Which patient should the nurse plan symptomatic treatment for hepatitis in the plan of care? 1) Hepatitis A 2) Hepatitis B 3) Hepatitis C 4) Hepatitis D 18. Which patient statement regarding the incubation period of hepatitis requires further education from the nurse? 1) “Hepatitis A has an incubation period of 15 to 50 days.” 2) “Hepatitis B has an incubation period of 30 to 60 days.” 3) “Hepatitis C has an incubation period of 2 to 25 weeks.” 4) “Hepatitis D has an incubation period of 2 to 8 weeks.” 19. Which information found in the patient’s health history supports the current diagnosis of cirrhosis? 1) Biliary disease 2) Social alcohol use 3) Hepatitis D infection NURSINGTB.COM 4) Chronic intravenous drug use 20. Which data collected by the nurse after a liver biopsy indicates the need for immediate action by the nurse? 1) The patient is awake and alert. 2) The patient’s blood pressure is 90/60 mm Hg. 3) The patient’s heart rate is 80 beats per minute. 4) The patients respiratory rate is 16 breaths per minute. 21. Which therapeutic prescription should the nurse question when providing care to a patient who is diagnosed with ascites? 1) Furosemide 2) Spironolactone 3) Placement of a shunt 4) Three gram per day sodium diet 22. Which assessment data indicates to the nurse that the patient may be experiencing decreased clotting factors as a complication of cirrhosis? 1) Epistaxis 2) Yellow skin 3) Clay-colored stool 4) Personality changes 23. Which assessment data indicates to the nurse that the patient may be experiencing an increased ammonia level, a complication of cirrhosis? 1) Epistaxis
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) Yellow skin 3) Clay-colored stool 4) Personality changes 24. Which oral agent should the nurse include in the plan of care for a patient who is diagnosed with hepatitis B? 1) Ribavirin 2) Tenofovir 3) Interferon-alpha 4) Pegylated interferon 25. Which clinical manifestation assessed by the nurse supports the patient’s diagnosis of liver cancer? 1) Increased appetite 2) Shortness of breath 3) Decreased liver enzymes 4) Pain in the left upper quadrant 26. Which is a common cause of death for a patient who presents for care in the emergency department (ED) with liver trauma suffered as a result of a motor vehicle accident? 1) Infection 2) Hemorrhage 3) Cardiac arrest 4) Respiratory arrest Multiple Response Identify one or more choices that best complete the statement or answer the question.
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27. The nurse is providing care to several patients who are diagnosed with hepatitis. Which diagnoses indicate an acute infection? Select all that apply. 1) Hepatitis A 2) Hepatitis B 3) Hepatitis C 4) Hepatitis D 5) Hepatitis E 28. The nurse is providing care to several patients who are diagnosed with hepatitis. Which patients could have avoided infection with a vaccination? Select all that apply. 1) Hepatitis A 2) Hepatitis B 3) Hepatitis C 4) Hepatitis D 5) Hepatitis E 29. For which hepatitis infections would the nurse include interferon and antivirals in the plan of care? Select all that apply. 1) Hepatitis A 2) Hepatitis B 3) Hepatitis C 4) Hepatitis D 5) Hepatitis E
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Completion Complete each statement. 30. During an interview with a patient diagnosed with hepatitis B, the nurse obtains the following data: 10 kg weight loss is noted from the patient’s last visit four months ago; review of systems reveals 1) limiting fatigue, 2) not well enough for sexual intercourse but doubts if her husband will be willing to use a condom, 3) drinks three to five mixed drinks weekly socially, 4) RUQ pain rated at 6/10, and 5) “constant” pruritus. Prioritize the nursing diagnoses formulated for this patient. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Acute Pain 2) Deficient Knowledge 3) Imbalanced Nutrition 4) Impaired Skin Integrity
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 59: Coordinating Care for Patients With Hepatic Disorders Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Describing the epidemiology of the hepatic disorders Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 HAV and HEV are transmitted by the fecal-oral route. 2 HBV is transmitted by blood, body fluids, and perinatal routes. 3 HCV is transmitted by blood and body fluids. 4 HDV is transmitted by blood, body fluids, and perinatal routes. PTS: 1 CON: Infection ANS: 4 2. NURSINGTB.COM Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Describing the epidemiology of the hepatic disorders Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult 1
2
3
4
Feedback The students who said that infected needles, contaminated food or fluids, alcoholism, or drug overdose can cause different types of hepatitis were correct and do not require further education. The students who said that infected needles, contaminated food or fluids, alcoholism, or drug overdose can cause different types of hepatitis were correct and do not require further education. The students who said that infected needles, contaminated food or fluids, alcoholism, or drug overdose can cause different types of hepatitis were correct and do not require further education. The student who believes the bite of a mosquito or tick will transmit hepatitis is incorrect and needs further education.
PTS: 1
CON: Infection
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3. ANS: 3 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Discussing the medical management of: Hepatitis Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Donating blood will not increase the risk of acquiring HBV. 2 HBV is not spread in water. 3 Obtaining postexposure prophylaxis treatment will best help the patient’s parents from acquiring HBV. The HBV vaccine is started concurrently. 4 Alcohol abuse is implicated in nonviral hepatitis. PTS: 1 CON: Infection 4. ANS: 1 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hepatic disorders Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective CareNURSINGTB.COM Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 The social worker is an expert at identifying additional resources for treatment of substance abuse. 2 The primary provider, pharmacist, and dietitian will all contribute to the plan of care. 3 The primary provider, pharmacist, and dietitian will all contribute to the plan of care. 4 The primary provider, pharmacist, and dietitian will all contribute to the plan of care. PTS: 1 CON: Infection 5. ANS: 3 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with hepatic disorders Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
Feedback Most patients recover from acute viral hepatitis without pharmacological treatment and certainly without liver transplant. Most patients recover from acute viral hepatitis without pharmacological treatment and certainly without liver transplant. Patient education on acceptable pain medication is necessary due to the toxic effect of common over-the-counter pain medicine. A low-fat, high-calorie diet is recommended.
PTS: 1 CON: Infection 6. ANS: 1 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Describing the epidemiology of the hepatic disorders Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 The patient will need additional intervention if weight loss occurs and if the patient has continued itching. No additional intervention is needed if hand washing is performed correctly or pain is 2 controlled. NURSINGTB.COM 3 4
The health department must be notified if a food service worker is diagnosed due to possible exposure of patrons. No additional intervention is needed if hand washing is performed correctly or pain is controlled.
PTS: 1 CON: Infection 7. ANS: 3 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Describing the epidemiology of the hepatic disorders Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Aspirin is not a risk factor for hepatitis. 2 Ibuprofen is not a risk factor for hepatitis. 3 Acetaminophen is a risk factor for hepatitis. 4 Naproxen sodium is not a risk factor for hepatitis. PTS: 1
CON: Infection
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
8. ANS: 4 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Describing the epidemiology of the hepatic disorders Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 This statement indicates correct understanding of toxins that cause hepatitis. 2 This statement indicates correct understanding of toxins that cause hepatitis. 3 This statement indicates correct understanding of toxins that cause hepatitis. 4 Valproic acid is a medication, not toxin, that causes hepatitis. PTS: 1 CON: Infection 9. ANS: 2 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Hepatitis Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] NURSINGTB.COM Concept: Infection Difficulty: Moderate Feedback 1 Coma indicates stage 4 hepatic encephalopathy. 2 Tremors indicate stage 1 hepatic encephalopathy. 3 Disorientation indicates stage 2 hepatic encephalopathy. 4 Difficulty to awaken indicates stage 3 hepatic encephalopathy. PTS: 1 CON: Infection 10. ANS: 3 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Hepatitis Chapter page reference: 1307-1313 Heading: Cirrhosis Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Coma indicates stage 4 hepatic encephalopathy. 2 Tremors indicate stage 1 hepatic encephalopathy. 3 Disorientation indicates stage 2 hepatic encephalopathy. 4 Difficulty to awaken indicates stage 3 hepatic encephalopathy.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1 CON: Infection 11. ANS: 4 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Hepatitis Chapter page reference: 1307-1313 Heading: Cirrhosis Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Coma indicates stage 4 hepatic encephalopathy. 2 Tremors indicate stage 1 hepatic encephalopathy. 3 Disorientation indicates stage 2 hepatic encephalopathy. 4 Difficulty to awaken indicates stage 3 hepatic encephalopathy. PTS: 1 CON: Infection 12. ANS: 1 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Hepatitis Chapter page reference: 1307-1313 Heading: Cirrhosis Integrated Processes: Communication and Documentation NURSINGTB.COM Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Coma indicates stage 4 hepatic encephalopathy. 2 Tremors indicate stage 1 hepatic encephalopathy. 3 Disorientation indicates stage 2 hepatic encephalopathy. 4 Difficulty to awaken indicates stage 3 hepatic encephalopathy. PTS: 1 CON: Infection 13. ANS: 3 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of hepatic disorders Chapter page reference: 1314-1316 Heading: Liver Cancer Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 An elevated, not decreased, AST supports the diagnosis of liver failure.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2 3 4
A decreased, not elevated, albumin level supports the diagnosis of liver failure. An elevated ammonia level supports the diagnosis of liver failure. An elevated, not decreased, total bilirubin supports the diagnosis of liver failure.
PTS: 1 CON: Digestion 14. ANS: 3 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with hepatic disorders Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 This statement is included in the education for the hepatitis B, not A, vaccine. 2 This statement is included in the education for the hepatitis B, not A, vaccine. 3 This statement is appropriate to include in the teaching session for a patient who will receive the hepatitis A vaccine. 4 This statement is included in the education for the hepatitis B, not A, vaccine. PTS: 1 CON: Infection 15. ANS: 1 NURSINGTB.COM Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with hepatic disorders Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 This information is appropriate for a patient who will receive the hepatitis B vaccine. 2 This information is appropriate for a patient who will receive the hepatitis A vaccine. 3 This information is appropriate for a patient who will receive the hepatitis A vaccine. 4 This information is appropriate for a patient who will receive the hepatitis A vaccine. PTS: 1 CON: Infection 16. ANS: 3 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Cirrhosis Chapter page reference: 1307-1313 Heading: Cirrhosis Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation
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Cognitive level: Application [Applying] Concept: Digestion Difficulty: Moderate Feedback 1 Asterixis is a term used to describe flapping of the hands and arms that occurs with hepatic encephalopathy. 2 Euphoria is not the term the nurse will use to describe the sweet fecal smell of the breath. 3 Fetor hepaticus is the term used to describe the sweet fecal smell of the breath that occurs with hepatic encephalopathy. 4 Rigid extremities is not the terminology the nurse will use to describe the sweet fecal smell of the breath. PTS: 1 CON: Digestion 17. ANS: 1 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hepatic disorders Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy
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1 2 3 4
Feedback The nurse anticipates the patient diagnosed with hepatitis A to be treated symptomatically. The nurse anticipates the patient diagnosed with hepatitis B to be treated with interferon and antivirals. The nurse anticipates the patient diagnosed with hepatitis C to be treated with interferon and antivirals. The nurse anticipates the patient diagnosed with hepatitis D to be treated with interferon and antivirals.
PTS: 1 CON: Infection 18. ANS: 2 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hepatic disorders Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1 2 3 4
Feedback This statement indicates correct understanding of the incubation period of hepatitis A. This statement indicates the need for additional education regarding the incubation period of hepatitis B. This statement indicates correct understanding of the incubation period of hepatitis C. This statement indicates correct understanding of the incubation period of hepatitis D.
PTS: 1 CON: Infection 19. ANS: 1 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Describing the epidemiology of the hepatic disorders Chapter page reference: 1307-1313 Heading: Cirrhosis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy
1 2 3 4
Feedback Biliary disease is a risk factor for cirrhosis. Chronic alcoholism, not social alcohol use, is a risk factor for cirrhosis. Hepatitis A, B, and C, not D, are risk factors for cirrhosis. Chronic alcoholism, not intravenous drug use, is a risk factor for cirrhosis.
NURSINGTB.COM PTS: 1 CON: Digestion 20. ANS: 2 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of hepatic disorders Chapter page reference: 1314-1316 Heading: Liver Cancer Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Digestion Difficulty: Difficult Feedback 1 This assessment data does not require intervention by the nurse. 2 A decrease in blood pressure may indicate bleeding; therefore, this data requires intervention by the nurse. 3 This assessment data does not require intervention by the nurse. 4 This assessment data does not require intervention by the nurse. PTS: 1 CON: Digestion 21. ANS: 4 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Discussing the medical management of: Cirrhosis
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter page reference: 1307-1313 Heading: Cirrhosis Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Digestion Difficulty: Moderate Feedback 1 Furosemide is an appropriate prescription for this patient. 2 Spironolactone is an appropriate prescription for this patient. 3 Placement of a shunt is an appropriate prescription for this patient. 4 A diet of less than 2g of sodium per day is anticipated for this patient; therefore, this prescription should be questioned by the nurse. PTS: 1 CON: Digestion 22. ANS: 1 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Cirrhosis Chapter page reference: 1307-1313 Heading: Cirrhosis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy NURSINGTB.COM Feedback 1 Epistaxis, or a nose bleed, is assessment data that indicates decreased clotting factors. 2 Yellow skin, or jaundice, indicates increased bilirubin level. 3 Clay-colored stool indicates increased bilirubin level. 4 Personality changes indicate elevated ammonia levels. PTS: 1 CON: Digestion 23. ANS: 4 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Cirrhosis Chapter page reference: 1307-1313 Heading: Cirrhosis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Digestion Difficulty: Easy Feedback 1 Epistaxis, or a nose bleed, is assessment data that indicates decreased clotting factors. 2 Yellow skin, or jaundice, indicates increased bilirubin level. 3 Clay-colored stool indicates increased bilirubin level. 4 Personality changes indicate elevated ammonia levels.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1 CON: Digestion 24. ANS: 2 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Discussing the medical management of: Hepatitis Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy
1 2 3 4
Feedback Ribavirin is pharmacological treatment for hepatitis C, not hepatitis B. Tenofovir is an oral pharmacological agent used to treatment hepatitis B. Interferon-alpha is a parenteral agent used to treat hepatitis B. Pegylated interferon is a parenteral agent used to treat hepatitis B.
PTS: 1 CON: Infection 25. ANS: 2 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Liver cancer Chapter page reference: 1314-1316 Heading: Liver Cancer NURSINGTB.COM Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Easy Feedback 1 Anorexia is a clinical manifestation the nurse anticipates with liver cancer. 2 Shortness of breath is a clinical manifestation anticipated for a patient diagnosed with liver cancer. 3 Increased, not decreased, liver enzymes is anticipated for a patient diagnosed with liver cancer. 4 Pain in the right, not left, upper quadrant is anticipated for a patient diagnosed with liver cancer. PTS: 1 CON: Cellular Regulation 26. ANS: 2 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Liver trauma Chapter page reference: 1316-1318 Heading: Liver Trauma Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding]
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Concept: Perfusion Difficulty: Easy Feedback 1 Infection is not a common cause of death for a patient who presents with liver trauma. 2 Hemorrhage is a common cause of death for a patient who presents with liver trauma. 3 Cardiac arrest is not a common cause of death for a patient who presents with liver trauma. 4 Respiratory arrest is not a common cause of death for a patient who presents with liver trauma. PTS: 1
CON: Perfusion
MULTIPLE RESPONSE 27. ANS: 1, 4, 5 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Describing the epidemiology of the hepatic disorders Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy
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1. 2. 3. 4. 5.
Feedback This is correct. Hepatitis A is an acute infection. This is incorrect. Hepatitis B is a chronic infection. This is incorrect. Hepatitis C is a chronic infection. This is correct. Hepatitis D is an acute infection. This is correct. Hepatitis E is an acute infection.
PTS: 1 CON: Infection 28. ANS: 1, 2, 4 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Hepatitis Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy
1. 2. 3.
Feedback This is correct. Hepatitis A can be prevented with a vaccination. This is correct. Hepatitis B can be prevented with a vaccination. This is incorrect. Hepatitis C cannot be prevented with a vaccination.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
4. 5.
This is correct. Hepatitis D is prevented with an HBV. This is incorrect. Hepatitis E cannot be prevented with a vaccination.
PTS: 1 CON: Infection 29. ANS: 2, 3, 4 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Discussing the medical management of: Hepatitis Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate
1. 2. 3. 4. 5. PTS: 1 COMPLETION
Feedback This is incorrect. Hepatitis A is treated symptomatically. This is correct. Hepatitis B is treated with interferon and antiviral therapy. This is correct. Hepatitis C is treated with interferon and antiviral therapy. This is correct. Hepatitis D is treated with interferon and antiviral therapy. This is incorrect. Hepatitis E is treated symptomatically. CON: Infection
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30. ANS: 1234 Chapter number and title: 59, Coordinating Care for Patients With Hepatic Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with hepatic disorders Chapter page reference: 1301-1307 Heading: Hepatitis Integrated Processes: Nursing Process: Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Hard
1.
2.
Feedback Relieving the pain associated with hepatitis and preventing the spread of infection are priorities of hepatitis management. Interventions related to knowledge deficit will address the potential for spread of the infection to the patient’s husband, use of alcohol, imbalanced nutrition, and impaired skin integrity. Relieving the pain associated with hepatitis and preventing the spread of infection are priorities of hepatitis management. Interventions related to knowledge deficit will address the potential for spread of the infection to the patient's husband, use of alcohol, imbalanced nutrition, and impaired skin integrity.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3.
4.
PTS: 1
Relieving the pain associated with hepatitis and preventing the spread of infection are priorities of hepatitis management. Interventions related to knowledge deficit will address the potential for spread of the infection to the patient's husband, use of alcohol, imbalanced nutrition, and impaired skin integrity. Relieving the pain associated with hepatitis and preventing the spread of infection are priorities of hepatitis management. Interventions related to knowledge deficit will address the potential for spread of the infection to the patient's husband, use of alcohol, imbalanced nutrition, and impaired skin integrity. CON: Infection
Chapter 60: Coordinating Care for Patients With Biliary and Pancreatic Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is providing care to a patient who is being admitted to rule out acute pancreatitis. Which item found in the patient’s history increases the patient’s risk for this disease process? 1) Systemic lupus 2) Alcoholism 3) Cystic fibrosis 4) Hypertriglyceridemia 2. A patient diagnosed with chronic pancreatitis asks if there are any alternative therapies that might help with NURSINGTB.CO treating the condition. Which alternative and complementary therapy is inappropriate to include in the teaching session with this patient? 1) Qigong 2) Herbal kava tea 3) Magnetic field therapy 4) Low-salt, low-fat vegetarian diet 3. A patient was discharged after hospitalization for acute pancreatitis with instructions on the use of analgesics, cautions on the importance of avoiding alcohol and smoking, and recommendations for a low-fat diet. Which outcome would indicate the need for further intervention by the nurse? 1) The patient continues to experience nausea. 2) The patient is free from alterations in nutritional status. 3) The patient experiences reduction or elimination of pain. 4) The patient remains free from alterations in fluid balance. 4. Which data collected during the health history places the patient at risk for acalculous cholecystitis? 1) Spider bite 2) Gallstones 3) Sickle cell disease 4) Diabetes insipidus 5. The nurse is asked to explain the common laboratory values associated with acute pancreatitis. Which should the nurse include as the cause of decreased albumin? 1) Poor nutrition 2) Bile flow obstruction
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3) Gallstone pancreatitis 4) Fat necrosis and malnutrition 6. The nurse is asked to explain the common laboratory values associated with acute pancreatitis. Which should the nurse include as the cause of an elevated AST? 1) Poor nutrition 2) Bile flow obstruction 3) Gallstone pancreatitis 4) Fat necrosis and malnutrition 7. The nurse is asked to explain the common laboratory values associated with acute pancreatitis. Which should the nurse include as the cause of hypocalcemia? 1) Poor nutrition 2) Bile flow obstruction 3) Gallstone pancreatitis 4) Fat necrosis and malnutrition 8. The nurse is asked to explain the common laboratory values associated with acute pancreatitis. Which should the nurse include as the cause of an elevated ALT? 1) Poor nutrition 2) Bile flow obstruction 3) Gallstone pancreatitis 4) Fat necrosis and malnutrition 9. The nurse is asked to explain the common laboratory values associated with acute pancreatitis. Which should the nurse include as the cause of an elevated WBC count? 1) Poor nutrition NURSINGTB.COM 2) Gallstone pancreatitis 3) Inflammatory process 4) Fat necrosis and malnutrition 10. Which patient data supports Ranson’s criteria for acute pancreatitis at admission? 1) Patient age is 43 years 2) WBC less than 16,000/mL 3) BUN greater than 5 mg/dL 4) Glucose greater than 200 mg/dL 11. The nurse is teaching a patient about the approved therapeutic agents for acute pancreatitis. Which patient statement indicates the need for further education? 1) “Opioids are used to treat pain.” 2) “Spasmolytics are used to relax the sphincter of Oddi.” 3) “Proton pump inhibitors are used to increase gastric acid secretions.” 4) “Anticholinergics are used to decrease the release of pancreatic enzymes.” 12. The nurse is conducting patient education regarding prescribed drugs for acute pancreatitis. Which agent should the nurse include as one that is used for pain management? 1) Spasmolytics 2) H2 Antagonist 3) Opioid narcotics 4) Pancreatic enzymes
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13. The nurse is conducting patient education regarding prescribed drugs for acute pancreatitis. Which agent should the nurse include as one that is used to decrease gastric acid secretions? 1) Spasmolytics 2) H2 Antagonist 3) Opioid narcotics 4) Pancreatic enzymes 14. The nurse is conducting patient education regarding prescribed drugs for acute pancreatitis. Which agent should the nurse include as one that is used for digesting fats and proteins? 1) Spasmolytics 2) H2 Antagonist 3) Opioid narcotics 4) Pancreatic enzymes 15. The nurse is conducting patient education regarding prescribed drugs for acute pancreatitis. Which agent should the nurse include as one that is used to relax smooth muscle and the sphincter of Oddi? 1) Spasmolytics 2) H2 Antagonist 3) Opioid narcotics 4) Pancreatic enzymes 16. The nurse is providing care to a patient who is diagnosed with acute necrotizing pancreatitis. Which agent should the nurse anticipate to be prescribed for this patient? 1) Antibiotic 2) Octreotide 3) Histamine antagonist 4) Proton pump inhibitor NURSINGTB.COM 17. The nurse is reviewing the health history for a patient who is diagnosed with chronic pancreatitis. Which data supports the patient’s current diagnosis? 1) Trauma 2) Gallstones 3) Cystic fibrosis 4) Hypotriglyceridemia 18. The nurse is reviewing the health history for a patient who is diagnosed with acute pancreatitis. Which data supports the patient’s current diagnosis? 1) Trauma 2) Cystic fibrosis 3) Hypercalcemia 4) Hypertriglyceridemia 19. The nurse is providing care to a patient who scores a 4 with the Ranson’s score. Which conclusion by the nurse is most appropriate? 1) This patient has a 2% chance of mortality. 2) This patient has a 15% chance of mortality. 3) This patient has a 40% chance of mortality. 4) This patient has a 100% chance of mortality. 20. Which is the priority nursing action when providing care to a patient with a nasogastric tube (NGT) in place following a pancreaticoduodenectomy? 1) Irrigating the tube
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2) Checking for placement 3) Replacing the tube pulled out by the patient 4) Hanging a sign over the bed stating, “DO NOT Manipulate the NGT” 21. The nurse is providing care to a pregnant patient who is diagnosed with gallstones. Which should the nurse include in the teaching session with the patient regarding this occurrence? 1) “You are genetically at risk for developing gallstones.” 2) “A diet high in saturated fat is causing your gallstones.” 3) “An elevated progesterone level is causing your gallstones.” 4) “Your prescribed cholesterol-lowering drug is causing your gallstones.” 22. The nurse is providing care to several patients in the emergency department (ED). Which patient is most likely to present with vague symptoms of cholecystitis? 1) An adolescent male patient 2) A young adult male patient 3) A pregnant woman in the second trimester 4) An older adult female patient diagnosed with diabetes 23. The nurse is providing care to a patient who is diagnosed with gallstones. Which preferred treatment method should the nurse include in the teaching session? 1) Lithotripsy 2) Low-fat diet 3) Oral agents to dissolve the stones 4) Laparoscopic cholecystectomy 24. Which data found in the patient’s health history supports the current diagnosis of pancreatic cancer? 1) Nonsmoker NURSINGTB.COM 2) Vegetarian diet 3) Diabetes mellitus 4) Acute pancreatitis 25. Which assessment data collected by the nurse supports the patient’s diagnosis of pancreatic cancer? 1) Weight gain 2) Hyperglycemia 3) Sharp back pain 4) Yellowing of the sclera Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. The nurse is providing care to a patient admitted with acute pancreatitis. Which data support the patient’s diagnosis? Select all that apply. 1) Steatorrhea 2) Hypotension 3) Nausea and vomiting 4) Elevated temperature 5) Severe epigastric pain
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27. The nurse is providing care to an older adult patient admitted to the medical unit for acute gastric and left upper abdominal pain radiating to the back. The health-care provider has diagnosed the patient with chronic pancreatitis. Which items are appropriate to include in the discharge teaching for this patient? Select all that apply. 1) Taking antacids 2) Encouraging a high-fat diet 3) Monitoring weight every week 4) Eliminating alcoholic beverages 5) Properly administering pancrelipase 28. The nurse is providing care to an older adult patient with a history of alcohol abuse who is admitted to the hospital with acute pancreatitis. Which treatment options should the nurse plan for when caring for this patient? Select all that apply. 1) High-fat diet 2) Opioid analgesics 3) Total parenteral nutrition 4) Nasogastric tube to suction 5) Pancrelipase administration
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Chapter 60: Coordinating Care for Patients With Biliary and Pancreatic Disorders Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Describing the epidemiology of biliary and pancreatic disorders Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Inflammation Difficulty: Easy Feedback 1 Autoimmune disorders, such as systemic lupus, cystic fibrosis, and hypertriglyceridemia are all risk factors for chronic pancreatitis. 2 Risk factors for acute pancreatitis include alcoholism and gallstones. 3 Autoimmune disorders, such as systemic lupus, cystic fibrosis, and hypertriglyceridemia are all risk factors for chronic pancreatitis. 4 Autoimmune disorders, such as systemic lupus, cystic fibrosis, and hypertriglyceridemia are all risk factors for chronic pancreatitis.
NaUtiRonSINGTB.COM PTS: 1 CON: Inflamm 2. ANS: 2 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with biliary and pancreatic disorders Chapter page reference: 1332-1334 Heading: Chronic Pancreatitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate 1
2
Feedback The complementary and alternative therapies that have proven to be effective if used in conjunction with traditional treatment while under the care of a health -care provider include fasting or a low-salt, low-fat vegetarian diet; qigong, which is a system of gentle exercise, meditation, and controlled breathing and is believed to balance the flow of qi (a vital life force) through the body; and magnetic field therapy. Herbal kava tea is not a complementary and alternative therapy that has been proven effective in the treatment of chronic pancreatitis.
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3
4
The complementary and alternative therapies that have proven to be effective if used in conjunction with traditional treatment while under the care of a health -care provider include fasting or a low-salt, low-fat vegetarian diet; qigong, which is a system of gentle exercise, meditation, and controlled breathing and is believed to balance the flow of qi (a vital life force) through the body; and magnetic field therapy. The complementary and alternative therapies that have proven to be effective if used in conjunction with traditional treatment while under the care of a health -care provider include fasting or a low-salt, low-fat vegetarian diet; qigong, which is a system of gentle exercise, meditation, and controlled breathing and is believed to balance the flow of qi (a vital life force) through the body; and magnetic field therapy.
PTS: 1 CON: Inflammation 3. ANS: 1 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with biliary and pancreatic disorders Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Inflammation Difficulty: Easy Feedback 1 The patient who continues to experience nausea requires further intervention by the NURSINGTB.COM nurse. 2 Indications that would suggest that the patient has implemented the recommendations include a reduction or elimination of pain, is free from alterations in nutritional status, and is free from alterations in fluid balance. 3 Indications that would suggest that the patient has implemented the recommendations include a reduction or elimination of pain, is free from alterations in nutritional status, and is free from alterations in fluid balance. 4 Indications that would suggest that the patient has implemented the recommendations include a reduction or elimination of pain, is free from alterations in nutritional status, and is free from alterations in fluid balance. PTS: 1 CON: Inflammation 4. ANS: 3 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Describing the epidemiology of biliary and pancreatic disorders Chapter page reference: 1322-1326 Heading: Cholecystitis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Inflammation Difficulty: Easy Feedback
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1 2 3 4
A spider bite is a risk factor for acute pancreatitis. Gallstones are a risk factor for acute pancreatitis. Sickle cell disease is a risk factor for acalculous cholecystitis. Diabetes mellitus, not insipidus, is a risk factor for acalculous cholecystitis.
PTS: 1 CON: Inflammation 5. ANS: 1 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of biliary and pancreatic disorders Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate Feedback 1 A decreased albumin level is caused by poor nutrition. 2 An elevated AST is caused by bile flow obstruction. 3 An elevated ALT is caused by gallstone pancreatitis. 4 A decreased calcium level, or hypocalcemia, is caused by fat necrosis, hypoalbuminemia, and malnutrition. PTS: 1 CON: Inflamm NaUtiRo nSINGTB.COM 6. ANS: 2 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of biliary and pancreatic disorders Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate Feedback 1 A decreased albumin level is caused by poor nutrition. 2 An elevated AST is caused by bile flow obstruction. 3 An elevated ALT is caused by gallstone pancreatitis. 4 A decreased calcium level, or hypocalcemia, is caused by fat necrosis, hypoalbuminemia, and malnutrition. PTS: 1 CON: Inflammation 7. ANS: 4 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of biliary and pancreatic disorders
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Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate Feedback 1 A decreased albumin level is caused by poor nutrition. 2 An elevated AST is caused by bile flow obstruction. 3 An elevated ALT is caused by gallstone pancreatitis. 4 A decreased calcium level, or hypocalcemia, is caused by fat necrosis, hypoalbuminemia, and malnutrition. PTS: 1 CON: Inflammation 8. ANS: 3 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of biliary and pancreatic disorders Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Inflammation NURSINGTB.COM Difficulty: Moderate Feedback 1 A decreased albumin level is caused by poor nutrition. 2 An elevated AST is caused by bile flow obstruction. 3 An elevated ALT is caused by gallstone pancreatitis. 4 A decreased calcium level, or hypocalcemia, is caused by fat necrosis, hypoalbuminemia, and malnutrition. PTS: 1 CON: Inflammation 9. ANS: 3 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of biliary and pancreatic disorders Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Nursing Process - Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate Feedback 1 A decreased albumin level is caused by poor nutrition. 2 An elevated ALT is caused by gallstone pancreatitis. 3 An elevated WBC count is caused by the inflammatory process.
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A decreased calcium level, or hypocalcemia, is caused by fat necrosis, hypoalbuminemia, and malnutrition.
PTS: 1 CON: Inflammation 10. ANS: 4 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Acute pancreatitis Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate Feedback 1 A patient who is greater than 55 years of age supports Ranson’s criteria for acute pancreatitis at admission. 2 A WBC greater, not less, than 16,000/mL supports Ranson’s criteria for acute pancreatitis at admission. 3 A BUN increase greater than 5 mg/dL after fluid resuscitation supports Ranson’s criteria for acute pancreatitis at 48 hours. 4 The patient who presents with a glucose greater than 200 mg/dL at admission supports Ranson’s criteria for acute pancreatitis.
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PTS: 1 CON: Inflammation ANS: 3 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Discussing the medical management of: Acute pancreatitis Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Inflammation Difficulty: Difficult Feedback 1 This statement indicates correct understanding for opioids. 2 This statement indicates correct understanding for spasmolytics. 3 Proton pump inhibitors are used to decrease, not increase, gastric acid secretions. 4 This statement indicates correct understanding for anticholinergics. PTS: 1 CON: Inflammation 12. ANS: 3 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Discussing the medical management of: Acute pancreatitis Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Nursing Process: Implementation
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Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate Feedback 1 This agent is used to relax smooth muscle and the sphincter of Oddi. 2 This agent is used to decrease gastric acid secretions. 3 This agent is used for pain management. 4 This agent is used to help digest fats and proteins. PTS: 1 CON: Inflammation 13. ANS: 2 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Discussing the medical management of: Acute pancreatitis Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate Feedback 1 This agent is used to relax smooth muscle and the sphincter of Oddi. 2 This agent is used to decrease gastric acid secretions. 3 This agent is used for pain maN naUgem R SeIn tN. GTB.COM 4 This agent is used to help digest fats and proteins. PTS: 1 CON: Inflammation 14. ANS: 4 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Discussing the medical management of: Acute pancreatitis Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate Feedback 1 This agent is used to relax smooth muscle and the sphincter of Oddi. 2 This agent is used to decrease gastric acid secretions. 3 This agent is used for pain management. 4 This agent is used to help digest fats and proteins. PTS: 1 CON: Inflammation 15. ANS: 1 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Discussing the medical management of: Acute pancreatitis
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Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate Feedback 1 This agent is used to relax smooth muscle and the sphincter of Oddi. 2 This agent is used to decrease gastric acid secretions. 3 This agent is used for pain management. 4 This agent is used to help digest fats and proteins. PTS: 1 CON: Inflammation 16. ANS: 1 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Discussing the medical management of: Acute pancreatitis Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Inflammation Difficulty: Easy
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1 2 3 4
Antibiotics are anticipated for a patient who is diagnosed with acute necrotizing pancreatitis. Octreotide is prescribed to decrease secretion of enzymes. Histamine antagonists are prescribed to decrease gastric acid secretions. Proton pump inhibitors are prescribed to decrease gastric acid secretions.
PTS: 1 CON: Inflammation 17. ANS: 3 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Chronic pancreatitis Chapter page reference: 1332-1334 Heading: Chronic Pancreatitis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Inflammation Difficulty: Easy Feedback 1 Trauma is a cause for acute, not chronic, pancreatitis. 2 Gallstones cause acute, not chronic, pancreatitis. 3 Cystic fibrosis is a cause for chronic pancreatitis. 4 Hypertriglyceridemia, not hypotriglyceridemia, causes chronic pancreatitis.
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PTS: 1 CON: Inflammation 18. ANS: 1 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Acute pancreatitis Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Inflammation Difficulty: Easy 1 2 3 4
Feedback Trauma is a cause for acute pancreatitis. Cystic fibrosis causes chronic pancreatitis. Hypercalcemia causes chronic pancreatitis. Hypertriglyceridemia causes chronic pancreatitis.
PTS: 1 CON: Inflammation 19. ANS: 2 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Describing the epidemiology of biliary and pancreatic disorders Chapter page reference: 1326-1332 NURSINGTB.COM Heading: Acute Pancreatitis Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Knowledge [Remembering] Concept: Inflammation Difficulty: Easy Feedback 1 A score of 0-2 yields this conclusion. 2 A score of 3-4 yields this conclusion. 3 A score of 5-6 yields this conclusion. 4 A score of 7-8 yields this conclusion. PTS: 1 CON: Inflammation 20. ANS: 4 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Discussing the medical management of: Pancreatic cancer Chapter page reference: 1334-1338 Heading: Pancreatic Cancer Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment – Safety and Infection Control Cognitive level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback
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1 2 3 4
These NGTs should not be repositioned or irrigated or checked for placement. They are placed intraoperatively. Doing so can cause a breakdown of the anastomotic site. These NGTs should not be repositioned or irrigated or checked for placement. They are placed intraoperatively. Doing so can cause a breakdown of the anastomotic site. If a patient removes his NGT, it is not to be replaced by the nursing staff. A member of the surgical team should be notified. After a Whipple’s or pancreaticoduodenectomy, NGTs are placed postoperatively to decompress the stomach, prevent bloating, and remove gastric acid secretions. A DO NOT MANIPULATE NGT sign should be placed on the wall above the patient’s head.
PTS: 1 CON: Safety 21. ANS: 3 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with biliary and pancreatic disorders Chapter page reference: 1322-1326 Heading: Cholecystitis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate Feedback 1 There is no evidence to support that the patient is a Pima or Chippewa Indian, which have a genetic predisposition fNorUgRa lls SItoNneGs.T B.COM 2 There is no evidence that the patient’s diet is high in saturated fat, which can cause gallstones. 3 Pregnant patients are at an increased risk for gallstones due to elevated progesterone levels. This is the most likely cause for this patient’s current diagnosis. 4 There is no evidence the patient is currently prescribed cholesterol-lowering medications, which can cause gallstones. PTS: 1 CON: Inflammation 22. ANS: 4 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Describing the epidemiology of biliary and pancreatic disorders Chapter page reference: 1322-1326 Heading: Cholecystitis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Inflammation Difficulty: Easy
1 2
Feedback There is no evidence to support that this patient will present with vague symptoms of cholecystitis. There is no evidence to support that this patient will present with vague symptoms of cholecystitis.
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There is no evidence to support that this patient will present with vague symptoms of cholecystitis. Older adult patients, and those with a concurrent diagnosis of diabetes, are likely to present with vague symptoms of cholecystitis.
PTS: 1 CON: Inflammation 23. ANS: 4 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Discussing the medical management of: Cholecystitis Chapter page reference: 1322-1326 Heading: Cholecystitis Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate Feedback 1 Lithotripsy is no longer the treatment of choice for gallstones. 2 A low-fat diet is recommended to decrease the risk for developing gallstones in the future; however, this is not the treatment for the patient who currently has gallstones. 3 Oral agents to dissolve gallstones are used in conjunction with lithotripsy. 4 The treatment of choice for gallstones is a laparoscopic cholecystectomy. PTS: 1 CON: Inflammation 24. ANS: 3 NURSINGTB.COM Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Pancreatic cancer Chapter page reference: 1334-1338 Heading: Pancreatic Cancer Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Easy Feedback 1 Smoking is a risk factor for pancreatic cancer. 2 Consumption of meat is a risk factor for pancreatic cancer. 3 Diabetes mellitus is a risk factor for the development of pancreatic cancer. 4 Chronic pancreatitis is a risk factor for pancreatic cancer. PTS: 1 CON: Cellular Regulation 25. ANS: 4 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Pancreatic cancer Chapter page reference: 1334-1338 Heading: Pancreatic Cancer Integrated Processes: Nursing Process: Assessment
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Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Easy Feedback 1 Weight loss is a clinical manifestation associated with pancreatic cancer. 2 Hyperglycemia is not a clinical manifestation associated with pancreatic cancer. 3 A dull pain in the epigastric area and the back are clinical manifestations associated with pancreatic cancer. 4 Jaundice, which manifests with yellowing of the sclera, is a clinical manifestation associated with pancreatic cancer. It is caused by the obstruction of the bile duct. PTS: 1
CON: Cellular Regulation
MULTIPLE RESPONSE 26. ANS: 2, 3, 4, 5 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Acute pancreatitis Chapter page reference: 1326-1332 Heading: Acute Pancreatitis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [UnN d eUrsRtaSndIiN n gG] TB.COM Concept: Inflammation Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is incorrect. Steatorrhea is a clinical manifestation that is associated with chronic pancreatitis. This is correct. Acute pancreatitis presents with severe epigastric pain, nausea, vomiting, elevated temperature, and hypotension. This is correct. Acute pancreatitis presents with severe epigastric pain, nausea, vomiting, elevated temperature, and hypotension. This is correct. Acute pancreatitis presents with severe epigastric pain, nausea, vomiting, elevated temperature, and hypotension. This is correct. Acute pancreatitis presents with severe epigastric pain, nausea, vomiting, elevated temperature, and hypotension.
PTS: 1 CON: Inflammation 27. ANS: 1, 4, 5 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with biliary and pancreatic disorders Chapter page reference: 1332-1334 Heading: Chronic Pancreatitis Integrated Processes: Teaching and Learning
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Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate
1.
2. 3. 4.
5.
Feedback This is correct. Appropriate teaching for a patient diagnosed with chronic pancreatitis includes eliminating alcoholic beverages, proper administration of pancrelipase, and the importance of taking antacids to prevent the destruction of the enzymes by hydrochloric acid. This is incorrect. The patient should be taught to follow a low-fat diet. This is incorrect. The patient’s weight should be monitored every other day. This is correct. Appropriate teaching for a patient diagnosed with chronic pancreatitis includes eliminating alcoholic beverages, proper administration of pancrelipase, and the importance of taking antacids to prevent the destruction of the enzymes by hydrochloric acid. This is correct. Appropriate teaching for a patient diagnosed with chronic pancreatitis includes eliminating alcoholic beverages, proper administration of pancrelipase, and the importance of taking antacids to prevent the destruction of the enzymes by hydrochloric acid.
PTS: 1 CON: Inflammation 28. ANS: 2, 3, 4 Chapter number and title: 60, Coordinating Care for Patients With Biliary and Pancreatic Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with biliary and pancreatic disorders Chapter page reference: 1326-1332 Heading: Acute Pancreatitis NURSINGTB.COM Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Inflammation Difficulty: Moderate
1. 2. 3. 4. 5.
PTS: 1
Feedback This is incorrect. A low-fat, not a high-fat, diet will be implemented once the patient is able to eat by mouth. This is correct. Opioid analgesics are often necessary for the acute pain experienced by the patient. This is correct. Total parenteral nutrition is initiated and a nasogastric tube is inserted and connected to suction. This is correct. Total parenteral nutrition is initiated and a nasogastric tube is inserted and connected to suction. This is incorrect. Pancrelipase is prescribed for patients with chronic pancreatitis, not acute pancreatitis. CON: Inflammation
Chapter 61: Assessment of Renal and Urinary Function
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Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is preparing to conduct a male genitourinary assessment. Which approach is least likely to be used during this process? 1) Percussion 2) Palpation 3) Inspection 4) Auscultation 2. The nurse is conducting a genitourinary assessment for an older adult male patient. Which is an expected finding based on the patient’s age? 1) Thick pubic hair on the external genitalia 2) Larger and harder testicles 3) Atrophy of the penis 4) Elastic scrotal sac 3. The nurse is conducting a health history interview while assessing a male patient who presents with genitourinary symptoms. Which assessment question is most appropriate? 1) “Have you noticed any unusual discharge from your penis?” 2) “Do you have blood in your urine?” 3) “What color is your penile discharge?” 4) “Is there any odor to the discharge?” 4. The nurse is caring for an older adult patient on a medical-surgical unit. The patient tells the nurse, “I don't get any sleep at night because I have to get up and use the bathroom every couple of hours!” When providing an explanation for the nocturia, whicN h U staRteSmIe N n tGb T y B th. e C nuO rsM e is the most appropriate? 1) “As you get older, there is a decrease in number of nephrons.” 2) “As you get older, there is a decrease in the blood supply to your bladder.” 3) “As you get older, you may have a decrease in bladder capacity.” 4) “As you get older, there is a decrease in cardiac output, which can cause your symptoms.” 5. A patient is diagnosed with high blood pressure that is not responding to medications. The nurse suspects renal stenosis. When assessing for this condition, which location will the nurse use for auscultation? 1) Renal arteries 2) Bladder 3) Ureters 4) Internal urethral sphincter 6. The nurse is caring for a group of patients on a medical-surgical unit. Which patient does the nurse anticipate to be at the greatest risk for alterations in urinary elimination? 1) The patient with hypertension who takes a diuretic to manage blood pressure 2) An 80-year-old male reporting frequent urination at night 3) A 25-year-old female patient with low self-esteem 4) A patient who had bladder cancer and now has a newly created ileal conduit 7. The nurse is caring for an older adult patient with a history of urinary tract infections (UTIs). Which action by the nurse would decrease the risk of the patient experiencing future UTIs? 1) Instruct the patient to completely empty the bladder. 2) Tell the patient to increase sugar in the diet. 3) Encourage the patient to take bubble baths. 4) Remind the patient to wipe from back to front.
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8. The nurse is providing care to a patient at a local clinic. The nurse suspects that the patient is experiencing a urinary tract infection. Which urinalysis result supports the nurse’s suspicions? 1) pH 5.2 2) Negative glucose 3) WBC 10-15 4) Specific gravity 1.012 9. The nurse is providing care to an older adult patient who is experiencing urinary incontinence. Which independent nursing intervention is the most appropriate for this patient? 1) Encouraging increased fluid intake 2) Providing catheter care 3) Instructing on self-catheterization 4) Implementing hygiene care 10. The nurse is providing care to a patient who is experiencing urinary retention. Which diagnostic tool does the nurse anticipate will be ordered for this patient? 1) Ultrasonic bladder scan 2) Urinalysis 3) Intravenous pyelography (IVP) 4) Cystoscopy 11. The nurse is providing education information regarding urinary health at an assisted living facility. When planning topics to include in the session, which is appropriate for the nurse to consider? 1) Full urinary control usually occurs at four or five years of age. 2) Because of neuromuscular immaturity, voluntary urinary control is absent. 3) The kidneys reach maximum sizNe U beRt w SeIenN 35 G TaBnd.4C0OyMears of age. 4) Renal blood flow decreases because of vascular changes and a decrease in cardiac output. 12. The nurse is providing care to a patient who is burning upon urination. Which diagnostic tool does the nurse anticipate will be ordered for this patient? 1) Ultrasonic bladder scan 2) Urinalysis 3) Intravenous pyelography (IVP) 4) Cystoscopy 13. The nurse is providing care to a patient who is experiencing symptoms of a kidney stone. Which diagnostic tool does the nurse anticipate will be ordered for this patient? 1) Ultrasonic bladder scan 2) Urinalysis 3) Intravenous pyelography (IVP) 4) Cystoscopy 14. The nurse is providing care to a patient who requires the removal of a kidney stone. Which procedure does the nurse anticipate will be ordered for this patient? 1) Ultrasonic bladder scan 2) Urinalysis 3) Intravenous pyelography (IVP) 4) Cystoscopy 15. The nurse is providing care to a patient with less than 100 mL of urine output in a 24-hour period. Which term should the nurse use when documenting this occurrence?
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1) 2) 3) 4)
Anuria Dysuria Enuresis Hematuria
16. The nurse is providing care to a patient who is experiencing painful urination. Which term should the nurse use when documenting this occurrence? 1) Anuria 2) Dysuria 3) Enuresis 4) Hematuria 17. The nurse is providing care to a patient who is experiencing involuntary urination at night. Which term should the nurse use when documenting this occurrence? 1) Anuria 2) Dysuria 3) Enuresis 4) Hematuria 18. The nurse is providing care to a patient with blood in the urine. Which term should the nurse use when documenting this occurrence? 1) Anuria 2) Dysuria 3) Enuresis 4) Hematuria 19. The nurse is providing care to a patieN ntUwRhS o I staNteGsT , “BM.yCdO o cMtor says I am experiencing nocturia. What does that mean?” Which response by the nurse is most appropriate? 1) “It means you have pain radiating to your groin.” 2) “It means you have the sudden urge to void immediately.” 3) “It means you are getting up frequently at night to urinate.” 4) “It means you are unable to completely empty your bladder.” 20. The nurse is providing care to a patient who states, “My doctor says I am experiencing renal colic. What does that mean?” Which response by the nurse is most appropriate? 1) “It means you have pain radiating to your groin.” 2) “It means you have the sudden urge to void immediately.” 3) “It means you are getting up frequently at night to urinate.” 4) “It means you are unable to completely empty your bladder.” 21. The nurse is providing care to a patient who states, “My doctor says I am experiencing urinary urgency. What does that mean?” Which response by the nurse is most appropriate? 1) “It means you have pain radiating to your groin.” 2) “It means you have the sudden urge to void immediately.” 3) “It means you are getting up frequently at night to urinate.” 4) “It means you are unable to completely empty your bladder.” 22. The nurse is providing care to a patient who states, “My doctor says I am experiencing urinary retention. What does that mean?” Which response by the nurse is most appropriate? 1) “It means you have pain radiating to your groin.” 2) “It means you have the sudden urge to void immediately.” 3) “It means you are getting up frequently at night to urinate.”
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4) “It means you are unable to completely empty your bladder.” Multiple Response Identify one or more choices that best complete the statement or answer the question. 23. The nurse is conducting a health history interview for a patient who presents with urinary symptoms. Which questions are appropriate? Select all that apply. 1) “What is your menstrual history?” 2) “What is your pregnancy history?” 3) “What is your sexual history?” 4) “Do you have pain when voiding?” 5) “Do you take showers or tub baths?” 24. The nurse is preparing to conduct a genitourinary physical assessment for a male patient. Which will the nurse use during the assessment process? Select all that apply. 1) Stethoscope 2) Sterile gloves 3) Water-soluble lubricant 4) Speculum 5) Otoscope 25. The nurse admits a patient to the medical unit for a urinary disorder. Which questions are appropriate for the nurse to include when assessing the patient’s voiding pattern? 1) How many times do you urinate in a 24-hour period? 2) Has your pattern of urination changed recently? 3) How often do you get out of bedNaUt R n iS ghIt N toGuT rinBa . te C ? OM 4) What color is your urine? 5) Does your urine have any type of odor?
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Chapter 61: Assessment of Renal and Urinary Function Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter/learning objective: Describing the procedure for completing a history and physical assessment of the renal and urinary systems Chapter page reference: 1352-1356 Heading: Assessment Integrated Processes: Nursing Process - Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy 1 2 3 4
Feedback Percussion is not a physical assessment approach that is routinely used during the male genitourinary assessment. Palpation is a physical assessment approach that is routinely used during the male genitourinary assessment. Inspection is a physical assessment approach that is routinely used during the male genitourinary assessment. Auscultation is a physical asseNssUmRe S n t IapNpG roTacBh.thCa O t iM s routinely used during the male genitourinary assessment.
PTS: 1 CON: Urinary Elimination 2. ANS: 3 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter/learning objective: Discussing changes in renal and urinary system function associated with aging Chapter page reference: 1342-1352 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process - Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate
1 2 3 4
Feedback Pubic hair tends to thin, not thicken, on the external genitalia with age. Testicles tend to become smaller and softer with age. Atrophy of the penis is an expected assessment finding for an older adult patient. The scrotal sac for an older adult patient tends to lose elasticity.
PTS: 1 CON: Urinary Elimination 3. ANS: 2 Chapter number and title: 61, Assessment of Renal and Urinary Function
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Chapter/learning objective: Describing the procedure for completing a history and physical assessment of the renal and urinary systems Chapter page reference: 1352-1356 Heading: Assessment Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate 1 2 3 4
Feedback Asking the patient about unusual discharge is more appropriate for a patient who presents with penile discharge. Asking the patient if there is blood in the urine is an appropriate question when the patient presents with genitourinary symptoms. Asking about the color of penile discharge is more appropriate when the patient presents with discharge. Asking about the odor of penile discharge is more appropriate when the patient presents with discharge.
PTS: 1 CON: Urinary Elimination 4. ANS: 3 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Discussing changes in renal and urinary system function associated with aging Chapter page reference: 1342-1352 NURSINGTB.COM Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 A decrease in the number of nephrons decreases the filtration rate. 2 A decrease in blood supply causes an increase in urine concentration. 3 Approximately 70% of older women and 50% of older men have to get up two or more times during the night to empty their bladders due to decreased bladder capacity. 4 A decrease in cardiac output decreases peripheral circulation, which would decrease urinary output day or night. PTS: 1 CON: Urinary Elimination 5. ANS: 1 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of the renal and urinary systems Chapter page reference: 1352-1356 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying]
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Concept: Urinary Elimination; Assessment Difficulty: Moderate Feedback 1 The nurse should auscultate the renal arteries by placing the bell of the stethoscope lightly in the areas of the renal arteries, located in the left and right upper abdominal quadrants. Systolic bruits (“whooshing” sounds) may indicate renal artery stenosis. 2 This is not the appropriate location for auscultation. 3 This is not the appropriate location for auscultation. 4 This is not the appropriate location for auscultation. PTS: 1 CON: Urinary Elimination | Assessment 6. ANS: 2 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Discussing changes in renal and urinary system function associated with aging Chapter page reference: 1342-1352 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy Feedback 1 The patient with high blood pressure takes medication to remove excess fluid from the body, and as long as urine elimination increases, there should be no problems. 2 The patient who is 80 years olN dU with RSfIreNquGeTn tBu.rinCaOtioMn at night is having problems with his prostate. Older male adults experience urinary retention due to prostate enlargement causing an alteration in urinary elimination. 3 The 25-year-old experiencing low self-esteem has a psychological problem and will need therapy to find the root of the problem. 4 The patient who had bladder cancer and now has an ileal conduit doesn't have kidney damage, only the bladder removed. Continued urine production through the ileal conduit will need to be observed and assessed frequently by the staff. PTS: 1 CON: Urinary Elimination 7. ANS: 1 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Discussing changes in renal and urinary system function associated with aging Chapter page reference: 1342-1352 Heading: Overview of Anatomy and Physiology Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Completely emptying the bladder prevents stasis of urine, which would contribute to a urinary tract infection. 2 The patient should decrease the use of sugar in the diet because sugar promotes bacterial growth.
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3 4
Irritating soaps and bubble baths can contribute to infections and should be avoided. The patient should wipe from front to back because wiping from back to front would contaminate the urinary meatus.
PTS: 1 CON: Urinary Elimination 8. ANS: 3 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Correlating relevant diagnostic examinations to renal and urinary system function Chapter page reference: 1356-1365 Heading: Diagnostic Studies Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy
1 2 3 4
Feedback A urinalysis typically consists of the pH, glucose, specific gravity, protein, and WBC count. The pH, glucose, and specific gravity are all within normal limits. A urinalysis typically consists of the pH, glucose, specific gravity, protein, and WBC count. The pH, glucose, and specific gravity are all within normal limits. A normal WBC is 0-4. The WBC count for this patient is high and indicates infection. A urinalysis typically consists of the pH, glucose, specific gravity, protein, and WBC count. The pH, glucose, and specific gravity are all within normal limits.
NURSINGTB.COM PTS: 1 CON: Urinary Elimination 9. ANS: 4 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Discussing changes in renal and urinary system function associated with aging Chapter page reference: 1342-1352 Heading: Overview of Anatomy and Physiology Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Encouraging increased fluid intake is appropriate for a patient who is dehydrated. 2 Instructing on self-catheterization and providing catheter care is appropriate for a patient who is diagnosed with urinary retention. 3 Instructing on self-catheterization and providing catheter care is appropriate for a patient who is diagnosed with urinary retention. 4 Patients with urinary incontinence require determination of the cause, appropriate treatment, and hygiene care. PTS: 1 CON: Urinary Elimination 10. ANS: 1 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Correlating relevant diagnostic examinations to renal and urinary system function
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Chapter page reference: 1356-1365 Heading: Diagnostic Studies Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy Feedback 1 An ultrasonic bladder scan is the diagnostic test that is used to examine for residual urine. 2 A urinalysis is often used to monitor the urine for infection. 3 An IVP is used to diagnosis a kidney stone. 4 A cystoscopy allows direct visualization of the bladder wall and urethra. It is often used to remove stones. PTS: 1 CON: Urinary Elimination 11. ANS: 4 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Discussing changes in renal and urinary system function associated with aging Chapter page reference: 1342-1352 Heading: Overview of Anatomy and Physiology Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Urinary Elimination NURSINGTB.COM Difficulty: Moderate
1 2 3 4
Feedback While this statement is true regarding urinary health, it is not appropriate for this presentation to older adult patients. While this statement is true regarding urinary health, it is not appropriate for this presentation to older adult patients. While this statement is true regarding urinary health, it is not appropriate for this presentation to older adult patients. When planning an education session regarding urinary health at an assisted living facility, the nurse would include information that affects the urinary health of the older adult patient. Information that is appropriate for the nurse to consider is the decrease in renal blood flow due to vascular changes and that urinary incontinence may occur because of issues with mobility and neurological impairment.
PTS: 1 CON: Urinary Elimination 12. ANS: 2 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Correlating relevant diagnostic examinations to renal and urinary system function Chapter page reference: 1356-1365 Heading: Diagnostic Studies Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding]
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Concept: Urinary Elimination Difficulty: Easy
1 2 3 4
Feedback An ultrasonic bladder scan is the diagnostic test that is used to examine for residual urine. A urinalysis is often used to monitor the urine for infection. An IVP is used to diagnose a kidney stone. A cystoscopy allows direct visualization of the bladder wall and urethra. It is often used to remove stones.
PTS: 1 CON: Urinary Elimination 13. ANS: 3 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Correlating relevant diagnostic examinations to renal and urinary system function Chapter page reference: 1356-1365 Heading: Diagnostic Studies Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy
1 2 3 4
Feedback An ultrasonic bladder scan is tN heUdRiaSgI noNstGicTteBs. t tha COt iMs used to examine for residual urine. A urinalysis is often used to monitor the urine for infection. An IVP is used to diagnose a kidney stone. A cystoscopy allows direct visualization of the bladder wall and urethra. It is often used to remove stones.
PTS: 1 CON: Urinary Elimination 14. ANS: 4 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Correlating relevant diagnostic examinations to renal and urinary system function Chapter page reference: 1356-1365 Heading: Diagnostic Studies Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy
1 2 3
Feedback An ultrasonic bladder scan is the diagnostic test that is used to examine for residual urine. A urinalysis is often used to monitor the urine for infection. An IVP is used to diagnose a kidney stone.
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4
A cystoscopy allows direct visualization of the bladder wall and urethra. It is often used to remove stones.
PTS: 1 CON: Urinary Elimination 15. ANS: 1 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of the renal and urinary systems Chapter page reference: 1352-1356 Heading: Assessment Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Anuria is the term used for a patient who is experiencing less than 100 mL of urinary output in a 24-hour period. 2 Dysuria is the term used for a patient who is experiencing painful urination. 3 Enuresis is the term used for a patient who is experiencing involuntary urination at night. 4 Hematuria is the term used for a patient who has blood in the urine. PTS: 1 CON: Urinary Elimination 16. ANS: 2 NURSINGTB.COM Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of the renal and urinary systems Chapter page reference: 1352-1356 Heading: Assessment Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Anuria is the term used for a patient who is experiencing less than 100 mL of urinary output in a 24-hour period. 2 Dysuria is the term used for a patient who is experiencing painful urination. 3 Enuresis is the term used for a patient who is experiencing involuntary urination at night. 4 Hematuria is the term used for a patient who has blood in the urine. PTS: 1 CON: Urinary Elimination 17. ANS: 3 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of the renal and urinary systems Chapter page reference: 1352-1356
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Heading: Assessment Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Anuria is the term used for a patient who is experiencing less than 100 mL of urinary output in a 24-hour period. 2 Dysuria is the term used for a patient who is experiencing painful urination. 3 Enuresis is the term used for a patient who is experiencing involuntary urination at night. 4 Hematuria is the term used for a patient who has blood in the urine. PTS: 1 CON: Urinary Elimination 18. ANS: 4 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of the renal and urinary systems Chapter page reference: 1352-1356 Heading: Assessment Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination NURSINGTB.COM Difficulty: Moderate Feedback 1 Anuria is the term used for a patient who is experiencing less than 100 mL of urinary output in a 24-hour period. 2 Dysuria is the term used for a patient who is experiencing painful urination. 3 Enuresis is the term used for a patient who is experiencing involuntary urination at night. 4 Hematuria is the term used for a patient who has blood in the urine. PTS: 1 CON: Urinary Elimination 19. ANS: 3 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of the renal and urinary systems Chapter page reference: 1352-1356 Heading: Assessment Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Pain radiating to the groin is termed renal colic. 2 The sudden urge to void immediately is termed urgency.
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3 4
Nocturia is the term used to describe getting up frequently at night to urinate. The inability to completely empty the bladder is termed retention.
PTS: 1 CON: Urinary Elimination 20. ANS: 1 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of the renal and urinary systems Chapter page reference: 1352-1356 Heading: Assessment Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Pain radiating to the groin is termed renal colic. 2 The sudden urge to void immediately is termed urgency. 3 Nocturia is the term used to describe getting up frequently at night to urinate. 4 The inability to completely empty the bladder is termed retention. PTS: 1 CON: Urinary Elimination 21. ANS: 2 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: DescribinNgUthReSp I roN c eGd T u rB e . f oC r cOoM mpleting a history and physical assessment of the renal and urinary systems Chapter page reference: 1352-1356 Heading: Assessment Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Pain radiating to the groin is termed renal colic. 2 The sudden urge to void immediately is termed urgency. 3 Nocturia is the term used to describe getting up frequently at night to urinate. 4 The inability to completely empty the bladder is termed retention. PTS: 1 CON: Urinary Elimination 22. ANS: 4 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of the renal and urinary systems Chapter page reference: 1352-1356 Heading: Assessment Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying]
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Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Pain radiating to the groin is termed renal colic. 2 The sudden urge to void immediately is termed urgency. 3 Nocturia is the term used to describe getting up frequently at night to urinate. 4 The inability to completely empty the bladder is termed retention. PTS: 1
CON: Urinary Elimination
MULTIPLE RESPONSE 23. ANS: 4, 5 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of the renal and urinary systems Chapter page reference: 1352-1356 Heading: Assessment Integrated Processes: Nursing Process - Assessment Client Need: Physiological Integrity - Physiological Adaptation Cognitive Level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate
1. 2. 3. 4. 5.
NURSINGTB.COM Feedback This is incorrect. Questions about the patient’s menstrual history are more appropriate if the patient is experiencing amenorrhea. This is incorrect. Questions about the patient’s pregnancy history are more appropriate if the patient is experiencing amenorrhea. This is incorrect. Questions about the patient’s sexual history are more appropriate if the patient is experiencing amenorrhea. This is correct. It is appropriate to ask the patient about pain when voiding when the patient presents with urinary symptoms. This is correct. It is appropriate to ask the patient about the use of tub or shower baths when the patient presents with urinary symptoms.
PTS: 1 CON: Urinary Elimination 24. ANS: 1, 3 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter/learning objective: Describing the procedure for completing a history and physical assessment of the renal and urinary systems Chapter page reference: 1352-1356 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Assessment; Urinary Elimination Difficulty: Easy
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1. 2. 3. 4. 5.
Feedback This is correct. A stethoscope is equipment that is used during the genitourinary physical assessment for a male patient. This is incorrect. Nonsterile gloves, not sterile gloves, are used during the genitourinary physical assessment for a male patient. This is correct. Water-soluble lubricant is used during the genitourinary physical assessment for a male patient. This is incorrect. A speculum is used for a female, not a male, genitourinary assessment. This is incorrect. A penlight, not an otoscope, is needed when conducting a male genitourinary assessment.
PTS: 1 CON: Assessment | Urinary Elimination 25. ANS: 1, 2, 3 Chapter number and title: 61, Assessment of Renal and Urinary Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of the renal and urinary systems Chapter page reference: 1352-1356 Heading: Assessment Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate
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1.
2.
3.
4. 5.
PTS: 1
Feedback This is correct. When assessing the patient’s voiding pattern, it is appropriate for the nurse to ask how many times the patient voids in a 24-hour period; if the pattern of urination has changed frequently; and how often the patient gets out of bed at night to urinate. This is correct. When assessing the patient’s voiding pattern, it is appropriate for the nurse to ask how many times the patient voids in a 24-hour period; if the pattern of urination has changed frequently; and how often the patient gets out of bed at night to urinate. This is correct. When assessing the patient’s voiding pattern, it is appropriate for the nurse to ask how many times the patient voids in a 24-hour period; if the pattern of urination has changed frequently; and how often the patient gets out of bed at night to urinate. This is incorrect. Questions regarding the color and odor associated with urine are appropriate when assessing urine characteristics. This is incorrect. Questions regarding the color and odor associated with urine are appropriate when assessing urine characteristics. CON: Urinary Elimination
Chapter 62: Coordinating Care for Patients With Renal Disorders Multiple Choice Identify the choice that best completes the statement or answers the question.
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1. The nurse is caring for a patient admitted with a diagnosis of acute kidney injury. The patient asks the nurse, “Are my kidneys failing? Will I need a kidney transplant?” Which response by the nurse is the most appropriate? 1) “No, don't think that. You're going to be fine.” 2) “Your condition can be reversed with prompt treatment and usually will not destroy the kidney.” 3) “Kidney transplantation is likely, and it would be a good idea to start talking to family members.” 4) “When the doctor comes to see you, we can talk about whether you will need a transplant.” 2. A young school-age patient is in the hospital with acute kidney injury following a streptococcus infection. The parents are Spanish-speaking and speak little English. The parents, through an interpreter, ask the nurse what mistake they made that caused the child to be so sick. Which response by the nurse is the most appropriate? 1) “Your child does not have enough dietary protein.” 2) “Your child has a congenital defect that led to renal failure.” 3) “Your child's renal failure has been caused by a low calcium level.” 4) “Your child's recent infection may have caused the renal failure.” 3. The nurse is planning care for the patient with acute kidney injury. The nurse plans the patient’s care based on the nursing diagnosis of Excess Fluid Volume. Which assessment data supports this nursing diagnosis? 1) Pitting edema in the lower extremities 2) Bowel sounds positive in four quadrants 3) Wheezing in the lungs 4) Generalized weakness
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4. A patient with renal failure is receiving peritoneal dialysis. The nurse is explaining the process to the patient. Which statement would the nurse include in a discussion with the patient? 1) “The peritoneum is more permeable because of the presence of excess metabolites.” 2) “The metabolites will diffuse from the interstitial space to the bloodstream mainly through diffusion and ultrafiltration.” 3) “The peritoneum acts as a semipermeable membrane through which wastes move by diffusion and osmosis.” 4) “The solutes in the dialysate will enter the bloodstream through the peritoneum.” 5. The nurse is caring for a patient who is diagnosed with acute kidney injury. When reviewing the patient’s laboratory data, which finding indicates that a patient has met the expected outcomes? 1) Decreasing serum creatinine 2) Decreasing neutrophil count 3) Decreasing lymphocyte count 4) Decreasing erythrocyte count 6. The nurse is administering peritoneal dialysis to a patient with acute kidney injury. The nurse notes the presence of a cloudy dialysate return. After notifying the health-care provider, which action by the nurse is the most appropriate? 1) Measure abdominal girth 2) Document the cloudy dialysate 3) Culture the dialysate return 4) Increase dialysate instillation
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
7. The nurse is providing education to a patient who is diagnosed with renal carcinoma. The patient states, “My doctor says I am a stage I. What does that mean?” Which response by the nurse is most appropriate? 1) “Your cancer is limited to the renal capsule.” 2) “Your cancer involves the perirenal fat but is confined to fascia with metastasis to the adrenal gland.” 3) “Your cancer involves the regional lymph node, renal vein, and vena cava.” 4) “Your cancer involves metastases to other sites in the body.” 8. The nurse is providing care to a patient who is diagnosed with renal trauma. The patient is experiencing hematuria and contusions but has normal imaging studies. Which grade of renal trauma should the nurse document? 1) Grade 1 2) Grade 2 3) Grade 3 4) Grade 4 9. The nurse is providing care to a patient who is diagnosed with renal trauma. The patient has a renal laceration that is greater than 1 cm in depth, but the laceration does not involve the collecting system. Which grade of renal trauma should the nurse document? 1) Grade 1 2) Grade 2 3) Grade 3 4) Grade 4 10. A patient agrees to receive long-term hemodialysis to treat chronic kidney disease. For which surgical procedure should the nurse instruct this patient? 1) Insertion of a double-lumen cathNe U terRiS n tI o N thG e T suB b c.laCvO ia M n artery 2) Placement of a peritoneal catheter 3) Insertion of a subarachnoid-peritoneal shunt 4) Placement of an arteriovenous fistula 11. A patient with acute kidney injury is complaining of a metallic taste in the mouth and has no appetite. Based on this data, which intervention by the nurse is the most appropriate? 1) Provide mouth care before meals 2) Administer an antiemetic as prescribed 3) Restrict fluids 4) Encourage the intake of protein, salt, and potassium 12. The nurse is caring for a patient with chronic kidney disease who is pale and experiencing fatigue. The nurse attributes these symptoms to anemia secondary to chronic kidney disease. The patient’s spouse asks why the patient is anemic. Which response by the nurse is the most appropriate? 1) “Your spouse has a genetic tendency for the development of anemia.” 2) “The increased metabolic waste products in the body depress the bone marrow and cause anemia.” 3) “There is a decreased production by the kidneys of the hormone erythropoietin, which is the cause of anemia.” 4) “The patient is not eating enough iron-rich foods, which is causing anemia.” 13. The nurse is caring for a patient from another country who was admitted with hypertension and chronic kidney disease. The patient is receiving hemodialysis three times a week. The nurse is assessing the client’s diet, and the patient reports the use of salt substitutes. When teaching the patient to avoid salt substitute, which rationale supports this teaching point?
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1) 2) 3) 4)
They will increase the risk of AV fistula infection. They will cause the patient to retain fluid. They will interact with the client’s antihypertensive medications. They can potentiate hyperkalemia.
14. The nurse is caring for an older adult patient diagnosed with chronic kidney disease. The patient reports no bowel movement in the past two days. Based on this data, which condition is the patient at an increased risk for developing? 1) Metabolic acidosis 2) Hypocalcemia 3) Increased serum creatinine levels 4) Hyperkalemia 15. The nurse is planning care for a patient with chronic kidney disease and osteoporosis. After reviewing the patient’s medical record, which is the priority nursing diagnosis for this patient? 1) Anxiety 2) Disturbed Body Image 3) Risk for Injury 4) Risk for Bleeding 16. The nurse is preparing to discharge a patient with chronic kidney disease. The nurse is teaching the patient and family about administering calcium acetate tablets by mouth with each meal at home. Which explanation about this medication is the most appropriate? 1) “The calcium acetate will lower your serum phosphate levels.” 2) “The calcium acetate helps to neutralize your gastric acids.” 3) “The calcium acetate will help to stimulate your appetite.” T Bcr.eaCtiO 4) “The calcium acetate will decreaNsU e R y oS urIsN e rG um n iM n e levels.” 17. A nurse evaluating the therapeutic effect of the drug sodium polystyrene sulfonate (Kayexalate) for a patient diagnosed with chronic kidney disease. Which therapeutic effect from the medication does the nurse anticipate? 1) Decreased serum sodium 2) Increased stool excretion 3) Decreased urine specific gravity 4) Decreased serum potassium 18. The nurse is providing care for a patient diagnosed with chronic kidney disease who is experiencing hyperkalemia. When planning meals for this patient, which choice would be most appropriate for this patient? 1) Hamburger on a bun, banana 2) Cold cuts with bun with fresh pears 3) Spaghetti and meat sauce, breadsticks 4) Carrots and green, leafy vegetables 19. A patient with a history of hypertension is diagnosed with chronic kidney disease. When the patient asks the nurse how this occurred, which response by the nurse is the most appropriate? 1) “Thickening of the kidney structures and gradual death of nephrons has caused this diagnosis.” 2) “Cysts compress renal tissue that destroys the kidneys, causing this diagnosis.” 3) “High blood pressure reduces renal blood flow and harms the kidney tissue, causing this diagnosis.” 4) “Immune complexes form in the kidney tissue that causes inflammation, causing this diagnosis.”
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
20. During a home visit, the nurse is concerned that an older adult patient is developing chronic kidney disease. The patient has no history of cardiovascular disease. Which data in the patient’s assessment caused the nurse to have this concern? 1) Progressive edema 2) Complaints of hip joint pain 3) Recent increase in hunger and thirst 4) Warm moist skin 21. While caring for a patient with chronic kidney disease, the nurse tracks the patient’s serum albumin level. For which nursing diagnosis is the action most indicated? 1) Excess Fluid Volume 2) Imbalanced Nutrition: Less Than Body Requirements 3) Risk for Ineffective Perfusion 4) Risk for Infection 22. The nurse instructs a patient with chronic kidney disease on the prescribed medication furosemide (Lasix). Which patient statement indicates that teaching has been effective? 1) “I will take this medication to keep my calcium balance normal.” 2) “This medication will make sure I have enough red blood cells in my body.” 3) “I will take this pill to keep the protein level in my body stable.” 4) “This pill will reduce the swelling in my body and get rid of the extra potassium.” 23. A patient with chronic kidney disease is experiencing manifestations of anemia. Based on this data, which treatment does the nurse anticipate for this patient? 1) Begin fluid restriction. 2) Administer intravenous glucose NanUdRinSsI ulN inG . TB.COM 3) Begin a low-sodium diet. 4) Epoetin injections 24. The nurse is providing care to a patient who may have polycystic kidney disease. Which is the first symptom the nurse should assess this patient for? 1) Hypertension 2) Hematuria 3) Urinary frequency 4) Urinary calculi 25. The nurse is providing care to a patient diagnosed with polycystic kidney disease. Which assessment finding would indicate to the nurse that the patient is experiencing an infection? 1) Increased temperature 2) Increased blood pressure 3) Decreased white blood cell count 4) Decreased urine output Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. A patient with frequent urinary tract infections is seen in the urology clinic and is at risk for acute kidney injury. The nurse reviews the patient’s medical history. Which item supports the patient’s being at risk for acute kidney injury? Select all that apply. 1) Dehydration
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
2) 3) 4) 5)
Renal calculi Ineffective wound healing Low serum albumin Hypertension
27. The nurse is concerned that an older adult patient is at risk for developing acute kidney injury. Which information in the patient’s history supports the nurse’s concern? Select all that apply. 1) Diagnosed with hypotension 2) Recent aortic valve replacement surgery 3) Prescribed high doses of intravenous antibiotics 4) Total hip replacement surgery five years ago 5) Taking medication for type 2 diabetes mellitus 28. The nurse is preparing to administer hemodialysis treatment for a patient with chronic kidney disease. Which laboratory values does the nurse anticipate prior to the patient’s treatment? Select all that apply. 1) Increased blood urea nitrogen (BUN) 2) Decreased potassium 3) Decreased phosphorus 4) Increased urine osmolality 5) Increased creatinine
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 62: Coordinating Care for Patients With Renal Disorders Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Describing the indications, management, and complications associated with renal transplantation Chapter page reference: 1381-1385 Heading: Acute Kidney Injury Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Telling the patient that everything will be fine is condescending, provides no information, and is not within the nurse’s ability to know. 2 Acute kidney injury is often resolved without the need for transplant if treatment is initiated quickly. 3 There is no need to start lining up donors or wait for the provider to arrive to explore options. 4 There is no need to start lining up donors or wait for the provider to arrive to explore NURSINGTB.COM options. PTS: 1 CON: Urinary Elimination 2. ANS: 4 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Describing the epidemiology of renal disorders Chapter page reference: 1381-1385 Heading: Acute Kidney Injury Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 A low-protein or low-calcium diet will not lead to acute kidney injury. 2 In this case, the child has no evidence of a congenital defect leading to acute kidney injury. 3 A low-protein or low-calcium diet will not lead to acute kidney injury. 4 Patients with streptococcus are at risk for kidney and cardiac sequelae. PTS: 1 CON: Urinary Elimination 3. ANS: 1 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Acute kidney injury Chapter page reference: 1381-1385 Heading: Acute Kidney Injury Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy Feedback 1 The patient in acute kidney injury will likely be edematous, as the kidneys are not producing urine. 2 Bowel sounds in four quadrants is a normal assessment finding. 3 Wheezing in the lungs is an assessment consistent with asthma. 4 Generalized weakness may be due to whatever disease process precipitated the acute kidney injury. PTS: 1 CON: Urinary Elimination 4. ANS: 3 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Discussing the medical management of: Acute kidney injury Chapter page reference: 1392-1399 Heading: Renal Replacement Therapies Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [ApplyiN ngU] RSINGTB.CO Concept: Urinary Elimination Difficulty: Moderate Feedback 1 The peritoneum acts as a semipermeable membrane, allowing substances to move from an area of high concentration (the blood) to an area of lower concentration (the dialysate). Metabolic waste products and excess water can be eliminated through osmosis and diffusion utilizing the peritoneum as the semipermeable membrane. 2 The peritoneum acts as a semipermeable membrane, allowing substances to move from an area of high concentration (the blood) to an area of lower concentration (the dialysate). Metabolic waste products and excess water can be eliminated through osmosis and diffusion utilizing the peritoneum as the semipermeable membrane. 3 The peritoneum acts as a semipermeable membrane, allowing substances to move from an area of high concentration (the blood) to an area of lower concentration (the dialysate). Metabolic waste products and excess water can be eliminated through osmosis and diffusion utilizing the peritoneum as the semipermeable membrane. 4 The peritoneum acts as a semipermeable membrane, allowing substances to move from an area of high concentration (the blood) to an area of lower concentration (the dialysate). Metabolic waste products and excess water can be eliminated through osmosis and diffusion utilizing the peritoneum as the semipermeable membrane. PTS: 1 CON: Urinary Elimination 5. ANS: 1 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of renal disorders Chapter page reference: 1381-1385 Heading: Acute Kidney Injury Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy Feedback 1 Creatinine is the metabolic end product of creatinine phosphate and is excreted via the kidneys in relatively constant amounts. 2 Neutrophils, lymphocytes, and erythrocytes are not used to monitor the return of renal function. 3 Neutrophils, lymphocytes, and erythrocytes are not used to monitor the return of renal function. 4 Neutrophils, lymphocytes, and erythrocytes are not used to monitor the return of renal function. PTS: 1 CON: Urinary Elimination 6. ANS: 3 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Describing the indications, management, and complications associated with renal replacement therapies Chapter page reference: 1392-1399 Heading: Renal Replacement Therapies NURSINGTB.COM Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Urinary Elimination Difficulty: Difficult
1
2 3
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Feedback Measurement of abdominal girth is performed prior to the dialysis procedure, and although increased girth could indicate peritonitis, culturing the return is more important. Documenting the cloudy dialysate and nursing actions taken would be necessary but is not the next-priority action. The return should be clear. The presence of cloudy drainage might indicate peritonitis, and the nurse should culture the return in order to help identify the presence and type of organism that could be causing the infection. The instillation part of the procedure is completed prior to the collection of the dialysate return, and the rate of the instillation has no relationship to the development of an infection.
PTS: 1 CON: Urinary Elimination 7. ANS: 1 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Renal cancer
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter page reference: 1376-1379 Heading: Renal Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Stage I renal carcinoma is limited to the renal capsule. 2 Stage II renal carcinoma involves the perirenal fat but is confined to fascia with metastasis to the adrenal gland. 3 Stage III renal carcinoma involves the regional lymph node, renal vein, and vena cava. 4 Stage IV renal carcinoma involves metastases to other sites in the body. PTS: 1 CON: Urinary Elimination 8. ANS: 1 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Renal trauma Chapter page reference: 1379-1380 Heading: Renal Trauma Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination NURSINGTB.COM Difficulty: Moderate
1 2 3 4
Feedback Grade 1 renal trauma presents with hematuria and contusions; however, the patient will have normal imaging studies. Grade 2 renal trauma will present with nonexpanding hematomas and superficial lacerations. Grade 3 renal trauma will present with renal lacerations greater than 1 cm in depth not involving the collecting system. Grade 4 renal trauma will present with renal laceration or fracture extending into the collecting system. The patient will have injuries of the renal artery or vein but with controlled hemorrhage. The expanding hematomas compress the kidney.
PTS: 1 CON: Urinary Elimination 9. ANS: 3 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Renal trauma Chapter page reference: 1379-1380 Heading: Renal Trauma Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Difficulty: Moderate
1 2 3 4
Feedback Grade 1 renal trauma presents with hematuria and contusions; however, the patient will have normal imaging studies. Grade 2 renal trauma will present with nonexpanding hematomas and superficial lacerations. Grade 3 renal trauma will present with renal lacerations greater than 1 cm in depth not involving the collecting system. Grade 4 renal trauma will present with renal laceration or fracture extending into the collecting system. The patient will have injuries of the renal artery or vein but with controlled hemorrhage. The expanding hematomas compress the kidney.
PTS: 1 CON: Urinary Elimination 10. ANS: 4 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Describing the indications, management, and complications associated with renal replacement therapies Chapter page reference: 1392-1399 Heading: Renal Replacement Therapies Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy NURSINGTB.COM Feedback 1 A double-lumen catheter inserted into a major artery is used as temporary vascular access for continuous renal replacement therapy. 2 A peritoneal catheter is used for peritoneal dialysis and not hemodialysis. 3 A subarachnoid-peritoneal shunt is used to remove excess cerebral spinal fluid and not for hemodialysis. 4 For long-term vascular access needed for hemodialysis, an arteriovenous (AV) fistula is created. The fistula is created by surgical anastomosis of an artery and vein, usually the radial artery and cephalic vein. It takes about a month for the fistula to mature so that it can be used for taking and replacing blood during dialysis. PTS: 1 CON: Urinary Elimination 11. ANS: 1 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with renal disorders Chapter page reference: 1381-1385 Heading: Acute Kidney Injury Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1
2 3 4
A metallic taste in the mouth is due to a build-up of uremia. The nurse should provide mouth care before meals to reduce this taste sensation and improve the patient's oral intake. An antiemetic is prescribed for nausea. Restricting fluids will not reduce the metallic taste in the mouth. Encouraging the intake of protein, salt, and potassium will exacerbate the build-up of uremia that is causing the metallic taste in the mouth.
PTS: 1 CON: Urinary Elimination 12. ANS: 3 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Chronic kidney disease Chapter page reference: 1385-1392 Heading: Chronic Kidney Disease Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate
1 2 3
4
Feedback Diet and heredity do not factor into the production of erythropoietin. Metabolic wastes do not suppress the bone marrow. Anemia is common in patientsNwUiR th SreIn al N GdiTseBas.eC. AOmMong the factors causing the anemia are decreased production of erythropoietin by the kidneys and shortened red blood cell (RBC) life. Erythropoietin is involved in the stimulation of the bone marrow to produce RBCs. Diet and heredity do not factor into the production of erythropoietin.
PTS: 1 CON: Urinary Elimination 13. ANS: 4 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with renal failure Chapter page reference: 1385-1392 Heading: Chronic Kidney Disease Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy
1 2
Feedback An AV fistula does need to be protected from injury, and infection could be caused by constricting clothing, venipunctures, and other items. Increases in weight do need to be reported to the health-care provider as a possible indication of fluid volume excess, but this is not the reason why salt substitute is to be avoided.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3 4
The control of hypertension is essential in the management of a patient with kidney disease, but salt substitute is not known to interact with antihypertensive medications. Many salt substitutes use potassium chloride. Potassium intake is carefully regulated in clients with renal failure, and the use of salt substitutes will worsen hyperkalemia.
PTS: 1 CON: Urinary Elimination 14. ANS: 4 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Chronic kidney disease Chapter page reference: 1385-1392 Heading: Chronic Kidney Disease Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy Feedback 1 Metabolic acidosis and serum creatinine levels may not directly correlate with a decrease in the glomerular filtration rate in the elderly and are not directly affected by constipation. 2 Hypocalcemia does not occur with constipation. 3 Metabolic acidosis and serum creatinine levels may not directly correlate with a decrease in the glomerular filtration rate in the elderly and are not directly affected by constipation. NURSINGTB.COM 4 Constipation exacerbates hyperkalemia, and it is important to monitor CRF clients who already have impairment of potassium. PTS: 1 CON: Urinary Elimination 15. ANS: 3 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with renal disorders Chapter page reference: 1385-1392 Heading: Chronic Kidney Disease Integrated Processes: Nursing Process: Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Urinary Elimination Difficulty: Difficult
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Feedback Anxiety is not related to osteoporosis. The patient on hemodialysis may have a disturbed body image, but in this case, it is specified that the patient has significant osteoporosis. The patient with chronic kidney disease with osteoporosis is at high risk for fractures; therefore, preventing injury is the priority nursing diagnosis. The patient is at risk for anemia, but not bleeding.
PTS: 1
CON: Urinary Elimination
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
16. ANS: 1 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with renal failure Chapter page reference: 1385-1392 Heading: Chronic Kidney Disease Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 The patient with chronic kidney disease has elevated phosphate levels due to the inability of the damaged kidney to excrete this electrolyte. Calcium acetate, when given with meals, will bind serum phosphorus and therefore lower the serum level. 2 Although calcium acetate can act as an antacid and neutralize gastric acid when given between meals, this is not the reason it is given to a patient with chronic kidney disease. 3 This medication has no effect on appetite stimulation. 4 Calcium acetate has no effect on serum creatinine. PTS: 1 CON: Urinary Elimination 17. ANS: 4 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with renal failure Chapter page reference: 1385-1392 NURSINGTB.COM Heading: Chronic Kidney Disease Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy Feedback 1 This drug acts as an exchange resin allowing for potassium excretion; therefore, it may lead to increased sodium levels. 2 Although the patient might have increased stools, the therapeutic effectiveness of the drug is measured by monitoring the serum potassium. 3 This drug does not affect the specific gravity. 4 The patient with chronic kidney disease is unable to excrete potassium, and therefore the drug sodium polystyrene sulfonate (Kayexalate) is utilized in order to exchange sodium for potassium in the large intestine, resulting in decreased serum potassium levels. PTS: 1 CON: Urinary Elimination 18. ANS: 3 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with renal failure Chapter page reference: 1385-1392
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Heading: Chronic Kidney Disease Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Application [Applying] Concept: Urinary Elimination; Nutrition Difficulty: Moderate Feedback 1 Carrots; green, leafy vegetables; pears; and bananas are high in potassium. 2 Carrots; green, leafy vegetables; pears; and bananas are high in potassium. 3 Spaghetti and meat sauce with breadsticks would be the most appropriate meal from the choices provided. 4 Carrots; green, leafy vegetables; pears; and bananas are high in potassium. PTS: 1 CON: Urinary Elimination | Nutrition 19. ANS: 3 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Chronic kidney disease Chapter page reference: 1385-1392 Heading: Chronic Kidney Disease Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate
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Feedback Diabetic nephropathy causes renal failure by thickening and sclerosis of the glomerular basement membrane and the glomerulus with a gradual destruction of nephrons. Polycystic kidney disease causes renal failure by multiple bilateral cysts gradually compressing renal tissue, impairing renal perfusion and leading to ischemia, which damages and destroys normal kidney tissue. Longstanding hypertension leads to sclerosis and narrowing of renal arterioles and small arteries with subsequent reduction of blood flow. This leads to ischemia, glomerular destruction, and tubular atrophy. Systemic lupus erythematosus causes renal failure by the formation of immune complexes in the capillary basement membrane, which lead to inflammation and sclerosis.
PTS: 1 CON: Urinary Elimination 20. ANS: 1 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Chronic kidney disease Chapter page reference: 1385-1392 Heading: Chronic Kidney Disease Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding]
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Concept: Urinary Elimination Difficulty: Easy Feedback 1 The manifestations of chronic kidney disease often are missed in aging patients because edema may be attributed to heart failure or high blood pressure to preexisting hypertension. 2 Hip joint pain is not a manifestation of chronic kidney disease in the older patient. 3 An increase in hunger and thirst could be an indication of diabetes mellitus and not chronic kidney disease in the older patient. 4 A patient with chronic kidney disease will have pale dry skin with poor turgor. PTS: 1 CON: Urinary Elimination 21. ANS: 2 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with renal disorders Chapter page reference: 1385-1392 Heading: Chronic Kidney Disease Integrated Processes: Nursing Process: Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate
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Feedback Assessin g for edema and monito NUriRngShIeNarGt rTatBe an .Cd Ob lood M pressure would be interventions for the diagnosis of Excess Fluid Volume. Interventions appropriate for the diagnosis of Imbalanced Nutrition: Less Than Body Requirements include monitoring laboratory values such as serum albumin. Monitoring for orthostatic blood pressure changes would be appropriate for the diagnosis of Risk for Ineffective Perfusion. Monitoring the white blood cell count would be an intervention appropriate for the diagnosis of Risk for Infection.
PTS: 1 CON: Urinary Elimination 22. ANS: 4 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with renal failure Chapter page reference: 1385-1392 Heading: Chronic Kidney Disease Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Urinary Elimination Difficulty: Difficult
1
Feedback Oral phosphorus-binding agents, such as calcium carbonate or calcium acetate, are given to lower serum phosphate levels and normalize serum calcium levels.
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2 3 4
Folic acid and iron supplements are given to combat anemia associated with chronic kidney disease. There is no medication provided to a patient with chronic kidney disease that is used to stabilize protein levels in the body. Furosemide (Lasix) is a loop diuretic that may be prescribed to reduce extracellular fluid volume and edema. Diuretic therapy also can reduce hypertension and cause potassium wasting, lowering serum potassium levels.
PTS: 1 CON: Urinary Elimination 23. ANS: 4 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Designing a plan of care that includes pharmacological, dietary, and lifestyle considerations for patients with renal failure Chapter page reference: 1385-1392 Heading: Chronic Kidney Disease Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy Feedback 1 A fluid restriction would be indicated for uremia caused by chronic kidney disease. 2 Intravenous glucose and insulin may be used to reduce excessive potassium that is caused by chronic kidney disease. 3 A low-sodiu m diet is used to hNe lp URreSd uc I Ne GfluTidB vo . CluOmMe excess that is caused by chronic kidney disease. 4 Epoetin injections are used in the treatment of anemia caused by chronic kidney disease. This medication supplies a hormone typically created in the kidneys that signals the bone marrow to produce more red blood cells. In chronic kidney disease, this hormone production will be reduced. PTS: 1 CON: Urinary Elimination 24. ANS: 1 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Polycystic kidney disease Chapter page reference: 1368-1370 Heading: Polycystic Kidney Disease Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Urinary Elimination Difficulty: Difficult
1 2
Feedback Hypertension is the first symptom the nurse should assess for when a patient is suspected of having polycystic kidney disease. While hematuria is a symptom of polycystic kidney disease, this is not the first symptom the nurse should assess this patient for.
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While urinary frequency is a symptom of polycystic kidney disease, this is not the first symptom the nurse should assess this patient for. While urinary calculi is a symptom of polycystic kidney disease, this is not the first symptom the nurse should assess this patient for.
PTS: 1 CON: Urinary Elimination 25. ANS: 1 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Polycystic kidney disease Chapter page reference: 1368-1370 Heading: Polycystic Kidney Disease Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy Feedback 1 An increased temperature is data that indicates an infection. 2 Hypertension does not indicate infection. 3 An increased, not decreased, white blood cell count indicates infection. 4 Decreased urine output alone is not an indicator of infection. PTS: 1
CON: Urinary Elimination
NURSINGTB.COM MULTIPLE RESPONSE 26. ANS: 1, 2, 5 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Describing the epidemiology of renal disorders Chapter page reference: 1381-1385 Heading: Acute Kidney Injury Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is correct. Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury. This is correct. Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury. This is incorrect. Ineffective wound healing has not been shown to cause acute kidney injury unless the infection becomes systemic. This is incorrect. A low serum albumin does not cause acute kidney injury. This is correct. Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury.
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PTS: 1 CON: Urinary Elimination 27. ANS: 1, 2, 3 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Describing the epidemiology of renal disorders Chapter page reference: 1381-1385 Heading: Acute Kidney Injury Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy
1.
2.
3.
4. 5.
Feedback This is correct. Hypotension, scheduled for aortic valve replacement surgery, and receiving high doses of intravenous antibiotics increase this client’s risk for developing acute kidney injury. This is correct. Hypotension, scheduled for aortic valve replacement surgery, and receiving high doses of intravenous antibiotics increase this client’s risk for developing acute kidney injury. This is correct. Hypotension, scheduled for aortic valve replacement surgery, and receiving high doses of intravenous antibiotics increase this client’s risk for developing acute kidney injury. This is incorrect. A previous history of major surgery and current treatment for type 2 diabetes mellitus are not identified risk factors for the development of acute kidney injury. This is incorrect. A prevN ioUusRhSisItoNryGoTf B m. ajC orOsM u rgery and current treatment for type 2 diabetes mellitus are not identified risk factors for the development of acute kidney injury.
PTS: 1 CON: Urinary Elimination 28. ANS: 1, 5 Chapter number and title: 62, Coordinating Care for Patients With Renal Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of renal disorders Chapter page reference: 1385-1392 Heading: Chronic Kidney Disease Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate
1. 2. 3. 4.
Feedback This is correct. The patient will also have an increased blood urea nitrogen (BUN) level due to the damaged kidneys. This is incorrect. Both phosphorus and potassium increase during renal failure due to the inability of the kidney to excrete them. This is incorrect. Both phosphorus and potassium increase during renal failure due to the inability of the kidney to excrete them. This is incorrect. The damaged kidney is unable to excrete solutes; therefore, the serum osmolality will be increased and the urine osmolality will be decreased.
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5.
PTS: 1
This is correct. The damaged kidney is unable to excrete waste products, including creatinine, so it will be increased. CON: Urinary Elimination
Chapter 63: Coordinating Care for Patients With Urinary Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse provides education for a patient who is experiencing urinary incontinence. Which statement by the patient indicates the need for further education? 1) “Relaxation of pelvic muscles may be a factor in incontinence.” 2) “Reduced urethral resistance can be a cause of incontinence.” 3) “Incontinence is normal with aging.” 4) “A disturbance of my bladder is a factor in the development of incontinence.” 2. The nurse is attempting to place a urinary catheter for an older adult female patient. The nurse is unable to visualize the patient’s urinary meatus. Which alternate position for catheterization may be appropriate for this patient? 1) Side-lying, lifting up the buttock 2) Supine, with the HOB elevated at 30° 3) Supine, with the head of bed (HOB) elevated at 45° 4) Supine, with the bed flat, legs bent and apart in stir ru p s
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3. The nurse is caring for a patient with a urinary catheter. Which nursing diagnosis is a priority for this patient? 1) Chronic Pain related to an obstruction 2) Risk for Impaired Skin Integrity related to incontinence 3) Risk for Infection related to catheter placement 4) Self-Care Deficit related to presence of urinary catheter 4. The nurse is caring for a patient who will be discharged with an indwelling catheter. The nurse has provided education to the patient and family about catheter care once the patient is discharged. Which patient or family action indicates a correct understanding of the information presented? 1) Hanging the drainage bag on the towel rod 2) Taking a shower each day instead of taking a tub bath 3) Restricting the amounts of fluids per day 4) Emptying the drainage bag twice a day 5. The nurse is working in a urology clinic and is providing care for a patient with urinary stress incontinence. The nurse has chosen the diagnosis of Stress Urinary Incontinence related to sphincter incompetence. Which is the desired outcome for a patient with this diagnosis? 1) The patient will stop the flow of urine when voiding. 2) The patient will improve her incontinence within one month. 3) The patient will empty her bladder every time she voids. 4) The patient will perform four to five squeezes (Kegel exercises) for 10-15 seconds. 6. The nurse is caring for a patient with a history of chronic urinary tract infections. The nurse is planning care for this patient based on the priority nursing diagnosis of urinary retention related to scarring. Based on this data, which prescription does the nurse anticipate from the health-care provider?
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1) 2) 3) 4)
Antibiotic therapy An anticholinergic medication Intermittent straight catheterization Removal of bladder stones
7. The nurse is assessing an adult patient in a urology clinic. The patient reports that she has been having “accidents” and expresses frustration about this normal part of aging. Which response by the nurse is the most appropriate? 1) “Tell me more about what you are experiencing.” 2) “You may need to have surgery to manage this problem.” 3) “I understand you are frustrated about this occurrence.” 4) “Unfortunately, aging and incontinence go hand in hand.” 8. The nurse is reviewing discharge instructions for a patient diagnosed with urinary incontinence resulting from a urinary tract infection. Which statement made by the patient indicates the need for further education? 1) “I should drink plenty of water to prevent damage to my kidneys while I am on the antibiotics for the infection.” 2) “Drinking cranberry juice will decrease the risk for developing urinary tract infections.” 3) “I will contact the health-care provider prior to taking over-the-counter medications while on my antibiotic.” 4) “I will continue to hold my urine while in public so that I do not get another infection.” 9. The nurse is triaging a patient who presents to the urgent care clinic with symptoms of severe flank pain with spasms, nausea, vomiting, and oliguria. The patient states that the pain was initially intermittent and radiated from the lower back to the lower quadrants of the abdomen. Which action by the nurse is the most appropriate? 1) Complete the physical assessmeN n tURSINGTB.COM 2) Refer the patient to a urologist 3) Instruct the patient to increase fluids 4) Obtain a urine specimen for culture 10. A nurse is providing care to a group of patients on a urology unit. Which patient does the nurse identify as being at the greatest risk for developing urinary stones? 1) A 35-year-old female with quadriplegia from an auto accident 2) A 65-year-old male with a recent history of myocardial infarction 3) A 50-year-old male with type II diabetes mellitus 4) A 25-year-old female with several episodes of urinary infection 11. The nurse educator is speaking with a group of students about renal disorders. Which statement is appropriate for the educator to include regarding renal stones? 1) “Older adult patients are particularly at risk for urolithiasis.” 2) “Young- or middle-age adult men are at an increased risk for stones.” 3) “Women have a greater risk overall than men.” 4) “Frequency is greater in the northern United States.” 12. A patient is admitted to the emergency department and diagnosed with urinary calculi after experiencing symptoms for one week. When planning care for this patient, which nursing diagnosis is the most appropriate? 1) Risk for Constipation 2) Risk for Disuse Syndrome 3) Imbalanced Nutrition 4) Activity Intolerance
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13. The nurse is caring for a patient with a history of kidney stones. The stones have been analyzed and are all composed of calcium phosphate. Based on this data, which foods should the nurse teach the patient to avoid? 1) Chicken, beef, and ham products 2) Organ meats, sardines, and seafood 3) Tomatoes, fruits, and nuts 4) Flour, milk, and ice cream 14. A patient with urinary calculi is admitted to the hospital. When planning care for this patient, which goal is most appropriate? 1) The patient will lose 25 pounds in three months. 2) The patient will ambulate three times a day. 3) The patient will request pain medication at the onset of pain. 4) The patient will shower independently. 15. The nurse providing care to a patient whose medication therapy for the treatment of renal calculi has failed. Based on this data, which treatment option does the nurse anticipate for this patient? 1) Lithotripsy 2) Surgical removal 3) Dietary control 4) Initiation of IV fluids 16. The nurse is preparing to discharge a patient who underwent lithotripsy in the treatment of a kidney stone. What should the nurse teach the patient to prevent further complications of urinary calculi after discharge? 1) “You will need to increase your oral fluid intake to 1 L/day.” 2) “It will be important that you not drive while taking pain medications.” 3) “It will be important to maintainNaUdRieS t hIigNhGinTpBu. rinCeO s.”M 4) “You will need to monitor for the signs and symptoms of a urinary tract infection (UTI).” 17. A patient admitted to the hospital with a diagnosis of gout has also been diagnosed with uric acid renal calculi. When planning meals for this patient, which diet will the nurse anticipate? 1) Low-purine diet 2) Low-sodium diet 3) A diet high in calcium 4) A diet low in calcium 18. The nurse on the medical unit is admitting an older adult patient whose primary symptoms include fatigue, pruritus, and pain in the right flank area. When conducting this patient’s assessment, which technique is the most appropriate? 1) Palpation over the costovertebral angles and flanks 2) Blunt percussion over the costovertebral angles and flanks 3) Palpation of the lower pole of both kidneys 4) Capturing of both kidneys 19. The nurse is providing care to a patient with a spinal cord injury. Which type of incontinence should the nurse include in this patient’s plan of care? 1) Urge 2) Stress 3) Overflow 4) Functional
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20. The nurse is providing care to a patient who is experiencing urine leakage when coughing or laughing. Which type of incontinence should the nurse include in this patient’s plan of care? 1) Urge 2) Stress 3) Overflow 4) Functional 21. The nurse is providing care to a patient with urge incontinence. Which drug classification should the nurse include in the patient’s plan of care? 1) Anticholinergic 2) Topical estrogen 3) Alpha-adrenergic agonist 4) Calcium channel blocker 22. The nurse is providing care to a patient with stress incontinence. Which drug classification should the nurse include in the patient’s plan of care? 1) Anticholinergic 2) Topical estrogen 3) Alpha-adrenergic agonist 4) Calcium channel blocker 23. The nurse is providing care to a patient with benign prostatic hyperplasia (BPH). Which drug classification should the nurse include in the patient’s plan of care? 1) Diuretic 2) Anticholinergic 3) Topical estrogen 4) Alpha-adrenergic agonist NURSINGTB.COM 24. Which intervention should the nurse include in the patient’s plan of care to decrease the risk for developing a catheter-associated urinary tract infection? 1) Implementing intermittent catheterization 2) Administering the prescribed prophylactic antibiotic 3) Retaining the indwelling catheter throughout hospitalization 4) Encouraging the consumption of cranberry juice twice per day 25. The nurse is providing care to a patient who is diagnosed with bladder cancer and receiving Bacille CalmetteGuérin therapy. Which is the priority teaching point for this patient? 1) Straining all urine to assess for calculi 2) Flushing the toilet immediately after urination 3) Pouring two cups of bleach in the toilet and flushing 20 minutes later 4) Notifying the health-care provider if the patient does not void every two hours Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. The nurse is providing care to a patient who is diagnosed with stress incontinence. Which assessment data would the nurse expect to collect while performing the patient’s health history and physical? Select all that apply. 1) Urine leakage while talking 2) Urine leakage while coughing 3) Urine leakage while laughing
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4) Skin breakdown on the buttock 5) A urinary catheter 27. The nurse is providing training for the clinical staff of a skilled care facility and wants to include information on functional incontinence. Which risk factors for functional incontinence will the nurse include in the training? Select all that apply. 1) Limited mobility 2) Impaired vision 3) Lack of access to facilities 4) Dementia 5) Depression Completion Complete each statement. 28. A patient is complaining of dull flank pain. List the order of the steps the nurse should take in conducting the physical assessment for this patient. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Instruct the patient 2) Position the patient 3) Assess the general appearance 4) Inspect the abdomen for color, contour, symmetry, and distention
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Chapter 63: Coordinating Care for Patients With Urinary Disorders Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with urinary disorders Chapter page reference: 1408-1412 Heading: Incontinence Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Urinary Elimination Difficulty: Difficult Feedback 1 A disturbance of the bladder, relaxation of the pelvic muscles, and reduced urethral resistance are all potential factors in the development of incontinence. 2 A disturbance of the bladder, relaxation of the pelvic muscles, and reduced urethral resistance are all potential factors in the development of incontinence. 3 Incontinence is not a normal result of aging. 4 A disturbance of the bladder, relaxation of the pelvic muscles, and reduced urethral resistance are all potential factN orUs R inSthIeNdG e vTelBo . p mCeO nM t of incontinence. PTS: 1 CON: Urinary Elimination 2. ANS: 1 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with urinary disorders Chapter page reference: 1405-1408 Heading: Urolithiasis Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Because of estrogen-mediated changes in the perineal area of postmenopausal women, the urinary meatus may be very difficult to visualize. The side-lying position, lifting up the buttock, is an alternative that provides better visualization of the urinary meatus. 2 The supine position, regardless of the leg position or height of the bed, would not increase the visualization of the urinary meatus because it is more distal from the changes in the perineal area. 3 The supine position, regardless of the leg position or height of the bed, would not increase the visualization of the urinary meatus because it is more distal from the changes in the perineal area.
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The supine position, regardless of the leg position or height of the bed, would not increase the visualization of the urinary meatus because it is more distal from the changes in the perineal area.
PTS: 1 CON: Urinary Elimination 3. ANS: 3 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with urinary disorders Chapter page reference: 1405-1408 Heading: Urolithiasis Integrated Processes: Nursing Process: Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Urinary Elimination Difficulty: Difficult Feedback 1 There is no indication that the patient is experiencing chronic pain. 2 While there is an increased risk for impaired skin integrity and a self-care deficit, these are not priorities for this patient. 3 The patient who has a urinary catheter in place is at an increased risk for infection, which is the priority diagnosis. 4 While there is an increased risk for impaired skin integrity and a self-care deficit, these are not priorities for this patient.
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PTS: 1 CON: Urinary Elimination ANS: 2 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with urinary disorders Chapter page reference: 1405-1408 Heading: Urolithiasis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Urinary Elimination Difficulty: Difficult Feedback 1 Hanging the drainage bag on the towel rod is too high. The drainage bag should be hung below the bladder. 2 The patient should take a shower rather than a tub bath because sitting in a tub allows bacteria to easily access the urinary tract. 3 Adequate amounts of fluids should be consumed to help prevent sediments and infections. 4 The drainage bag should be emptied regularly, not just once a day but at least three times a day. PTS: 1 5. ANS: 4
CON: Urinary Elimination
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Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with urinary disorders Chapter page reference: 1408-1412 Heading: Incontinence Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Patients are not instructed to stop the flow of urine when voiding, because this could lead to retention. 2 Improved continence takes three to six months, so one month is not a realistic goal. 3 Emptying the bladder completely every time she voids would not be realistic in the beginning. This will take time. 4 Performing four to five squeezes for 10-15 seconds is the goal to start with when teaching a patient Kegel exercises, which are used for stress and urge incontinence. PTS: 1 CON: Urinary Elimination 6. ANS: 3 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Discussing the medical management of: Urinary tract infections Chapter page reference: 1402-1404 Heading: Urinary Tract Infections NURSINGTB.COM Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy 1 2 3 4
Feedback Antibiotic therapy is not indicated, as the patient does not have an infection now. Anticholinergic medications can cause urinary retention. The health-care provider may order straight catheterization so the patient can be taught to self-catheterize and manage the urinary retention at home. Bladder stones are not the problem; scarring is.
PTS: 1 CON: Urinary Elimination 7. ANS: 1 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with urinary disorders Chapter page reference: 1402-1404 Heading: Urinary Tract Infection Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination
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Difficulty: Moderate Feedback 1 It is appropriate for the nurse to gather more information regarding the patient’s incontinence. 2 It is beyond the nurse’s scope of practice to recommend surgery to the patient. 3 Saying that the nurse understands does not help to determine the cause of the patient’s incontinence. 4 As the body ages, there are anatomical changes can increase the risk for urinary incontinence; however, this is not a normal part of aging. PTS: 1 CON: Urinary Elimination 8. ANS: 4 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with urinary disorders Chapter page reference: 1408-1412 Heading: Incontinence Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Urinary Elimination Difficulty: Difficult Feedback 1 This statement is appropriate and indicates appropriate understanding of the information presented. NURSINGTB.COM 2 This statement is appropriate and indicates appropriate understanding of the information presented. 3 This statement is appropriate and indicates appropriate understanding of the information presented. 4 A patient who is diagnosed with urinary incontinence secondary to a urinary tract infection will require specific education. The patient who states that he or she will hold their urine while in public to decrease the risk of another infection requires more education. Urinary retention is a contributing factor to urinary tract infections. PTS: 1 CON: Urinary Elimination 9. ANS: 2 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with urinary disorders Chapter page reference: 1405-1408 Heading: Urolithiasis Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 While this action is important, it would not be appropriate in an emergency situation.
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2
3 4
Hydroureter is a complication that occurs when a renal calculus moves into the ureter and blocks and dilates the ureter. Symptoms include severe pain and spasms, nausea, vomiting, and diminished volume of urine. Hydroureter is a medical emergency that can lead to shock, infection, and subsequent impaired renal function; medical collaboration should be initiated immediately. While this action is important, it would not be appropriate in an emergency situation. While this action is important, it would not be appropriate in an emergency situation.
PTS: 1 CON: Urinary Elimination 10. ANS: 1 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Describing the epidemiology of urinary disorders Chapter page reference: 1405-1408 Heading: Urolithiasis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 The 35-year-old female with quadriplegia from an auto accident experiences prolonged immobility, which will increase calcium loss from bones and therefore increase the chance of calcium stones precipitating in the urinary system. 2 A 65-year-old male with a recent history of myocardial infarction, 50-year-old male with type II diabetes mellitus, NanUdR2S 5-IyeNa G r-oTldBf.em a leMwith several episodes of urinary CO infection do not have as great a risk because they do not remain immobile for long periods of time. 3 A 65-year-old male with a recent history of myocardial infarction, 50-year-old male with type II diabetes mellitus, and 25-year-old female with several episodes of urinary infection do not have as great a risk because they do not remain immobile for long periods of time. 4 A 65-year-old male with a recent history of myocardial infarction, 50-year-old male with type II diabetes mellitus, and 25-year-old female with several episodes of urinary infection do not have as great a risk because they do not remain immobile for long periods of time. PTS: 1 CON: Urinary Elimination 11. ANS: 2 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Describing the epidemiology of urinary disorders Chapter page reference: 1405-1408 Heading: Urolithiasis Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 This statement is not accurate.
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2 3 4
Men who are in young to middle age are affected two to three times more than women of that age. This statement is not accurate. The frequency of the occurrence of renal stones in the United States is greatest in the southern and midwestern states.
PTS: 1 CON: Urinary Elimination 12. ANS: 3 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with urinary disorders Chapter page reference: 1405-1408 Heading: Urolithiasis Integrated Processes: Nursing Process: Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Activity intolerance, risk for constipation, and risk for disuse syndrome are not as appropriate because the symptoms of urinary calculi do not lead to these diagnoses. 2 Activity intolerance, risk for constipation, and risk for disuse syndrome are not as appropriate because the symptoms of urinary calculi do not lead to these diagnoses. 3 The patient with urinary calculi, or kidney stones, of lengthy duration is at risk for imbalanced nutrition from the NreUsuRltSinIg N n aGuT seBa..COM 4 Activity intolerance, risk for constipation, and risk for disuse syndrome are not as appropriate because the symptoms of urinary calculi do not lead to these diagnoses. PTS: 1 CON: Urinary Elimination 13. ANS: 4 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with urinary disorders Chapter page reference: 1405-1408 Heading: Urolithiasis Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Basic Care and Comfort Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination; Nutrition Difficulty: Easy Feedback 1 Organ meats, sardines, seafood, tomatoes, fruits, nuts, chicken, beef, and ham products are not high in calcium and do not need to be restricted for this patient. 2 Organ meats, sardines, seafood, tomatoes, fruits, nuts, chicken, beef, and ham products are not high in calcium and do not need to be restricted for this patient. 3 Organ meats, sardines, seafood, tomatoes, fruits, nuts, chicken, beef, and ham products are not high in calcium and do not need to be restricted for this patient.
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Flour, milk, and milk products such as ice cream have high calcium levels and, therefore, are recommended to be reduced to decrease the risk of further episodes of calcium-containing calculi.
PTS: 1 CON: Urinary Elimination | Nutrition 14. ANS: 3 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with urinary disorders Chapter page reference: 1405-1408 Heading: Urolithiasis Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Dietary changes will need to be made to prevent further formation of stones, but weight loss is not necessarily a goal with this disease process. 2 The patient with urinary calculi is able to ambulate and shower independently. 3 Intense pain is the hallmark of urinary calculi, or kidney stones, that are passing through the urinary system. The nurse teaches the patient to request pain medication at the onset of pain in order to provide faster relief. 4 The patient with urinary calculi is able to ambulate and shower independently.
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PTS: 1 CON: Urinary Elimination ANS: 1 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Discussing the medical management of: Urolithiasis Chapter page reference: 1405-1408 Heading: Urolithiasis Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy Feedback 1 When medication fails to dissolve stones, the preferred method of treatment is lithotripsy, which is using sound waves to crush the stones so they can be passed out of the urinary system. 2 Depending on the location of the stones, surgery may be the next step in the treatment process. 3 Diet and fluids are used to prevent further stone formation. 4 Diet and fluids are used to prevent further stone formation. PTS: 1 CON: Urinary Elimination 16. ANS: 4 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders
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Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with urinary disorders Chapter page reference: 1405-1408 Heading: Urolithiasis Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Fluid intake per day should be 2.5-3.0 L. 2 By discharge, the stones should have passed and there would be no need for pain medication. 3 Foods high in purines, such as organ meats, are to be avoided. 4 The patient with stones may develop a UTI when formed stones obstruct urinary flow. These symptoms should be reported as early as possible to the primary care provider. PTS: 1 CON: Urinary Elimination 17. ANS: 1 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with urinary disorders Chapter page reference: 1405-1408 Heading: Urolithiasis Integrated Processes: Nursing Process: Planning OfMort Client Need: Physiological Integrity N –U BaRsS icI CN arG eT anB d. CC om Cognitive level: Application [Applying] Concept: Urinary Elimination; Nutrition Difficulty: Moderate Feedback 1 A low-purine diet is appropriate in the management of a patient with uric acid renal calculi. 2 A low-sodium diet is useful in the management of a patient with cystine renal calculi, and a diet limiting foods high in calcium is useful when managing a patient with calcium phosphate renal calculi. 3 A low-sodium diet is useful in the management of a patient with cystine renal calculi, and a diet limiting foods high in calcium is useful when managing a patient with calcium phosphate renal calculi. 4 A low-sodium diet is useful in the management of a patient with cystine renal calculi, and a diet limiting foods high in calcium is useful when managing a patient with calcium phosphate renal calculi. PTS: 1 CON: Urinary Elimination | Nutrition 18. ANS: 2 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with urinary disorders Chapter page reference: 1405-1408 Heading: Urolithiasis
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Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Palpation of the costovertebral angles and flanks can be used to reveal any pain or tenderness. 2 Blunt percussion in a frail older individual is contraindicated. 3 This is not the most appropriate assessment technique for this patient. 4 This is not the most appropriate assessment technique for this patient. PTS: 1 CON: Urinary Elimination 19. ANS: 3 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with urinary disorders Chapter page reference: 1408-1412 Heading: Incontinence Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy
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NURSINGTB.COM Feedback Urge incontinence occurs when there is bladder exposure to irritants such as caffeine, artificial sweeteners, or nicotine. The patient will experience a strong urge to urinate followed by uncontrolled leakage. Stress incontinence is more common in women and occurs when abdominal pressure increases: laughing, coughing, lifting, exercising. Overflow incontinence occurs with spinal cord injury. The bladder is flaccid/enlarged due to obstruction, and the patient experiences frequent urination. Functional incontinence occurs when the patient is unable to get to the toilet or communicate the need to do so. The patient is continent, but environmental factors lead to loss of urine in inappropriate area.
PTS: 1 CON: Urinary Elimination 20. ANS: 2 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Incontinence Chapter page reference: 1408-1412 Heading: Incontinence Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy
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Feedback Urge incontinence occurs when there is bladder exposure to irritants such as caffeine, artificial sweeteners, or nicotine. The patient will experience a strong urge to urinate followed by uncontrolled leakage. Stress incontinence is more common in women and occurs when abdominal pressure increases: laughing, coughing, lifting, exercising. Overflow incontinence occurs with spinal cord injury. The bladder is flaccid/enlarged due to obstruction, and the patient experiences frequent urination. Functional incontinence occurs when the patient is unable to get to the toilet or communicate the need to do so. The patient is continent, but environmental factors lead to loss of urine in inappropriate area.
PTS: 1 CON: Urinary Elimination 21. ANS: 1 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Discussing the medical management of: Incontinence Chapter page reference: 1408-1412 Heading: Incontinence Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate
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Anticholinergic drugs are used to treat stress incontinence and mixed incontinence. They block nervous stimulation from the parasympathetic nervous system to help relax and control bladder muscle contractions. Topical estrogens are used in stress incontinence to help restore moisture and flexibility of the urethra. Alpha-adrenergic agonists, beta-adrenergic agonists, and calcium channel blockers all promote urethral relaxation; aid in issues of urinary retention, for example, issues associated with BPH. Alpha-adrenergic agonists, beta-adrenergic agonists, and calcium channel blockers all promote urethral relaxation; aid in issues of urinary retention, for example, issues associated with BPH.
PTS: 1 CON: Urinary Elimination 22. ANS: 2 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Discussing the medical management of: Incontinence Chapter page reference: 1408-1412 Heading: Incontinence Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback
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2 3
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Anticholinergic drugs are used to treat stress incontinence and mixed incontinence. They block nervous stimulation from the parasympathetic nervous system to help relax and control bladder muscle contractions. Topical estrogens are used in stress incontinence to help restore moisture and flexibility of the urethra. Alpha-adrenergic agonists, beta-adrenergic agonists, and calcium channel blockers all promote urethral relaxation; aid in issues of urinary retention, for example, issues associated with BPH. Alpha-adrenergic agonists, beta-adrenergic agonists, and calcium channel blockers all promote urethral relaxation; aid in issues of urinary retention, for example, issues associated with BPH.
PTS: 1 CON: Urinary Elimination 23. ANS: 4 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Discussing the medical management of: Incontinence Chapter page reference: 1408-1412 Heading: Incontinence Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Diuretics are used to increase ur NUinRe SouItpNuGt fTorBa.pCatOieMnt with renal issues. 2 Anticholinergic drugs are used to treat stress incontinence and mixed incontinence. They block nervous stimulation from the parasympathetic nervous system to help relax and control bladder muscle contractions. 3 Topical estrogens are used in stress incontinence to help restore moisture and flexibility of the urethra. 4 Alpha-adrenergic agonists, beta-adrenergic agonists, and calcium channel blockers all promote urethral relaxation; aid in issues of urinary retention, for example, issues associated with BPH. PTS: 1 CON: Urinary Elimination 24. ANS: 1 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with urinary disorders Chapter page reference: 1402-1404 Heading: Urinary Tract Infections Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Evidence-Based Practice Difficulty: Moderate Feedback 1 Intermittent catheterization should be considered as an alternative to an indwelling catheter to reduce the risk for catheter-associated infections.
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2 3 4
Antibiotic prophylaxis should not be routinely used because of concerns of antibiotic resistance. Catheters should be removed as soon as they are no longer needed to prevent catheterassociated infections. Insufficient data exist regarding the use of cranberry products to decrease the risk of catheter-associated urinary tract infections.
PTS: 1 CON: Evidence-Based Practice 25. ANS: 3 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with urinary disorders Chapter page reference: 1412-1414 Heading: Bladder Cancer Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Urinary Elimination; Safety Difficulty: Difficult Feedback 1 This teaching point is appropriate for a patient diagnosed with urinary calculi. 2 The toilet must be treated prior to flushing. 3 The patient should be taught to pour two cups of bleach into the toilet after urination and allow it to sit for 20 minutes prior to flushing. This is to ensure that others are not infected with the bacteria usedNinU th RisSItrea N Gt mTeBnt.reg C OimMen. 4 There is no need to notify the health-care provider if the patient does not void every two hours. PTS: 1
CON: Urinary Elimination | Safety
MULTIPLE RESPONSE 26. ANS: 2, 3, 4 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Incontinence Chapter page reference: 1408-1412 Heading: Incontinence Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy
1. 2.
Feedback This is incorrect. Stress incontinence does not involve urine leakage when talking. This is correct. Stress incontinence involves a small leakage of urine when a patient laughs, coughs, or lifts something heavy, not if a patient just carries on a conversation.
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3. 4. 5.
This is correct. Stress incontinence involves a small leakage of urine when a patient laughs, coughs, or lifts something heavy, not if a patient just carries on a conversation. This is correct. If the patient has been experiencing incontinence, the nurse might expect to see the skin inflamed and irritated because urine is very irritating to the skin. This is incorrect. A patient with incontinence would wear some kind of undergarment pad; a urinary catheter is not an expected finding.
PTS: 1 CON: Urinary Elimination 27. ANS: 1, 2, 3, 4 Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Describing the epidemiology of urinary disorders Chapter page reference: 1408-1412 Heading: Incontinence Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate
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2.
3.
4.
5. PTS: 1
Feedback This is correct. An immobilized patient may experience incontinence if a call light is not within reach; a patient with Alzheimer disease, along with other forms of dementia, may perceive the urge to void but be unable to interpret its meaning or respond by seeking a bathroom. A patient with impaired vision may not be able to find the bathroom. Minimal facilities can create problems in urinary control. This is correct. An immobilized patient may experience incontinence if a call light is not within reach; a patient with Alzheimer disease, along with other forms of dementia, may perceive the urge to void but be unable to interpret its meaning or respond by seeking a bathroom. A patient with impaired vision may not be able to find the bathroom. Minimal facilities can create problems in urinary control. This is correct. An immobilized patient may experience incontinence if a call light is not within reach; a patient with Alzheimer disease, along with other forms of dementia, may perceive the urge to void but be unable to interpret its meaning or respond by seeking a bathroom. A patient with impaired vision may not be able to find the bathroom. Minimal facilities can create problems in urinary control. This is correct. An immobilized patient may experience incontinence if a call light is not within reach; a patient with Alzheimer disease, along with other forms of dementia, may perceive the urge to void but be unable to interpret its meaning or respond by seeking a bathroom. A patient with impaired vision may not be able to find the bathroom. Minimal facilities can create problems in urinary control. This is incorrect. Depression is not usually related to incontinence. CON: Urinary Elimination
COMPLETION 28. ANS: 1234
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Chapter number and title: 63, Coordinating Care for Patients With Urinary Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with urinary disorders Chapter page reference: 1405-1408 Heading: Urolithiasis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback: A quick survey of the patient enables the nurse to identify any immediate problem as well as the patient’s ability to participate in the assessment. Begin the examination with the patient in a supine position with the abdomen exposed from the nipple line to the pubis. Assess general appearance and inspect the patient’s skin for color, hydration status, scales, masses, indentations, or scars. PTS: 1
CON: Urinary Elimination
Chapter 64: Assessment of Reproductive Function Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is assessing for vaginal bleeding during the health history. Which question is appropriate? 1) “How many pads or tampons are used in a 2-hour period?” 2) “How many pads or tampons areN uUseRdSinIaN1G0T -hB o u.rCp eOrM iod?” 3) “How many pads or tampons are used in a 24-hour period?” 4) “How many pads or tampons are used in a 72-hour period?” 2. During the health history focused on reproductive function, the nurse should begin with questions about which topic? 1) Sexual satisfaction 2) Self-care 3) Sexual practices 4) Symptoms 3. The nurse is assessing a patient who reports vaginal discharge for one week, itching, and mild dysuria. Which question is appropriate to include in the assessment history for this patient? 1) “What is the color of the discharge?” 2) “Does your sexual partner have the same symptoms?” 3) “How often do you have vaginal bleeding?” 4) “How would you describe your normal flow?” 4. A yearly Pap test is recommended to screen for which type of cancer? 1) Ovarian 2) Vaginal 3) Uterine 4) Cervical 5. Before beginning to perform a gynecological assessment, the nurse would ask the patient to perform which action?
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1) 2) 3) 4)
Taking short, quick breaths to lessen the discomfort Assuming the supine position Emptying the bladder Reviewing the medical history
6. The nurse is collecting a health history for a patient during a routine health maintenance visit. The patient states, “I am in menopause.” Which conclusion by the nurse is most appropriate based on this data? 1) The patient is no longer sexually active. 2) The patient has never had any children. 3) The patient has a sexually transmitted infection. 4) The patient has not had a menstrual period in a year. 7. The nurse is conducting a health maintenance visit for an older adult female patient. Which is an expected finding for this patient based on age? 1) Enlarged clitoris 2) Copious vaginal secretions 3) Increased risk for vaginal infections 4) Decreased risk for painful intercourse 8. The nurse is assessing the patient for clinical manifestations associated with premenstrual syndrome. Which question is appropriate? 1) “How often do you have intercourse?” 2) “Are you able to achieve orgasm?” 3) “Do you experience bloating?” 4) “How many sexual partners have you had?” 9. The nurse is preparing a patient for aNpeUlvRicS eIxN am GiTn aBti.o nC. W OMhich patient position is most appropriate? 1) Side-lying 2) Supine 3) Lithotomy 4) Prone 10. Which is a primary function of the male genitourinary system? 1) Protecting the ova 2) Regulating estrogen production 3) Secreting insulin 4) Manufacturing sperm 11. The nurse is conducting a male genitourinary assessment. Which hormone often decreases after the age of 50 years? 1) Testosterone 2) Progesterone 3) Growth-stimulating hormone 4) Luteinizing hormone 12. The nurse is assessing the patient for an inguinal hernia. To palpate for a hernia at the external inguinal ring, the nurse inserts the right index finger into which location? 1) Rectum 2) Femoral area 3) Scrotal sac above the testicles 4) None of the above
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13. Which is the recommended procedure for palpating the testicle? 1) Use the first two fingers of each hand to palpate firmly 2) Gently palpate using the fingers of both hands 3) Palpate firmly using the palmar surface of one hand 4) Gently palpate using the thumb and first two fingers of one hand 14. The nurse is examining an adult patient who complains of left inguinal pain. Bowel sounds are auscultated in the scrotum, and the nurse palpates a bulge at the external inguinal ring when the patient coughs. Based on this data, which diagnosis does the nurse suspect? 1) Hydrocele 2) Spermatocele 3) Rectocele 4) Hernia 15. The nurse is conducting a genitourinary assessment for an older adult male patient. Which is an expected finding based on the patient’s age? 1) Thick pubic hair on the external genitalia 2) Larger and harder testicles 3) Atrophy of the penis 4) Elastic scrotal sac 16. The nurse is conducting a sexual history interview. Which assessment question is appropriate? 1) “Have you ever had a kidney stone?” 2) “Have you had any changes in your voiding pattern?” 3) “How many times do you wake up during the night to void?” 4) “Are you using birth control?”
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17. The nurse is conducting a health history for a patient who presents with erectile dysfunction. Which question is most appropriate? 1) “Do you have sex with men, women, or both?” 2) “Which types of sexual activity do you participate in?” 3) “Do you have more than one partner?” 4) “Have you maintained an interest in sex?” 18. The nurse is conducting a health history for a patient who seeks care for breast pain. Which question from the nurse is most appropriate? 1) “Where is the lump or mass located?” 2) “Is there discomfort when you palpate your breast?” 3) “When did you notice the lump?” 4) “Have you had a recent injury to your breast?” 19. Which is the first step when teaching a patient to perform a self-breast examination? 1) Using the pads of the fingers to palpate the breast symmetrically 2) Compressing the nipple looking for discharge 3) Inspecting the breasts in the mirror 4) Reporting any redness or inflammation 20. The nurse is assessing a patient who presents with nipple discharge. Which question from the nurse is appropriate? 1) “Have you ever had this problem before?” 2) “How would you rate your pain on a scale of 0 to 10?” 3) “Has there been a change in your bra size?”
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4) “Have you had any nipple piercings?” 21. Which is the most likely cause of bloody discharge from the nipple? 1) Breast cancer 2) Intraductal papilloma 3) Fibrocystic breast disease 4) Side effect of medication 22. Which is a normal finding during a breast examination? 1) Asymmetry 2) Dimpling 3) Puckering 4) Erythema 23. Which inspection finding during a breast examination would be considered abnormal? 1) Bilateral nipple inversion 2) Nipples that point outward, slightly upward, and lateral 3) Bilateral nipple eversion 4) Unilateral nipple inversion 24. How should the nurse position a patient for palpation of the breast and axillae during the physical assessment? 1) Supine with arms at her side 2) Supine with arms over her head 3) Supine with arm over her head and pillow under shoulder of side being examined 4) Supine with arm over her head and a pillow under shoulder opposite side being examined 25. A female patient complains of having a "strange discharge" from the vagina. Which diagnostic test would be NURSINGTB.CO useful to aid in the diagnosis of this patient's disorder? 1) Biopsy 2) Complete blood count 3) Serum hormone levels 4) Papanicolaou smear Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. Which are the primary functions of the female reproductive system? Select all that apply. 1) Protecting ova for fertilization 2) Transporting the fertilized ova for implantation 3) Nourishing the developing fetus 4) Producing sperm 5) Providing a drainage site for the excretion of urine 27. The nurse is assessing the patient’s scrotum. Which are normal assessment findings? Select all that apply. 1) Darker skin color than rest of the body 2) Swelling 3) Left testicle slightly lower than right testicle 4) Erythema 5) Hydrocele
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28. The nurse is using transillumination during a scrotal assessment. Which conditions will produce a red glow? Select all that apply. 1) Orchitis 2) Atrophic testicle 3) Hydrocele 4) Spermatocele 5) Hernia 29. The nurse is providing education to a patient who is scheduled for a mammogram. Which information should the nurse include in the teachings session? Select all that apply. 1) “You should avoid using deodorant prior to testing.” 2) “You will need to remove all jewelry prior to this test.” 3) “You will remove all your clothing from the waist down.” 4) “Your health-care provider will contact you with the results.” 5) “You will need to have a full bladder for the test to be accurate.” 30. The nurse is providing education to a patient who will use a diaphragm for birth control. Which patient statements indicate the need for additional education regarding this method of birth control? Select all that apply. 1) “This method is close to 99% effective when used properly.” 2) “This method does not increase my risk for blood clots.” 3) “I will need to insert it prior to sexual intercourse.” 4) “I will need to keep it in place for 12 hours after intercourse.” 5) “This method may not be effective when I am prescribed antibiotics.”
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Chapter 64: Assessment of Reproductive Function Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate 1 2 3 4
Feedback When assessing vaginal bleeding, the nurse would not ask how many pads or tampons are used in a 2-hour period. When assessing vaginal bleeding, the nurse would not ask how many pads or tampons are used in a 10-hour period. The nurse will ask the patient how many pads or tampons are used in a 24-hour period to assess how much bleeding occurs. When assessing vaginal bleedN inU g ,RthSe InuNrG s eTwBo . u lC d O n oMt ask how many pads or tampons are used in a 72-hour period.
PTS: 1 CON: Female Reproduction 2. ANS: 4 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate Feedback 1 Sexual satisfaction questions are appropriate near the end of the history. 2 Self-care practice questions are appropriate near the end of the history. 3 Sexual practice questions are appropriate near the end of the history. 4 Reproductive health history questions relate to sexual function, fertility, sexual satisfaction, sexual practices, and self-care. Begin by asking about symptoms the patient is experiencing. PTS: 1
CON: Female Reproduction
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3. ANS: 1 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate Feedback 1 It is appropriate for the nurse to ask the patient to describe the color of the vaginal discharge. 2 Asking if the patient’s sexual partner has the same symptoms is more appropriate for a patient who presents with a lesion. 3 Asking the patient about vaginal bleeding is more appropriate if the patient presents with abnormal vaginal bleeding. 4 Asking the patient about the normal menstrual flow is more appropriate for a patient who presents with vaginal bleeding. PTS: 1 CON: Female Reproduction 4. ANS: 4 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Correlating relevant diagnostic examinations to reproductive function Chapter page reference: 1425-1431 NURSINGTB.COM Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Female Reproduction Difficulty: Easy Feedback 1 There is no screening test for ovarian cancer. 2 There is no screening test for vaginal cancer. 3 There is no screening test for uterine cancer. 4 A Pap smear can detect precancerous and cancerous cell changes in the cervix and may also detect HPV.
PTS: 1 CON: Female Reproduction 5. ANS: 3 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying]
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Concept: Female Reproduction Difficulty: Moderate Feedback 1 Gynecological examination should not be painful. Taking short, quick breaths may help with anxiety. 2 The lithotomy position is assumed by the patient for the exam. 3 Emptying the bladder may reduce the discomfort of the exam and prevent embarrassment if bladder control is lost during the exam. 4 While reviewing the medical history is important, this is not the priority action at this time. PTS: 1 CON: Female Reproduction 6. ANS: 4 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Discussing changes in reproductive function associated with aging Chapter page reference: 1432 Heading: Age-Related Changes in the Female and Male Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Female Reproduction Difficulty: Easy
1 2 3 4
Feedback Just because a patient is in meN noUpau RSseIdNo es GTnBo t.mCeOanMthe patient is no longer sexually active. Just because a patient is in menopause does not mean the patient is childless. Menopause is not a type of sexually transmitted infection. Menopause indicates the patient has not had a menstrual period in one year.
PTS: 1 CON: Female Reproduction 7. ANS: 3 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Discussing changes in reproductive function associated with aging Chapter page reference: 1432 Heading: Age-Related Changes in the Female and Male Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Female Reproduction Difficulty: Easy Feedback 1 Atrophy of the clitoris is an expected finding for an older adult patient. 2 A decrease in vaginal secretions is an expected finding for an older adult patient. 3 The older adult patient is at an increased risk for vaginal infections due to the changes in the vagina. 4 The older adult patient is at an increased risk for painful intercourse.
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PTS: 1 CON: Female Reproduction 8. ANS: 3 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate
1 2 3 4
Feedback Asking the patient about the frequency of intercourse is more appropriate when assessing sexual functioning. Asking the patient about the ability to achieve an orgasm is more appropriate when assessing sexual functioning. Bloating is a common clinical manifestation associated with premenstrual syndrome. Asking the patient about the number of sexual partners is more appropriate when assessing sexual functioning.
PTS: 1 CON: Female Reproduction 9. ANS: 3 Chapter number and title: 64, Assessment of Reproductive Function NURSINGTB.COM Chapter learning objective: Describing the procedure for completing a history and physical assessment of reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Female Reproduction Difficulty: Easy Feedback 1 The side-lying position is not appropriate for a pelvic examination. 2 The supine position is not appropriate for a pelvic examination. 3 The appropriate patient position for a pelvic examination is the lithotomy position. 4 The prone position is not appropriate for a pelvic examination. PTS: 1 CON: Female Reproduction 10. ANS: 4 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Discussing the function of the reproductive system Chapter page reference: 1423-1425 Heading: Male Reproductive System Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding]
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Concept: Male Reproduction Difficulty: Easy Feedback 1 Protecting the ova is a primary function of the female genitourinary system. 2 While the male genitourinary system does regulate male hormones, estrogen is not a primary male hormone. 3 Insulin is not secreted by the male genitourinary system. 4 Manufacturing sperm is a primary function of the male genitourinary system. PTS: 1 CON: Female Reproduction 11. ANS: 1 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Discussing changes in reproductive function associated with aging Chapter page reference: 1432 Heading: Age-Related Changes in the Female and Male Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Male Reproduction Difficulty: Easy Feedback 1 Testosterone is responsible for the development of secondary sexual characteristics and reproductive capacity. Reduction in testosterone levels occurs by the age of 50. 2 Progesterone and luteinizing hormone are female hormones. 3 Growth-stimu latin g hormone is after the age of 50. N UnoRt Sa IhoNrm GoTnBe th.atCOd ecreases M 4 Progesterone and luteinizing hormone are female hormones. PTS: 1 CON: Male Reproduction 12. ANS: 3 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Male Reproduction Difficulty: Moderate Feedback 1 The right index finger is not placed in the rectum when assessing for an inguinal hernia. 2 The femoral area is not palpated to assess for an inguinal hernia. 3 To palpate for inguinal hernias, ask the patient to bear down while the nurse palpates the inguinal area. Place the dominant index finger in the patient’s scrotal sac above the testicle and invaginate the scrotal skin. 4 One of the answer choices is correct. PTS: 1
CON: Male Reproduction
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13. ANS: 4 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Male Reproduction Difficulty: Moderate Feedback 1 The thumb is used in addition to the first two fingers. 2 This is not the technique used for this assessment. 3 This is not the technique used for this assessment. 4 Gently palpate a testicle between your thumb and your first two fingers. Note the size, shape, consistency, and presence or absence of masses. PTS: 1 CON: Male Reproduction 14. ANS: 4 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to reproductive function Chapter page reference: 1423-1425 Heading: Male Reproductive System NURSINGTB.COM Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Male Reproduction Difficulty: Easy Feedback 1 Hydroceles and spermatoceles are conditions related to the testes. 2 Hydroceles and spermatoceles are conditions related to the testes. 3 A rectocele is herniation of the rectum into the vagina. 4 To assess for femoral hernias, palpate the femoral canal, which is located below the femoral artery, and have the patient bear down or cough. PTS: 1 CON: Male Reproduction 15. ANS: 3 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Discussing changes in reproductive function associated with aging Chapter page reference: 1432 Heading: Age-Related Changes in the Female and Male Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Male Reproduction Difficulty: Easy Feedback
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1 2 3 4
Pubic hair tends to thin, not thicken, on the external genitalia with age. Testicles tend to become smaller and softer with age. Atrophy of the penis is an expected assessment finding for an older adult patient. The scrotal sac for an older adult patient tends to lose elasticity.
PTS: 1 CON: Male Reproduction 16. ANS: 4 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate Feedback 1 The nurse will ask the patient about a history of kidney stones when assessing for genitourinary symptoms. 2 The nurse will ask the patient about changes in the voiding pattern when assessing for genitourinary symptoms. 3 The nurse will ask the patient how many voids occur during the night when assessing for genitourinary symptoms. 4 An appropriate question whenNcon URduc S ItinNgGaTsBex.u al C Oh iMstory interview is to ask the patient if birth control is used. PTS: 1 CON: Female Reproduction 17. ANS: 4 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Male Reproduction Difficulty: Difficult Feedback 1 Asking the patient who sex is shared with is more appropriate when assessing the patient’s sexual history. 2 Asking the patient about participation in different types of sex is more appropriate when assessing the patient’s sexual history. 3 Asking the patient the current number of sexual partners is more appropriate when assessing the patient’s sexual history. 4 Asking the patient about the current interest in sex is an appropriate question when assessing erectile dysfunction.
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PTS: 1 CON: Male Reproduction 18. ANS: 2 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Female Reproduction Difficulty: Difficult
1 2 3 4
Feedback Asking the patient where a lump or mass is located is more appropriate if the patient presents with a mass versus breast pain. It is appropriate for the nurse to ask the patient if there is discomfort with palpation when the patient presents with breast pain. Asking the patient when a lump was first noticed is more appropriate if the patient presents with a mass versus breast pain. Asking the patient if there was a recent injury to the breast is more appropriate if the patient presents with a mass versus breast pain.
PTS: 1 CON: Female Reproduction 19. ANS: 3 NURSINGTB.COM Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing]] Concept: Female Reproduction Difficulty: Difficult Feedback 1 This is the second step when teaching a patient how to perform a self-breast examination. 2 This is the third step when teaching a patient how to perform a self-breast examination. 3 This is the first step when teaching a patient how to perform a self-breast examination. 4 This is the fourth step when teaching a patient who to perform a self-breast examination. PTS: 1 CON: Female Reproduction 20. ANS: 1 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of reproductive function Chapter page reference: 1425-1431
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Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Female Reproduction Difficulty: Difficult
1 2 3 4
Feedback An appropriate question to ask the patient with nipple discharge is asking the patient if the problem has been experienced before. Asking the patient to rate pain is more appropriate for a patient who presents with breast discomfort. Asking the patient if there is a change in breast size is more appropriate for a patient who presents with breast pain or a breast mass. Asking the patient if there is a history of nipple piercings is more appropriate for a patient who presents with pain versus discharge.
PTS: 1 CON: Female Reproduction 21. ANS: 1 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Correlating relevant diagnostic examinations to reproductive function Chapter page reference: 1418-1422 Heading: Female Reproductive System Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation NURSINGTB.CO Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Easy
1 2 3 4
Feedback Breast cancer can cause bloody nipple discharge. Intraductal papilloma can cause serous or serosanguineous nipple discharge. Fibrocystic breast disease usually does not have nipple discharge but does have fluidfilled cysts. Certain medications can cause lactation.
PTS: 1 CON: Cellular Regulation 22. ANS: 1 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Correlating relevant diagnostic examinations to reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Female Reproduction Difficulty: Easy Feedback 1 Asymmetry is a normal finding during a breast examination.
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2 3 4
Dimpling is not a normal finding during a breast examination and can indicate cancer. Puckering is not a normal finding during a breast examination and can indicate cancer. Erythema is not a normal finding during a breast examination and can indicate infection.
PTS: 1 CON: Female Reproduction 23. ANS: 4 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Correlating relevant diagnostic examinations to reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Female Reproduction Difficulty: Easy Feedback 1 This is not an abnormal finding. 2 This is not an abnormal finding. 3 This is not an abnormal finding. 4 Nipple changes such as eversion to inversion or changes in the direction they are pointing may indicate an underlying mass. PTS: 1 CON: Female Reproduction 24. ANS: 3 NURSINGTB.COM Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Describing the procedure for completing a history and physical assessment of reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate Feedback 1 This is not an appropriate position. 2 This is not an appropriate position. 3 Have the woman lie on the exam table in the supine position and place a small pillow or rolled towel under the shoulder on the side you will examine first. This position spreads the breast tissue over the chest wall. 4 This is not an appropriate position. PTS: 1 CON: Female Reproduction 25. ANS: 4 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Correlating relevant diagnostic examinations to reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems
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Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Female Reproduction Difficulty: Easy
1 2 3 4
Feedback This diagnostic test may or may not be helpful in diagnosing this patient. This diagnostic test may or may not be helpful in diagnosing this patient. This diagnostic test may or may not be helpful in diagnosing this patient. The patient is complaining of a strange discharge from her vagina. A Papanicolaou smear would be the most helpful in diagnosing the cause of that symptom.
PTS: 1
CON: Female Reproduction
MULTIPLE RESPONSE 26. ANS: 1, 2, 3, 5 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Discussing the function of the reproductive system Chapter page reference: 1418-1422 Heading: Female Reproductive System Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [UnN d eUrsRtaSndIinNgG] TB.COM Concept: Female Reproduction Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is correct. One of the primary functions of the female reproductive system is protecting the ova for fertilization. This is correct. One of the primary functions of the female reproductive system is transporting the fertilized ova for implantation. This is correct. One of the primary functions of the female reproductive system is nourishing the developing fetus. This is incorrect. Producing sperm is a primary function of the male, not the female, reproductive system. This is correct. One of the primary functions of the female reproductive system is providing a drainage site for the excretion of urine.
PTS: 1 CON: Female Reproduction 27. ANS: 1, 3 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Identifying key anatomical components of the reproductive system Chapter page reference: 1423-1425 Heading: Male Reproductive System Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance
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Cognitive level: Comprehension [Understanding] Concept: Male Reproduction Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is correct. The scrotum is darker in color than the rest of the body. This is incorrect. Swelling is not a normal assessment finding. This is correct. The left testicle is expected to hang slightly lower than the right testicle. This is incorrect. Erythema is not a normal assessment finding. This is incorrect. A hydrocele is not a normal assessment finding.
PTS: 1 CON: Male Reproduction 28. ANS: 3, 4 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Correlating relevant diagnostic examinations to reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Male Reproduction Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is incorrect. Orchitis N UisRnoStIa NcoGnTd iBtio.nCthOaMt produces a red glow with transillumination . This is incorrect. An atrophic testicle is not a condition that produces a red glow with a transillumination. This is correct. A hydrocele will produce a red glow with transillumination. This is correct. A spermatocele will produce a red glow with transillumination. This is incorrect. A hernia will not produce a red glow with transillumination.
PTS: 1 CON: Male Reproduction 29. ANS: 1, 4 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to reproductive function Chapter page reference: 1425-1431 Heading: Assessment of Male and Female Reproductive Systems Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate
1. 2.
Feedback This is correct. Deodorant, lotions, and creams should be avoided the day of the test until the mammogram has been completed. This is incorrect. Jewelry removal is required for an MRI, not a mammogram.
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3. 4. 5.
This is incorrect. The patient would remove clothing from the waist down for an ultrasound, not a mammogram. This is correct. Results can take a few days; therefore, the nurse should tell the patient the health-care provider will contact her with the results in a few days. This is incorrect. A full bladder is often required for an abdominal ultrasound, not a mammogram.
PTS: 1 CON: Female Reproduction 30. ANS: 1, 4, 5 Chapter number and title: 64, Assessment of Reproductive Function Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to reproductive function Chapter page reference: 1418-1422 Heading: Female Reproductive System Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive level: Analysis [Analyzing] Concept: Female Reproduction Difficulty: Difficult
1. 2. 3. 4. 5. PTS: 1
Feedback This is correct. This method of birth control is 85% to 95% effective. This is incorrect. This method of birth control does not increase the risk of blood clots like those that are hormone dependent. This is incorrect. This mNetUhoRdSoI f bi Nrth GTcBo n.tro COl m Must be inserted prior to sexual intercourse. This is correct. The diaphragm must be left in place 6, not 12, hours after intercourse. This is correct. Hormone-based contraceptives may be ineffective with antibiotics. CON: Female Reproduction
Chapter 65: Coordinating Care for Female Patients With Reproductive and Breast Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A patient recovering from a hysterectomy does not want to take the prescribed estrogen replacement therapy because of the fear of developing breast cancer. Which response by the nurse is the most appropriate? 1) “The risk of breast cancer is slightly increased for women who opt to take estrogen replacement therapy.” 2) “Perhaps you should consider an estrogen-progestin combination therapy.” 3) “The risk of breast cancer is not increased for women who have had a hysterectomy and take estrogen replacement medications.” 4) “Taking estrogen replacement is required after a hysterectomy.” 2. The nurse is instructing a group of women between the ages of 40 and 50 about early detection of breast cancer. What should the nurse include in this teaching? 1) Perform monthly breast self-exams 2) See a health-care provider if there is a strong family history of breast cancer
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3) Have a yearly mammogram 4) Have a clinical breast exam performed by a health-care provider every five years 3. During an assessment, the nurse notes that a patient receiving radiation treatments for breast cancer has excoriated skin. What is the priority nursing diagnosis for this patient? 1) Excess Fluid Volume 2) Ineffective Breathing Pattern 3) Risk for Infection 4) Activity Intolerance 4. The nurse is caring for a patient with metastatic breast cancer receiving chemotherapy. Even though the prognosis is poor, the patient tells the nurse that the plan is to do everything to survive. How should the nurse respond to this patient? 1) “You have a great attitude, and I am here to support you through education.” 2) “It is important to plan for your death, even though there is a chance you will survive.” 3) “You should face the reality of the situation. You do not have a good chance of survival.” 4) “I am going to speak with your family regarding your unrealistic expectations.” 5. The nurse is reviewing the plan of care for a patient being treated with brachytherapy for breast cancer. Which assessment finding indicates that the patient’s skin integrity has been maintained? 1) Skin intact 2) Skin dry and excoriated 3) Skin stretched 4) Skin damp and sweaty 6. A patient prescribed tamoxifen (Nolvadex) for breast cancer treatment asks the nurse how the medication works. What is the best response by N th U e nRuS rsI e ?NGTB.COM 1) “Tamoxifen works by inhibiting the cellular mitosis of breast cancer.” 2) “Tamoxifen works by blocking estrogen receptors on breast tissue.” 3) “Tamoxifen works by binding to the DNA of breast cancer cells.” 4) “Tamoxifen works by inhibiting the metabolism of breast cancer cells.” 7. The nurse instructs a patient recovering from a mastectomy on ways to prevent lymphedema. Which patient statement indicates that teaching has been successful? 1) “I should do the exercises on my affected arm every day.” 2) “I have to take no special precautions.” 3) “I should avoid cleansing my skin with soap.” 4) “Eating fresh fruits and vegetables will prevent my arm from swelling.” 8. A menopausal patient is concerned that intercourse with her spouse has become increasingly painful. What should the nurse explain about the changes in this patient’s body after menopause? 1) Cervical mucus is thicker. 2) Estrogen levels increase. 3) Sexual desire diminishes. 4) Vaginal lubrication decreases. 9. A female patient is prescribed an androgen medication to treat an estrogen-sensitive type of breast cancer. What should the nurse instruct this patient about the medication? 1) There is an increased risk of multiple births. 2) Monitor weight weekly. 3) Report calf pain or dyspnea. 4) It must be taken with food.
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10. A nurse is caring for a patient who is perimenopausal and states that she has recently had frequent bacterial vaginal infections. Which reason for these infections will the nurse include in the response to the patient? 1) Decreased vaginal pH 2) Increased vaginal pH 3) Increased estrogen level 4) Decreased vasomotor stability 11. A nurse working in an outpatient women’s health clinic is caring for a patient in menopause. When discussing hormone replacement therapy (HRT) with the patient, the nurse should include which statement? 1) “Most healthy, recently menopausal women should not use HRT for relief of hot flashes and vaginal dryness.” 2) “HRT is the least effective treatment for menopausal hot flashes and vaginal dryness.” 3) “If vaginal dryness and painful intercourse are the only symptoms, then low-dose vaginal estrogen is preferred.” 4) “The risk of blood clots in the legs or lungs is further increased by using transdermal patches, gels, or sprays.” 12. A female patient asks what causes the symptoms of menopause. On which hormonal function should the nurse focus when responding to this patient's question? 1) Increased estrogen levels 2) Increased progesterone levels 3) Estrone as the major hormone 4) Increased luteinizing hormone levels 13. A patient with a history of breast cancer who is entering menopause is seeking information about how to manage hot flashes. What informatioN n U caRn SbeIpNroGvTidBed.tC o O thM e patient? 1) Soy and black cohosh can be used to manage the hot flashes associated with menopause. 2) The patient should be advised that she will have to wait until menopause has finished for the hot flashes to cease. 3) Estrogen is the only reliable method of treatment for hot flashes. 4) Olive oil and black cohosh are effective in the management of hot flashes. 14. A patient who is postmenopausal confides in the nurse about pain experienced during intercourse. What should the nurse instruct the patient to do? 1) Use vaginal lubricants during intercourse 2) Avoid intercourse 3) Tolerate this problem because it is a normal part of aging 4) Decrease the frequency of intercourse to decrease the pain 15. A nurse is caring for a patient who complains of pain with menstruation. What is true regarding the etiology and pathophysiology of this condition? 1) Primary dysmenorrhea is caused by decreased levels of prostaglandins, causing the contractions of the uterus to increase in strength. 2) Primary dysmenorrhea begins within the first three or four menstrual periods after menarche and will occur with each ovulatory cycle during the teens and 20s of a woman’s life. 3) Secondary dysmenorrhea is more common than primary dysmenorrhea. 4) Primary dysmenorrhea causes include endometriosis, tumors, cysts, pelvic adhesions, pelvic inflammatory disease, infections, cervical stenosis, uterine leiomyomas, and adenomyosis.
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16. The nurse identifies that a patient is at risk for dysfunctional uterine bleeding. What did the nurse assess in this patient to lead to this clinical diagnosis? 1) Low level of stress 2) Weight gain of 5 lbs in five years 3) Uses birth control pills for contraception 4) Limits intake of high-fat foods 17. A young adolescent patient is concerned about experiencing severe cramps with menstruation. How should the nurse respond to this patient? 1) “This is not normal but is something that can be treated.” 2) “You have cramps because you started your periods too early.” 3) “Cramps are seen in those who just start having periods and will become less severe as you get older.” 4) “You need to see a gynecologist for a pelvic examination.” 18. The nurse has identified the diagnosis of Ineffective Coping for a patient with severe premenstrual syndrome. What should be included in this patient’s plan of care? 1) Encourage frequent rest periods 2) Suggest four ounces of wine each day 3) Encourage exercise and relaxation techniques 4) Instruct to avoid contraception during menstruation if engaging in sexual intercourse 19. The nurse is developing strategies to be used for the relief of menstrual cramping in a teaching session to a group of young women. What should be the focus of these strategies? 1) Minimization of menstrual flow 2) Avoidance of uterine contraction SuIscNleGTB.COM 3) Increase of blood flow to the uteNriU n eRm 4) Decrease in estrogen production 20. The nurse instructs a patient on ways to reduce premenstrual difficulty. Which patient statement indicates the instruction was beneficial? 1) The patient states the need to increase dietary sugar intake to promote energy. 2) The patient states that guided imagery does not help with the symptoms. 3) The patient states the need to increase intake of simple carbohydrates. 4) The patient states that reducing caffeine intake will help. 21. The nurse is caring for a patient recovering from a total hysterectomy. What should the nurse include when instructing this patient prior to discharge? 1) The importance of douching after intercourse for at least 6 weeks 2) Why bed rest is indicated for at least a month after the surgery 3) The risks and benefits of hormone replacement therapy 4) The importance of returning to normal activities of daily living as soon as possible 22. The nurse is conducting a health history interview for a female patient with a family history of ovarian cancer. Which information noted by the nurse indicates this patient has an increased risk for developing this type of cancer? 1) Two noted pregnancies 2) Long term oral contraceptive use 3) Currently breastfeeding an infant 4) Body mass index indicates obesity
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23. The nurse is assessing a patient who is at risk for endometrial cancer. Which is the priority question for the nurse to include in the health history? 1) “How many times have you been pregnant?” 2) “Do you experience irregular or heavy periods?” 3) “How often do you engage in sexual intercourse?” 4) “Have you ever been diagnosed with a sexually transmitted infection?” 24. Which patient has an increased risk for being diagnosed with cervical cancer in the later stages of the disease process? 1) 35-year-old Hispanic woman with a Pap smear one year ago 2) 45-year-old Caucasian woman with a Pap smear three years ago 3) 50-year-old Native American woman with a Pap smear four years ago 4) 55-year-old African American woman with a Pap smear six years ago 25. The nurse is preparing education for a patient who is diagnosed with endometriosis. Which should the nurse plan to include in the teaching session as a first-line treatment option? 1) Oral contraceptives 2) Aromatase inhibitors 3) Laparoscopy with biopsy 4) Gonadotropin-releasing hormone agonists Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. The nurse is reviewing data collected during a health history and physical assessment and determines that a patien t is at risk for dev elopin g breasNt cUa R n cSerI. N WG h iT chBd.a C ta OsuMppo rts th is p atien t’s risk for develop ing b reast cancer? Select all that apply. 1) Age 60 2) Breastfed both children 3) Sister had breast cancer 4) Body mass index 22 5) Menopause at age 58 27. The nurse is teaching a 34-year-old patient who has a sister and mother with a history of breast cancer about early screening for the health problem. Which should the nurse include in this teaching session? Select all that apply. 1) Routine monthly breast self-examination 2) Annual screening mammography 3) Routine breast exams to begin after age 35 4) Clinical breast examination every three years 5) Reporting of any changes in breast tissue to the health provider at the next routine visit 28. The nurse is providing care to a patient who was recently diagnosed with breast cancer. The nurse is providing education regarding the possible treatment options. Which options will the nurse include in the teaching session? Select all that apply. 1) Mastectomy 2) Hormone therapy 3) Lumpectomy 4) Palliative care 5) Radiation
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Chapter 65: Coordinating Care for Female Patients With Reproductive and Breast Disorders Answer Section MULTIPLE CHOICE 1. ANS: 3 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with reproductive disorders Chapter page reference: 1435-1441 Heading: Breast Cancer Integrated Processes: Communication and Documentation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate Feedback 1 The risk for the development of breast cancer is not greater for women who take estrogen replacement therapy after undergoing a hysterectomy. 2 Progestin therapies are not used for women who are in surgical menopause. Further, it is inappropriate for the nurse to make suggestions of a prescriptive nature, as it violates the scope of practice. 3 Estrogen replacement therapy is not associated with breast cancer for women who have undergone a hysterectomy. Taking estrogen after a hysterectomy is optional, not NURSINGTB.COM required. 4 While it is not mandatory for the patient to take estrogen replacement therapy after surgery, the nurse should clarify and correct misconceptions of the patient. PTS: 1 CON: Female Reproduction 2. ANS: 3 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of reproductive disorders Chapter page reference: 1435-1441 Heading: Breast Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Female Reproduction Difficulty: Easy
1
2
Feedback Breast self-exam is no longer recommended for all women. The American Cancer Society recommends that young women who choose to do breast self-exams have their technique validated by a health-care practitioner at a yearly physical exam. The earlier a lump is discovered, the greater the effectiveness of treatment. Discussing a family history of breast cancer would be part of the annual breast exam performed by a health-care provider.
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3 4
Yearly mammography for all women over the age of 40 is encouraged, as it decreases the mortality from breast cancer. It is inappropriate for women in this age group to have a clinical breast exam every five years.
PTS: 1 CON: Female Reproduction 3. ANS: 3 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with reproductive disorders Chapter page reference: 1435-1441 Heading: Breast Cancer Integrated Processes: Nursing Process: Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Cellular Regulation Difficulty: Difficult Feedback 1 The patient who receives radiation is more at risk for fluid volume deficit. 2 There is no evidence of respiratory difficulties in this patient. 3 Radiation causes skin excoriation. With the excoriation, the patient is at risk for infection due to skin breakdown. 4 Depending on the assessment, the patient may or may not have activity intolerance. PTS: 1 CON: Cellula rN R UeRguSlaItiNonGTB.COM 4. ANS: 1 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with reproductive disorders Chapter page reference: 1435-1441 Heading: Breast Cancer Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate
1
2
3
Feedback This patient is in the earliest stages of cancer treatment, with removal of the primary tumor about to take place. The nurse’s role is to support this patient’s optimism and help in fighting the disease by teaching about nutrition and other supportive actions the patient can take to minimize complications of treatment. Emphasizing the low survival rate, encouraging the patient to prepare for death, and talking with the family about the patient’s unrealistic expectations would not support the patient's optimism. While the prognosis may be poor, the outcome is not absolute, and the patient’s wish to do whatever is necessary to survive should be supported.
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4
Emphasizing the low survival rate, encouraging the patient to prepare for death, and talking with the family about the patient’s unrealistic expectations would not support the patient's optimism.
PTS: 1 CON: Cellular Regulation 5. ANS: 1 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with reproductive disorders Chapter page reference: 1435-1441 Heading: Breast Cancer Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Easy Feedback 1 The goal for the patient receiving radiation therapy to the chest is intact skin, which the nurse would expect to find. If the goal were not met, the nurse would find excoriation. 2 Skin that is damp with sweat, dry, or stretched is not consistent with radiation. 3 Skin that is damp with sweat, dry, or stretched is not consistent with radiation. 4 Skin that is damp with sweat, dry, or stretched is not consistent with radiation. PTS: 1 CON: Cellular Regulation 6. ANS: 2 NURSINGTB.COM Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with reproductive disorders Chapter page reference: 1435-1441 Heading: Breast Cancer Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Tamoxifen does not inhibit the cellular mitosis of breast cancer. 2 Breast cancer is dependent on estrogen for growth. Tamoxifen (Nolvadex) acts by blocking estrogen receptors; the tumor is deprived of estrogen. 3 Tamoxifen does not bind to the DNA of breast cancer cells. 4 Tamoxifen does not inhibit the metabolism of breast cancer cells. PTS: 1 CON: Cellular Regulation 7. ANS: 1 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with reproductive disorders Chapter page reference: 1435-1441 Heading: Breast Cancer
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Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Cellular Regulation Difficulty: Difficult
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Feedback Range-of-motion exercises in the affected arm help develop collateral drainage and prevent the development of lymphedema. The patient should be instructed to protect the affected limb by not permitting blood pressure measurement and avoiding tight jewelry and clothing on the limb. There is no reason for the patient to avoid cleansing the skin of the affected arm with soap. Consuming fresh fruits and vegetables will not prevent the development of lymphedema.
PTS: 1 CON: Cellular Regulation 8. ANS: 4 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with reproductive disorders Chapter page reference: 1445-1446 Heading: Menopause Integrated Processes: Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [UnN deUrsR taS ndIinNgG ] TB.COM Concept: Female Reproduction Difficulty: Easy
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Feedback The patient’s concerns are not related to cervical mucus. Older women remain capable of multiple orgasms and may, in fact, experience an increase in sexual desire after menopause. Vaginal lubrication and elasticity decrease with menopause along with decreased estrogen, and phases of the sexual response cycle may take longer to occur. Older women remain capable of multiple orgasms and may, in fact, experience an increase in sexual desire after menopause. Vaginal lubrication and elasticity decrease with menopause along with decreased estrogen, and phases of the sexual response cycle may take longer to occur. Older women remain capable of multiple orgasms and may, in fact, experience an increase in sexual desire after menopause. Vaginal lubrication and elasticity decrease with menopause along with decreased estrogen, and phases of the sexual response cycle may take longer to occur.
PTS: 1 CON: Female Reproduction 9. ANS: 2 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with reproductive disorders
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Chapter page reference: 1435-1441 Heading: Breast Cancer Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Easy
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Feedback Increased risk of multiple births is associated with female infertility medications. Androgen hormone replacements may be used to treat estrogen-dependent cancers. The nurse should instruct the patient of the risk of developing secondary male sex characteristics when taking this medication. This medication also affects body weight, so the nurse should instruct the patient to monitor body weight weekly. Reporting calf pain or dyspnea is associated with estrogen hormone replacement therapy. This medication does not need to be taken with food.
PTS: 1 CON: Cellular Regulation 10. ANS: 2 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Menopause Chapter page reference: 1445-1446 Heading: Menopause Integrated Processes: Nursing Process: Planning Client Need: Physiological IntegrityNURSINGTB.COM – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Female Reproduction Difficulty: Easy
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Feedback The vaginal pH does not decrease. In the perimenopausal patient, the vaginal pH increases, predisposing the patient to bacterial vaginal infections. In perimenopause, estrogen levels decrease, not increase. Decreased vasomotor stability leads to hot flashes, not vaginal bacterial infections.
PTS: 1 CON: Female Reproduction 11. ANS: 3 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with reproductive disorders Chapter page reference: 1445-1446 Heading: Menopause Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate
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Feedback Most healthy, recently menopausal women may use HRT for relief of hot flashes and vaginal dryness. Most healthy, recently menopausal women may use HRT for relief of hot flashes and vaginal dryness. If vaginal dryness and dyspareunia (painful intercourse) are the only symptoms, then low-dose vaginal estrogen is preferred. The risk is further lowered by using low-dose estrogen pills or transdermal patches, gels, or sprays.
PTS: 1 CON: Female Reproduction 12. ANS: 3 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Menopause Chapter page reference: 1445-1446 Heading: Menopause Integrated Processes: Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Female Reproduction Difficulty: Easy Feedback 1 As ovarian function decreases, the production of estrogen decreases and is replaced by estrone as the major ovarian estr NUo ge RSn .INGTB.COM 2 With decreased ovarian function, the second ovarian hormone, progesterone, which is produced during the luteal phase of the menstrual cycle, also is markedly reduced. 3 Estrone is produced in small amounts and has only about one-tenth the biological activity of estradiol. 4 With decreased ovarian function, the second ovarian hormone, progesterone, which is produced during the luteal phase of the menstrual cycle, also is markedly reduced. PTS: 1 CON: Female Reproduction 13. ANS: 1 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with reproductive disorders Chapter page reference: 1445-1446 Heading: Menopause Integrated Processes: Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Easy Feedback 1 The hot flashes can be successfully managed with soy and black cohosh. 2 Advising the patient to wait is inappropriate. 3 Estrogen is not the only reliable method of treatment for hot flashes. 4 Olive oil is not used to manage hot flashes.
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PTS: 1 CON: Cellular Regulation 14. ANS: 1 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with reproductive disorders Chapter page reference: 1445-1446 Heading: Menopause Integrated Processes: Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Female Reproduction Difficulty: Easy
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Feedback It is not uncommon for a postmenopausal female to report painful intercourse that is related to a decrease in vaginal lubrication. Vaginal lubricants can be very effective in reducing the pain experienced during intercourse. It is stereotypical to assume the patient would have less of a desire for intercourse at an older age. Avoidance and decreasing frequency of intercourse would not resolve the problem for the patient. While this is a normal part of aging, it is not therapeutic to tell the patient to tolerate the pain. Avoidance and decreasing frequency of intercourse would not resolve the problem for NURSINGTB.COM the patient.
PTS: 1 CON: Female Reproduction 15. ANS: 2 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Dysmenorrhea Chapter page reference: 1441-1442 Heading: Dysmenorrhea Integrated Processes: Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Female Reproduction Difficulty: Easy
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Feedback Primary dysmenorrhea is caused by the release of prostaglandins that cause the contractions of the uterus needed to expel menstrual fluid and tissue. Pain associated with menses, called dysmenorrhea, is one of the most common menstrual dysfunctions. Primary dysmenorrhea is very common among women with normal menstrual function and is more common than secondary dysmenorrhea. Primary dysmenorrhea begins within the first three or four menstrual periods after menarche and will occur with each ovulatory cycle during the teens and 20s of a woman's life.
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Secondary dysmenorrhea is related to pathology or diseases that affect the uterus and pelvic area. It is not more common than primary dysmenorrhea. Causes of secondary dysmenorrhea include endometriosis, tumors, cysts, pelvic adhesions, pelvic inflammatory disease, infections, cervical stenosis, uterine leiomyomas, and adenomyosis.
PTS: 1 CON: Female Reproduction 16. ANS: 3 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Describing the epidemiology of reproductive disorders Chapter page reference: 1441-1442 Heading: Dysmenorrhea Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Female Reproduction Difficulty: Easy
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Feedback A high, not low, level of stress is a risk factor for dysfunctional uterine bleeding. Extreme weight change is associated with dysfunctional uterine bleeding. Gaining 5 lbs in 5 years is not considered extreme weight change. A number of factors may predispose a woman to dysfunctional uterine bleeding. These factors include stress, extreme weight changes, and use of oral contraceptive agents. Dysfunctional uterine bleedingNiU s R usS uaIllN yG reTlaBte. d to COhoMrmonal imbalances and not associated with low-fat diets.
PTS: 1 CON: Female Reproduction 17. ANS: 3 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with reproductive disorders Chapter page reference: 1441-1442 Heading: Dysmenorrhea Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate Feedback 1 Primary dysmenorrhea is a normal occurrence. 2 The patient is an early adolescent, which is not too early to start having periods. 3 Primary dysmenorrhea occurs without specific pelvic pathology and is most often seen in girls who have just begun menstruating, becoming less severe after the mid-20s. Cramps are normal in the age range. 4 A number of factors may predispose a woman to dysfunctional uterine bleeding. These factors include stress, extreme weight changes, and use of oral contraceptive agents. PTS: 1
CON: Female Reproduction
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18. ANS: 3 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with reproductive disorders Chapter page reference: 1441-1442 Heading: Dysmenorrhea Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate Feedback 1 Frequent rest periods would be beneficial for a patient with dysfunctional uterine bleeding. 2 The patient should not be encouraged to have four ounces of wine each day. 3 Interventions to aid with ineffective coping for a patient with severe premenstrual syndrome include encouraging exercise and relaxation techniques and avoiding alcohol intake. 4 The patient should be instructed to use contraception if engaging in sexual intercourse during menstruation because ovulation and pregnancy can occur. PTS: 1 CON: Female Reproduction 19. ANS: 3 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Correlatin g c lini ca l manife s tat io ns to pathophysiolo gical processes of: NU RS I N GTB.C OM Dysmenorrhea Chapter page reference: 1441-1442 Heading: Dysmenorrhea Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate Feedback 1 There is no connection between the actual amount of flow and pain. 2 Uterine contraction cannot be avoided. 3 Menstrual cramping is a result of the muscle ischemia that occurs when the patient experiences powerful uterine contractions. Increase of blood flow to the uterine muscle through rest, some exercises, application of heat to the abdomen, and presence of milder uterine contractions (such as those associated with orgasm) can decrease pain and cramping. 4 Estrogen production should follow normal patterns and should not be altered. PTS: 1 CON: Female Reproduction 20. ANS: 4 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with reproductive disorders Chapter page reference: 1441-1442
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Heading: Dysmenorrhea Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Female Reproduction Difficulty: Difficult Feedback 1 This patient statement indicates the need for additional instruction because guided imagery can be used to reduce stress and promote relaxation, and simple carbohydrates and sugars should be reduced. 2 This patient statement indicates the need for additional instruction because guided imagery can be used to reduce stress and promote relaxation, and simple carbohydrates and sugars should be reduced. 3 This patient statement indicates the need for additional instruction because guided imagery can be used to reduce stress and promote relaxation, and simple carbohydrates and sugars should be reduced. 4 The patient stating that a reduction in caffeine intake will help is evidence that instruction was beneficial. PTS: 1 CON: Female Reproduction 21. ANS: 3 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with reproductive disorders Chapter page reference: 1435-1441 NURSINGTB.COM Heading: Breast Cancer Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate Feedback 1 Douching and sexual intercourse should be avoided for at least four to six weeks after the surgery. 2 Bed rest is not indicated when recovering from this surgery. 3 If the ovaries have been removed with a hysterectomy, the nurse should provide information on the risks and benefits of hormone replacement therapy because the patient is immediately thrust into menopause. 4 The patient should restrict physical activity for four to six weeks after the surgery. PTS: 1 CON: Female Reproduction 22. ANS: 4 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Describing the epidemiology of reproductive disorders Chapter page reference: 1449-1451 Heading: Ovarian Cancer Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding]
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Concept: Female Reproduction Difficulty: Easy Feedback 1 Pregnancy has a protective effect regarding ovarian cancer. 2 Long term oral contraceptive use has a protective effect regarding ovarian cancer. 3 Breastfeeding has a protective effect regarding ovarian cancer. 4 Obesity is a risk factor for the development of ovarian cancer. PTS: 1 CON: Female Reproduction 23. ANS: 2 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Describing the epidemiology of reproductive disorders Chapter page reference:1452-1454 Heading: Uterine Cancer Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate Feedback 1 The number of times a woman has been pregnant is not associated with endometrial cancer. 2 Irregular or heavy periods prior to menopause is a clinical manifestation associated with endometrial cancer. 3 Engaging in sexual intercours eN iU s no RSt as INsoGciTatBed.wCiOth Mend ometrial cancer. 4 Sexually transmitted infections are not associated with endometrial cancer. PTS: 1 CON: Female Reproduction 24. ANS: 4 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Describing the epidemiology of reproductive disorders Chapter page reference: 1454-1456 Heading: Cervical Cancer Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Female Reproduction Difficulty: Easy Feedback 1 This patient does not have a high risk for cervical cancer. 2 This patient does not have a high risk for cervical cancer. 3 This patient does not have a high risk for cervical cancer. 4 About half of cervical cancer cases are diagnosed in the late stages of the disease. Diagnosis in later stages occurs more frequently in women older than 50, black women, and women who have not had a Pap smear for more than five years. PTS: 1 25. ANS: 1
CON: Female Reproduction
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Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with reproductive disorders Chapter page reference: 1443-1444 Heading: Endometriosis Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate Feedback 1 Oral contraceptives are first-line treatment for endometriosis. 2 This drug, while appropriate for endometriosis, is not first-line treatment. 3 This is a diagnostic tool for endometriosis. 4 This drug, while appropriate for endometriosis, is not first-line treatment. PTS: 1
CON: Female Reproduction
MULTIPLE RESPONSE 26. ANS: 1, 3, 5 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Describing the epidemiology of reproductive disorders Chapter page reference: 1435-1441 Heading: Breast Cancer NURSINGTB.COM Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Easy
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Feedback This is correct. The risk for developing breast cancer increases with age. This is incorrect. Breastfeeding and maintaining a normal body weight lower a person's risk for developing breast cancer. This is correct. Having a first-degree relative with breast cancer increases the risk. This is incorrect. Breastfeeding and maintaining a normal body weight lower a person’s risk for developing breast cancer. This is correct. Menopause after the age of 55 also increases the risk for developing breast cancer.
PTS: 1 CON: Cellular Regulation 27. ANS: 2, 4 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with reproductive disorders Chapter page reference: 1435-1441 Heading: Breast Cancer
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Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate
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Feedback This is incorrect. While the American Cancer Society recommends that woman be familiar with what is normal regarding breast tissue, routine monthly breast self-examination is no longer recommended. This is correct. Since this patient’s mother and sister both have a history of breast cancer, she would be eligible for annual mammography. This is incorrect. Routine breast exams should begin at age 20, not age 35. This is correct. The American Cancer Society recommends clinical breast examination every three years from ages 20 to 39. This is incorrect. Prompt reporting of any change in the breast tissue to a health-care provider is recommended by the American Cancer Society.
PTS: 1 CON: Female Reproduction 28. ANS: 1, 2, 3, 5 Chapter number and title: 65, Coordinating Care for Female Patients With Reproductive and Breast Disorders Chapter learning objective: Discussing the medical management of: Breast cancer Chapter page reference: 1435-1441 Heading: Breast Cancer Integrated Processes: Nursing Process: Planning Client Need: Physiological IntegrityNURSINGTB.COM – Physiological Adaptation Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate
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Feedback This is correct. Treatment options appropriate for a patient newly diagnosed with breast cancer may include mastectomy, hormone therapy, lumpectomy, and radiation. This is correct. Treatment options appropriate for a patient newly diagnosed with breast cancer may include mastectomy, hormone therapy, lumpectomy, and radiation. This is correct. Treatment options appropriate for a patient newly diagnosed with breast cancer may include mastectomy, hormone therapy, lumpectomy, and radiation. This is incorrect. Palliative care will only be implemented once the patient’s cancer is considered to be terminal in nature. This is correct. Treatment options appropriate for a patient newly diagnosed with breast cancer may include mastectomy, hormone therapy, lumpectomy, and radiation. CON: Female Reproduction
Chapter 66: Coordinating Care for Male Patients With Reproductive and Breast Disorders Multiple Choice
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Identify the choice that best completes the statement or answers the question. 1. The nurse is preparing an educational program on risk factors for the development of prostate cancer. Which information will the nurse include as being the greatest risk factor for developing prostate cancer? 1) The patient’s age 2) A family history 3) A history of a vasectomy 4) A diet high in fat 2. While receiving discharge teaching, an adult patient recovering from a prostatectomy is distressed to learn that episodes of incontinence may occur. Which should the nurse teach the patient to help minimize incontinence? 1) Proper administration of incontinence medication 2) Steps to change the Foley catheter bag every day 3) Fluid restriction 4) Kegel exercises 3. A patient is scheduled to undergo a prostate biopsy. The patient asks the nurse what is expected immediately following the procedure. Which response by the nurse is the most appropriate? 1) “You will need to avoid strenuous activity for 24 hours.” 2) “Your sexual partners will need to be notified.” 3) “You will likely experience discomfort for 24-48 hours after the procedure.” 4) “You will not have any restrictions following the biopsy.” 4. The nurse is caring for a patient who has a continuous bladder irrigation running following a prostatectomy. During the shift, a total of 1500 mL of irrigant is infused. The Foley bag is emptied twice for the shift with totals of 850 mL and 950 mL. What N is U thR e S p aItiN e nGt’T s B a c. tuC a lOu M r ine output for the shift? 1) 300 mL 2) 250 mL 3) 100 mL 4) 950 mL 5. The nurse is caring for a patient who returns to the unit following transurethral resection of the prostate due to prostate cancer with a three-way Foley catheter in place. The patient states that he has the urge to urinate and wants the catheter removed. Which response by the nurse is the most appropriate? 1) “This must be a complication, because the Foley catheter is supposed to evacuate clots that cause the sensation you are describing.” 2) “The spasm is an unexpected finding because the procedure does not invade the urethra.” 3) “The sensation is caused by the silicone used in the catheter. I will speak to the doctor about switching to a different catheter.” 4) “This is an expected sensation, but the Foley catheter must remain in place.” 6. The nurse is preparing to discharge a patient recovering from prostate surgery for cancer. What should the nurse emphasize when providing discharge instructions for this patient? 1) “You may drive yourself home.” 2) “Avoid strenuous activity and heavy lifting for two weeks.” 3) “It is quite common to notice blood in your urine following this type of surgery.” 4) “Reduce your fluid intake so you won't need to void as often.” 7. A nursing instructor is teaching a group of student nurses about the cultural implications of prostate cancer. Which statement will the nursing instructor include in the teaching session? 1) “African-American men are at lowest risk for prostate cancer.”
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2) “Asian- and Native American men have the highest risk for developing prostate cancer.” 3) “Approximately one in eight men ages 70 and older will be diagnosed with prostate cancer.” 4) “A diet low in dairy increases a man’s risk for developing prostate cancer.” 8. The nurse is assessing a patient for symptoms of prostate cancer. Which symptoms would indicate the patient is experiencing an enlarged prostate? 1) Dysuria 2) Nerve pain 3) Bone pain 4) Bowel dysfunction 9. A patient with prostate cancer is being discharged from the hospital. Which educational topic is inappropriate for this patient? 1) Provide information on doses of complementary herbs 2) Teach the patient and his family noninvasive methods of pain control 3) Stress the importance of keeping patient appointments with health-care providers 4) Provide the patient and the patient’s family information on support groups 10. During a health history, the nurse learns that a patient has a recent onset of impotence. Which question will help identify a potential cause of this manifestation? 1) “Does this occur often?” 2) “For what diseases and disorders have you been treated?” 3) “Are you on any medications?” 4) “How does your partner feel about this problem?” 11. The nurse is conducting a health histoNryU w RiSthIaNpGatTieBn t.dCiaOgnMo sed with erectile dysfunction. Which finding could provide a possible cause for the patient’s problem? 1) Blood pressure of 118/68 mmHg 2) Body mass index (BMI) of 24.5 3) Alcohol intake of four to six beers each day 4) Plays golf twice a week 12. A patient is concerned about becoming impotent because of the inability to sustain an erection and a history of a sexually transmitted infection as a young adult. What is the nurse’s best response to this patient's concerns? 1) “An occasional incident like this is normal and common, and there is no reason to be concerned.” 2) “Sexually transmitted infections may result in sexual problems in adults.” 3) “Erectile dysfunction is the correct term for the inability to achieve or sustain an erection.” 4) “The medical diagnosis of erectile dysfunction is not made until the man has erection difficulties in 25% or more of his interactions.” 13. A male patient tells the nurse that he has no idea why his wife wants to stay married to him because he has not been able to “perform” sexually since his prostate surgery. Which diagnosis would be appropriate for this patient? 1) Ineffective Coping 2) Situational Low Self-Esteem 3) Hormonal Imbalance 4) Sexual Dysfunction
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14. The nurse is planning care for a patient with erectile dysfunction. What should the nurse include in this patient’s plan of care? 1) Names of psychologists with experience in treating the disorder 2) Types of devices and surgeries available to help with the disorder 3) Reason for disorder as being side effect of prescribed medication 4) Information on exact cause 15. The nurse is instructing a patient about the medication sildenafil (Viagra). Which patient statement indicates teaching has been effective? 1) “Viagra should be taken with food.” 2) “I can take Viagra anywhere from one to six hours before sex.” 3) “I can take only one pill in a 24-hour period.” 4) “Grapefruit juice will decrease the effects of Viagra.” 16. A patient asks for a prescription for tadalafil (Cialis). What would be important for the nurse know prior to planning interventions for this patient? 1) “Do you have diabetes mellitus?” 2) “Do you take blood pressure medication?” 3) “Do you have any sexually transmitted infections?” 4) “Do you use nitroglycerine?” 17. A nurse is caring for a patient who is prescribed a selective phosphodiesterase type 5 inhibitor for the treatment of erectile dysfunction. The nurse should include which statement when educating the patient regarding this medication? 1) “You should take this medication about 30 minutes before sexual activity.” 2) “The action of this medication will last up to 36 hours.” 3) “This medication will enhance eNreUctRioS n sIwNiG t hTo B r . wiC thO ouMt sexual stimulation .” 4) “This medication should not be taken more than twice daily.” 18. A nurse is treating a patient with diabetes mellitus who reports erectile dysfunction (ED). Which hormonal cause contributes to ED? 1) Increased prolactin levels 2) Decreased aldosterone levels 3) Decreased circulating catecholamines 4) Decreased thyroid-stimulating hormone 19. The nurse is caring for a patient diagnosed with benign prostatic hyperplasia (BPH) who is experiencing an increase in symptoms. Which statement by the patient would best explain the source of the increased symptoms? 1) “I have decreased oral intake at night.” 2) “I recently had a vasectomy.” 3) “I am using an over-the-counter cold medication for a cold.” 4) “I am taking over-the-counter saw palmetto.” 20. The nurse is caring for a male patient of Japanese descent who is experiencing urinary retention. The patient asks the nurse if it is possible that he is experiencing benign prostatic hyperplasia (BPH). Which response by the nurse is the most appropriate? 1) “No, you are not old enough to have BPH.” 2) “Your symptoms are not consistent with BPH.” 3) “Your provider will run some tests; however, you are considered low-risk for BPH.” 4) “Where did you get an idea that you might have BPH?”
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21. The nurse is providing follow-up care for a patient was recently diagnosed with benign prostatic hyperplasia (BPH). Which nursing diagnosis is the priority for the nurse to include in the patient’s plan of care? 1) Chronic Pain 2) Impaired Urinary Elimination 3) Constipation 4) Diarrhea 22. A patient is recovering from prostate surgery on a medical-surgical unit. The patient will be ready for discharge within the next few days. Which teaching point is appropriate for this patient? 1) The patient should not drive for six weeks after surgery. 2) The patient should call the health-care provider immediately for any pain. 3) The patient should increase the fiber in his diet. 4) The patient should avoid heavy lifting for two weeks after surgery. 23. A patient is recovering from minimally invasive surgery due to a diagnosis of benign prostatic hyperplasia (BPH). After assessing the patient, the nurse expects which outcome for this patient? 1) Bowel continence 2) Absence of pain 3) No postoperative treatment 4) Urinary continence 24. The nurse is providing care to a patient who is diagnosed with mild benign prostatic hyperplasia (BPH). Which lifestyle change is appropriate for this patient? 1) Increasing caffeine intake 2) Decreasing alcohol intake 3) Urinating at first urge 4) Using over-the-counter antihistaNmUinResS INGTB.COM 25. A patient reports getting up to urinate several times a night and difficulty starting a stream of urine. After medical testing is completed, a diagnosis of benign prostatic hyperplasia (BPH) is made. After conducting teaching regarding BPH, which statement by the patient indicates the need for further education? 1) “Alpha blockers can be used to control my symptoms.” 2) “I know I will get cancer of the prostate because of this.” 3) “As my condition progresses, I may need to consider surgical management.” 4) “There are nonsurgical treatment options available.” Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. A nurse is screening a patient for prostate cancer. Which assessment findings would cause the nurse to suspect that the patient has prostate cancer? Select all that apply. 1) Fatigue 2) Back pain 3) Hematuria 4) Scrotal edema 5) Upper extremity weakness 27. The nurse is caring for a patient with erectile dysfunction (ED). Which medication should the nurse anticipate being prescribed for this patient? Select all that apply. 1) Tadalafil (Cialis) 2) Sildenafil (Viagra)
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3) Buspirone (BuSpar) 4) Vardenafil (Levitra) 5) Methylphenidate (Ritalin) 28. The nurse is providing care to a patient who is diagnosed with benign prostatic hyperplasia (BPH). Which items in the patient’s health history may have contributed to this diagnosis? Select all that apply. 1) 70 years of age 2) Diet high in milk 3) Excessive exercise 4) Diet high in meat and fats 5) African-American ethnicity
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Chapter 66: Coordinating Care for Male Patients With Reproductive and Breast Disorders Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Describing the epidemiology of male reproductive disorders Chapter page reference: 1466-1470 Heading: Prostate Cancer Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Cellular Regulation Difficulty: Difficult Feedback 1 The greatest risk for developing prostate cancer is age. Prostate cancer affects one out of every eight men over the age of 60. 2 Genetics, vasectomy, and a diet high in fat are also risk factors. 3 Genetics, vasectomy, and a diet high in fat are also risk factors. 4 Genetics, vasectomy, and a diet high in fat are also risk factors. PTS: 1 CON: Cellular Regulation ANS: 4 2. NURSINGTB.COM Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with male reproductive disorders Chapter page reference: 1466-1470 Heading: Prostate Cancer Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Medication and Foley catheters are not appropriate long-term treatments for this complication. 2 Medication and Foley catheters are not appropriate long-term treatments for this complication. 3 Restricting fluids may cause further urinary problems and is not advised. 4 Urinary incontinence after surgery is not unexpected. Teaching the patient Kegel exercises is the best way to help him eliminate or reduce occasions of stress incontinence. PTS: 1 CON: Urinary Elimination 3. ANS: 3 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders
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Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of male reproductive disorders Chapter page reference: 1466-1470 Heading: Prostate Cancer Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Strenuous activity is avoided only for about four hours. 2 There is no need to notify sexual partners following the procedure. 3 The patient may experience discomfort for one to two days after the procedure. 4 The patient must restrict activity for only a short period after the procedure. PTS: 1 CON: Urinary Elimination 4. ANS: 1 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with male reproductive disorders Chapter page reference: 1466-1470 Heading: Prostate Cancer Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] NURSINGTB.COM Concept: Urinary Elimination Difficulty: Moderate Feedback 1 The total infused is 1500 mL. The total drained is 1800 mL. The total, or true output, is 300mL greater than the input. 2 This is not an accurate measurement of this patient’s urine output. 3 This is not an accurate measurement of this patient’s urine output. 4 This is not an accurate measurement of this patient’s urine output. PTS: 1 CON: Urinary Elimination 5. ANS: 4 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Discussing the medical management of: Prostate Cancer Chapter page reference: 1466-1470 Heading: Prostate Cancer Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 Antispasmodics may be prescribed for the patient with a three-way irrigation catheter. Spasms are not a complication of the catheter but rather an expected finding. 2 The procedure does invade the urethra.
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The substance that the catheter is made of does not affect spasms. Patients with a three-way Foley catheter usually complain of sensations of having to void despite the presence of the catheter. This urge to void is caused by the pressure exerted by the balloon in the internal sphincter of the bladder and the wide diameter of the catheter that is used for the purpose of irrigation.
PTS: 1 CON: Urinary Elimination 6. ANS: 3 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with male reproductive disorders Chapter page reference: 1466-1470 Heading: Prostate Cancer Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Cellular Regulation Difficulty: Moderate Feedback 1 The patient should not drive after surgery for at least two weeks. 2 The healing period after prostate surgery is four to eight weeks, and the patient should avoid strenuous activity during this time. 3 Blood in the urine is fairly common after surgery. 4 Continued increase in fluid intake will help the urine to remain dilute and reduce the risk of clot formation. NURSINGTB.COM PTS: 1 CON: Cellular Regulation 7. ANS: 3 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Describing the epidemiology of male reproductive disorders Chapter page reference: 1466-1470 Heading: Prostate Cancer Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Cellular Regulation; Diversity Difficulty: Feedback 1 African-Americans have the highest incidence of prostate cancer in the United States and the world, with rates greater than 60% higher than those seen in Caucasians. 2 Asian- and Native American men have the lowest risk for prostate cancer. 3 Approximately one in eight men ages 70 and older will be diagnosed with prostate cancer. 4 A diet high in dairy increases a man’s risk for developing prostate cancer. PTS: 1 CON: Cellular Regulation | Diversity 8. ANS: 1 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders
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Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Prostate Cancer Chapter page reference: 1466-1470 Heading: Prostate Cancer Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation; Urinary Elimination Difficulty: Easy 1 2 3 4
Feedback Symptoms of an enlarged prostate include hematuria, dysuria, reduction in urinary stream, nocturia, frequency of urination, and abnormal size of prostate on digital exam. This choice indicates nerve impingement. This choice indicates metastatic symptoms. This choice indicates metastatic symptoms.
PTS: 1 CON: Cellular Regulation | Urinary Elimination 9. ANS: 1 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with male reproductive disorders Chapter page reference: 1466-1470 Heading: Prostate Cancer Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective CareNURSINGTB.COM Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Easy Feedback 1 The nurse does not have authorization to provide information on doses of complementary herbs. 2 When providing discharge instructions to the patient with prostate cancer, the nurse will teach the patient and his family noninvasive methods of pain control and stress the importance of keeping patient appointments with health-care providers. The nurse will also provide the patient and his family information on support groups. 3 When providing discharge instructions to the patient with prostate cancer, the nurse will teach the patient and his family noninvasive methods of pain control and stress the importance of keeping patient appointments with health-care providers. The nurse will also provide the patient and his family information on support groups. 4 When providing discharge instructions to the patient with prostate cancer, the nurse will teach the patient and his family noninvasive methods of pain control and stress the importance of keeping patient appointments with health-care providers. The nurse will also provide the patient and his family information on support groups. PTS: 1 CON: Cellular Regulation 10. ANS: 2 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders
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Chapter learning objective: Developing a comprehensive plan of nursing care for patients with male reproductive disorders Chapter page reference: 1464-1466 Heading: Erectile Dysfunction Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Male Reproduction Difficulty: Difficult Feedback 1 Asking the patient if the impotence occurs often will not help identify the cause of the problem. 2 A patient's health history can provide clues to the underlying cause of impotence. The question “for what diseases and disorders have you been treated” would provide the nurse with information as to possible causes for the recent onset of the disorder. 3 The question “are you on any medication?” would be beneficial to ask; however, it should be an open-ended question and not a closed-ended question as identified. The nurse should ask the patient to “list any medications” instead of asking “are you on any medication?” which could be answered with a yes or no. 4 Asking the patient how the partner feels about the problem also will not help identify a possible cause. PTS: 1 CON: Male Reproduction 11. ANS: 3 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: DescribinNgUthReSepIidNeG mT ioB lo. gyCoOf male reproductive disorders Chapter page reference: 1464-1466 Heading: Erectile Dysfunction Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Male Reproduction Difficulty: Easy Feedback 1 Recreational sports, a body mass index within normal limits, and a normal blood pressure would not provide a possible cause for the patient’s recent experience with the disorder. 2 Recreational sports, a body mass index within normal limits, and a normal blood pressure would not provide a possible cause for the patient’s recent experience with the disorder. 3 The risk factors for erectile dysfunction are numerous. They include advancing age, diseases such as heart disease and diabetes, trauma, and the use of prescription or illicit drugs. Excessive use of alcohol can also result in erectile dysfunction. 4 Recreational sports, a body mass index within normal limits, and a normal blood pressure would not provide a possible cause for the patient’s recent experience with the disorder. PTS: 1 12. ANS: 1
CON: Male Reproduction
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Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with male reproductive disorders Chapter page reference: 1464-1466 Heading: Erectile Dysfunction Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Male Reproduction Difficulty: Moderate Feedback 1 This patient is concerned about his masculinity and sexual abilities. The correct answer at this point is to tell him that it is common and normal for men to experience occasional erectile difficulties. 2 This is true; however, this does not serve to alleviate the patient’s concerns. If the patient continues to have difficulties achieving or sustaining an erection, further investigation should take place. Simply correcting the patient’s use of medical terminology does not address his concerns. 3 This is true; however, this does not serve to alleviate the patient’s concerns. If the patient continues to have difficulties achieving or sustaining an erection, further investigation should take place. Simply correcting the patient’s use of medical terminology does not address his concerns. 4 This is true; however, this does not serve to alleviate the patient’s concerns. If the patient continues to have difficulties achieving or sustaining an erection, further investigation should take place. Simply correcting the patient’s use of medical terminolo gy does not address N h iU s R coS n cIe N rn G s . TB.COM PTS: 1 CON: Male Reproduction 13. ANS: 2 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with male reproductive disorders Chapter page reference: 1464-1466 Heading: Erectile Dysfunction Integrated Processes: Nursing Process: Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Male Reproduction Difficulty: Moderate Feedback 1 The patient is viewing himself as less than a man and is concerned with his wife wanting to remain married to him. Situational Low Self-Esteem is the most appropriate nursing diagnosis for the patient at this time. 2 The patient may or may not be experiencing ineffective coping. 3 Hormonal imbalance is not a nursing diagnosis. 4 Sexual dysfunction is associated with anxiety concerning the cause of the dysfunction, which is not the case for the patient. PTS: 1
CON: Male Reproduction
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14. ANS: 2 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Discussing the medical management of: Erectile dysfunction Chapter page reference: 1464-1466 Heading: Erectile Dysfunction Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Male Reproduction Difficulty: Moderate Feedback 1 The nurse should not provide the names of psychologists who treat the disorder. 2 When planning the care of a patient with erectile dysfunction, the nurse should include information on medications for treatment and types of devices and surgeries available to help with the disorder. 3 Explaining the reason for the disorder as being a side effect of prescribed medication could cause the patient to discontinue medication necessary to treat other health disorders and should not be done. 4 Because an exact cause may be difficult to determine for the patient, this would not be appropriate for the nurse to include in the patient's plan of care. PTS: 1 CON: Male Reproduction 15. ANS: 3 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with maleNreUpR roS duIcN tivGeTdB iso.rC deO rs Chapter page reference: 1464-1466 Heading: Erectile Dysfunction Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Male Reproduction Difficulty: Moderate Feedback 1 Sildenafil should be taken on an empty stomach, not with food. 2 The optimum time for administration is one hour before sex, but it can be taken up to four hours before sex. 3 Taking only one pill in a 24-hour period is the recommended dosing for sildenafil (Viagra). 4 Grapefruit juice can lead to increased, not decreased, levels of sildenafil. PTS: 1 CON: Male Reproduction 16. ANS: 4 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with male reproductive disorders Chapter page reference: 1464-1466 Heading: Erectile Dysfunction Integrated Processes: Nursing Process: Assessment
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Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Male Reproduction Difficulty: Moderate Feedback 1 Having diabetes mellitus is not a contraindication to the use of tadalafil (Cialis). 2 Taking blood pressure medication is not a contraindication to the use of tadalafil (Cialis). 3 Having a sexually transmitted infection is not a contraindication to the use of tadalafil (Cialis). 4 Combining tadalafil (Cialis) with nitroglycerine can lead to serious hypotension. PTS: 1 CON: Male Reproduction 17. ANS: 2 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with male reproductive disorders Chapter page reference: 1464-1466 Heading: Erectile Dysfunction Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Male Reproduction Difficulty: Moderate
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The patient should take the medication an hour prior to sexual activity, not 30 minutes. Sildenafil citrate (Viagra), vardenafil hydrochloride (Levitra), tadalafil (Cialis), and avanafil (Stendra) are all selective phosphodiesterase type 5 inhibitors used in the treatment of erectile dysfunction. The nurse should tell the patient that the action of this medication will last up to 36 hours. This medication will enhance erections only with sexual stimulation and should not be taken more than once daily. This medication will enhance erections only with sexual stimulation and should not be taken more than once daily.
PTS: 1 CON: Male Reproduction 18. ANS: 4 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Describing the epidemiology of male reproductive disorders Chapter page reference: 1464-1466 Heading: Erectile Dysfunction Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Male Reproduction Difficulty: Easy Feedback 1 This does not contribute to ED. 2 This does not contribute to ED.
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This does not contribute to ED. Hormonal causes of ED include decreased testosterone, decreased prolactin, and alterations in thyroid function. A decrease in thyroid-stimulating hormone (TSH) would be a cause of this disorder.
PTS: 1 CON: Male Reproduction 19. ANS: 3 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with male reproductive disorders Chapter page reference: 1460-1464 Heading: Benign Prostatic Hyperplasia (BPH) Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Analysis [Analyzing] Concept: Urinary Elimination Difficulty: Difficult Feedback 1 Decreased oral intake does not cause BPH. 2 A vasectomy does not affect the symptoms of BPH. 3 Use of cold medications can increase symptoms because of their anticholinergic properties. 4 Use of saw palmetto and decreased oral intake at night may resolve symptoms. PTS: 1 CON: UrinaryNEUliR mSinI atN ioG n TB.COM 20. ANS: 3 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with male reproductive disorders Chapter page reference: 1460-1464 Heading: Benign Prostatic Hyperplasia (BPH) Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate
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Feedback While age does increase the risk of BPH, it is not the only factor to consider. The patient is experiencing urinary retention, which is consistent with BPH. The nurse must always provide honest responses to patient questions. Telling the patient that the provider will run tests but due to his ethnicity, he is considered low-risk for developing BPH is the most appropriate response. Asking a patient where he got that idea is demeaning.
PTS: 1 CON: Urinary Elimination 21. ANS: 2 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders
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Chapter learning objective: Developing a comprehensive plan of nursing care for patients with male reproductive disorders Chapter page reference: 1460-1464 Heading: Benign Prostatic Hyperplasia (BPH) Integrated Processes: Nursing Process: Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Urinary Elimination Difficulty: Difficult Feedback 1 Acute pain, not chronic pain, is also an appropriate diagnosis. 2 The priority diagnosis for a patient diagnosed with BPH is Impaired Urinary Elimination. 3 Patients with BPH have problems associated with urinary elimination, not bowel elimination. Constipation and Diarrhea are not appropriate nursing diagnoses for this patient. 4 Patients with BPH have problems associated with urinary elimination, not bowel elimination. Constipation and Diarrhea are not appropriate nursing diagnoses for this patient. PTS: 1 CON: Urinary Elimination 22. ANS: 3 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with male reproductive disorders Chapter page reference: 1466-1470 NURSINGTB.COM Heading: Prostate Cancer Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Urinary Elimination Difficulty: Moderate Feedback 1 The patient may not drive for two weeks after surgery. 2 The patient is taught to avoid heavy lifting for four to eight weeks after discharge and to call the doctor for severe abdominal or chest pain. 3 The patient should be encouraged to increase the fiber in his diet, as straining for bowel movements after surgery can cause increased pressure in the prostate area. The patient and family are taught good dietary habits to keep bowel movements regular and soft. 4 The patient is taught to avoid heavy lifting for four to eight weeks after discharge and to call the doctor for severe abdominal or chest pain. PTS: 1 CON: Urinary Elimination 23. ANS: 4 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Developing a comprehensive plan of nursing care for patients with male reproductive disorders Chapter page reference: 1460-1464 Heading: Benign Prostatic Hyperplasia (BPH)
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Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy Feedback 1 Most patients, due to pain and swelling in the area, may have problems with constipation immediately following the surgical intervention. 2 The patient will need postoperative teaching and will experience some amount of discomfort. 3 The patient will need postoperative teaching and will experience some amount of discomfort. 4 After surgery and removal of the catheter, the patient should return to urinary continence as expected. PTS: 1 CON: Urinary Elimination 24. ANS: 3 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with male reproductive disorders Chapter page reference: 1460-1464 Heading: Benign Prostatic Hyperplasia (BPH) Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] NURSINGTB.COM Concept: Urinary Elimination Difficulty: Easy Feedback 1 The patient should also eliminate caffeine and alcohol from the diet. 2 The patient should also eliminate caffeine and alcohol from the diet. 3 A patient who is diagnosed with mild BPH is often treated with lifestyle changes and a “wait and see” approach. Urinating at first urge is a lifestyle change that is appropriate for this patient. 4 It is also important for this patient to avoid using over-the-counter antihistamines. PTS: 1 CON: Urinary Elimination 25. ANS: 2 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Benign prostatic hyperplasia Chapter page reference: 1460-1464 Heading: Benign Prostatic Hyperplasia (BPH) Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Urinary Elimination Difficulty: Difficult Feedback 1 Alpha blockers will help control the symptoms.
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BPH is benign condition that does not necessarily progress to cancer. It is caused by an increase in size of the prostate gland and is seen in older males. There are nonsurgical treatments available, such as medication to shrink the gland along with surgical management, such as resection. There are nonsurgical treatments available, such as medication to shrink the gland along with surgical management, such as resection.
PTS: 1
CON: Urinary Elimination
MULTIPLE RESPONSE 26. ANS: 1, 2, 3 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Prostate cancer Chapter page reference: 1466-1470 Heading: Prostate Cancer Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Cellular Regulation Difficulty: Easy
1.
2.
3. 4. 5.
Feedback This is correct. Unfortu nNa U telRy S , m IaNnyGpTaBtie.nCts OwMith prostate cancer remain undiagnosed until the cancer is well established. Hematuria, back pain, bilateral lower extremity weakness, and fatigue are symptoms associated with prostate cancer. This is correct. Unfortunately, many patients with prostate cancer remain undiagnosed until the cancer is well established. Hematuria, back pain, bilateral lower extremity weakness, and fatigue are symptoms associated with prostate cancer. This is correct. Unfortunately, many patients with prostate cancer remain undiagnosed until the cancer is well established. Hematuria, back pain, bilateral lower extremity weakness, and fatigue are symptoms associated with prostate cancer. This is incorrect. Scrotal edema is not a clinical manifestation associated with prostate cancer. This is incorrect. Upper extremity weakness is not a clinical manifestation associated with prostate cancer.
PTS: 1 CON: Cellular Regulation 27. ANS: 1, 2, 4 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Discussing the medical management of: Erectile dysfunction Chapter page reference: 1464-1466 Heading: Erectile Dysfunction Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Male Reproduction Difficulty: Easy
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1. 2. 3. 4. 5.
Feedback This is correct. Tadalafil (Cialis) works to relax the smooth muscles in the penis, allowing increased blood flow to the penis resulting in an erection. This is correct. Sildenafil (Viagra) works to relax the smooth muscles in the penis, allowing increased blood flow to the penis resulting in an erection. This is incorrect. Buspirone (Buspar) is an antianxiety agent and is not effective for erectile dysfunction (ED). This is correct. Vardenafil (Levitra) works to relax the smooth muscles in the penis, allowing increased blood flow to the penis resulting in an erection. This is incorrect. Methylphenidate (Ritalin) is a mild central nervous system stimulant and is not effective for ED.
PTS: 1 CON: Male Reproduction 28. ANS: 1, 4, 5 Chapter number and title: 66, Coordinating Care for Male Patients With Reproductive and Breast Disorders Chapter learning objective: Describing the epidemiology of male reproductive disorders Chapter page reference: 1460-1464 Heading: Benign Prostatic Hyperplasia (BPH) Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Urinary Elimination Difficulty: Easy
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1. 2. 3. 4. 5.
PTS: 1
Feedback This is correct. Although the exact cause is unknown, risk factors associated with BPH are increasing age, men of African-American descent, and a diet high in meat and fat. This is incorrect. No link has been made to milk or exercise. This is incorrect. No link has been made to milk or exercise. This is correct. Although the exact cause is unknown, risk factors associated with BPH are increasing age, men of African-American descent, and a diet high in meat and fat. This is correct. Although the exact cause is unknown, risk factors associated with BPH are increasing age, men of African-American descent, and a diet high in meat and fat. CON: Urinary Elimination
Chapter 67: Coordinating Care for Patients With Sexually Transmitted Infection Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A patient reports an open area on the penis. Which question will help the nurse with data collection? 1) “Do you think you have a disease?” 2) “Have you had sexual intercourse recently?” 3) “Are you promiscuous?” 4) “When did you initially notice this open area?”
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2. A patient is experiencing dysuria, urinary frequency, and vaginal discharge. For which sexually transmitted infection should the nurse prepare the patient for testing? 1) Syphilis 2) Vaginitis 3) Chlamydia 4) Trichomoniasis 3. A patient diagnosed with a sexually transmitted infection reports having “no idea” how the illness was contracted. Which nursing diagnosis would be appropriate for the patient at this time? 1) Anxiety 2) Knowledge Deficit 3) Ineffective Coping 4) Sexual Dysfunction 4. The nurse is planning care for a patient with a history of sexually transmitted infections. What should be included in this plan of care? 1) Instruction to limit sexual contact until recovered from illness 2) Plan for the patient to contact sexual partners regarding the diagnosis 3) Need to increase fluids and rest 4) Importance of adequate nutrition 5. A patient with syphilis is allergic to penicillin. Based on this data, which medication does the nurse anticipate as appropriate for this patient? 1) Doxycycline 2) Amoxicillin 3) Gentamicin 4) Erythromycin NURSINGTB.COM 6. The nurse is planning care to address pain in the patient with genital herpes. Which intervention would be appropriate for this patient? 1) Increase the intake of cranberry juice 2) Clean lesions two or three times a day with warm water and soap 3) Dry lesions with a hair dryer turned to the hot setting 4) Wear tight cotton clothing 7. A public health nurse is educating a group of adults regarding sexually transmitted infections. Which is an appropriate statement by the nurse? 1) “Males have higher rates of gonorrhea and chlamydia, whereas women have higher rates of syphilis.” 2) “Men are disproportionately affected by STIs compared to women and infants.” 3) “Women often experience few early manifestations of the infection, delaying diagnosis and treatment.” 4) “The incidence of STIs is highest among young Caucasian females.” 8. A gray vaginal discharge with an unpleasant fishy or musty odor is likely to be a symptom of which infection? 1) Candidiasis 2) Trichomonas 3) Gonorrhea 4) Chlamydia
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9. An adolescent patient worriedly shows the nurse a wart located on her vulva. Based on this data which diagnosis does the nurse suspect? 1) Condyloma 2) Genital herpes 3) Chancre 4) Secondary syphilis 10. After a 5% acetic acid wash is applied to the cervix, the cervix blanches white. Based on this data, which conclusion by the nurse is appropriate? 1) Bacterial vaginosis 2) Monilial vaginitis 3) HPV 4) Cervical cancer 11. During a physical assessment, the nurse notes vesicles. Which disease process is associated with this clinical manifestation? 1) Secondary syphilis 2) Herpes simplex virus 3) Hyperthyroidism 4) Gonorrhea 12. A young adult patient reports penile discharge and dysuria for three days. Which is the most likely cause of the patient’s clinical manifestations? 1) Sexually transmitted infection 2) Orchitis 3) Spermatocele 4) All of the above NURSINGTB.COM 13. Which is not a warning sign of a sexually transmitted infection (STI)? 1) Penile discharge 2) Penile lesion 3) Testicular mass 4) Dysuria 14. Which is not considered a risk factor for male patients in terms of contracting a sexually transmitted infection (STI)? 1) Multiple sexual partners 2) Smoking 3) Intravenous (IV) drug use 4) Unprotected sex 15. When conducting a physical examination, the nurse notes that the patient has a systemic rash. Which sexually transmitted infection may be the cause for this clinical manifestation? 1) Herpes simplex virus 2) Gonorrhea 3) Secondary syphilis 4) Chlamydia 16. Which is a clinical manifestation associated with neurosyphilis? 1) Systemic rash 2) Vesicles 3) Penile discharge
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4) Psychosis 17. Which patient is at greatest risk for developing chlamydia trachomatis infection? 1) 16-year-old, sexually active, using no contraceptive 2) 22-year-old mother of two, developed dyspareunia 3) 35-year-old woman on oral contraceptives 4) 48-year-old woman with hot flashes and night sweats 18. The health-care provider prescribes metronidazole (Flagyl) for a woman diagnosed with trichomoniasis. Which statement should the nurse include in the discharge instructions for this patient? 1) “Both partners must be treated with the medication.” 2) “Alcohol does not need to be avoided while taking this medication.” 3) “It will turn your urine orange.” 4) “This medication could produce drowsiness.” 19. Which patient should the nurse anticipate a prescription for ceftriaxone (Rocephin) IM and doxycycline (Vibramycin) orally? 1) A pregnant patient with gonorrhea and a yeast infection 2) A nonpregnant patient with gonorrhea and chlamydia 3) A pregnant patient with syphilis 4) A nonpregnant patient with chlamydia and trichomoniasis 20. Which diagnostic test should the nurse question when prescribed for a patient diagnosed with pelvic inflammatory disease (PID)? 1) CBC (complete blood count) with differential 2) Vaginal culture for Neisseria gonorrhoeae 3) Throat culture for StreptococcusNAURSINGTB.COM 4) Nucleic acid amplification test (NAAT) 21. The nurse is providing care to a patient who will have abnormal cervical tissue removed via cryosurgery. Which term should the nurse use when educating the patient about this procedure? 1) Ablation 2) Excision 3) Hysterectomy 4) Chemotherapy 22. The nurse is providing care to a patient who will have the uterus removed due to uterine cancer. Which term should the nurse use when educating the patient about this procedure? 1) Ablation 2) Excision 3) Hysterectomy 4) Chemotherapy 23. The nurse is providing care to a patient who will have advanced cervical lesions removed via cold knife conization. Which term should the nurse use when educating the patient about this procedure? 1) Ablation 2) Excision 3) Hysterectomy 4) Chemotherapy 24. Which clinical manifestation noted during the physical examination is a prodromal sign for genital herpes? 1) Dysuria
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2) Muscle pain 3) Abnormal sensation 4) Swollen lymph nodes 25. The nurse is providing care to a patient who will receive toxic medication via intravenous infusion to treat cancer. Which term should the nurse use when educating the patient about this procedure? 1) Ablation 2) Excision 3) Hysterectomy 4) Chemotherapy Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. During an assessment, the nurse suspects a patient is experiencing genital herpes. Which clinical manifestations cause the nurse to come to this conclusion? Select all that apply. 1) Low blood pressure 2) Headache 3) Fever 4) Back pain 5) Vaginal discharge 27. The nurse instructs a married couple on the importance of treatment for a chlamydia infection. Which statements indicate that teaching was effective? Select all that apply. 1) “He could get an infection in the tube that carries the urine out.” 2) “She could have severe vaginal N itcUhR in S g.I ” NGTB.COM 3) “It could cause us to develop rashes.” 4) “She could develop a worse infection of the uterus and tubes.” 5) “She could become pregnant.”
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Chapter 67: Coordinating Care for Patients With Sexually Transmitted Infection Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Developing a comprehensive plan of nursing care for patients with sexually transmitted infections Chapter page reference: 1486-1489 Heading: Genital Herpes Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 This a close-ended question and won’t yield the information required. 2 Determining the date of the last episode of sexual intercourse might be indicated later if a disease is diagnosed. 3 Asking the patient about promiscuity is judgmental. 4 It will be important to record the onset of the open area. PTS: 1 CON: Infection 2. ANS: 3 NURSINGTB.COM Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Chlamydia trachomatis Chapter page reference: 1489-1490 Heading: Chlamydia Trachomatis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 This sexually transmitted infection (STI) targets other organs. 2 This sexually transmitted infection (STI) targets other organs. 3 Chlamydia invades the same target organs as gonorrhea, which include the cervix and male urethra, and creates the manifestations of dysuria, urinary frequency, and discharge. 4 This sexually transmitted infection (STI) targets other organs. PTS: 1 CON: Infection 3. ANS: 2 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with sexually transmitted infections
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Chapter page reference: 1480 Heading: Introduction Integrated Processes: Nursing Process: Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 There is not enough information to determine if the patient has sexual dysfunction, ineffective coping, or anxiety. 2 The patient having no idea how the illness was contracted indicates a deficit in knowledge regarding the transmission of sexually transmitted infections. 3 There is not enough information to determine if the patient has sexual dysfunction, ineffective coping, or anxiety. 4 There is not enough information to determine if the patient has sexual dysfunction, ineffective coping, or anxiety. PTS: 1 CON: Infection 4. ANS: 2 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Developing a comprehensive plan of nursing care for patients with sexually transmitted infections Chapter page reference: 1480 Heading: Introduction Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective CareNURSINGTB.COM Environment – Management of Care Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate
1 2 3 4
Feedback The nurse should instruct the patient to avoid, not just limit, sexual contact until recovered from the illness. The patient has a history of sexually transmitted infections. The nurse should discuss with the patient a plan for sexual partners to be contacted regarding the diagnosis. The need to increase fluids, rest, and nutrition is important, but not as important as the patient contacting sexual partners regarding the diagnosis. The need to increase fluids, rest, and nutrition is important, but not as important as the patient contacting sexual partners regarding the diagnosis
PTS: 1 CON: Infection 5. ANS: 1 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with sexually transmitted infections Chapter page reference: 1484-1486 Heading: Syphilis Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential
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Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Patients allergic to penicillin are given oral doses of doxycycline or tetracycline for 14 days for the treatment of syphilis. 2 Gentamicin, amoxicillin, and erythromycin are not prescribed for the treatment of syphilis. 3 Gentamicin, amoxicillin, and erythromycin are not prescribed for the treatment of syphilis. 4 Gentamicin, amoxicillin, and erythromycin are not prescribed for the treatment of syphilis. PTS: 1 CON: Infection 6. ANS: 2 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Developing a comprehensive plan of nursing care for patients with sexually transmitted infections Chapter page reference: 1486-1489 Heading: Genital Herpes Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate NURSINGTB.COM Feedback 1 Fluids that increase urine acidity such as cranberry juice should be avoided. 2 Measures to reduce the discomfort of herpes lesions include cleansing the lesions two or three times a day with warm water and soap. 3 Lesions should be dried using a hair dryer turned to a cool setting. 4 It is important to wear loose cotton clothing that will not trap moisture. PTS: 1 CON: Infection 7. ANS: 3 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Describing the epidemiology of sexually transmitted infections Chapter page reference: 1480 Heading: Introduction Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Women have higher rates of gonorrhea and chlamydia, whereas men, especially men who have sex with men, have higher rates of syphilis. 2 Women and infants are disproportionately affected by STIs. 3 Women often experience few early manifestations of sexually transmitted infection, delaying diagnosis and treatment.
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4
The incidence of STIs is highest among people of color.
PTS: 1 CON: Infection 8. ANS: 2 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Chlamydia trachomatis Chapter page reference: 1489-1490 Heading: Chlamydia Trachomatis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Candidiasis causes a white, curdlike discharge. 2 Trichomonas often manifests by a vaginal discharge that is gray or white, thin, homogenous, with a malodorous, unpleasant fishy or musty odor. 3 Gonorrhea causes a yellow or green discharge. 4 Chlamydia causes a clear to white discharge. PTS: 1 CON: Infection 9. ANS: 1 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: DevelopiN n gUaRcSom IpNrGehTenBs.iv Ce pOlaMn of nursing care for patients with sexually transmitted infections Chapter page reference: 1480 Heading: Introduction Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Warty lesions on the labia and within the vestibule are known as condyloma acuminatum, caused by human papillomavirus (HPV) infection. 2 The data does not support the diagnosis of genital herpes. 3 The data does not support the diagnosis of chancre. 4 The data does not support the diagnosis of secondary syphilis. PTS: 1 CON: Infection 10. ANS: 3 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of sexually transmitted infections Chapter page reference: 1480-1483 Heading: Human Papillomavirus Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential
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Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Wet mounts detect bacterial vaginosis and monilial vaginitis. 2 Wet mounts detect bacterial vaginosis and monilial vaginitis. 3 Rapid acetowhitening or blanching may indicate presence of HPV, causative agent of genital warts. 4 The Pap test assesses for cervical cancer. PTS: 1 CON: Infection 11. ANS: 2 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Genital herpes Chapter page reference: 1486-1489 Heading: Genital Herpes Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy 1 2 3 4
Feedback Vesicles are not clinical manifN esUtaRtion S Is NasGsoTcBiat.edCwOiMth secondary syphilis. Vesicles are a clinical manifestation associated with herpes simplex virus. Vesicles are not clinical manifestations associated with hyperthyroidism. Vesicles are not clinical manifestations associated with gonorrhea.
PTS: 1 CON: Infection 12. ANS: 1 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Developing a comprehensive plan of nursing care for patients with sexually transmitted infections Chapter page reference: 1480 Heading: Introduction Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 A penile discharge is often an indication of an STI (especially gonorrhea and chlamydia). 2 Orchitis is an inflammation of the testes. 3 Spermatocele is a well-defined cystic mass on the testes or epididymis. 4 The assessment data does not support all of these conclusions.
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PTS: 1 CON: Infection 13. ANS: 3 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Developing a comprehensive plan of nursing care for patients with sexually transmitted infections Chapter page reference: 1480 Heading: Introduction Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Many diseases can be transmitted through sexual activity. These diseases include chlamydia, cytomegalovirus, hepatitis B, herpes simplex, human immunodeficiency virus (HIV), human papillomavirus, gonorrhea, and syphilis. Penile discharge is a clinical manifestation of many STIs. 2 Many diseases can be transmitted through sexual activity. These diseases include chlamydia, cytomegalovirus, hepatitis B, herpes simplex, human immunodeficiency virus (HIV), human papillomavirus, gonorrhea, and syphilis. A penile lesion is a clinical manifestation associated with STIs. 3 A testicular mass is not a clinical manifestation associated with an STI. A testicular mass may be benign or malignant. 4 Many diseases can be transmitted through sexual activity. These diseases include chlamydia, cytomegalovirus, hepatitis B, herpes simplex, human immunodeficiency virus (HIV), human papillomaN viUruRs,SgIonNoG rrT heB a,.a C ndOsM yph ilis. Dysuria is a clinical manifestation of many STIs. PTS: 1 CON: Infection 14. ANS: 2 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Describing the epidemiology of sexually transmitted infections Chapter page reference: 1480 Heading: Introduction Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback 1 Multiple sexual partners is a risk factor for STIs. 2 Although smoking poses health risks, it is not a risk factor for STIs. 3 IV drug use and sharing contaminated needles is a risk factor for STIs. 4 Unprotected sex is a risk factor for STIs. PTS: 1 CON: Infection 15. ANS: 3 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Primary, secondary, and tertiary syphilis Chapter page reference: 1484-1486 Heading: Syphilis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy 1 2 3 4
Feedback Herpes simplex virus presents with vesicles, not a systemic rash. Gonorrhea does not cause a systemic rash. Secondary syphilis often manifests with a systemic rash. Chlamydia does not cause a systemic rash.
PTS: 1 CON: Infection 16. ANS: 4 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Primary, secondary, and tertiary syphilis Chapter page reference: 1484-1486 Heading: Syphilis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [UnN deUrsRtaS ndIinNgG ] TB.CO Concept: Infection Difficulty: Easy Feedback 1 A systemic rash is a clinical manifestation associated with secondary syphilis. 2 Vesicles are a clinical manifestation associated with herpes simplex virus. 3 Penile discharge is a clinical manifestation associated with many sexually transmitted infections, including gonorrhea and chlamydia. 4 Psychosis is a clinical manifestation associated with neurosyphilis. PTS: 1 CON: Infection 17. ANS: 1 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Describing the epidemiology of sexually transmitted infections Chapter page reference: 1489-1490 Heading: Chlamydia Trachomatis Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy Feedback
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1
2 3 4
Teens have the highest incidence of sexually transmitted infections, especially chlamydia. A patient not using contraceptives is not using condoms, which decrease the risk of contracting an STI. Dyspareunia sometimes develops with chlamydia infection, but dyspareunia is not a symptom specific to chlamydia. There is no correlation between oral contraceptive use and an increased rate of chlamydia infection. Additionally, chlamydia is more commonly seen in young women. This patient is experiencing signs of menopause, not chlamydia infection.
PTS: 1 CON: Infection 18. ANS: 1 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with sexually transmitted infections Chapter page reference: 1480 Heading: Introduction Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 Both partners should be treated with the medication. 2 Alcohol should be avoided. 3 Metronidazo le does not turn thNeUurin RSeIo NranGgTe.B.COM 4 Metronidazole does not cause drowsiness. PTS: 1 CON: Infection 19. ANS: 2 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Discussing the medical management of: Gonorrhea Chapter page reference: 1490-1492 Heading: Neisseria Gonorrhoeae Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy
1 2 3 4
Feedback Doxycycline is contraindicated during pregnancy. This combined treatment provides dual treatment for gonorrhea and chlamydia because the two infections frequently occur together. Syphilis is treated with penicillin. Trichomoniasis is treated with metronidazole.
PTS: 1 20. ANS: 3
CON: Infection
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Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of sexually transmitted infections Chapter page reference: 1493-1494 Heading: Pelvic Inflammatory Disease (PID) Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 CBC with differential will give an indication of the severity of the infection. 2 Gonorrhea is a common cause of PID, and the patient should be tested for this. 3 Streptococcus of the throat is not associated with PID. 4 NAAT is a test for chlamydia, another cause of PID. PTS: 1 CON: Infection 21. ANS: 1 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Developing a comprehensive plan of nursing care for patients with sexually transmitted infections Chapter page reference: 1480-1483 Heading: Human Papillomavirus Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [ApplyiN ngU] RSINGTB.COM Concept: Female Reproduction Difficulty: Moderate
1 2 3 4
Feedback Ablation is the process of burning or freezing in order to remove abnormal cervical tissue. Most common procedures are cryosurgery and laser ablation. Excision is the process of resecting or removing tissue. Most commonly done procedure with advanced cervical lesions is cold knife conization (CKC). Hysterectomy is the removal of the uterus. Chemotherapy includes chemicals that have toxic effects used to kill cancer cells.
PTS: 1 CON: Female Reproduction 22. ANS: 3 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Developing a comprehensive plan of nursing care for patients with sexually transmitted infections Chapter page reference: 1480-1483 Heading: Human Papillomavirus Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate
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1 2 3 4
Feedback Ablation is the process of burning or freezing in order to remove abnormal cervical tissue. Most common procedures are cryosurgery and laser ablation. Excision is the process of resecting or removing tissue. Most commonly done procedure with advanced cervical lesions is cold knife conization (CKC). Hysterectomy is the removal of the uterus. Chemotherapy includes chemicals that have toxic effects used to kill cancer cells.
PTS: 1 CON: Female Reproduction 23. ANS: 2 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Developing a comprehensive plan of nursing care for patients with sexually transmitted infections Chapter page reference: 1480-1483 Heading: Human Papillomavirus Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate
1 2 3 4
Feedback Ablation is the process of burning or freezing in order to remove abnormal cervical tissue. Most common proced uN reU s ar ReS cIryNoGsuTrgBe.ryCand O Mlaser ablation. Excision is the process of resecting or removing tissue. Most commonly done procedure with advanced cervical lesions is cold knife conization (CKC). Hysterectomy is the removal of the uterus. Chemotherapy includes chemicals that have toxic effects used to kill cancer cells.
PTS: 1 CON: Female Reproduction 24. ANS: 3 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Genital herpes Chapter page reference: 1486-1489 Heading: Genital Herpes Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy 1 2 3 4
Feedback Dysuria is a symptom of genital herpes but not a prodromal sign. Muscle pain is a symptom of genital herpes but not prodromal sign. Tingling or an abnormal sensation prior to presence of the vesicle or ulcer is a prodromal sign for genital herpes. Swollen lymph nodes is a symptom of genital herpes but not a prodromal sign.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1 CON: Infection 25. ANS: 4 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Developing a comprehensive plan of nursing care for patients with sexually transmitted infections Chapter page reference: 1480 Heading: Introduction Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Female Reproduction Difficulty: Moderate 1 2 3 4
Feedback Ablation is the process of burning or freezing in order to remove abnormal cervical tissue. Most common procedures are cryosurgery and laser ablation. Excision is the process of resecting or removing tissue. Most commonly done procedure with advanced cervical lesions is cold knife conization (CKC). Hysterectomy is the removal of the uterus. Chemotherapy includes chemicals that have toxic effects used to kill cancer cells.
PTS: 1
CON: Female Reproduction
MULTIPLE RESPONSE
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26. ANS: 2, 3, 4, 5 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Genital herpes Chapter page reference: 1486-1489 Heading: Genital Herpes Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Infection Difficulty: Easy
1. 2. 3. 4. 5.
Feedback This is incorrect. Low blood pressure is not a manifestation of genital herpes. This is correct. Manifestations of genital herpes include headache, fever, vaginal discharge, and back pain. This is correct. Manifestations of genital herpes include headache, fever, vaginal discharge, and back pain. This is correct. Manifestations of genital herpes include headache, fever, vaginal discharge, and back pain. This is correct. Manifestations of genital herpes include headache, fever, vaginal discharge, and back pain.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1 CON: Infection 27. ANS: 1, 4 Chapter number and title: 67, Coordinating Care for Patients With Sexually Transmitted Infection Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with sexually transmitted infections Chapter page reference: 1489-1490 Heading: Chlamydia Trachomatis Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult
1. 2. 3. 4. 5. PTS: 1
Feedback This is correct. Chlamydia is a major cause of nongonococcal urethritis (NGU) in men. This is incorrect. Treatment for chlamydia does not cause vaginal itching. This is incorrect. Untreated syphilis, not chlamydia, can cause a rash. This is correct. Chlamydia cervicitis can ascend and become pelvic inflammatory disease or infection of the uterus, fallopian tubes, and sometimes ovaries. This is incorrect. Chlamydia can contribute to infertility. CON: Infection
Chapter 68: Managing Care for the Adult Patient With Obesity
NURSINGTB.COM Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is providing care to a patient who is eight hours postoperative for bariatric surgery. Which is the priority safety intervention when providing care for this patient? 1) Monitoring for flatus 2) Repositioning for comfort 3) Advancing to a clear liquid diet 4) Assessing the nasogastric tube for patency 2. The nurse is assessing an adult patient who is postoperative for bariatric surgery. Which assessment finding requires immediate intervention by the nurse? 1) Increased flatus 2) Increased back pain 3) Increased urine output 4) Increased bowel sounds 3. The nurse is providing medication teaching to an adult patient who is prescribed an anorectic drug for weight loss. Which finding in the patient’s medical record would cause the nurse to question this drug prescription? 1) History of hypertension 2) History of hyponatremia 3) History of hyperglycemia 4) History of hypothyroidism
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4. The nurse is planning care for a patient based on the National Institute of Health (NIH) classification of body weight. Which body mass index (BMI) calculated by the nurse indicates the patient is overweight? 1) 20.3 2) 24.5 3) 27.7 4) 30.9 5. The nurse is planning care for a patient based on the National Institute of Health (NIH) classification of body weight. Which body mass index (BMI) calculated by the nurse indicates the patient is diagnosed with class 1 obesity? 1) 20.3 2) 24.5 3) 27.7 4) 30.9 6. The nurse is planning care for a patient based on the National Institute of Health (NIH) classification of body weight. Which body mass index (BMI) calculated by the nurse indicates the patient is diagnosed with class 2 obesity? 1) 27.7 2) 30.9 3) 35.3 4) 40.1 7. The nurse is planning care for a patient based on the National Institute of Health (NIH) classification of body weight. Which body mass index (BMI) calculated by the nurse indicates the patient is diagnosed with class 3 extreme obesity? 1) 27.7 NURSINGTB.COM 2) 30.9 3) 35.3 4) 40.1 8. Which medication for diabetes is also considered an obesogenic drug? 1) Insulin 2) Prazosin 3) Propranolol 4) Dexamethasone 9. Which is a goal of Healthy People 2020 that affects nutrition education that the nurse provides to the patient? 1) An increase in bariatric surgery 2) An overall increase in body mass index 3) The maintenance of healthy body weight 4) The promotion of carbohydrate restricting diets 10. The nurse is assessing several patients at a local health fair. Which patient is at the greatest risk for obesity? 1) A young adult Caucasian female who lives in the city 2) An older adult African-American male who lives in the suburbs 3) A middle-aged unemployed Hispanic female who lives in a rural area 4) A middle-aged Native American male who has accepted a teaching job in the inner city 11. Which is an evidence-based benefit to bariatric surgery that the nurse should include in a teaching session for an obese patient who is considering this intervention? 1) “This surgery will assist in the management of your hypothyroidism.”
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2) “Research shows that you will live longer if you consent to this procedure.” 3) “You will lose weight at a slower pace; however, the weight loss is longer lasting.” 4) “Many people experience an improved quality of life and better management of diabetes mellitus.” 12. Which chronic health condition should the nurse include in the teaching session for a group of patients who are obese? 1) Osteoporosis 2) Acute kidney injury 3) Coronary artery disease 4) Type 1 diabetes mellitus 13. Which hormone should the nurse include in a teaching session regarding satiety? 1) Leptin 2) Estrogen 3) Testosterone 4) Progesterone 14. Which is an environmental factor that increases an individual’s risk for obesity? 1) Automation 2) Hypertension 3) Leptin mutation 4) Genetic polymorphisms 15. The nurse is planning care for an obese patient who will use calorie reduction diet therapy. Which patient statement indicates the need for further education? 1) “I should reduce my calorie intaN k eU5R00S cIaN loG riT e sBp. e rCwOe eMk .” 2) “I will reduce my calorie intake with the goal of a one to two lb loss each week.” 3) “If a very-low-calorie diet is recommended, I will be supervised by my doctor.” 4) “My goal is to engage in 30 minutes of moderate-intensity exercise most days of the week.” 16. Which behavioral therapy should the nurse include in a teaching session for an obese patient who is attempting weight loss? 1) Food logs 2) Phentermine 3) Aerobic exercise 4) Calorie reduction 17. Which physical activity should the nurse include in a teaching session for an obese patient who is attempting weight loss? 1) Food logs 2) Phentermine 3) Aerobic exercise 4) Calorie reduction 18. Which pharmacological therapy should the nurse include in a teaching session for an obese patient who is attempting weight loss? 1) Food logs 2) Phentermine 3) Aerobic exercise 4) Calorie reduction
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19. Which diet therapy should the nurse include in a teaching session for an obese patient who is attempting weight loss? 1) Food logs 2) Phentermine 3) Aerobic exercise 4) Calorie reduction 20. Which pharmacological therapy for weight loss can only be administered for 12 weeks when prescribed to a patient for weight loss? 1) Orlistat 2) Lorcaserin 3) Metformin 4) Phentermine 21. Which drug, prescribed for weight loss, should include information regarding loose and oily stools in the patient teaching session initiated by the nurse? 1) Orlistat 2) Lorcaserin 3) Metformin 4) Phentermine 22. Which prescription weight loss drug requires the nurse to administer pregnancy tests to the patient on a monthly basis? 1) Orlistat 2) Lorcaserin 3) Metformin NURSINGTB.COM 4) Phentermine 23. Which body mass index (BMI) calculated during the patient’s physical assessment indicates that bariatric surgery is an option for weight loss? 1) 37 2) 38 3) 39 4) 40 24. Which long-term complication of bariatric surgery should the nurse include in the teaching session for a patient who is considering this procedure for weight loss? 1) Anemia 2) Infection 3) Anastomosis leak 4) Pulmonary embolism Completion Complete each statement. 25. The nurse teaches a patient who weighs 185 lb and is 5 feet, 3 inches tall on an eating plan to reduce the total intake of calories per day. The body mass index that the nurse calculated to identify the type of eating plan to use for this patient is .
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Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. During a health assessment, a patient says, “I only eat carbohydrates and low-fat foods. I don’t understand why I am still gaining weight!” What should the nurse consider before responding to this patient? Select all that apply. 1) Carbohydrates should only be eaten at breakfast. 2) Excess carbohydrates are converted to fat. 3) Excess carbohydrates can lead to obesity. 4) A carbohydrate limited diet is the only way to not gain weight. 5) Carbohydrates should be high in fiber and low in sugar. 27. The nurse is planning care for a patient whose waist circumference is 48 inches and height is 5 feet, 2 inches. Based on this data, which topics are appropriate for the nurse to include in the patient teaching? Select all that apply. 1) Chronic lung disease 2) Osteoarthritis 3) Type 2 diabetes mellitus 4) Heart disease 5) High blood pressure
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Chapter 68: Managing Care for the Adult Patient With Obesity Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Developing a comprehensive plan of nursing care for patients with obesity Chapter page reference: 1500-1506 Heading: Management Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment Cognitive level: Analysis [Analyzing] Concept: Nutrition Difficulty: Difficult Feedback 1 Monitoring for flatus, repositioning for comfort, and advancing to a clear liquid diet may all be appropriate interventions for this patient; however, the safety priority is NG tube patency. 2 Monitoring for flatus, repositioning for comfort, and advancing to a clear liquid diet may all be appropriate interventions for this patient; however, the safety priority is NG tube patency. 3 Monitoring for flatus, repositioning for comfort, and advancing to a clear liquid diet may all be appropriate interventions for this patient; however, the safety priority is NG NURSINGTB.COM tube patency. 4 The priority nursing action during the first 24-hours postoperative period following bariatric surgery is assessing the nasogastric (NG) tube for patency. In gastroplasty procedures, the NG tube drains both the proximal pouch and the distal stomach. PTS: 1 CON: Difficult 2. ANS: 2 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Describing complications associated with morbid obesity Chapter page reference: 1500-1506 Heading: Management Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Nutrition Difficulty: Difficult Feedback 1 Increased flatus is a finding that indicates the nasogastric tube placed post-surgery can be removed. 2 Increased back pain is a clinical manifestation associated with anastomotic leaks (a leak of digestive juices and partially digested food through an anastomosis). This is the most common serious complication and cause of death after bariatric surgery. This assessment finding should be reported to the surgeon immediately.
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3 4
Decreased, not increased, urine output is a clinical manifestation associated with anastomotic leaks. Increased bowel sounds are an indication that the patient may be able to begin the progression to a regular diet postsurgery.
PTS: 1 CON: Nutrition 3. ANS: 1 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Developing a comprehensive plan of nursing care for patients with obesity Chapter page reference: 1500-1506 Heading: Management Integrated Processes: Nursing Process: Assessment Client Need: Physiological integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Nutrition Difficulty: Easy Feedback 1 A patient history of hypertension would require the nurse to question this drug prescription. Patients with hypertension should not take anorectic drugs because they may worsen their symptoms. 2 A history of hyponatremia and hyperglycemia is not a contraindication for the use of anorectic drugs for weight loss. 3 A history of hyponatremia and hyperglycemia is not a contraindication for the use of anorectic drugs for weight loss. 4 A history of hyperthyroidism, NnoUt RhySpIotNhyGroi TBdi.smC, OisMa contraindication for the use of anorectic drugs for weight loss. PTS: 1 CON: Nutrition 4. ANS: 3 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Identifying classifications of body weight Chapter page reference: 1498-1499 Heading: Classification of Body Weight Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Nutrition Difficulty: Easy
1 2 3 4
Feedback According to the NIH classification of body weight, this patient is underweight. The range for an underweight individual is a BMI of less than 18.5. According to the NIH classification of body weight, this patient is a normal weight. The range for a normal weight individual is a BMI of 18.5 to 24.9. According to the NIH classification of body weight, this patient is overweight. The range for an overweight individual is a BMI of 25.0 to 29.9. According to the NIH classification of body weight, this patient has class 1 obesity. The range for class 1 obesity is a BMI of 30.0 to 34.9.
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PTS: 1 CON: Nutrition 5. ANS: 4 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Identifying classifications of body weight Chapter page reference: 1498-1499 Heading: Classification of Body Weight Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Nutrition Difficulty: Easy
1 2 3 4
Feedback According to the NIH classification of body weight, this patient is underweight. The range for an underweight individual is a BMI of less than 18.5. According to the NIH classification of body weight, this patient is a normal weight. The range for a normal weight individual is a BMI of 18.5 to 24.9. According to the NIH classification of body weight, this patient is overweight. The range for an overweight individual is a BMI of 25.0 to 29.9. According to the NIH classification of body weight, this patient has class 1 obesity. The range for class 1 obesity is a BMI of 30.0 to 34.9.
PTS: 1 CON: Nutrition 6. ANS: 3 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity NURSINGTB.CO Chapter learning objective: Identifying classifications of body weight Chapter page reference: 1498-1499 Heading: Classification of Body Weight Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Nutrition Difficulty: Easy
1 2 3 4
Feedback According to the NIH classification of body weight, this patient is overweight. The range for an overweight individual is a BMI of 25.0 to 29.9. According to the NIH classification of body weight, this patient has class 1 obesity. The range for class 1 obesity is a BMI of 30.0 to 34.9. According to the NIH classification of body weight, this patient has class 2 obesity. The range for class 2 obesity is a BMI of 35.0 to 39.9. According to the NIH classification of body weight, this patient has class 3 extreme obesity. The range for class 3 extreme obesity is a BMI greater than 40.0.
PTS: 1 CON: Nutrition 7. ANS: 4 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Identifying classifications of body weight Chapter page reference: 1498-1499
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Heading: Classification of Body Weight Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Nutrition Difficulty: Easy
1 2 3 4
Feedback According to the NIH classification of body weight, this patient is overweight. The range for an overweight individual is a BMI of 25.0 to 29.9. According to the NIH classification of body weight, this patient has class 1 obesity. The range for class 1 obesity is a BMI of 30.0 to 34.9. According to the NIH classification of body weight, this patient has class 2 obesity. The range for class 2 obesity is a BMI of 35.0 to 39.9. According to the NIH classification of body weight, this patient has class 3 extreme obesity. The range for class 3 extreme obesity is a BMI greater than 40.0.
PTS: 1 CON: Nutrition 8. ANS: 1 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Describing the pathophysiology of obesity Chapter page reference: 1499-1500 Heading: Pathophysiology Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation NURSINGTB.CO Cognitive level: Comprehension [Understanding] Concept: Nutrition Difficulty: Easy Feedback 1 Insulin is a medication for diabetes mellitus that is an obesogenic drug. 2 Prazosin, an alpha-adrenergic blocker, is a medication for hypertension that is an obesogenic drug. 3 Propranolol, a beta-blocker, is a medication for hypertension that is an obesogenic drug. 4 Dexamethasone, a corticosteroid, is a hormone that is an obesogenic drug. PTS: 1 CON: Nutrition 9. ANS: 3 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Developing a comprehensive plan of nursing care for patients with obesity Chapter page reference: 1500-1506 Heading: Management Integrated Processes: Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Nutrition Difficulty: Easy Feedback 1 This is not a Healthy People 2020 goal. 2 This is not a Healthy People 2020 goal.
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The maintenance of healthy body weight, through the consumption of healthful diets, is a Healthy People 2020 goal. Healthful diets with the balanced intake of nutrients is a Healthy People 2020 goal.
PTS: 1 CON: Nutrition 10. ANS: 3 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Describing the pathophysiology of obesity Chapter page reference: 1498-1499 Heading: Epidemiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Nutrition Difficulty: Difficult
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Feedback This patient does not have risk factors associated with obesity. This patient is a member of a minority population, a risk factor for obesity; however, there is another patient with a higher risk. This patient is a member of a minority population, middle-aged, economically disadvantaged, and lives in rural setting. This patient is at the highest risk for obesity. This patient is a member of a minority population and is middle-aged, both risk factors for obesity; however, there is another patient with a higher risk.
NURSINGTB.COM PTS: 1 CON: Nutrition 11. ANS: 4 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Developing a teaching plan for a patient with obesity Chapter page reference: 1500-1506 Heading: Management Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Nutrition Difficulty: Moderate
1 2 3 4
Feedback Evidence does not support this statement. Evidence does not support this statement. Evidence suggests that the patient who has bariatric surgery experiences a greater weight loss than a patient who has conventional treatment. Evidence suggests that patients who have bariatric surgery have improvements in quality of life and the management of diabetes mellitus.
PTS: 1 CON: Nutrition 12. ANS: 3 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Describing complications associated with morbid obesity
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Chapter page reference: 1499-1500 Heading: Pathophysiology Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Nutrition Difficulty: Easy Feedback 1 Osteoarthritis, not osteoporosis, is a chronic health condition associated with obesity. 2 Chronic kidney disease, not acute kidney injury, is a health condition associated with obesity. 3 Coronary artery disease is a chronic health condition associated with obesity. 4 Type 2, not type 1, diabetes is a chronic health condition associated with obesity. PTS: 1 CON: Nutrition 13. ANS: 1 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Describing the pathophysiology of obesity Chapter page reference: 1499-1500 Heading: Pathophysiology Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Nutrition Difficulty: Easy NURSINGTB.COM Feedback 1 Leptin, a hormone produced by fat cells, plays a major role in body weight. One major role this hormone plays is communicating satiety with the hypothalamus. 2 Estrogen does not play a role in satiety. 3 Testosterone does not play a role in satiety. 4 Progesterone does not play a role in satiety. PTS: 1 CON: Nutrition 14. ANS: 1 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Describing the pathophysiology of obesity Chapter page reference: 1499-1500 Heading: Pathophysiology Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Nutrition Difficulty: Easy 1 2
Feedback Automation is an environmental factor that leads to a decrease in energy expenditure; therefore, this increases the risk for obesity. Hypertension is a consequence of, not a risk factor for, obesity.
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Leptin mutation is a risk factor for obesity; however, this is not an environmental factor. Genetic polymorphism is a risk factor for obesity; however, this is not an environmental factor.
PTS: 1 CON: Nutrition 15. ANS: 1 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Developing a teaching plan for a patient with obesity Chapter page reference: 1500-1506 Heading: Management Integrated Processes: Nursing Process: Evaluation Client Need: Health Promotion and Maintenance Cognitive level: Analysis [Analyzing] Concept: Nutrition Difficulty: Difficult
1 2 3
4
Feedback A calorie reduction of 500 to 1000 calories per day is required for weight loss. This statement indicates the need for further education. A calorie reduction of 500 to 1000 calories per day to yield a one to two lb weight loss each week indicates correct understanding. A very-low-calorie diet is only used in limited circumstances, and the patient would be supervised by a health-care professional. This statement indicates correct understanding. NURSINGTB.COM Engaging in 30 minutes of moderate-intensity exercise most days of the week is appropriate and indicates correct understanding.
PTS: 1 CON: Nutrition 16. ANS: 1 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Discussing the medical management of obesity Chapter page reference: 1500-1506 Heading: Management Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Nutrition Difficulty: Moderate 1 2 3 4
Feedback Food logs are considered a behavioral weight loss therapy. Phentermine is a pharmacological, not behavioral, weight loss therapy. Aerobic exercise is a physical activity for weight loss, not a behavioral therapy. Calorie reduction is a diet, not behavioral, weight loss therapy.
PTS: 1 CON: Nutrition 17. ANS: 3 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity
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Chapter learning objective: Developing a teaching plan for a patient with obesity Chapter page reference: 1500-1506 Heading: Management Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Nutrition Difficulty: Moderate
1 2 3 4
Feedback Food logs are considered a behavioral weight loss therapy and not a physical activity. Phentermine is a pharmacological weight loss therapy and not a physical activity. Aerobic exercise is a physical activity for weight loss. Calorie reduction is a diet weight loss therapy and not a physical activity.
PTS: 1 CON: Nutrition 18. ANS: 2 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Discussing the medical management of obesity Chapter page reference: 1500-1506 Heading: Management Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Nutrition NURSINGTB.COM Difficulty: Moderate
1 2 3 4
Feedback Food logs are considered a behavioral, not pharmacological, weight loss therapy. Phentermine is a pharmacological weight loss therapy. Aerobic exercise is a physical activity for weight loss, not a pharmacological therapy. Calorie reduction is a diet, not pharmacological, weight loss therapy.
PTS: 1 CON: Nutrition 19. ANS: 4 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Discussing the medical management of obesity Chapter page reference: 1500-1506 Heading: Management Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Nutrition Difficulty: Moderate 1 2 3
Feedback Food logs are considered a behavioral, not diet, weight loss therapy. Phentermine is a pharmacological, not diet, weight loss therapy. Aerobic exercise is a physical activity for weight loss, not a diet therapy.
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4
Calorie reduction is a diet weight loss therapy.
PTS: 1 CON: Nutrition 20. ANS: 4 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Discussing the medical management of obesity Chapter page reference: 1501 Heading: Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapy Cognitive level: Knowledge [Remembering] Concept: Nutrition Difficulty: Easy
1 2 3 4
Feedback Orlistat can be administered for more than 12 weeks when prescribed for weight loss. Lorcaserin can be administered for more than 12 weeks when prescribed for weight loss. Metformin is not typically prescribed for weight loss. Phentermine is administered for 12 weeks only when prescribed for weight loss.
PTS: 1 CON: Nutrition 21. ANS: 1 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: DevelopiN n gUaRtS e aIchNinGgTpB la . n fCoO r aMpatient with obesity Chapter page reference: 1500-1506 Heading: Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Nutrition Difficulty: Easy
1
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Feedback Orlistat is a pharmacological therapy for weight loss that can cause loose and oily stools; therefore, this information should be included in the teaching session for this patient. Lorcaserin does not cause loose and oily stools. Metformin does not cause loose and oily stools. Phentermine does not cause loose and oily stools.
PTS: 1 CON: Nutrition 22. ANS: 4 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Discussing the medical management of obesity Chapter page reference: 1500-1506 Heading: Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation
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Cognitive level: Comprehension [Understanding] Concept: Nutrition Difficulty: Easy Feedback 1 Orlistat is not teratogenic; therefore, the nurse would not administer monthly pregnancy tests. 2 Lorcaserin is not teratogenic; therefore, the nurse would not administer monthly pregnancy tests. 3 Metformin is not teratogenic; therefore, the nurse would not administer monthly pregnancy tests. 4 Phenteramine may cause birth defects; therefore, the nurse would ensure the female patient is using a reliable form of birth control and receives monthly pregnancy tests. PTS: 1 CON: Nutrition 23. ANS: 4 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Discussing the medical management of obesity Chapter page reference: 1498-1499 Heading: Classification of Body Weight Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Knowledge [Remembering] Concept: Nutrition Difficulty: Easy
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While this patient is overweight, bariatric surgery is not an option for weight loss. While this patient is overweight, bariatric surgery is not an option for weight loss. While this patient is overweight, bariatric surgery is not an option for weight loss. A BMI of 40 indicates category 3 obesity; therefore, bariatric surgery is an option for weight loss.
PTS: 1 CON: Nutrition 24. ANS: 1 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Developing a teaching plan for a patient with obesity Chapter page reference: 1500-1506 Heading: Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Nutrition Difficulty: Moderate Feedback 1 Anemia is a long-term complication of bariatric surgery. 2 Infection is a short-term, not long-term, complication of bariatric surgery. 3 Anastomosis leak is a short-term, not long-term, complication of bariatric surgery. 4 Pulmonary embolism is a short-term, not long-term, complication of bariatric surgery.
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PTS: 1
CON: Nutrition
COMPLETION 25. ANS: 32.77 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Identifying classifications of body weight Chapter page reference: 1498-1499 Heading: Classification of Body Weight Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Nutrition Difficulty: Moderate Feedback: The nurse should use the formula: weight (lb) / [height (in)] 2 703 for this calculation. The BMI is calculated by dividing weight in pounds (lb) by height in inches (in) squared and multiplying by a conversion factor of 703. The calculation would be 185 / 63 63 = 185 / 3969 = 0.0466112 703 = 32.77. PTS: 1
CON: Nutrition
MULTIPLE RESPONSE
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26. ANS: 2, 3, 5 Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Describing the pathophysiology of obesity Chapter page reference: 1499-1500 Heading: Pathophysiology Integrated Processes: Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Nutrition Difficulty: Easy
1. 2. 3. 4. 5.
PTS: 1 27. ANS: 3, 4, 5
Feedback This is incorrect. Carbohydrates should be eaten throughout the day. This is correct. When carbohydrates are consumed in excess, they are converted to fat and stored in adipose tissue, which can lead to weight gain and an increased risk for obesity. This is correct. When carbohydrates are consumed in excess, they are converted to fat and stored in adipose tissue, which can lead to weight gain and an increased risk for obesity. This is incorrect. Carbohydrate deficiencies lead to protein tissue wasting. This is correct. Carbohydrates should come from the consumption of foods high in fiber and low in added sugars. CON: Nutrition
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Chapter number and title: 68, Managing Care for the Adult Patient With Obesity Chapter learning objective: Developing a teaching plan for a patient with obesity Chapter page reference: 1500-1506 Heading: Management Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Nutrition Difficulty: Moderate
1. 2. 3.
4.
5.
PTS: 1
Feedback This is incorrect. The risk for chronic lung disease and osteoarthritis is not determined by the waist-to-height ratio. This is incorrect. The risk for chronic lung disease and osteoarthritis is not determined by the waist-to-height ratio. This is correct. The waist-to-height ratio is calculated by dividing the circumference of the waist in inches by the height in inches. For this patient, the waist-to-height ratio is 0.86, which places the patient in the category of high risk for chronic diseases such as type 2 diabetes mellitus, heart disease, and high blood pressure. This is correct. The waist-to-height ratio is calculated by dividing the circumference of the waist in inches by the height in inches. For this patient, the waist-to-height ratio is 0.86, which places the patient in the category of high risk for chronic diseases such as type 2 diabetes mellitus, heart disease, and high blood pressure. This is correct. The waist-to-height ratio is calculated by dividing the circumference of the waist in inches by the height in inches. For this patient, the waist-to-height ratio is 0.86, which places the patient in the N caUteRgoSrI y N ofGhT igB h . risCkOfoMr chronic diseases such as type 2 diabetes mellitus, heart disease, and high blood pressure. CON: Nutrition
Chapter 69: Substance Use Disorders in the Adult Population Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is conducting a class in the community regarding alcohol use to a group of college seniors. During the class a participant admits to frequently using alcohol. Which is the priority action of the nurse? 1) Initiate a community assessment of the campus 2) Contact the campus nurse and refer the student 3) Notify campus security to watch for driving under the influence 4) Complete a crisis assessment 2. A patient is admitted to the emergency department with signs of drug use. The patient reports having ingested Percocet and is experiencing respiratory depression. Based on this data, which prescription does the nurse anticipate for this patient? 1) Diazepam 2) Haldol 3) Vitamin B12 4) Naloxone
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3. The nurse is planning to implement addiction treatment groups at the inner city clinic. Which knowledge regarding addictions and its related therapies will facilitate implementation of the groups? 1) Relapse is a common feature of substance abuse. 2) Hereditary, as well as complex environmental influences, predisposes one to substance dependence. 3) Patients with a substance dependence cannot be held accountable for their actions. 4) Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are accepted treatment approaches. 4. The employee health nurse is providing care to an employee who was injured on the job. The patient has a history of drug addiction and is currently enrolled in a 12-step recovery program. In order to determine whether the employee was impaired at the time of the accident, which diagnostic tool will the nurse use? 1) Liver enzymes 2) Stool guaiac 3) Urine toxicology testing 4) Hair testing 5. The patient with a history of alcohol abuse is being discharged to a treatment facility. Which prescription does the nurse anticipate for this patient? 1) Disulfiram 2) Naloxone 3) Bupropion hydrochloride 4) Varenicline 6. The nurse is providing care to a patient diagnosed with alcoholism. The patient’s physical examination reveals a BMI of 18. Which prescription does the nurse anticipate to manage the patient’s nutritional status? 1) Sertraline NURSINGTB.COM 2) Methadone 3) Naloxone 4) Multivitamin with folic acid 7. The nurse assesses a patient with a history of alcoholism who is hospitalized with anorexia, dysphagia, odynophagia, and chest pressure after eating. Which nursing diagnosis is a priority for this patient? 1) Ineffective Coping 2) Imbalanced Nutrition: Less Than Body Requirements 3) Disturbed Sensory Perception 4) Disturbed Thought Processes 8. The nurse is evaluating outcome goals written by a student for a patient diagnosed with alcoholism who is being discharged from a detoxification program. Which outcome is appropriate for this patient? 1) Follow a 2000-calorie high-carbohydrate diet 2) Sponsor a participant in Alcoholics Anonymous (AA) meetings 3) Obtain at least six to eight hours of sleep per night 4) Acknowledge the blame that family members must take for codependent behavior 9. The nurse is conducting a health history for a patient and wants to determine the patient’s alcohol use. What question from the nurse will provide the greatest amount of information? 1) “Are you a heavy drinker?” 2) “How many alcoholic beverages do you drink each day?” 3) “Is alcohol use a concern for you?” 4) “Drinking doesn't cause any problems for you, does it?”
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10. The nurse is caring for a patient who is diagnosed with cocaine addiction. For which additional disorder should the nurse assess this patient? 1) Anxiety 2) Diabetes 3) Weight gain 4) Kidney stones 11. A nursing instructor is teaching a class about the role of dopamine in substance abuse. Which student statement indicates appropriate understanding? 1) “The dopamine D1 and dopamine D2 receptors are responsible for co-occurring disorders.” 2) “Dopamine increases opioid transmission, and this reinforces the cycle of substance abuse.” 3) “Dopamine causes changes in brain neurotransmission that enhance the cycle of substance abuse.” 4) “The dopamine D3 receptor is involved in drug-seeking behaviors.” 12. A college student is incoherent after taking “downers with beer.” For which health problem should the nurse also observe for in this patient? 1) Hallucinations 2) Respiratory depression 3) Seizure activity 4) Signs of withdrawal 13. The nurse is completing a health history and determines the patient would benefit from teaching about substance abuse. Which patient statement does not support the need for this teaching? 1) “I drink alcohol with my friends on the weekends.” 2) “I smoke cigarettes on a daily baNsU is.R ” SINGTB.COM 3) “I get good grades in school.” 4) “I became sexually active at the age of 13.” 14. The nurse is providing care to a patient with alcohol and opioid dependency. A family member states, “I don't understand why Naltrexone treatment is prescribed because it causes a high too, right?” Which response by the nurse is appropriate? 1) “Naltrexone will cause your daughter to become violently ill if she drinks alcohol or abuses drugs.” 2) “Naltrexone is less potent than the street drugs your daughter is currently taking and therefore safer.” 3) “Naltrexone diminishes the cravings your daughter will feel for alcohol and opioids.” 4) “Naltrexone will prevent your daughter from getting drunk when she drinks.” 15. A patient who is attending a Narcotics Anonymous (NA) program asks the nurse what the most important initial goal of attending the meetings is. When responding to the patient, which indication will the nurse take into account? 1) To admit to having a problem 2) To learn problem-solving skills 3) To take a moral inventory of self 4) To make amends to people they have hurt 16. After an assessment of a patient, a nursing student expresses a belief that drug addiction is not a real illness, as these patients “did it to themselves.” Which response by the staff nurse is appropriate? 1) “Sometimes a patient doesn't show much effort.” 2) “We are legally obligated to provide care.”
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3) “It is important to remain nonjudgmental when caring for any patient, even a drug addict.” 4) “You are right. I don't know why we bother.” 17. A patient being treated for an alcohol use disorder asks the nurse, “Can my children inherit this?” Which response by the nurse is most appropriate? 1) “The role of genetics is minor in comparison to the role of the environment.” 2) “Genetics does not seem to play a role in the development of substance use disorders.” 3) “The role of genetics in substance use disorders has not been determined.” 4) “Genetics plays a major role in the development of substance use disorders.” 18. The nurse is caring for a patient who requires an opiate medication for chronic pain associated with a previous injury. The patient tells the nurse, “Even though I don’t feel like I’m addicted to the medication, I get tremors in my hands if I miss a dose.” What is the nurse’s best response? 1) “You may be addicted to the medication, but not necessarily physically dependent.” 2) “You may be physically dependent on the medication, but not necessarily addicted.” 3) “The symptoms you describe are indicative of addiction, whether you feel you are or not.” 4) “The symptoms you describe relate to your disease state and are not normal.” 19. The nurse is caring for a patient who is an intravenous drug user. The nurse anticipates the need for assessment for which complication? 1) Cardiac tamponade 2) Myocardial infarction 3) Congestive heart failure 4) Infective endocarditis 20. A patient is brought to the emergency department by a parent. The nursing assessment reveals that the patient has been acting stran gely for th e pastNthUrR e eShI ouNrsGaTndB. is C h yOpM e rv igilan t, grand io se, and irritab le. Vital signs reveal hypertension, tachycardia, and some arrhythmias. Which substance does the nurse suspect that the patient has been using? 1) Alcohol 2) Marijuana 3) Heroin 4) Amphetamines 21. Ten hours after admission to the ICU following an auto accident, a patient begins to exhibit mild tachycardia, irritability, and tremors. Three hours later the patient has a grand mal seizure. Which condition does the nurse suspect? 1) Wernicke encephalopathy 2) Korsakoff syndrome 3) Undetected internal bleeding 4) Alcohol withdrawal syndrome 22. A patient addicted to heroin is prescribed methadone as part of the treatment process. The patient’s spouse asks, “I don’t understand the reason for the methadone treatment. Why replace heroin with methadone?” Which response by the nurse is accurate? 1) “Methadone is safe even in large doses.” 2) “Methadone replaces a more potent drug.” 3) “Methadone is a deterrent to using other drugs.” 4) “Methadone blocks the craving for and the action of opiates.” 23. The nurse is caring for a patient who is experiencing alcohol withdrawal. Which is the priority nursing diagnosis for this patient?
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1) 2) 3) 4)
Risk for Injury Ineffective Coping Disturbed Sensory Perception Disturbed Thought Processes
24. The nurse is caring for a patient with a substance use disorder who is admitted to the rehabilitation unit of the inpatient treatment facility. The nurse collaborates with the patient to establish and redefine mutual goals of treatment. What is the primary purpose of this action? 1) It develops the nurse–patient relationship. 2) It allows the nurse to self-reflect. 3) It encourages patient responsibility. 4) It provides evaluation of outcomes. 25. The nurse is providing an educational seminar for the families of patients diagnosed with a substance use disorder. Which statement will the nurse include in the teaching session regarding the addictive process? 1) “Manifestations exhibited are similar to those exhibited with behavioral disorders.” 2) “Manifestations exhibited are similar to those exhibited with cognitive disorders.” 3) “Manifestations exhibited are caused by changes in neurochemistry.” 4) “Manifestations exhibited are caused by changes in the emotional state.” Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. The nurse is conducting a crisis assessment for a patient who admits to cocaine use. Which questions are appropriate for the nurse to ask the patient during this process? Select all that apply. 1) “Are recreation al centers availabNleU? R ” SINGTB.COM 2) “What is the most significant stress/problem occurring in your life right now?” 3) “How long has this been a problem?” 4) “What are the living conditions of the neighborhood?” 5) “What other stresses do you have in your life?” 27. A patient is admitted to the emergency department after overdosing on phencyclidine piperidine (PCP). Based on this actions, which actions are appropriate by the nurse? Select all that apply. 1) Obtain materials to assist with lavage 2) Start an IV 3) Initiate seizure precautions 4) Induce vomiting 5) Administer ammonium chloride 28. A nurse working in the emergency department is caring for a patient who has overdosed on cocaine. The nurse receives a prescription to administer an antipsychotic medication from the health-care provider. Which symptom would this medication help to manage? Select all that apply. 1) Alkaline urine 2) Decreased deep tendon reflexes 3) Hyperpyrexia 4) Respiratory distress 5) CNS depression 29. Which are the priority nursing interventions when providing care to patients at various stages of the detoxification process? Select all that apply. 1) Vital signs
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2) 3) 4) 5)
Medication administration Motivational interviewing Intake and output Neurological assessment
30. Which symptoms common to substance abuse will the nurse include in the assessment process for a patient who is suspected of having a substance use disorder? Select all that apply. 1) Disregard for religious beliefs while abusing the substance 2) Lack of desire to quit using the substance 3) Need for greater amounts of the substance to achieve the same effect 4) Neglect of normal activities due to focus on obtaining or using more of the substance 5) Persistent craving for the substance
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 69: Substance Use Disorders in the Adult Population Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Analyzing the nursing care priorities for the hospitalized patient with a history of one or more substance use disorders Chapter page reference: 1527-1533 Heading: Screening and Interventions Integrated Processes: Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive level: Analysis [Analyzing] Concept: Addiction Difficulty: Difficult Feedback 1 A community assessment is not an appropriate action at this time. 2 Contacting the campus nurse is not advised without the student's permission. 3 There is no evidence that the student is driving under the influence. 4 In a trusting relationship, the nurse will complete a crisis assessment to determine the appropriate action. PTS: 1
CON: Addiction
2. ANS: 4 NURSINGTB.COM Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Describing options for treating substance use disorders Chapter page reference: 1527-1533 Heading: Screening and Interventions Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Addiction Difficulty: Easy 1 2 3 4
Feedback Diazepam can be prescribed to manage signs of an overdose. Haldol can be administered to manage an overdose of phencyclidine piperidine (PCP). Vitamin B12 is used to manage the neurological symptoms that might accompany a nitrate overdose. Percocet is a type of opiate. Naloxone is used to treat an overdose of opiates.
PTS: 1 CON: Addiction 3. ANS: 2 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Discussing the epidemiology of substance use disorders Chapter page reference: 1510-1515 Heading: Epidemiology
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Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Addiction Difficulty: Easy Feedback 1 Acknowledging relapse, treatment approaches, and behavioral intentions does not address the psychobiology of the illness. 2 Knowing the psychobiology aspects of heritability and predisposition to substance dependence, as well as the complex environmental influences, helps diminish stigma. 3 Acknowledging relapse, treatment approaches, and behavioral intentions does not address the psychobiology of the illness. 4 Acknowledging relapse, treatment approaches, and behavioral intentions does not address the psychobiology of the illness. PTS: 1 CON: Addiction 4. ANS: 3 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Describing options for treating substance use disorders Chapter page reference: 1509-1510 Heading: Diagnostic Criteria of Substance Use Disorders Integrated Processes: Physiological Integrity – Reduction of Risk Potential Client Need: Screening and Interventions Cognitive level: Comprehension [Understanding] Concept: Addiction NURSINGTB.COM Difficulty: Easy Feedback 1 Liver enzymes detect liver damage but are not specific to damage from substance abuse. A stool guaiac tests for blood. 2 Liver enzymes detect liver damage but are not specific to damage from substance abuse. A stool guaiac tests for blood. 3 Urine toxicology testing will determine whether the employee had drugs in his system during the shift in which the injury occurred. 4 Hair testing can detect substance use for up to 90 days and is not an accurate tool to determine whether the employee was impaired at the time of the injury. PTS: 1 CON: Addiction 5. ANS: 1 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Describing options for treating substance use disorders Chapter page reference: 1527-1533 Heading: Screening and Interventions Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Addiction Difficulty: Easy Feedback
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1 2 3 4
Disulfiram (Antabuse) causes the patient to become immediately and violently ill when consuming alcohol. Naloxone is administered to patients who overdose on opiates. Bupropion hydrochloride and varenicline are both medications to assist with smoking cessation. Bupropion hydrochloride and varenicline are both medications to assist with smoking cessation.
PTS: 1 CON: Addiction 6. ANS: 4 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Describing options for treating substance use disorders Chapter page reference: 1527-1533 Heading: Screening and Interventions Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Addiction Difficulty: Easy Feedback 1 Sertraline is used to reduce anxiety and stabilize mood. 2 Methadone is prescribed to manage heroin cravings. 3 Naloxone is used to manage an opiate overdose. 4 A patient with alcohol dependence may suffer from numerous nutritional deficiencies, including deficiencies in thiamNinUeR , fS olI icNaG cid, T Bv .itaCmOinMA, magnesium, and zinc. A multivitamin may be prescribed to help with these deficiencies. PTS: 1 CON: Addiction 7. ANS: 2 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Analyzing the nursing care priorities for the hospitalized patient with a history of one or more substance use disorders Chapter page reference: 1533-1536 Heading: Nursing Management Integrated Processes: Nursing Process: Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Addiction Difficulty: Difficult
1 2 3 4
Feedback Ineffective Coping is a potential diagnosis used in substance abuse; however, there is another diagnosis that takes priority. An alcoholic patient with anorexia is at risk for Imbalanced Nutrition: Less Than Body Requirements. This is a physiological diagnosis; therefore, this is the priority. Disturbed Thought Processes and Disturbed Sensory Perceptions are diagnoses used for delusions, hallucinations, and illusions that may occur during delirium tremens. Disturbed Thought Processes and Disturbed Sensory Perceptions are diagnoses used for delusions, hallucinations, and illusions that may occur during delirium tremens.
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PTS: 1 CON: Addiction 8. ANS: 3 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Analyzing the nursing care priorities for the hospitalized patient with a history of one or more substance use disorders Chapter page reference: 1533-1536 Heading: Nursing Management Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Addiction Difficulty: Moderate Feedback 1 The calorie requirement should be individualized and may not be 2000 calories. 2 New or returning members to AA should be sponsored and are not ready to sponsor another person. 3 Outcome measures for a patient discharging from alcohol detoxification are to obtain at least six to eight hours of sleep a night. 4 This patient should accept responsibility for his behavior in the family unit instead of assigning blame for codependent behavior. PTS: 1 CON: Addiction 9. ANS: 2 Chapter number and title: 69, Substance Use Disorders in the Adult Population NURSINGTB.CO Chapter learning objective: Analyzing the nursing care priorities for the hospitalized patient with a history of one or more substance use disorders Chapter page reference: 1533-1536 Heading: Nursing Management Integrated Processes: Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Addiction Difficulty: Moderate Feedback 1 Open-ended questions will elicit the greatest amount of information. Asking closed questions that can be answered with a “yes” or “no” will limit the information obtained. 2 Open-ended questions will elicit the greatest amount of information. Asking closed questions that can be answered with a “yes” or “no” will limit the information obtained. 3 Open-ended questions will elicit the greatest amount of information. Asking closed questions that can be answered with a “yes” or “no” will limit the information obtained. 4 Open-ended questions will elicit the greatest amount of information. Asking closed questions that can be answered with a “yes” or “no” will limit the information obtained. PTS: 1 CON: Addiction 10. ANS: 1 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Describing the clinical manifestations of specific substances commonly used by persons with a substance use disorder
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Chapter page reference: 1516-1527 Heading: Substances and Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive level: Comprehension [Understanding] Concept: Addiction Difficulty: Easy Feedback 1 Cocaine stimulates the nervous system; therefore, the nurse should also assess this patient for anxiety. 2 Weight gain, diabetes, and kidney stones are not linked to substance abuse. 3 Weight gain, diabetes, and kidney stones are not linked to substance abuse. 4 Weight gain, diabetes, and kidney stones are not linked to substance abuse. PTS: 1 CON: Addiction 11. ANS: 4 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Understanding how addictive substances affect the brain Chapter page reference: 1515-1516 Heading: How Psychoactive Drugs Affect the Brain Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Addiction Difficulty: Moderate NURSINGTB.COM Feedback 1 D1 and D2 receptors are not responsible for co-occurring disorders. 2 Ethanol, not dopamine, increases opioid transmission and reinforces the cycle of substance abuse. 3 Dopamine does not cause changes in brain neurotransmission that enhance the cycle of substance abuse. 4 Although most studies have focused on the role of dopamine D 1 and dopamine D2 receptors in sustaining the addictive danger of drugs, recent studies also have shown that the dopamine D3 receptor is involved in drug-seeking behavior. PTS: 1 CON: Addiction 12. ANS: 2 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Describing the clinical manifestations of specific substances commonly used by persons with a substance use disorder Chapter page reference: 1516-1527 Heading: Substances and Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Addiction Difficulty: Easy Feedback
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1 2
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Seizure activity, signs of withdrawal, and signs of hallucinations do not pose as great a risk for this patient as respiratory depression. Downers are central nervous system depressants. Barbiturates and alcohol are a lethal combination. The patient who has ingested both items is at risk for varying degrees of sedation, up to coma and death. Seizure activity, signs of withdrawal, and signs of hallucinations do not pose as great a risk for this patient as respiratory depression. Seizure activity, signs of withdrawal, and signs of hallucinations do not pose as great a risk for this patient as respiratory depression.
PTS: 1 CON: Addiction 13. ANS: 3 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Developing teaching strategies for adults with a diagnosis of substance use disorder Chapter page reference: 1533-1536 Heading: Nursing Management Integrated Processes: Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive level: Analysis [Analyzing] Concept: Addiction Difficulty: Difficult
1 2 3 4
Feedback Early sexual activity, smokingNcUigR arSetI teN s, GanTdBd. rinCkOinMg alcohol are all risk factors for teenage substance abuse. Early sexual activity, smoking cigarettes, and drinking alcohol are all risk factors for teenage substance abuse. Getting good grades is not a risk factor for substance abuse. Early sexual activity, smoking cigarettes, and drinking alcohol are all risk factors for teenage substance abuse.
PTS: 1 CON: Addiction 14. ANS: 3 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Describing options for treating substance use disorders Chapter page reference: 1527-1533 Heading: Screening and Interventions Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying] Concept: Addiction Difficulty: Moderate Feedback 1 Disulfiram, not naltrexone, will cause a person to become violently ill when alcohol is consumed. 2 This statement is not accurate. 3 Naltrexone diminishes the cravings for alcohol and opioids. 4 This statement is not accurate.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1 CON: Addiction 15. ANS: 1 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Describing options for treating substance use disorders Chapter page reference: 1527-1533 Heading: Screening and Interventions Integrated Processes: Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive level: Comprehension [Understanding] Concept: Addiction Difficulty: Easy Feedback 1 The initial outcome for patients in substance abuse programs is to admit they have a problem with drugs or alcohol. Patients will be unable to participate fully in a recovery program until they can admit that they have a substance abuse problem, admit the extent of that problem, and acknowledge how abuse has impacted their lives. 2 Learning problem-solving skills is a later outcome for a substance abuse program. 3 Taking a moral inventory and making amends are the fourth and eighth steps of Narcotics Anonymous and would not be initial outcomes. 4 Taking a moral inventory and making amends are the fourth and eighth steps of Narcotics Anonymous and would not be initial outcomes. PTS: 1 CON: Addiction 16. ANS: 3 NURSINGTB.COM Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Analyzing the nursing care priorities for the hospitalized patient with a history of one or more substance use disorders Chapter page reference: 1533-1536 Heading: Nursing Management Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Addiction Difficulty: Moderate Feedback 1 Nurses must provide a nonjudgmental attitude with their patients in order to promote trust and respect. Even if a patient is not currently making much effort toward management of addiction disorders, the development of a trusting relationship with the nurse helps to set the stage for movement toward recovery in the future. 2 Although it is true that nurses are legally obligated to provide care, this response is not patient-focused and is therefore inappropriate. 3 Nurses must provide a nonjudgmental attitude with their patients in order to promote trust and respect. Even if a patient is not currently making much effort toward management of addiction disorders, the development of a trusting relationship with the nurse helps to set the stage for movement toward recovery in the future.
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4
Nurses must provide a nonjudgmental attitude with their patients in order to promote trust and respect. Even if a patient is not currently making much effort toward management of addiction disorders, the development of a trusting relationship with the nurse helps to set the stage for movement toward recovery in the future.
PTS: 1 CON: Addiction 17. ANS: 3 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Discussing the epidemiology of substance use disorders Chapter page reference: 1510-1515 Heading: Epidemiology Integrated Processes: Communication and Documentation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Addiction Difficulty: Moderate
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Feedback Research has not yet determined the relationship between genetics and substance use disorders, particularly regarding why some people are more prone to addiction than others. Research has not yet determined the relationship between genetics and substance use disorders, particularly regarding why some people are more prone to addiction than others. Research has not yet determin ed the r el ati on shi p between gen etics and substance use N U R Swhy I N Gsome T B.people COM are more prone to addiction than disorders, particularly regarding others. Research has not yet determined the relationship between genetics and substance use disorders, particularly regarding why some people are more prone to addiction than others.
PTS: 1 CON: Addiction 18. ANS: 2 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Describing the difference between physical dependence and substance use disorders and key features of both Chapter page reference: 1516-1527 Heading: Substances and Clinical Manifestations Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Addiction Difficulty: Moderate Feedback 1 The patient may be physically dependent on the substance, but not necessarily addicted. Increasing frequency and amount of use creates physical dependence, in which the body becomes so dependent on the substance that without it, withdrawal symptoms will begin. Continued use leads to a breakdown in patterns of daily living, part of the addictive process. Addiction, not physical dependence, is considered a disease state.
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2
3
4
The patient may be physically dependent on the substance, but not necessarily addicted. Increasing frequency and amount of use creates physical dependence, in which the body becomes so dependent on the substance that without it, withdrawal symptoms will begin. Continued use leads to a breakdown in patterns of daily living, part of the addictive process. Addiction, not physical dependence, is considered a disease state. The patient may be physically dependent on the substance, but not necessarily addicted. Increasing frequency and amount of use creates physical dependence, in which the body becomes so dependent on the substance that without it, withdrawal symptoms will begin. Continued use leads to a breakdown in patterns of daily living, part of the addictive process. Addiction, not physical dependence, is considered a disease state. The patient may be physically dependent on the substance, but not necessarily addicted. Increasing frequency and amount of use creates physical dependence, in which the body becomes so dependent on the substance that without it, withdrawal symptoms will begin. Continued use leads to a breakdown in patterns of daily living, part of the addictive process. Addiction, not physical dependence, is considered a disease state.
PTS: 1 CON: Addiction 19. ANS: 4 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Describing the clinical manifestations of specific substances commonly used by persons with a substance use disorder Chapter page reference: 1516-1527 Heading: Substances and Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [UnN deUrsRtaSndIiN n gG] TB.COM Concept: Addiction Difficulty: Easy Feedback 1 Cardiac tamponade, congestive heart failure, and myocardial infarction may occur in intravenous drug users; however, these individuals are at greatest risk for developing infective endocarditis. 2 Cardiac tamponade, congestive heart failure, and myocardial infarction may occur in intravenous drug users; however, these individuals are at greatest risk for developing infective endocarditis. 3 Cardiac tamponade, congestive heart failure, and myocardial infarction may occur in intravenous drug users; however, these individuals are at greatest risk for developing infective endocarditis. 4 A relatively uncommon disease in the general population, infective endocarditis involves an infection of the interior surface of the heart, usually stemming from bacteria in the bloodstream. These infections then lead to destruction of cardiac tissue, causing irreparable damage to the valves of the heart and symptoms consistent with both systemic infection and cardiac dysfunction. Patients who abuse drugs by injection are at greatest risk for developing infective endocarditis. PTS: 1 CON: Addiction 20. ANS: 4 Chapter number and title: 69, Substance Use Disorders in the Adult Population
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Chapter learning objective: Describing the clinical manifestations of specific substances commonly used by persons with a substance use disorder Chapter page reference: 1516-1527 Heading: Substances and Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Addiction Difficulty: Moderate Feedback 1 Alcohol intoxication may manifest in relaxed euphoria, lack of concentration, and decreased inhibitions. 2 Marijuana intoxication manifests in euphoria and relaxation and does not typically cause hypertension, tachycardia, or arrhythmias. 3 Heroin intoxication causes decreased respiratory rate and depth and bradycardia, not tachycardia. 4 Amphetamine intoxication includes symptoms of hypervigilance, grandiosity, and irritability. PTS: 1 CON: Addiction 21. ANS: 4 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Describing the clinical manifestations of specific substances commonly used by persons with a substance use disorder Chapter page reference: 1516-1527 NURSINGTB.COM Heading: Substances and Clinical Manifestations Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Addiction Difficulty: Easy Feedback 1
2 3 4
Wernicke encephalopathy is a neurologic disease characterized by ataxia, sixth cranial nerve palsy, nystagmus, and confusion. Korsakoff syndrome is a disturbance in short-term memory that occurs in individuals who have been drinking for many years. An undetected internal hemorrhage would not present with the symptoms outlined. Alcohol withdrawal syndrome is marked by mild tachycardia, irritability, and tremors.
PTS: 1 CON: Addiction 22. ANS: 4 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Describing options for treating substance use disorders Chapter page reference: 1527-1533 Heading: Screening and Interventions Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Application [Applying]
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Concept: Addiction Difficulty: Moderate
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Feedback Methadone does not replace more potent drugs or act as a deterrent to other drug use. The doses of methadone are strictly regulated and administered by health professionals. Methadone does not replace more potent drugs or act as a deterrent to other drug use. The doses of methadone are strictly regulated and administered by health professionals. Methadone does not replace more potent drugs or act as a deterrent to other drug use. The doses of methadone are strictly regulated and administered by health professionals. Methadone blocks the craving for and the action of opiates such as heroin.
PTS: 1 CON: Addiction 23. ANS: 1 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Analyzing the nursing care priorities for the hospitalized patient with a history of one or more substance use disorders Chapter page reference: 1533-1536 Heading: Nursing Management Integrated Processes: Nursing Process: Diagnosis Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Addiction Difficulty: Difficult
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A patient who is experiencing alcohol withdrawal is at risk for injury from delirium tremens. Death from delirium tremens can occur from volume depletion, electrolyte imbalance, or cardiac arrhythmia. Ineffective coping is not the priority for the patient experiencing alcohol withdrawal. Disturbed thought processes and disturbed sensory perceptions are diagnoses used for delusions, hallucinations, and illusions that may occur during delirium tremens; however, these are not highest priority diagnoses. Disturbed thought processes and disturbed sensory perceptions are diagnoses used for delusions, hallucinations, and illusions that may occur during delirium tremens; however, these are not highest priority diagnoses.
PTS: 1 CON: Addiction 24. ANS: 3 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Analyzing the nursing care priorities for the hospitalized patient with a history of one or more substance use disorders Chapter page reference: 1533-1536 Heading: Nursing Management Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Addiction Difficulty: Easy Feedback
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1 2 3 4
While this action may help to develop the nurse–patient relationship, this is not its primary purpose. The primary purpose of collaboration is not to allow the nurse to self-reflect, nor is it to provide evaluation of outcomes. The primary purpose of collaboration with the patient to establish and redefine mutual goals of treatment is to encourage patient responsibility. The primary purpose of collaboration is not to allow the nurse to self-reflect, nor is it to provide evaluation of outcomes.
PTS: 1 CON: Addiction 25. ANS: 3 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Understanding how addictive substances affect the brain Chapter page reference: 1515-1516 Heading: How Psychoactive Drugs Affect the Brain Integrated Processes: Teaching and Learning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Addiction Difficulty: Moderate Feedback 1 The manifestations are not similar to behavioral or cognitive disorders. 2 The manifestations are not similar to behavioral or cognitive disorders. 3 Patients diagnosed with a substance use disorder exhibit addictive behavior due to changes in neurochemistry. NURSINGTB.COM 4 The manifestations associated with the addictive process are not caused by changes in the emotional state. PTS: 1
CON: Addiction
MULTIPLE RESPONSE 26. ANS: 2, 3, 5 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Analyzing the nursing care priorities for the hospitalized patient with a history of one or more substance use disorders Chapter page reference: 1533-1536 Heading: Nursing Management Integrated Processes: Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Addiction Difficulty: Moderate
1.
Feedback This is incorrect. Asking about recreational centers and the living conditions of the neighborhood are more appropriate when conducting a community crisis assessment.
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This is correct. When conducting a crisis assessment for a patient who admits to using an illegal substance that is associated with addiction, the nurse will ask the patient about the most significant stress occurring in life right now, how long the problem has been occurring, and the other stresses in the patient’s life. This is correct. When conducting a crisis assessment for a patient who admits to using an illegal substance that is associated with addiction, the nurse will ask the patient about the most significant stress occurring in life right now, how long the problem has been occurring, and the other stresses in the patient’s life. This is incorrect. Asking about recreational centers and the living conditions of the neighborhood are more appropriate when conducting a community crisis assessment. This is correct. When conducting a crisis assessment for a patient who admits to using an illegal substance that is associated with addiction, the nurse will ask the patient about the most significant stress occurring in life right now, how long the problem has been occurring, and the other stresses in the patient’s life.
PTS: 1 CON: Addiction 27. ANS: 2, 3, 5 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Describing options for treating substance use disorders Chapter page reference: 1527-1533 Heading: Screening and Interventions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Addiction NURSINGTB.COM Difficulty: Moderate
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Feedback This is incorrect. Lavage would be an inappropriate treatment for inhalation of any substance. Narcan is a narcotic antagonist administered for opiate overdose. This is correct. The patient has taken an overdose of phencyclidine piperidine (PCP), which can produce an adrenaline-like response, or “speed” reaction. PCP overdose is associated with possible hypertensive crisis, respiratory arrest, hyperthermia, and seizures. The patient will require an IV line. The patient will need to have seizure precautions such as padded side rails initiated. The patient may also be given ammonium chloride to acidify the urine to help excrete the drug. This is correct. The patient has taken an overdose of phencyclidine piperidine (PCP), which can produce an adrenaline-like response, or “speed” reaction. PCP overdose is associated with possible hypertensive crisis, respiratory arrest, hyperthermia, and seizures. The patient will require an IV line. The patient will need to have seizure precautions such as padded side rails initiated. The patient may also be given ammonium chloride to acidify the urine to help excrete the drug. This is incorrect. Vomiting is induced for overdoses of alcohol, barbiturates, and benzodiazepines.
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5.
This is correct. The patient has taken an overdose of phencyclidine piperidine (PCP), which can produce an adrenaline-like response, or “speed” reaction. PCP overdose is associated with possible hypertensive crisis, respiratory arrest, hyperthermia, and seizures. The patient will require an IV line. The patient will need to have seizure precautions such as padded side rails initiated. The patient may also be given ammonium chloride to acidify the urine to help excrete the drug.
PTS: 1 CON: Addiction 28. ANS: 3, 4 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Describing options for treating substance use disorders Chapter page reference: 1527-1533 Heading: Screening and Interventions Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Addiction Difficulty: Easy
1.
2. 3. 4. 5.
Feedback This is incorrect. Antipsychotic medications are used in the treatment of patients who have overdosed on crack or cocaine. These medications help to manage the hyperpyrexia, respiratory distress, acidic urine, and convulsions associated with the overdose. CNS depression and decreased deep tendon reflexes do not occur in acute cocaine overdose. This is incorrect. This is correct. This is correct. This is incorrect.
PTS: 1 CON: Addiction 29. ANS: 1, 2, 4, 5 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Analyzing the nursing care priorities for the hospitalized patient with a history of one or more substance use disorders Chapter page reference: 1533-1536 Heading: Nursing Management Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Addiction Difficulty: Difficult
1.
Feedback This is correct. Priority nursing interventions for patients in the detoxification process are those that relate to patient safety and will include careful monitoring of vital signs, monitoring fluid volume and electrolyte levels, monitoring neurological status, and safe administration of medications to ensure patient medical conditions do not place patients at further risk for injury.
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This is correct. Priority nursing interventions for patients in the detoxification process are those that relate to patient safety and will include careful monitoring of vital signs, monitoring fluid volume and electrolyte levels, monitoring neurological status, and safe administration of medications to ensure patient medical conditions do not place patients at further risk for injury. This is incorrect. Motivational interviewing, including assessing patients’ readiness to change, does not take priority over patient safety during the detoxification process. This is correct. Priority nursing interventions for patients in the detoxification process are those that relate to patient safety and will include careful monitoring of vital signs, monitoring fluid volume and electrolyte levels, monitoring neurological status, and safe administration of medications to ensure patient medical conditions do not place patients at further risk for injury. This is correct. Priority nursing interventions for patients in the detoxification process are those that relate to patient safety and will include careful monitoring of vital signs, monitoring fluid volume and electrolyte levels, monitoring neurological status, and safe administration of medications to ensure patient medical conditions do not place patients at further risk for injury.
PTS: 1 CON: Addiction 30. ANS: 3, 4, 5 Chapter number and title: 69, Substance Use Disorders in the Adult Population Chapter learning objective: Identifying common substances used by persons with a substance use disorder and general physical, behavioral, and psychosocial signs of common substance use disorders Chapter page reference: 1516-1527 Heading: Substances and Clinical Manifestations Integrated Processes: Nursing ProcesN s:UARssSe I ss N mG enTt B.COM Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Addiction Difficulty: Moderate
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2. 3. 4. 5. PTS: 1
Feedback This is incorrect. Patients who have a substance use disorder experience some universal symptoms: a need for greater amounts of the substance to achieve the same effect, neglect of normal activities due to focus on obtaining or using more of the substance, and a persistent craving for the substance. The patient with a substance use disorder does not necessarily disregard his or her religious beliefs or lack the desire to quit. Some patients have a desire to reduce their use of the substance but have difficulty doing so. This is incorrect. This is correct. This is correct. This is correct. CON: Addiction
Chapter 70: Emergency, Trauma, and Environmental Injuries
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Multiple Choice Identify the choice that best completes the statement or answers the question. 1. What should the nurse do to assist a patient brought to the emergency department as a victim of a gunshot wound? 1) Ask the patient who shot him 2) Bathe the patient and provide a clean gown 3) Ask the patient where the weapon is 4) Preserve the chain of evidence 2. A patient is brought into the emergency department after being assaulted. It is suspected that the patient has a spinal cord injury. Which diagnostic test does the nurse anticipate based on the data collected? 1) Computed tomography (CT) scan 2) X-ray 3) Ultrasound 4) Magnetic resonance imaging (MRI) 3. A patient recovering from a motor vehicle crash develops hypotension and jugular distension with a tracheal deviation. Based on this data, which should the nurse suspect occurred? 1) Hemorrhage 2) Compensatory shock 3) Hypovolemic shock 4) Tension pneumothorax 4. Which observation indicates that interventions provided to a patient with neck injuries from a motor vehicle crash have been successful? 1) Urine is clear and odorless fromNinUdR wS elI l inNgGc T a thBe.teC r OM 2) Moves all four extremities independently, feeds self, and participates in partial bath 3) Unable to move independently in bed 4) Rests in bed with lights and television turned off 5. Which intervention would be a priority when providing care to a patient recovering from thoracic injuries sustained from a motor vehicle crash? 1) Monitor urine output 2) Assess vital signs 3) Perform passive range of motion to all extremities 4) Assist to deep breathe and cough every two hours 6. A nurse is developing a plan of care for a patient with traumatic injuries from a motor vehicle crash. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications? 1) Provide active or passive exercises at least once every eight hours 2) Encourage coughing, deep breathing, and incentive spirometry 3) Assist the patient in turning at least every two hours 4) Assist the patient in turning at least every eight hours 7. Which assessment data indicates the patient is experiencing a late symptom associated with chronic aspirin overdose? 1) Emesis 2) Nausea 3) Tinnitus 4) Ecchymosis
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8. The emergency department nurse is triaging patients. Which patient should be prioritized? 1) An adult patient experiencing mild chest pain 2) An adolescent patient with a possible fractured wrist 3) An older adult patient with a hip fracture who is in pain 4) A school-age patient with asthma presenting with dyspnea 9. The registered nurse (RN) is the team leader for a group of patients using the functional model of nursing. The team of nurses includes two licensed practical nurses (LPNs) and an unlicensed assistive personnel (UAP). Which task will the RN delegate to the UAP? 1) Taking vital signs 2) Providing wound care 3) Conducting discharge teaching 4) Administering oral medications 10. A medical-surgical unit is expecting a large volume of patient admissions after a train derailment. Which member of the nursing care team will prioritize care for the unit? 1) Charge nurse 2) Nurse supervisor 3) Licensed practical nurse 4) Unlicensed assistive personnel 11. Which is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care? 1) Cystitis 2) Concussion 3) Lacerated arm NURSINGTB.COM 4) Fractured femur 12. Which nursing action is appropriate when conducting a secondary survey during the emergency assessment? 1) Maintaining privacy 2) Having suction available 3) Giving supplemental oxygen 4) Assigning a nurse to support family members 13. Which member of the health-care team, when using the team nursing approach, is responsible for prioritizing patient care? 1) Team leader 2) Charge nurse 3) Licensed practical nurse 4) Unlicensed assistive personnel 14. The nurse is conducting a primary survey during the emergency assessment. Which nursing action is appropriate during the breathing assessment? 1) Assessing for edema 2) Counting respiratory rate 3) Checking for foreign bodies 4) Monitoring for respiratory distress 15. The nurse is conducting a primary survey during an emergency assessment. Which is the priority nursing action related to breathing in response to this assessment? 1) Having suction available
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2) Assessing pupil size and reactivity 3) Immobilizing any obvious deformities 4) Obtaining blood samples for type and crossmatch 16. The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment? 1) Determining drug allergies 2) Noting the general appearance 3) Examining the neck for stiffness 4) Auscultating for heart and lung sounds 17. Which is the essential nursing skill for the triage process in the emergency department? 1) Evaluating care 2) Setting priorities 3) Formulating diagnoses 4) Implementing interventions 18. The nurse is providing care to several patients in the emergency department. Which patient would require priority care from the nurse? 1) An adult patient with an ankle sprain 2) An infant with a rash of unknown origin 3) An adult patient with unstable vital signs and chest pain 4) A pediatric patient with multiple fractures following a motor vehicle accident 19. The nurse is providing care to several patients in the emergency department. Which patient is the priority when using the three-tiered triage system? 1) A patient with a simple fracture NURSINGTB.COM 2) A patient experiencing renal colic 3) A patient with severe abdominal pain 4) A patient with chest pain and diaphoresis 20. Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma patient with a penetrating wound? 1) Documenting the patient’s care 2) Formulating the patient’s plan of care 3) Reassessing the patient’s level of consciousness 4) Transferring the patient to the general medical unit 21. Which is the priority nursing action when providing care to a patient with a penetrating abdominal wound? 1) Assessing bowel sounds 2) Stabilizing the impaled object 3) Administering prescribed pain medication 4) Scheduling a CT scan to determine retroperitoneal bleeding 22. Which treatment should the nurse prepare to administer when providing care to a toddler who presents after an accidental overdose of aspirin? 1) Gastric lavage 2) Activated charcoal 3) Peritoneal dialysis 4) Vitamin D injection
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23. Which assessment data related to the patient’s airway would indicate the need for priority intervention by the nurse? 1) Eupnea 2) Tachycardia 3) Hypotension 4) Agonal breaths Multiple Response Identify one or more choices that best complete the statement or answer the question. 24. Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply. 1) Inserting a nasogastric tube 2) Immobilizing the cervical spine 3) Arranging for diagnostic studies 4) Preparing for chest tube insertion 5) Applying direct pressure to a wound 25. What would the nurse working in the emergency department identify as clinical priorities for the treatment of a patient with a gunshot wound? Select all that apply. 1) Airway maintenance 2) Obtaining medical history 3) Ventilation assistance 4) Hemorrhage control 5) Hypothermia prevention
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26. Which are the top priorities when conducting a primary patient survey during the emergency assessment? Select all that apply. 1) Airway 2) Disability 3) Breathing 4) Circulation 5) Cervical spine Completion Complete each statement. 27. The nurse is providing care to several patients in the emergency department. In which order should the nurse assess and provide care to the patients? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) A patient with a leg laceration requiring sutures 2) A patient with abdominal pain rated as a 7 on a numeric pain scale 3) A patient who has multiple trauma due to a motor vehicle accident 4) A patient who took an overdose of opioids with a respiratory rate of eight breaths per minute 28. The nurse is providing care to a trauma patient. What is the correct order of steps the nurse will implement when providing care to this patient? Select all that apply. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234)
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1) Clear the airway 2) Protect the cervical spine 3) Perform chest compressions 4) Provide supplemental oxygen
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Chapter 70: Emergency, Trauma, and Environmental Injuries Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Examining in hospital emergency/trauma care priorities Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Nursing Difficulty: Moderate 1
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Feedback Because the majority of gunshot wounds require an investigation by law enforcement, nurses working in emergency departments and trauma centers should be familiar with their agency’s protocols for maintaining evidence required by law enforcement. Often, law enforcement does not want the victim’s hands or the area around the victim’s wounds cleansed. Clothes and personal items are often wanted as evidence. The nurse should not bathe the patient and provide a clean gown. The nurse should not ask the patient who shot him or whereNtU h eRwSe I a pNo G n T is.BT.heCnOuM rse should preserve the chain of evidence. Because the majority of gunshot wounds require an investigation by law enforcement, nurses working in emergency departments and trauma centers should be familiar with their agency’s protocols for maintaining evidence required by law enforcement. Often, law enforcement does not want the victim’s hands or the area around the victim’s wounds cleansed. Clothes and personal items are often wanted as evidence. The nurse should not bathe the patient and provide a clean gown. The nurse should not ask the patient who shot him or where the weapon is. The nurse should preserve the chain of evidence. Because the majority of gunshot wounds require an investigation by law enforcement, nurses working in emergency departments and trauma centers should be familiar with their agency’s protocols for maintaining evidence required by law enforcement. Often, law enforcement does not want the victim’s hands or the area around the victim’s wounds cleansed. Clothes and personal items are often wanted as evidence. The nurse should not bathe the patient and provide a clean gown. The nurse should not ask the patient who shot him or where the weapon is. The nurse should preserve the chain of evidence.
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Because the majority of gunshot wounds require an investigation by law enforcement, nurses working in emergency departments and trauma centers should be familiar with their agency’s protocols for maintaining evidence required by law enforcement. Often, law enforcement does not want the victim’s hands or the area around the victim’s wounds cleansed. Clothes and personal items are often wanted as evidence. The nurse should not bathe the patient and provide a clean gown. The nurse should not ask the patient who shot him or where the weapon is. The nurse should preserve the chain of evidence.
PTS: 1 CON: Nursing 2. ANS: 4 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected emergencies Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Reduction of Risk Potential Cognitive level: Comprehension [Understanding] Concept: Nursing Difficulty: Easy Feedback 1 A computed tomography (CT) scan is performed if internal bleeding is suspected. 2 An x-ray will be performed for potential broken or fractured bones. 3 An ultrasound is performed if internal bleeding is suspected. 4 An MRI will be performed if there is a risk for spinal cord injuries, injuries to the muscles, or abdominal injuries. PTS: 1 CON: Nursing 3. ANS: 4 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Defining major complications of trauma Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Nursing Difficulty: Easy Feedback 1 Tracheal deviation and jugular vein distention are not associated with hemorrhage, compensatory shock, or hypovolemic shock. 2 Tracheal deviation and jugular vein distention are not associated with hemorrhage, compensatory shock, or hypovolemic shock. 3 Tracheal deviation and jugular vein distention are not associated with hemorrhage, compensatory shock, or hypovolemic shock.
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A tension pneumothorax is life threatening and requires immediate intervention. On inspiration, air enters the pleural space, does not escape on expiration, and increases the intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured lung.
PTS: 1 CON: Nursing 4. ANS: 2 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Developing a comprehensive plan of nursing care for patients with selected emergencies Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Nursing Difficulty: Easy Feedback 1 The other observations indicate that the patient is not yet recovered from the injuries or that interventions for the injuries have not yet been successful. The patient who is in bed with the lights and television turned off might need additional psychosocial support. 2 The patient sustained neck injuries from a motor vehicle accident. With these types of injuries, there is a risk for paralysis. Evidence that interventions have been successful for this patient includes movinNgUalRl S foI urNeG x tT reB m. itiC esOinMd epend en tly , feeding self, and participating in partial bath care. This means the patient has mobility, which is a successful outcome. 3 The other observations indicate that the patient is not yet recovered from the injuries or that interventions for the injuries have not yet been successful. The patient who is in bed with the lights and television turned off might need additional psychosocial support. 4 The other observations indicate that the patient is not yet recovered from the injuries or that interventions for the injuries have not yet been successful. The patient who is in bed with the lights and television turned off might need additional psychosocial support. PTS: 1 CON: Nursing 5. ANS: 4 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Developing a comprehensive plan of nursing care for patients with selected emergencies Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Nursing Difficulty: Difficult
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Feedback Monitoring urine output and assessing vital signs are important but not the priority at this time. Monitoring urine output and assessing vital signs are important but not the priority at this time. The patient may be able to perform active range of motion for all extremities, so this intervention may or may not be indicated. The patient has thoracic injuries and might be reluctant to deep breathe and cough because of pain. The nurse needs to ensure that the patient breathes deeply and coughs every two hours to mobilize secretions and prevent respiratory complications.
PTS: 1 CON: Nursing 6. ANS: 3 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Developing a comprehensive plan of nursing care for patients with selected emergencies Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Nursing Difficulty: Moderate Feedback 1 Encouragin g exercise improveNs U mR usSc le I NtoGn eT, Ban.dCenc O Mou ragin g coughing and deep breathing reduces the risk of respiratory complications, but neither helps reduce the risk of integumentary complications. 2 Encouraging exercise improves muscle tone, and encouraging coughing and deep breathing reduces the risk of respiratory complications, but neither helps reduce the risk of integumentary complications. 3 Assisting the patient to turn at least every two hours is the most appropriate intervention for the nurse to include in the plan of care to reduce the risk of integumentary complications. 4 Turning the patient every eight hours will not reduce the risk of integumentary complications. PTS: 1 CON: Nursing 7. ANS: 4 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Poisoning Chapter page reference: 1553-1562 Heading: Poisoning Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies Cognitive level: Comprehension [Understanding] Concept: Medication Difficulty: Easy Feedback
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Emesis, tinnitus, and nausea are all early clinical manifestations of acute aspirin poisoning. Emesis, tinnitus, and nausea are all early clinical manifestations of acute aspirin poisoning. Emesis, tinnitus, and nausea are all early clinical manifestations of acute aspirin poisoning. Ecchymosis is a late symptom associated with a chronic aspirin overdose.
PTS: 1 CON: Medication 8. ANS: 4 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Examining in hospital emergency/trauma care priorities Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Nursing Difficulty: Difficult Feedback 1 An adult patient experiencing mild chest pain would be an ESI-2. 2 An adolescent patient with a possible wrist fracture would be an ESI-4. 3 An older adult patient with a hip fracture who is experiencing pain would be an ESI-3. 4 According to the Five-Level Emergency Severity Index (ESI), a patient experiencing severe respirato ry distress suchN as URthSeIscNh oGoTl-Bag.e CpOatMien t with asthma who is having difficulty breathing (dyspnea) would receive priority care as an ESI-1. PTS: 1 CON: Nursing 9. ANS: 1 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Examining in hospital emergency/trauma care priorities Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Nursing Difficulty: Moderate Feedback 1 When working in an environment that uses the functional model of nursing, each team member will be delegated tasks for a group of patients by the team leader, the RN. The RN will delegate taking vital signs to the UAP. 2 One of the LPNs can provide wound care. 3 Typically, the RN is the member of the team who will conduct discharge teaching. 4 An LPN is able to administer oral medications. PTS: 1 10. ANS: 1
CON: Nursing
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Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Identifying the roles of health-care professionals on the emergency care team Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Nursing Difficulty: Easy 1
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Feedback A charge nurse coordinates care and assignments and may ultimately be the only person familiar with all the needs of any individual patient; therefore, it is this member of the team that will prioritize care for the patients who are being admitted. The nurse supervisor may be in charge of assigning the trauma patients to individual units. The licensed practical nurse will receive a patient assignment on the unit but will not prioritize care for the unit. The unlicensed assistive personnel will be delegated tasks by other members of the nursing team.
PTS: 1 CON: Nursing 11. ANS: 2 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Examining in hospital emergency/trauma care priorities Chapter page reference: 1540-1553NURSINGTB.COM Heading: Emergency Nursing Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Nursing Difficulty: Difficult
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Feedback Cystitis, a lacerated arm, and a fractured femur would not necessitate priority nursing care. A concussion, which is a type of head injury, is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care. Cystitis, a lacerated arm, and a fractured femur would not necessitate priority nursing care. Cystitis, a lacerated arm, and a fractured femur would not necessitate priority nursing care.
PTS: 1 CON: Nursing 12. ANS: 4 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Developing a comprehensive plan of nursing care for patients with selected emergencies Chapter page reference: 1540-1553
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Heading: Emergency Nursing Integrated Processes: Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Nursing Difficulty: Difficult Feedback 1 Maintaining privacy, having suction available, and giving supplemental oxygen are all interventions during the primary survey. 2 Maintaining privacy, having suction available, and giving supplemental oxygen are all interventions during the primary survey. 3 Maintaining privacy, having suction available, and giving supplemental oxygen are all interventions during the primary survey. 4 A nursing action that is appropriate during the secondary survey is assigning a nurse, or other team member, to support family members. PTS: 1 CON: Nursing 13. ANS: 1 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Identifying the roles of health-care professionals on the emergency care team Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] NURSINGTB.COM Concept: Nursing Difficulty: Easy Feedback 1 When using the team nursing approach, the team leader, who is a registered nurse, is responsible for coordinating a group of licensed and unlicensed personnel to provide patient care to a small group of patients, including the prioritization of patient care. 2 The charge nurse is responsible for assigning team members to each team leader. 3 The licensed practical nurse and the unlicensed assistive personnel will receive their assigned tasks and patient care from the team leader. 4 The licensed practical nurse and the unlicensed assistive personnel will receive their assigned tasks and patient care from the team leader. PTS: 1 CON: Nursing 14. ANS: 2 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Examining in hospital emergency/trauma care priorities Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Application [Applying] Concept: Nursing Difficulty: Moderate Feedback
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Nursing actions that are appropriate when conducting a primary survey during the airway assessment include assessing for edema, checking for foreign bodies, and monitoring for respiratory distress. Counting the respiratory rate is a nursing action appropriate during the breathing assessment. Nursing actions that are appropriate when conducting a primary survey during the airway assessment include assessing for edema, checking for foreign bodies, and monitoring for respiratory distress. Nursing actions that are appropriate when conducting a primary survey during the airway assessment include assessing for edema, checking for foreign bodies, and monitoring for respiratory distress.
PTS: 1 CON: Nursing 15. ANS: 1 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Examining in hospital emergency/trauma care priorities Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Nursing Difficulty: Difficult Feedback 1 The priority nursing actions reN laUteR d S toIbN reG atT h iB n g.wChOe nM conducting a primary survey during an emergency assessment include having suction available and giving supplemental oxygen. 2 Assessing pupil size and reactivity is an appropriate nursing action during the brief neurological assessment. 3 Immobilization of any obvious deformities is a nursing action appropriate in response to data obtained during the disability portion of the assessment. 4 Obtaining blood samples for a type and crossmatch is a nursing action appropriate in response to data obtained during the circulation portion of the assessment. PTS: 1 CON: Nursing 16. ANS: 1 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Examining in hospital emergency/trauma care priorities Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Nursing Difficulty: Difficult Feedback 1 The priority nursing action during the health history portion of the assessment is to determine drug allergies.
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Noting the general appearance, examining the neck for stiffness, and auscultating for heart and lung sounds are actions that occur during the head-to-toe physical assessment, not the health history. Noting the general appearance, examining the neck for stiffness, and auscultating for heart and lung sounds are actions that occur during the head-to-toe physical assessment, not the health history. Noting the general appearance, examining the neck for stiffness, and auscultating for heart and lung sounds are actions that occur during the head-to-toe physical assessment, not the health history.
PTS: 1 CON: Nursing 17. ANS: 2 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Identifying the roles of health-care professionals on the emergency care team Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Nursing Difficulty: Easy Feedback 1 Evaluating care, formulating diagnoses, and implementing interventions are all nursing skills used in the emergency department; however, these are not essential during the triage process. 2 Setting priorities is an essential nursing skill for the triage, or assessment, process that occurs in the emergency department. 3 Evaluating care, formulating diagnoses, and implementing interventions are all nursing skills used in the emergency department; however, these are not essential during the triage process. 4 Evaluating care, formulating diagnoses, and implementing interventions are all nursing skills used in the emergency department; however, these are not essential during the triage process. PTS: 1 CON: Nursing 18. ANS: 3 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Examining in hospital emergency/trauma care priorities Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Nursing Difficulty: Difficult
1
Feedback An adult patient with an ankle sprain and an infant with a rash of unknown origin are both classified as nonurgent.
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An adult patient with an ankle sprain and an infant with a rash of unknown origin are both classified as nonurgent. An adult patient with unstable vital signs would receive priority care based on the threetiered triage system due to emergent, or life-threatening, injury. A pediatric patient with multiple fractures following a motor vehicle accident is classified as an urgent patient.
PTS: 1 CON: Nursing 19. ANS: 4 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Examining in hospital emergency/trauma care priorities Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Nursing Difficulty: Difficult Feedback 1 The patient with a simple fracture is nonurgent. 2 The patients with renal colic and severe abdominal pain are classified as urgent. 3 The patients with renal colic and severe abdominal pain are classified as urgent. 4 The patient with chest pain and diaphoresis is classified as emergent and would require priority care.
NURSINGTB.COM PTS: 1 CON: Nursing 20. ANS: 1 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Examining in hospital emergency/trauma care priorities Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Nursing Difficulty: Difficult Feedback 1 The priority nursing actions after completion of the secondary survey during the emergency assessment include documenting all patient care and administering tetanus prophylaxis. 2 Formulating the patient’s plan of care, reassessing level of consciousness, and transferring the patient to the general medical unit are nursing actions implemented once the patient is stable. 3 Formulating the patient’s plan of care, reassessing level of consciousness, and transferring the patient to the general medical unit are nursing actions implemented once the patient is stable. 4 Formulating the patient’s plan of care, reassessing level of consciousness, and transferring the patient to the general medical unit are nursing actions implemented once the patient is stable.
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PTS: 1 CON: Nursing 21. ANS: 2 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Examining in hospital emergency/trauma care priorities Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Nursing Difficulty: Difficult
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Feedback While assessing bowel sounds, administering pain medication, and scheduling a CT scan to determine retroperitoneal bleeding are important interventions, these are not the priorities in this situation. The priority nursing action when providing care to a patient with a penetrating abdominal wound is to stabilize the impaled object to prevent further injury. While assessing bowel sounds, administering pain medication, and scheduling a CT scan to determine retroperitoneal bleeding are important interventions, these are not the priorities in this situation. While assessing bowel sounds, administering pain medication, and scheduling a CT scan to determine retroperitoneal bleeding are important interventions, these are not the priorities in this situation. NURSINGTB.COM
PTS: 1 CON: Nursing 22. ANS: 2 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Discussing the medical management of selected emergencies Chapter page reference: 1553-1562 Heading: Poisoning Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Comprehension [Understanding] Concept: Nursing Difficulty: Easy Feedback 1 Gastric lavage will not remove concentrations of aspirin. 2 The nurse would prepare to administer activated charcoal to the client and repeat every four hours, if needed, for a client with active bowel sounds. 3 Hemodialysis, not peritoneal dialysis, is a treatment that may be prescribed for a client who presents with an overdose of aspirin. 4 Vitamin K, not D, is administered to assist with clotting. PTS: 1 CON: Nursing 23. ANS: 4 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Examining in hospital emergency/trauma care priorities
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Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity – Physiological Adaptation Cognitive level: Analysis [Analyzing] Concept: Nursing Difficulty: Difficult Feedback 1 Dyspnea, not eupnea, would indicate the need for priority intervention. This patient is experiencing normal respirations. 2 Tachycardia and hypotension are also priority assessment data that indicate the need for intervention; however, this data indicates circulatory, and not respiratory, compromise. 3 Tachycardia and hypotension are also priority assessment data that indicate the need for intervention; however, this data indicates circulatory, and not respiratory, compromise. 4 Dyspnea, agonal breaths, and an inability to speak are all assessment data that indicate a compromised airway and the need for priority intervention by the nurse. PTS: 1
CON: Nursing
MULTIPLE RESPONSE 24. ANS: 2, 4, 5 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Developing a comprehensive plan of nursing care for patients with selected emergencies NURSINGTB.COM Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Nursing Difficulty: Moderate
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Feedback This is incorrect. The secondary survey begins after addressing each step of the primary survey and starting any lifesaving interventions. The secondary survey is a brief, systematic process that aims to identify all injuries. Nursing actions appropriate during the secondary, not primary, survey include inserting a nasogastric tube and arranging for diagnostic studies. This is correct. The primary survey focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life -threatening conditions so that appropriate interventions can be started. Nursing actions that are appropriate during the primary survey include immobilizing the cervical spine, preparing for chest tube insertion, and applying direct pressure to a wound. This is incorrect. The secondary survey begins after addressing each step of the primary survey and starting any lifesaving interventions. The secondary survey is a brief, systematic process that aims to identify all injuries. Nursing actions appropriate during the secondary, not primary, survey include inserting a nasogastric tube and arranging for diagnostic studies.
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4.
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This is correct. The primary survey focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life -threatening conditions so that appropriate interventions can be started. Nursing actions that are appropriate during the primary survey include immobilizing the cervical spine, preparing for chest tube insertion, and applying direct pressure to a wound. This is correct. The primary survey focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life -threatening conditions so that appropriate interventions can be started. Nursing actions that are appropriate during the primary survey include immobilizing the cervical spine, preparing for chest tube insertion, and applying direct pressure to a wound.
PTS: 1 CON: Nursing 25. ANS: 1, 3, 4, 5 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Examining in hospital emergency/trauma care priorities Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Nursing Difficulty: Difficult
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Feedback This is correct. Clinical priorities for the treatment of gunshot wound are the following: maintain airway and assN isU t vRenStiIlaNtioGnTaB s . neC ceOssMary, control hemorrhage, prevent hypothermia. Also necessary is a rapid, recurrent assessment of the patient’s neurological status, as well as prevention of infection. This is incorrect. While obtaining the patient’s medical history is important, this action would not be priority and would take place after the priority assessment and treatment. Once the safety of the patient is assured, then the nurse will manage the patient’s emotional state and obtain the medical history. This is correct. Clinical priorities for the treatment of gunshot wound are the following: maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia. Also necessary is a rapid, recurrent assessment of the patient’s neurological status, as well as prevention of infection. This is correct. Clinical priorities for the treatment of gunshot wound are the following: maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia. Also necessary is a rapid, recurrent assessment of the patient’s neurological status, as well as prevention of infection. This is correct. Clinical priorities for the treatment of gunshot wound are the following: maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia. Also necessary is a rapid, recurrent assessment of the patient’s neurological status, as well as prevention of infection.
PTS: 1 CON: Nursing 26. ANS: 1, 5 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Examining in hospital emergency/trauma care priorities
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Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Assessment Client Need: Safe an Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Nursing Difficulty: Difficult
1. 2. 3. 4. 5.
PTS: 1
Feedback This is correct. Airway and stabilization of the cervical spine are the top priorities when conducting a primary patient survey during the emergency assessment. This is incorrect. The nurse will then focus on breathing, circulation, and disability. This is incorrect. The nurse will then focus on breathing, circulation, and disability. This is incorrect. The nurse will then focus on breathing, circulation, and disability. This is correct. Airway and stabilization of the cervical spine are the top priorities when conducting a primary patient survey during the emergency assessment. CON: Nursing
COMPLETION 27. ANS: 4321 Chapter number and title: Emergency, Trauma, and Environmental Injuries Be.rgCeOn cMy /trauma care priorities Chapter learning objective: ExamininNgUinRhSoI spNitG alT em Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Nursing Difficulty: Difficult Feedback: When using the Five-Level Emergency Severity Index (ESI), an ESI-1 is the highest priority while an ESI-5 is the lowest priority. The patient who took an overdose of opioids and is experiencing bradypnea (respiratory rate of less than 10 breaths per minute) is the priority at ESI-1. The patient who has multiple trauma due to a motor vehicle accident is an ESI-2. The patient with abdominal pain rated as a 7 using the numeric pain scale is an ESI-3. A patient with a leg laceration requiring sutures is an ESI-4. PTS: 1 CON: Nursing 28. ANS: 1243 Chapter number and title: Emergency, Trauma, and Environmental Injuries Chapter learning objective: Examining in hospital emergency/trauma care priorities Chapter page reference: 1540-1553 Heading: Emergency Nursing Integrated Processes: Nursing Process: Implementation Client Need: Safe an Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing]
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Concept: Nursing Difficulty: Difficult Feedback: The first step the nurse takes when providing care to a trauma patient is to clear the airway. The second step is to protect the cervical spine. The third step is to provide supplemental oxygen. The fourth step is to perform chest compressions. PTS: 1
CON: Nursing
Chapter 71: Mass Casualty and Disaster Preparedness Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which is the critical factor among health-care professionals, state agencies, and federal agencies to determine when and how to evacuate safely during a natural disaster? 1) Cooperation 2) Classification 3) Collaboration 4) Communication 2. A workplace violence prevention plan is often one component of a hospital disaster plan. Which unit assumes priority for implementation and evaluation of this component to the plan? 1) Medical unit 2) Surgical unit 3) Radiology department NURSINGTB.COM 4) Emergency department 3. Which is the priority in the preparedness of health-care professionals in any type of disaster plan? 1) Identification of hazards 2) Cooperation with state authorities 3) Collaboration with local authorities 4) Implementation of federal mandates 4. Which treatment for anthrax should be included in the biological agent portion of a disaster plan for terrorist attacks? 1) Antivirals 2) Antitoxins 3) Antibiotics 4) Vaccinations 5. Which medication should be listed as the antidote to a nerve agent in the disaster plan for a terrorist attack? 1) Atropine 2) Dopamine 3) Epinephrine 4) Norepinephrine 6. Which is the priority nursing action to include in a disaster plan for the radioactive dust and smoke that can cause illness from a radiologic dispersal device (RDD)? 1) Covering the nose 2) Protecting the eyes 3) Decontaminating the skin
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4) Administering prophylactic antibiotics 7. Which health-care team member is a first responder when an emergency or mass casualty incident (MCI) occurs? 1) Fireman 2) Police officer 3) Critical care nurse 4) Unlicensed assistive personnel 8. Which situation does not cover nurses who respond to a mass casualty incident (MCI) for malpractice or negligent lawsuits under the Good Samaritan Act? 1) Terrorist act 2) Neighborhood fire 3) Roadside car accident 4) High school sporting event 9. The nurse is a first responder for a health-care organization for a mass casualty incident. Which injury would the nurse tag as yellow during the triage process? 1) Ankle sprain 2) Hypovolemic shock 3) Open femur fracture 4) Massive head trauma 10. Which amount of time is appropriate for nurse to spend triaging each patient during a mass casualty incident? 1) Less than 10 seconds 2) Less than 15 seconds 3) Less than 30 seconds NURSINGTB.COM 4) Less than 60 seconds 11. The nurse is helping devise a training plan to familiarize health-care providers with emergency response procedures. Which training measure is most effective to adequately prepare the trainees? 1) Drills 2) Tabletop exercises 3) Access to the policy 4) Computer simulations 12. The nurse is a member of the critical incident stress management unit that looks to meet the psychosocial needs of first responders after a mass casualty incident. Which action by the nurse is appropriate when conducting a session? 1) Arranging group discussion 2) Administering anti-anxiety medication 3) Scheduling individual therapy appointments 4) Documenting individual responses to the session 13. Which type of event can often be handled by an individual hospital disaster plan without collaboration with other systems? 1) A motor vehicle accident involving five cars 2) A tornado destroying 50 homes and businesses 3) An act of terrorism injuring and kills hundreds of people 4) A hurricane causing flooding, displacing thousands of people 14. Which organization in the United States mandates ongoing disaster preparedness for hospitals?
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1) 2) 3) 4)
The Joint Commission (TJC) The local government The state government The Occupational Safety and Health Administration (OSHA)
15. A nurse manager is a member of the emergency response planning team for a hospital located in the Rocky Mountains. Which type of natural disaster will the nurse manager recommend be included in their hospital disaster plan? 1) Tornado 2) Hurricane 3) Avalanche 4) Earthquake 16. The nurse manager is reviewing the hospital disaster plan with other members of the committee. Which is the minimum number of disaster drills the committee must plan and implement each year? 1) Two 2) Three 3) Four 4) Five 17. The nurse administrator for a long-term care facility is implementing a disaster response plan for staff and residents. Which staff member statements indicate correct understanding of the plan? 1) “We have to implement annual drills.” 2) “Nursing homes are not required to have a plan.” 3) “Our facility is held to the same standards as hospital facilities.” 4) “This is an important component to receive insurance payments for care.”
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18. Which public health risk became a major focus for hospitals after the September 11, 2001 terrorist attacks? 1) Anthrax exposure 2) Multi-casualty incidents 3) Mass casualty incidents (MCI) 4) Weapons of mass destruction (WMD) 19. The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a patient who is experiencing hypovolemic shock due to a penetrating wound? 1) Red 2) Black 3) Green 4) Yellow 20. Which emergency medical system (EMS) first responders can perform triage during mass casualty incidents? 1) Unlicensed assistive personnel 2) Nurses appointed to a field team 3) A physician who survives the incident 4) Community response team members 21. Which patient injury would receive a black tag by the triage nurse during a mass casualty incident? 1) Concussion 2) Ankle sprain 3) Open femur fracture 4) Full-thickness body burns
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22. A green-tagged patient arrives at the emergency department after a mass casualty incident (MCI) involving radiation. Which is the priority nursing action for this patient? 1) Implementing decontamination measures 2) Performing a head-to-toe physical examination 3) Placing a special bracelet with a disaster number 4) Taking a digital photo and placing it on the medical record 23. Which entity is responsible for activating the disaster plan during a mass casualty incident (MCI)? 1) Local emergency management system 2) State emergency management system 3) Federal emergency management agency 4) Hospital-level emergency management system Multiple Response Identify one or more choices that best complete the statement or answer the question. 24. Which threats, included in the term “NBC,” lead to the implementation of improved emergency medical services (EMS) and hospital safety programs? Select all that apply. 1) Nuclear 2) Biological 3) Botulism 4) Chemical 5) Nipah virus 25. A nurse is working an evening shift when a fire breaks out at the hospital. Which actions by the nurse are appropriate? Select all that apply. NURSINGTB.COM 1) Removing patients from immediate danger 2) Discontinuing the use of oxygen for all patients 3) Using a wheelchair to move a bedridden patient 4) Directing ambulatory patients to walk to a safe location 5) Containing the fire immediately to avoid patient evacuation 26. Which nursing actions are necessary when initiating care for patients who have been injured in a natural disaster? Select all that apply. 1) Taking risks 2) Using principles 3) Stepping into the unknown 4) Showing a commanding presence 5) Formulating individualized plans of care 27. Which psychosocial nursing actions are appropriate when providing patient care after a community disaster? Select all that apply. 1) Performing triage of injuries 2) Administering first aid to wounds 3) Offering choices whenever possible 4) Establishing rapport through active listening 5) Requesting assistance from crisis counselors 28. The nurse is contributing to a disaster plan for a possible terrorist attack. Which biological agents should be included in the plan? Select all that apply. 1) Rubella
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2) 3) 4) 5)
Anthrax Measles Botulism Tularemia
29. Which are the most common types of injuries that should be identified along with treatment options in an organizational disaster plan for the use of explosive devices as agents of terrorism? Select all that apply. 1) Burn 2) Blast 3) Crush 4) Penetration 5) Psychological 30. Which nursing actions during a mass casualty incident should be included in the triage portion of an organizational disaster plan? Select all that apply. 1) Treatment 2) Stabilization 3) Evaluation of interventions 4) Formulation of nursing diagnosis 5) Decontamination for suspected contamination
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Chapter 71: Mass Casualty and Disaster Preparedness Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Identifying current concepts in disaster response Chapter page reference: 1590-1592 Heading: Current Concepts in Disaster Preparedness and Response Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Safety Difficulty: Easy Feedback 1 Cooperation, classification, and collaboration, while important, are not the critical factors to determine when and how to safely evacuate during a natural disaster. 2 Cooperation, classification, and collaboration, while important, are not the critical factors to determine when and how to safely evacuate during a natural disaster. 3 Cooperation, classification, and collaboration, while important, are not the critical factors to determine when and how to safely evacuate during a natural disaster. 4 Communication is the critical factor among health-care professionals, state agencies, and federal agencies to determine when and how to evacuate safety during a natural NURSINGTB.COM disaster. PTS: 1 CON: Safety 2. ANS: 4 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Identifying current concepts in disaster response Chapter page reference: 1590-1592 Heading: Current Concepts in Disaster Preparedness and Response Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Safety Difficulty: Easy Feedback 1 Medical units, surgical units, and mental health departments may also require such plans; however, these units have system barriers that decrease the risk for violence when compared to emergency departments. 2 Medical units, surgical units, and mental health departments may also require such plans; however, these units have system barriers that decrease the risk for violence when compared to emergency departments. 3 Medical units, surgical units, and mental health departments may also require such plans; however, these units have system barriers that decrease the risk for violence when compared to emergency departments.
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4
The Emergency Nursing Association (ENA) supports comprehensive workplace violence prevention plans to be included as a component of the organizational disaster plan. The ENA recommends that the comprehensive workplace violence prevention plan be implemented and evaluated in every emergency department.
PTS: 1 CON: Safety 3. ANS: 1 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Identifying current concepts in disaster response Chapter page reference: 1590-1592 Heading: Current Concepts in Disaster Preparedness and Response Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Safety Difficulty: Easy Feedback 1 Identification of hazards is the priority in the preparedness of health-care professionals in any type of disaster plan. 2 While cooperation with state authorities, collaboration with local authorities, and implementation of federal mandates also play a role in being prepared for a disease, these are not the priority because it is essential to identify the specific hazard in order to implement the most appropriate portion of the disaster plan. 3 While cooperation with state authorities, collaboration with local authorities, and implementation of federal mandates al so p la y a ro le in being prepared for a disease, these URS I N GtoTidentify B .C OMthe specific hazard in order to are not the priority because it isNessential implement the most appropriate portion of the disaster plan. 4 While cooperation with state authorities, collaboration with local authorities, and implementation of federal mandates also play a role in being prepared for a disease, these are not the priority because it is essential to identify the specific hazard in order to implement the most appropriate portion of the disaster plan. PTS: 1 CON: Safety 4. ANS: 3 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Discussing the hospital response to a disaster including triage, personal protective equipment, decontamination, surge planning, and mental health Chapter page reference: 1579-1590 Heading: Overview of Disasters Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Safety Difficulty: Easy Feedback 1 Antivirals would not be effective against anthrax, and there is no established treatment for most viruses that cause hemorrhagic fever. 2 Botulism is treated with antitoxin, though several vaccines are being studied.
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3 4
Anthrax is treated effectively with antibiotics if sufficient supplies are available and the organisms are not resistant. Smallpox can be prevented or the incidence reduced by vaccination, even when first given after exposure.
PTS: 1 CON: Safety 5. ANS: 1 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Discussing the hospital response to a disaster including triage, personal protective equipment, decontamination, surge planning, and mental health Chapter page reference: 1579-1590 Heading: Overview of Disasters Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Safety Difficulty: Easy 1 2 3 4
Feedback Atropine should be listed as the antidote for nerve agent poisoning in the disaster plan for a terrorist attack. Dopamine, epinephrine, and norepinephrine are not medications used to treat nerve agent poisoning. Dopamine, epinephrine, and norepinephrine are not medications used to treat nerve agent poisoning. NURSINGTB.COM Dopamine, epinephrine, and norepinephrine are not medications used to treat nerve agent poisoning.
PTS: 1 CON: Safety 6. ANS: 1 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Discussing the hospital response to a disaster including triage, personal protective equipment, decontamination, surge planning, and mental health Chapter page reference: 1593-1596 Heading: Hospital Response to a Disaster Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult Feedback 1 The priority nursing action to protect against the radioactive dust and smoke that can cause illness from an RDD is covering the nose and the mouth to decrease the risk for inhalation. 2 Protecting the eyes is the priority if present during the explosion, but not necessarily when exposed to the subsequent dust and smoke. 3 Decontaminating the skin is important but not the priority. 4 Administering prophylactic antibiotics will not be effective to prevent illness related to an RDD.
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PTS: 1 CON: Safety 7. ANS: 3 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Identifying current concepts in disaster response Chapter page reference: 1590-1592 Heading: Current Concepts in Disaster Preparedness and Response Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Safety Difficulty: Easy Feedback 1 Firemen and police officers are first responders but are not members of the health -care team. 2 Firemen and police officers are first responders but are not members of the health-care team. 3 Critical care nurses are often considered emergency medical personnel that respond to emergency or MCIs. 4 Unlicensed assistive personnel are not first responders. PTS: 1 CON: Safety 8. ANS: 1 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Identifying current concepts in disaster response Chapter page reference: 1590-1592 NURSINGTB.CO Heading: Current Concepts in Disaster Preparedness and Response Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Legal Difficulty: Easy
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Feedback When terrorist acts occur, nurses are often required to go to an assigned site to offer aid. When this occurs, the nurse is not covered from malpractice or negligent lawsuits. Nurses who respond to injuries that occur in a neighborhood fire, roadside car accident, or a high school sporting event are covered under the Good Samaritan Act. Nurses who respond to injuries that occur in a neighborhood fire, roadside car accident, or a high school sporting event are covered under the Good Samaritan Act. Nurses who respond to injuries that occur in a neighborhood fire, roadside car accident, or a high school sporting event are covered under the Good Samaritan Act.
PTS: 1 CON: Legal 9. ANS: 3 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Describing essential nursing tasks in response to a disaster Chapter page reference: 1596-1598 Heading: Nurse’s Role During a Disaster
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Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Assessment Difficulty: Moderate
1 2 3 4
Feedback An ankle sprain is a minor injury that would be tagged as green. Hypovolemic shock is a life-threatening injury that requires immediate intervention and would be tagged as red. When using a triage tag system, an open femur fracture is an urgent but not lifethreatening injury that would be tagged as yellow. A massive head injury is tagged black as the patient is expected to die.
PTS: 1 CON: Assessment 10. ANS: 2 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Describing essential nursing tasks in response to a disaster Chapter page reference: 1596-1598 Heading: Nurse’s Role During a Disaster Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Knowledge [Remembering] Concept: Assessment Difficulty: Easy
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Feedback Triage of victims of an emergency or an MCI must be conducted in less than 15 seconds. The other time frames, 10 seconds, 30 seconds, and 60 seconds, are not accurate. Triage of victims of an emergency or an MCI must be conducted in less than 15 seconds. The other time frames, 10 seconds, 30 seconds, and 60 seconds, are not accurate. Triage of victims of an emergency or an MCI must be conducted in less than 15 seconds. The other time frames, 10 seconds, 30 seconds, and 60 seconds, are not accurate. Triage of victims of an emergency or an MCI must be conducted in less than 15 seconds. The other time frames, 10 seconds, 30 seconds, and 60 seconds, are not accurate.
PTS: 1 CON: Assessment 11. ANS: 1 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Identifying current concepts in disaster response Chapter page reference: 1590-1592 Heading: Current Concepts in Disaster Preparedness and Response Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding]
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Concept: Safety Difficulty: Easy Feedback 1 Hospital disaster drills are priority training measures to familiarize health-care providers with emergency response procedure. 2 Other methods that can also be used include tabletop exercises and computer simulations; however, these methods will not provide immersive practice comparable to well-planned drills. 3 Access to the policy is important but will not provide real world experience for emergency response procedures. 4 Other methods that can also be used include tabletop exercises and computer simulations; however, these methods will not provide immersive practice comparable to well-planned drills. PTS: 1 CON: Safety 12. ANS: 1 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Listing the essential elements of a personal preparedness plan Chapter page reference: 1596-1598 Heading: Nurse’s Role During a Disaster Integrated Processes: Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Nursing Difficulty: Moderate
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Feedback Many hospitals and DMATs have a critical incident stress management unit, which arranges group discussions to allow participants to share and validate their feelings and emotions about the experience. This is important for emotional recovery. The nurse does not administer anti-anxiety medications to the participants, schedule individual therapy appointments, or document individual responses to the group session. The nurse does not administer anti-anxiety medications to the participants, schedule individual therapy appointments, or document individual responses to the group session. The nurse does not administer anti-anxiety medications to the participants, schedule individual therapy appointments, or document individual responses to the group session.
PTS: 1 CON: Nursing 13. ANS: 1 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Discussing the hospital response to a disaster including triage, personal protective equipment, decontamination, surge planning, and mental health Chapter page reference: 1593-1596 Heading: Hospital Response to a Disaster Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care
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Cognitive level: Comprehension [Understanding} Concept: Health Care System Difficulty: Easy
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Feedback A multi-casualty event, such as a motor vehicle accident involving five cars, is an event that can often be handled with the implementation of an individual hospital disaster plan without collaboration with other systems. Any mass casualty event, such as a tornado, an act of terrorism, or a hurricane, often requires not only the implementation of the hospital disaster plan but collaboration with other systems. Any mass casualty event, such as a tornado, an act of terrorism, or a hurricane, often requires not only the implementation of the hospital disaster plan but collaboration with other systems. Any mass casualty event, such as a tornado, an act of terrorism, or a hurricane, often requires not only the implementation of the hospital disaster plan but collaboration with other systems.
PTS: 1 CON: Health Care System 14. ANS: 1 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Identifying current concepts in disaster response Chapter page reference: 1590-1592 Heading: Current Concepts in Disaster Preparedness and Response Integrated Processes: Nursing Process: Planning NURSINGTB.COM Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Knowledge [Remembering] Concept: Safety Difficulty: Easy Feedback 1 In the United States, The Joint Commission mandates that hospitals have an emergency preparedness plan that is tested through drills or actual participation in a real event at least twice yearly. 2 The local government, the state government, and OSHA do not mandate that hospitals have an emergency preparedness plan that is tested twice per year. 3 The local government, the state government, and OSHA do not mandate that hospitals have an emergency preparedness plan that is tested twice per year. 4 The local government, the state government, and OSHA do not mandate that hospitals have an emergency preparedness plan that is tested twice per year. PTS: 1 CON: Safety 15. ANS: 3 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Describing the many types of disasters and their impact Chapter page reference: 1579-1590 Heading: Overview of Disasters Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding]
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Concept: Health Care System Difficulty: Easy
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Feedback There is not a significant risk for tornados, hurricanes, or earthquakes in this region of the country. There is not a significant risk for tornados, hurricanes, or earthquakes in this region of the country. Disaster drills are ideally planned based on a risk assessment or vulnerability analysis that identifies the events most likely to occur in a particular community. For a hospital in the Rocky Mountains, there is a significant risk for an avalanche. The nurse manager will, therefore, recommend that avalanche planning be included in the hospital disaster plan. There is not a significant risk for tornados, hurricanes, or earthquakes in this region of the country.
PTS: 1 CON: Health Care System 16. ANS: 1 Chapter number and title: 1, Mass Casualty and Disaster Preparedness Chapter learning objective: Discussing the hospital response to a disaster including triage, personal protective equipment, decontamination, surge planning, and mental health Chapter page reference: 1593-1596 Heading: Hospital Response to a Disaster Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehensive [UndersN taU ndRinSgI ] NGTB.COM Concept: Health Care System Difficulty: Easy
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Feedback While it is appropriate to have more than the minimum number of disaster drills each year, the minimum that must be implemented per The Joint Commission (TJC) requirements is twice per calendar year. While it is appropriate to have more than the minimum number of disaster drills each year, the minimum that must be implemented per The Joint Commission (TJC) requirements is twice per calendar year. While it is appropriate to have more than the minimum number of disaster drills each year, the minimum that must be implemented per The Joint Commission (TJC) requirements is twice per calendar year. While it is appropriate to have more than the minimum number of disaster drills each year, the minimum that must be implemented per The Joint Commission (TJC) requirements is twice per calendar year.
PTS: 1 CON: Health Care System 17. ANS: 1 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Discussing the hospital response to a disaster including triage, personal protective equipment, decontamination, surge planning, and mental health Chapter page reference: 1593-1596
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Heading: Hospital Response to a Disaster Integrated Processes: Nursing Process: Evaluation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Health Care System Difficulty: Difficult Feedback 1 Hospitals are not the only health-care agencies that are required to practice disaster drills. Long-term care (LTC) facilities are also mandated to have annual drills to prepare for mass casualty events. Part of the response plan must include a method for evacuation of residents from the facility in a timely and safe manner. 2 Nursing homes are also required to have a disaster response plan. 3 Long-term care facilities are not held to the same standards as hospital facilities. 4 Insurance payment for medical care is not contingent on the implementation of a disaster response plan. PTS: 1 CON: Health Care System 18. ANS: 4 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Describing the many types of disasters and their impact Chapter page reference: 1579-1590 Heading: Overview of Disasters Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] NURSINGTB.COM Concept: Health Care System Difficulty: Easy Feedback 1 Anthrax exposure occurred in the aftermath of the terrorist attacks; however, this public health risk has not become a major focus. 2 Multi-casualty and mass casualty incidents have always been included in hospital response plans. 3 Multi-casualty and mass casualty incidents have always been included in hospital response plans. 4 Weapons of mass destruction (WMD) rapidly became a focus of public health risk after the terrorist attacks that occurred on September 11, 2001. PTS: 1 CON: Health Care System 19. ANS: 1 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Describing essential nursing tasks in response to a disaster Chapter page reference: 1596-1598 Heading: Nurse’s Role During a Disaster Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Assessment Difficulty: Moderate Feedback
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The nurse would use a red tag for a patient who has injuries that are an immediate threat to life, such as hypovolemic shock, during mass casualty conditions. A black tag is used for a patient who is expected and allowed to die. A green tag is used for a patient with minor injuries that do not require immediate treatment. A yellow tag is used for a patient who has major injuries requiring treatment.
PTS: 1 CON: Assessment 20. ANS: 2 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Identifying current concepts in disaster response Chapter page reference: 1590-1592 Heading: Current Concepts in Disaster Preparedness and Response Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Health Care System Difficulty: Easy Feedback 1 Unlicensed assistive personnel can assist with providing patient care in a hospital setting under the direction of a licensed practitioner. 2 Paramedics and nurses appointed to a field team are the EMS first responders who can perform triage during a mass casualty incident. 3 A physician who survives the incident can assist with treatment; however, this individual is not necessarily traineN d U foR r tri SIagNe.GTB.COM 4 Community response team members can assist first responders; however, these individuals are not trained for triage. PTS: 1 CON: Health Care System 21. ANS: 4 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Describing essential nursing tasks in response to a disaster Chapter page reference: 1596-1598 Heading: Nurse’s Role During a Disaster Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Nursing Difficulty: Moderate Feedback 1 Patients with a concussion, ankle sprain, and open femur fracture would receive yellow and green tags. 2 Patients with a concussion, ankle sprain, and open femur fracture would receive yellow and green tags. 3 Patients with a concussion, ankle sprain, and open femur fracture would receive yellow and green tags.
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A black tag indicates the patient has suffered an extensive injury and is expected, or allowed, to die. Typical examples of black-tagged patients are those with massive head trauma, extensive full-thickness body burns, and high cervical spinal cord injury requiring mechanical ventilation.
PTS: 1 CON: Nursing 22. ANS: 1 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Describing essential nursing tasks in response to a disaster Chapter page reference: 1596-1598 Heading: Nurse’s Role During a Disaster Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Analysis [Analyzing] Concept: Health Care System Difficulty: Difficult Feedback 1 The priority nursing action for a green-tagged patient who arrives at the ED after exposure to radiation is implementing decontamination measures. These measures are the priority because it is essential that members of the health-care team and patients are not exposed to the radiation while providing care. 2 While the other nursing actions (performing a head-to-toe physical examination, placing a special bracelet with a disaster number, and taking a digital photo and placing it on the medication record) should occur during the admission process to the ED, these are not the priority actions. 3 While the other nursing actions (performing a head-to-toe physical examination, placing a special bracelet with a disaster number, and taking a digital photo and placing it on the medication record) should occur during the admission process to the ED, these are not the priority actions. 4 While the other nursing actions (performing a head-to-toe physical examination, placing a special bracelet with a disaster number, and taking a digital photo and placing it on the medication record) should occur during the admission process to the ED, these are not the priority actions. PTS: 1 CON: Health Care System 23. ANS: 4 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Identifying current concepts in disaster response Chapter page reference: 1593-1596 Heading: Hospital Response to a Disaster Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Health Care System Difficulty: Easy Feedback 1 Local emergency management systems may communicate with the hospital from the field to determine how many patients the hospital can accept.
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State and federal emergency management systems may contact hospitals for notification purposes of a mass casualty incident. State and federal emergency management systems may contact hospitals for notification purposes of a mass casualty incident. Each hospital has its own policy that specifies who has the authority to activate and how to activate the disaster or emergency preparedness plan.
PTS: 1
CON: Health Care System
MULTIPLE RESPONSE 24. ANS: 1, 2, 4 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Identifying current concepts in disaster response Chapter page reference: 1590-1592 Heading: Current Concepts in Disaster Preparedness and Response Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Comprehension [Understanding] Concept: Health Care System Difficulty: Easy
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Feedback This is correct. The term “NBC” was coined to describe nuclear, biological, and chemical th reats. In respon se, emergenNcU y R mS edIicNalGsT e rB v i. c eCs O (EMMS ) agencies and hosp itals imp rov ed safety by upgrading their decontamination facilities, equipment, and all levels of personal protective equipment to better protect staff. This is correct. The term “NBC” was coined to describe nuclear, biological, and chemical threats. In response, emergency medical services (EMS) agencies and hospitals improved safety by upgrading their decontamination facilities, equipment, and all levels of personal protective equipment to better protect staff. This is incorrect. Botulism and nipah virus are two specific examples of biological threats. This is correct. The term “NBC” was coined to describe nuclear, biological, and chemical threats. In response, emergency medical services (EMS) agencies and hospitals improved safety by upgrading their decontamination facilities, equipment, and all levels of personal protective equipment to better protect staff. This is incorrect. Botulism and nipah virus are two specific examples of biological threats.
PTS: 1 CON: Health Care System 25. ANS: 1, 3, 4 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Describing essential nursing tasks in response to a disaster Chapter page reference: 1596-1598 Heading: Nurse’s Role During a Disaster Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Safety
Difficulty: Moderate
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Feedback This is correct. According to the fire safety portion of the emergency response for internal disasters, the nurse should remove patients from immediate danger, use a wheelchair to move bedridden patients, and direct ambulatory patients to walk to a safe location. This is incorrect. The nurse should discontinue oxygen for patients who can breathe without it but not for all patients. This is correct. According to the fire safety portion of the emergency response for internal disasters, the nurse should remove patients from immediate danger, use a wheelchair to move bedridden patients, and direct ambulatory patients to walk to a safe location. This is correct. According to the fire safety portion of the emergency response for internal disasters, the nurse should remove patients from immediate danger, use a wheelchair to move bedridden patients, and direct ambulatory patients to walk to a safe location. This is incorrect. The nurse should seek to contain the fire only after everyone is out of danger and there is no risk of injury for self or others.
PTS: 1 CON: Safety 26. ANS: 1, 2, 3, 4 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Describing essential nursing tasks in response to a disaster Chapter page reference: 1596-1598 Heading: Nurse’s Role During a Disaster Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Safety Difficulty: Moderate
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Feedback This is correct. Nursing actions that are required when initiating care for patients who have been injured in a natural disaster include taking risks, using principles, stepping into the unknown, and showing a commanding presence. This is correct. Nursing actions that are required when initiating care for patients who have been injured in a natural disaster include taking risks, using principles, stepping into the unknown, and showing a commanding presence. This is correct. Nursing actions that are required when initiating care for patients who have been injured in a natural disaster include taking risks, using principles, stepping into the unknown, and showing a commanding presence. This is correct. Nursing actions that are required when initiating care for patients who have been injured in a natural disaster include taking risks, using principles, stepping into the unknown, and showing a commanding presence. This is incorrect. Formulating individualized plans of care is not a nursing action that is appropriate when providing care to patients who have been injured in a natural disaster. This step is implemented later in the patient’s care.
PTS: 1 CON: Safety 27. ANS: 3, 4, 5 Chapter number and title: 71, Mass Casualty and Disaster Preparedness
Chapter learning objective: Describing essential nursing tasks in response to a disaster Chapter page reference: 1596-1598 Heading: Nurse’s Role During a Disaster Integrated Processes: Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive level: Application [Applying] Concept: Nursing Difficulty: Moderate
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Feedback This is incorrect. Performing triage of injuries and administering first aid to wounds are not psychosocial nursing actions. This is incorrect. Performing triage of injuries and administering first aid to wounds are not psychosocial nursing actions. This is correct. Psychosocial nursing actions appropriate when providing care after a community disaster include offering choices whenever possible, establishing rapport through active listening, and requesting assistance from crisis counselors. This is correct. Psychosocial nursing actions appropriate when providing care after a community disaster include offering choices whenever possible, establishing rapport through active listening, and requesting assistance from crisis counselors. This is correct. Psychosocial nursing actions appropriate when providing care after a community disaster include offering choices whenever possible, establishing rapport through active listening, and requesting assistance from crisis counselors.
PTS: 1 CON: Nursing 28. ANS: 2, 4, 5 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Describing the many types of disasters and their impact Chapter page reference: 1579-1590 Heading: Overview of Disasters Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Safety Difficulty: Moderate
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PTS: 1
Feedback This is incorrect. Measles and rubella are not biological agents commonly used in terrorist attacks; therefore, these would not be included in a disaster plan for terrorist attacks. This is correct. Biological agents most commonly used in terrorist attacks include anthrax, smallpox, botulism, plague, tularemia, and hemorrhagic fever. This is incorrect. Measles and rubella are not biological agents commonly used in terrorist attacks; therefore, these would not be included in a disaster plan for terrorist attacks. This is correct. Biological agents most commonly used in terrorist attacks include anthrax, smallpox, botulism, plague, tularemia, and hemorrhagic fever. This is correct. Biological agents most commonly used in terrorist attacks include anthrax, smallpox, botulism, plague, tularemia, and hemorrhagic fever. CON: Safety
29. ANS: 2, 3, 4 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Describing the many types of disasters and their impact Chapter page reference: 1579-1590 Heading: Overview of Disasters Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Safety Difficulty: Moderate
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Feedback This is incorrect. Burn injury and psychological injuries are possible; however, these are not the most common injuries that result when explosive devices are used as agents of terrorism. This is correct. Blast, crush, and penetration injuries are most common when explosive devices are used as an agent of terrorism. These injuries should be identified in the organizational disaster plan along with appropriate treatment options for each. This is correct. Blast, crush, and penetration injuries are most common when explosive devices are used as an agent of terrorism. These injuries should be identified in the organizational disaster plan along with appropriate treatment options for each. This is correct. Blast, crush, and penetration injuries are most common when explosive devices are used as an agent of terrorism. These injuries should be identified in the organizational disaster plan along with appropriate treatment options for each. This is incorrect. Burn injury and psychological injuries are possible; however, these are not NhGenTB the most common injuries thN atUreRsS u lI t w e x. plC osOivMe devices are used as agents of terrorism.
PTS: 1 CON: Safety 30. ANS: 1, 2, 5 Chapter number and title: 71, Mass Casualty and Disaster Preparedness Chapter learning objective: Describing the many types of disasters and their impact Chapter page reference: 1579-1590 Heading: Overview of Disasters Integrated Processes: Nursing Process: Planning Client Need: Safe and Effective Care Environment – Management of Care Cognitive level: Application [Applying] Concept: Safety Difficulty: Moderate
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Feedback This is correct. Victims need to be treated and stabilized and, if there is known or suspected contamination, decontaminated at the scene. This is correct. Victims need to be treated and stabilized and, if there is known or suspected contamination, decontaminated at the scene. This is incorrect. Evaluation of interventions and formulation of nursing diagnoses is not implemented until the patient is admitted to the hospital. This is incorrect. Evaluation of interventions and formulation of nursing diagnoses is not implemented until the patient is admitted to the hospital.
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PTS: 1
This is correct. Victims need to be treated and stabilized and, if there is known or suspected contamination, decontaminated at the scene. CON: Safety
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