Chapter 01: The Evolution of Nursing Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. What is a nursing program considered when certified by a state agency? a. Accredited b. Approved c. Provisional d. Exemplified ANS: B Approved means certified by a state agency for having met minimum standards; accredited means certified by the NLN for having met more complex standards. Provisional and exemplified are not terms used in regard to nursing program certification. DIF: Cognitive Level: Knowledge TOP: Nursing programs MSC: NCLEX: N/A
REF: 10 OBJ: 5 KEY: Nursing Process Step: N/A
2. Which of the following must the nurse recognize regarding the health care delivery system? a. It includes all states. b. It affects the illness of patients. c. Insurance companies are not involved. d. The major goal is to achieve optimal levels of health care. ANS: D The nurse must recognize that in the health care delivery system, the major goal is to achieve optimal levels of health care. The health care system consists of a network of agencies, facilities, and providers involved with health care in a specified geographic area. Insurance companies do have involvement in the health care system. The illness of patients is not necessarily affected by the health care system. DIF: Cognitive Level: Comprehension TOP: Health care systems MSC: NCLEX: N/A
REF: 12 OBJ: 7 KEY: Nursing Process Step: N/A
3. What is required by the health care team to identify the needs of a patient and to design care to meet those needs? a. The Kardex b. The health care provider’s order sheet c. An individualized care plan d. The nurse’s notes ANS: C
An individualized care plan involves all health care workers and outlines care to meet the needs of the individual patient. The Kardex, health care provider’s order sheet, and nurse’s notes do not identify the needs of the patient nor are they designed to assist all members of the health care team to meet those needs. DIF: Cognitive Level: Comprehension REF: 13 TOP: Care plan KEY: Nursing Process Step: Planning
OBJ: 8 | 9 MSC: NCLEX: N/A
4. Patient care emphasis on wellness, rather than illness, begins as a result of: a. increased education concerning causes of illness. b. improved insurance payments. c. decentralized care centers. d. increased number of health care givers. ANS: A The acute awareness of preventive medicine has resulted in today’s emphasis on education about issues such as smoking, heart disease, drug and alcohol abuse, weight control, and mental health and wellness promotion activities. This preventive education has resulted in an emphasis on wellness, rather than illness. Improved insurance payments, decentralized care centers, and increased numbers of health care givers did not influence an emphasis on wellness. DIF: Cognitive Level: Comprehension REF: 12 TOP: Wellness KEY: Nursing Process Step: N/A
OBJ: 4 | 8 MSC: NCLEX: N/A
5. What is the most effective process to ensure that the care plan is meeting the needs of the patient? a. Documentation b. Communication c. Evaluation d. Planning ANS: B Communication is the primary essential component among the health care team to evaluate and modify the care plan. Documentation, evaluation, and planning are not primary essential components to ensure the care plan is meeting the needs of the patient. DIF: Cognitive Level: Comprehension TOP: Communication MSC: NCLEX: N/A
REF: 17 OBJ: 8 KEY: Nursing Process Step: N/A
6. How does an interdisciplinary approach to patient treatment enhance care? a. By improving efficiency of care b. By reducing the number of caregivers c. By preventing the fragmentation of patient care d. By shortening hospital stay ANS: C
An interdisciplinary approach prevents fragmentation of care. An interdisciplinary approach does not improve the efficiency of care, reduce the number of caregivers, or shorten hospital stay. DIF: Cognitive Level: Comprehension TOP: Interdisciplinary approach MSC: NCLEX: N/A
REF: 16 OBJ: 8 | 9 KEY: Nursing Process Step: N/A
7. How may a newly licensed LPN/LVN practice? a. Independently in a hospital setting b. With an experienced LPN/LVN c. Under the supervision of a health care provider or RN d. As a sole health care provider in a clinic setting ANS: C An LPN/LVN practices under the supervision of a health care provider, dentist, OD, or RN. DIF: Cognitive Level: Knowledge TOP: Vocational nursing MSC: NCLEX: N/A
REF: 11 OBJ: 11 KEY: Nursing Process Step: N/A
8. Whose influence on nursing practice in the 19th century was related to improvement of patient environment as a method of health promotion? a. Clara Barton b. Linda Richards c. Dorothea Dix d. Florence Nightingale ANS: D The influence of Florence Nightingale was highly significant in the 19th century as she fought for sanitary conditions, fresh air, and general improvement in the patient environment. Clara Barton developed the American Red Cross in 1881. Linda Richards is known as the first trained nurse in America, was responsible for the development of the first nursing and hospital records, and is credited with the development of our present-day documentation system. Dorothea Dix was the pioneer crusader for elevation of standards of care for the mentally ill and superintendent of female nurses of the Union Army. DIF: Cognitive Level: Knowledge TOP: Nursing leaders MSC: NCLEX: N/A
REF: 17 OBJ: 2 | 4 KEY: Nursing Process Step: N/A
9. What document identifies the roles and responsibilities of the LPN/LVN? a. NLN Accreditation Standards b. Nurse Practice Act c. NAPNE Code d. American Nurses’ Association Code ANS: B
The LPN/LVN functions under the Nurse Practice Act. NLN Accreditation Standards, the NAPNE Code, and the American Nurses’ Association Code do not identify the roles and responsibilities of the LPN/LVN. DIF: Cognitive Level: Knowledge TOP: Roles and responsibilities MSC: NCLEX: N/A
REF: 12 | 14 OBJ: 11 KEY: Nursing Process Step: N/A
10. What is a cost-effective delivery of care used by many hospitals that allows the LPN/LVN to work with the RN to meet the needs of patients? a. Focused nursing b. Team nursing c. Case management d. Primary nursing ANS: C Case management is a cost-effective method of care. Focused nursing, team nursing, and primary nursing are not cost-effective methods of delivering care that allow the LPN/LVN to work with the RN to meet patient needs. DIF: Cognitive Level: Comprehension TOP: Patient care delivery systems MSC: NCLEX: N/A
REF: 15 OBJ: 7 | 9 KEY: Nursing Process Step: N/A
11. What is the title of the American Hospital Association’s 1972 document that outlines the patient’s expectations to be treated with dignity and compassion? a. Code of Ethics b. Patient’s Bill of Rights c. OBRA d. Advance directives ANS: B Patient expectations are outlined by the Patient’s Bill of Rights. Patient expectations are not outlined in the Code of Ethics, OBRA, or advance directives. DIF: Cognitive Level: Knowledge TOP: Patient’s rights MSC: NCLEX: N/A
REF: 16 OBJ: 4 | 8 KEY: Nursing Process Step: N/A
12. The relationships among nursing, patients, health, and the environment are the basis for: a. care plans. b. nursing models. c. health care provider’s orders. d. evaluation of patient care. ANS: B Nursing models are theories based on the relationship between nursing, patients, health, and environment. Care plans, health care provider’s orders, and evaluation of patient care are not based on the relationships among nursing, patients, health, and environment.
DIF: Cognitive Level: Comprehension TOP: Nursing models MSC: NCLEX: N/A
REF: 17 OBJ: 1 KEY: Nursing Process Step: N/A
13. What system reduces the number of employees but still provides quality care for patients? a. Team nursing b. Cross-training c. Use of critical pathways d. Case management ANS: B Cross-training reduces the number of employees but does not alter the quality of patient care. Team nursing, use of critical pathways, and case management do not reduce the number of employees while continuing to provide quality care for patients. DIF: Cognitive Level: Comprehension REF: 15 TOP: Patient care KEY: Nursing Process Step: N/A
OBJ: 8 MSC: NCLEX: N/A
14. What is the purpose of licensing laws for LPN/LVNs? a. To limit the number of LPN/LVNs b. Prevention of malpractice c. Protection of the public from unqualified people d. To increase revenue for the state board of nursing ANS: C The purpose of licensing laws for LPN/LVNs is to protect the public from unqualified health care providers. Licensing laws’ purpose is not to limit the number of LPNs/LVNs, prevent malpractice, or increase revenue for the state board of nursing. DIF: Cognitive Level: Comprehension REF: 11 TOP: Licensure KEY: Nursing Process Step: N/A
OBJ: 4 | 9 | 10 MSC: NCLEX: N/A
15. What premise is Maslow’s hierarchy of needs based on? a. All needs are equally important. b. Basic needs must be met before the next level of needs can be met. c. Self-actualization is a primary need. d. Individuals prioritize needs the same way. ANS: B Maslow’s hierarchy of needs is based on the premise that basic needs must be met first. It is not based on all needs being equally important or that individuals prioritize needs the same way. Self-actualization is not a primary need according to Maslow. DIF: Cognitive Level: Comprehension TOP: Maslow’s Hierarchy of Needs MSC: NCLEX: N/A
REF: 12 | 13 OBJ: 8 KEY: Nursing Process Step: N/A
16. What must the nurse realize when assessing physical and social environmental factors affecting health and illness?
a. b. c. d.
They affect one another. They cause illness. They cause patients to react similarly. They can be separated.
ANS: A Physical and social factors affect each other, cannot be separated, and cause each patient to react in a unique manner. They do not necessarily cause illness or cause patients to react similarly, and they cannot be separated. DIF: Cognitive Level: Comprehension REF: 14 TOP: Environmental factors KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 4 | 8
17. What organization, established during World War II, provided nursing education and training? a. Nightingale school b. Cadet Nurse Corps c. Public health department d. Frontier Nursing Service ANS: B The Cadet Nurse Corps was established during World War II to provide nursing education and training. The Nightingale school, public health department, and Frontier Nursing Service are not organizations established during World War II to provide nursing education and training. DIF: Cognitive Level: Knowledge TOP: Nursing education MSC: NCLEX: N/A
REF: 5 OBJ: 1 | 4 KEY: Nursing Process Step: N/A
18. What is a modern educational advancement program for the LPN/LVN to enter RN education? a. Repetition b. Exclusion c. Articulation d. Coexistence ANS: C Most states have some type of articulation program in which the LPN/LVN can achieve advanced standing in an RN program without having to enroll in the entire curriculum. Repetition, exclusion, and coexistence do not refer to educational advancement. DIF: Cognitive Level: Knowledge TOP: Nursing education MSC: NCLEX: N/A
REF: 10 OBJ: 1 | 9 KEY: Nursing Process Step: N/A
19. Where did Florence Nightingale’s original nursing education take place? a. Saint Thomas
b. Kings College Hospital c. Crimean Hospital d. Kaiserswerth School ANS: D Florence Nightingale trained at Kaiserswerth School. Florence Nightingale’s original training was not at Saint Thomas, Kings College Hospital, or Crimean Hospital. DIF: Cognitive Level: Knowledge TOP: Nursing programs MSC: NCLEX: N/A
REF: 2 OBJ: 2 KEY: Nursing Process Step: N/A
20. What system of comprehensive patient care considers the physical, emotional, and social environment and spiritual needs of a person? a. Interdependent care b. Holistic health care c. Illness prevention care d. Health promotion care ANS: B Holistic health care encompasses the physical, emotional, social, and spiritual aspects of the patient. DIF: Cognitive Level: Comprehension REF: 12 TOP: Health care KEY: Nursing Process Step: N/A
OBJ: 8 MSC: NCLEX: N/A
21. What official agency exists exclusively for LPN/LVN membership and promotes standards for the LPN/LVN? a. NFLPN b. ANA c. NLN d. NAPNES ANS: A The NFLPN exists solely for the LPN/LVN. The other options have membership that includes RNs and the lay public. DIF: Cognitive Level: Knowledge TOP: Nursing organizations MSC: NCLEX: N/A
REF: 10 OBJ: 5 | 6 | 9 KEY: Nursing Process Step: N/A
22. What score does the graduate practical nurse require to be issued a license upon completion of the computerized examination? a. 70% or better b. This is defined and set by each state c. Designated as “pass” d. Within the 75th percentile ANS: C
Currently graduates of an approved vocational school are eligible to take the licensing examination and be awarded a license with a score of “pass” that is recognized by all states. DIF: Cognitive Level: Knowledge TOP: Licensure examination MSC: NCLEX: N/A
REF: 12 OBJ: 3 KEY: Nursing Process Step: N/A
23. What document, published in 1965 by the ANA, clearly defined two levels of nursing practice? a. Licensing standards b. Position paper c. Smith-Hughes Act d. Nurse practice act ANS: B The ANA’s position paper of 1965 defined two levels of nursing: registered nurse and technical nurse. Licensing standards, the Smith-Hughes Act, and the nurse practice act were not documents defining two levels of nursing practice published in 1965. DIF: Cognitive Level: Knowledge TOP: Position paper MSC: NCLEX: N/A
REF: 11 OBJ: 3 | 4 | 9 KEY: Nursing Process Step: N/A
24. What is the wellness/illness continuum defined as? a. A concept that never changes b. The range of a person’s total health c. A continuum influenced only by one’s physical condition d. An idea that focuses strictly on an individual’s social well-being ANS: B The wellness/illness continuum is defined as the range of a person’s total health. This continuum is ever changing, and it is influenced by the individual’s physical condition, mental condition, and social well-being. DIF: Cognitive Level: Comprehension TOP: Wellness/illness continuum MSC: NCLEX: N/A
REF: 12 OBJ: 8 KEY: Nursing Process Step: N/A
25. According to Maslow’s hierarchy of needs, what is an individual’s most basic need? a. Safety and security b. Love/belongingness c. Physiologic d. Self-actualization e. Esteem ANS: C Abraham Maslow believed that an individual’s behavior is formed by the individual’s attempts to meet essential human needs, which he identified as physiologic, safety and security, love and belongingness, and esteem and self-actualization.
DIF: Cognitive Level: Comprehension TOP: Maslow’s Hierarchy of Needs MSC: NCLEX: N/A
REF: 12 | 13 OBJ: 8 KEY: Nursing Process Step: N/A
MULTIPLE RESPONSE 1. Florence Nightingale established a nursing school at Saint Thomas Hospital in London. What was it characterized by? (Select all that apply.) a. Allowing all applicants who applied to be enrolled b. Offering formal and practical educational experiences c. Keeping records of students’ progress d. Focusing on sanitation and hygiene e. Retaining a registry of all graduates ANS: B, C, D, E The nursing school established by Florence Nightingale rigorously screened its applicants. The curriculum, which included both formal education and practical experiences, was focused on hygiene and sanitation. The school kept records of the students’ progress during their school years, and also kept a registry of the graduates. DIF: Cognitive Level: Comprehension REF: 3 OBJ: 1 | 2 TOP: School established by Florence Nightingale KEY: Nursing Process Step: N/A MSC: NCLEX: N/A COMPLETION 1. Primitive medical interventions were based on the belief that illness was caused by the presence of spirits. ANS: evil Illness was thought to be caused by the inhabitation of the body by evil spirits. Medical interventions were designed to drive out the evil spirits by introducing good spirits. DIF: Cognitive Level: Comprehension TOP: Primitive health care MSC: NCLEX: N/A
REF: 1 OBJ: 1 KEY: Nursing Process Step: N/A
2. During early civilization men performed witchcraft and rituals to induce the bad spirits to leave the body of the ailing person. ANS: medicine Medicine men performed witchcraft and rituals to induce the bad spirits to leave the body of the ailing person during early civilization.
DIF: Cognitive Level: Knowledge TOP: Primitive health care MSC: NCLEX: N/A
REF: 2 OBJ: 1 KEY: Nursing Process Step: N/A
3. The National Council of State Boards of Nursing (NCSBN) performs a job analysis every years to determine the scope of practice of LPN/LVNs. ANS: 3 three The National Council of State Boards of Nursing performs a job analysis every 3 years to measure the scope of practice for LPN/LVNs. DIF: Cognitive Level: Knowledge TOP: National Council analysis MSC: NCLEX: N/A
REF: 18 OBJ: 6 | 9 KEY: Nursing Process Step: N/A
4. Graduates of the first school for training the practical nurse were referred to as nurses. ANS: attendant The first school for training the practical nurse started in Brooklyn, New York, in 1892 and was conducted under the auspices of the Young Women’s Christian Association (YWCA). The Ballard School, as it was known, was approximately 3 months in duration and trained its students to care for the chronically ill, invalids, children, and the elderly. The main emphasis was on home care and included cooking, nutrition, basic science, and basic procedures. Graduates of this program were referred to as attendant nurses. DIF: Cognitive Level: Knowledge TOP: Attendant nurses MSC: NCLEX: N/A
REF: 9 OBJ: 1 KEY: Nursing Process Step: N/A
5. In 1949, the National Federation of Licensed Practical Nurses (NFLPN) was founded by Lillian . ANS: Kuster In 1949, the National Federation of Licensed Practical Nurses (NFLPN) was founded by Lillian Kuster. This association is the official membership organization for licensed practical nurses/licensed vocational nurses (LPN/LVNs), and membership is limited to LPNs and LVNs. DIF: Cognitive Level: Knowledge REF: 10 TOP: National Federation of Licensed Practical Nurses
OBJ: 2
KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
Chapter 02: Legal and Ethical Aspects of Nursing Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. When a nurse becomes involved in a legal action, the first step to occur is that a document is filed in an appropriate court. What is this document called? a. Deposition b. Appeal c. Complaint d. Summons ANS: C A document called a complaint is filed in an appropriate court as the first step in litigation. A deposition is when witnesses are required to undergo questioning by the attorneys. An appeal is a request for a review of a decision by a higher court. A summons is a court order that notifies the defendant of the legal action. DIF: Cognitive Level: Knowledge REF: 24 TOP: Legal KEY: Nursing Process Step: N/A
OBJ: 1 MSC: NCLEX: N/A
2. The nurse caring for a patient in the acute care setting assumes responsibility for a patient’s care. What is this legally binding situation? a. Nurse-patient relationship b. Accountability c. Advocacy d. Standard of care ANS: A When the nurse assumes responsibility for a patient’s care, the nurse-patient relationship is formed. This is a legally binding “contract” for which the nurse must take responsibility. Accountability is being responsible for one’s own actions. An advocate is one who defends or pleads a cause or issue on behalf of another. Standards of care define acts whose performance is required, permitted, or prohibited. DIF: Cognitive Level: Comprehension REF: 24 TOP: Legal KEY: Nursing Process Step: N/A
OBJ: 3 MSC: NCLEX: N/A
3. What are the universal guidelines that define appropriate measures for all nursing interventions? a. Scope of practice b. Advocacy c. Standard of care d. Prudent practice ANS: C
Standards of care define actions that are permitted or prohibited in most nursing interventions. These standards are accepted as legal guidelines for appropriateness of performance. The laws that formally define and limit the scope of nursing practice are called nurse practice acts. An advocate is one who defends or pleads a cause or issue on behalf of another. Prudent is a term that refers to careful and/or wise practice. DIF: Cognitive Level: Knowledge REF: 22 TOP: Legal KEY: Nursing Process Step: N/A
OBJ: 4 MSC: NCLEX: N/A
4. An LPN/LVN is asked by the RN to administer an IV chemotherapeutic agent to a patient in the acute care setting. What law should this nurse refer to before initiating this intervention? a. Standards of care b. Regulation of practice c. American Nurses’ Association Code d. Nurse practice act ANS: D It is the nurse’s responsibility to know the nurse practice act in his or her state. Standards of care, regulation of practice, and the American Nurses’ code are not laws that the nurse should refer to before initiating this treatment. DIF: Cognitive Level: Application REF: 26 TOP: Legal KEY: Nursing Process Step: N/A
OBJ: 5 MSC: NCLEX: N/A
5. A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be found guilty of: a. malpractice. b. harm to the patient. c. negligence. d. failure to follow the nurse practice act. ANS: A The nurse can be held liable for malpractice for acts of omission. Failure to meet a legal duty, thus causing harm to another, is malpractice. The nurse practice act has general guidelines that can support the charge of malpractice. DIF: Cognitive Level: Application REF: 24 TOP: Legal KEY: Nursing Process Step: N/A
OBJ: 2 MSC: NCLEX: N/A
6. Patients have expectations regarding the health care services they receive. To protect these expectations, which of the following has become law? a. American Hospital Association’s Patient’s Bill of Rights b. Self-Determination Act c. American Hospital Association’s Standards of Care d. The Joint Commission’s rights and responsibilities of patients ANS: A
Patients have expectations regarding the health care services they receive. In 1972, the American Hospital Association (AHA) developed the Patient’s Bill of Rights. The Self-Determination Act, American Hospital Association’s Standards of Care, and The Joint Commission’s rights and responsibilities do not address patients’ expectations regarding health care. DIF: Cognitive Level: Comprehension REF: 27 TOP: Legal KEY: Nursing Process Step: N/A
OBJ: 3 | 4 MSC: NCLEX: N/A
7. The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed? a. Physical assessment b. Interview c. Informed consent d. Surgical checklist ANS: C The doctrine of informed consent refers to full disclosure of the facts the patient needs to make an intelligent (informed) decision before any invasive treatment or procedure is performed. A physical assessment, interview, and surgical checklist are not required before this procedure. DIF: Cognitive Level: Application REF: 27 TOP: Legal KEY: Nursing Process Step: N/A
OBJ: 8 MSC: NCLEX: N/A
8. When a nurse protects the information in a patient’s record, what ethical responsibility is the nurse fulfilling? a. Privacy b. Disclosure c. Confidentiality d. Absolute secrecy ANS: C The nurse has an ethical and legal duty to protect information about a patient and preserve confidentiality. Some disclosures are legal and anticipated, and may not be subject to the rules of confidentiality. None of the information in a chart is considered secret. DIF: Cognitive Level: Comprehension TOP: Confidentiality MSC: NCLEX: N/A
REF: 29-30 OBJ: 9 KEY: Nursing Process Step: N/A
9. An older adult is admitted to the hospital with numerous bodily bruises, and the nurse suspects elder abuse. What is the best nursing action? a. Cover the bruises with bandages. b. Take photographs of the bruises. c. Ask the patient if anyone has hit her. d. Report the bruises to the charge nurse. ANS: D
The law stipulates that the health care professional is required to report certain information to the appropriate authorities. The report should be given to a supervisor or directly to the police, according to agency policy. When acting in good faith to report mandated information (e.g., certain communicable diseases or gunshot wounds), the health care professional is protected from liability. DIF: Cognitive Level: Application REF: 31 TOP: Elder abuse KEY: Nursing Process Step: N/A
OBJ: 9 MSC: NCLEX: N/A
10. What is the best way for a nurse to avoid a lawsuit? a. Carry malpractice insurance. b. Spend time with the patient. c. Provide compassionate, competent care. d. Answer all call lights quickly. ANS: C The best defense against a lawsuit is to provide compassionate and competent nursing care. Carrying malpractice insurance is prudent, but it will not avoid a lawsuit. Spending time with patients and answering call lights quickly will not necessarily help avoid a lawsuit. DIF: Cognitive Level: Comprehension TOP: Avoiding a lawsuit MSC: NCLEX: N/A
REF: 29 OBJ: 8 KEY: Nursing Process Step: N/A
11. The nurse is caring for a patient with a do-not-resuscitate (DNR) order. Although the nurse may disagree with this order, what is his or her legal obligation? a. To question the health care provider b. To seek advice from the family c. To discuss it with the patient d. To follow the order ANS: D When a DNR order is written in the chart, the nurse has a duty to follow the order. Questioning the health care provider, seeking advice from the family, and discussing it with the patient are not legal obligations of the nurse. DIF: Cognitive Level: Application REF: 37 TOP: Legal KEY: Nursing Process Step: N/A
OBJ: 10 | 14 MSC: NCLEX: N/A
12. The nurse has strong moral convictions that abortions are wrong. When assigned to assist with an abortion, what is the most appropriate action for the nurse to take? a. Ask for another assignment. b. Leave work. c. Transfer to another floor. d. Protest to the supervisor. ANS: A The nurse should not abandon the patient, but ask for another assignment.
DIF: Cognitive Level: Application REF: 37 TOP: Ethics KEY: Nursing Process Step: N/A
OBJ: 9 | 16 MSC: NCLEX: N/A
13. The new LPN/LVN is concerned regarding what should or should not be done for patients. What resource will best provide this information? a. Nurse practice act b. Standards of care c. Scope of nursing practice d. Professional organizations ANS: B Standards of care define what should or should not be done for patients. The nurse practice act, scope of nursing practice, and professional organizations do not provide the best information as to what should or should not be done for patients. DIF: Cognitive Level: Comprehension TOP: Standards of care MSC: NCLEX: N/A
REF: 24 OBJ: 5 KEY: Nursing Process Step: N/A
14. What role is the nurse who diligently works for the protection of patients’ interests playing? a. Caregiver b. Health care administrator c. Advocate d. Health care evaluator ANS: C A nurse accepts the role of advocate when, in addition to general care, the nurse protects the patient’s interests. Caregiver, health care administrator, and health care evaluator are not terms for the nurse who diligently works for the protection of patients. DIF: Cognitive Level: Comprehension REF: 25 TOP: Advocate KEY: Nursing Process Step: N/A
OBJ: 9 | 12 MSC: NCLEX: N/A
15. When asked to perform a procedure that the nurse has never done before, what should the nurse do to legally protect himself or herself? a. Go ahead and do it. b. Refuse to perform it, citing lack of knowledge. c. Discuss it with the charge nurse, asking for direction. d. Ask another nurse who has performed the procedure. ANS: C The nurse cannot use ignorance as an excuse for nonperformance. The nurse should ask for direction from the charge nurse, explaining she has never performed the procedure independently. DIF: Cognitive Level: Application REF: 26 TOP: Legal KEY: Nursing Process Step: N/A
OBJ: 8 MSC: NCLEX: N/A
16. The nurse is assisting a patient to clarify values by encouraging the expression of feelings and thoughts related to the situation. What is the most appropriate action for the nurse? a. Compare values with those of the patient. b. Make a judgment. c. Withhold an opinion. d. Give advice. ANS: C The nurse can assist the patient in values clarification without giving an opinion. DIF: Cognitive Level: Application TOP: Values clarification MSC: NCLEX: N/A
REF: 35 OBJ: 3 | 8 KEY: Nursing Process Step: N/A
17. What fundamental principle must the nurse first observe when confronted with an ethical decision? a. Autonomy b. Beneficence c. Respect for people d. Nonmaleficence ANS: C The first fundamental principle is respect for people. Autonomy, beneficence, and nonmaleficence are not the first fundamental principles to observe when confronted with an ethical decision. DIF: Cognitive Level: Comprehension REF: 36 TOP: Ethics KEY: Nursing Process Step: N/A
OBJ: 13 | 15 MSC: NCLEX: N/A
18. A nurse working on an acute care medical surgical unit is aware that his or her first duty is to the patient’s health, safety, and well-being. Given this knowledge, which of the following is most necessary for the nurse to report? a. Unethical behavior of other staff members b. A worker who arrives late c. Favoritism shown by nursing administration d. Arguments among the staff ANS: A A member of the nursing profession must report behavior that does not meet established standards. Unethical behavior involves failing to perform the duties of a competent caring nurse. DIF: Cognitive Level: Application TOP: Unethical behavior MSC: NCLEX: N/A
REF: 36 OBJ: 13 KEY: Nursing Process Step: N/A
19. A nurse is considering purchasing malpractice insurance. What should the nurse be aware of regarding malpractice insurance provided by the hospital? a. Only offers protection while on duty.
b. Is limited in the amount of coverage. c. Is difficult to renew. d. Can be terminated at any time. ANS: A Most institutional insurance only provides liability coverage if the nurse is on duty at that facility. DIF: Cognitive Level: Comprehension TOP: Malpractice insurance MSC: NCLEX: N/A
REF: 32 OBJ: 2 KEY: Nursing Process Step: N/A
20. Which is a nursing care error that violates the Health Insurance Portability and Accountability Act (HIPAA)? a. Administering a stronger dose of drug than was ordered b. Refusing to give a patient’s daughter information over the phone c. Informing the patient’s medical power of attorney of a medication change d. Leaving a copy of the patient’s history and physical in the photocopier ANS: D Leaving the document in the photocopier could expose it to the public. Inappropriate drug administration is possible malpractice. Sharing information with the power of attorney is legal. Refusing to give a patient’s daughter information over the phone is appropriate practice. DIF: Cognitive Level: Comprehension REF: 27 OBJ: 7 TOP: Health Insurance Portability and Accountability Act (HIPAA) KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 21. Which of the following could cause a nurse to be cited for malpractice? a. Refusing to give 60 mg of morphine as ordered b. Giving prochlorperazine (Compazine) to a patient allergic to phenothiazines c. Dragging an injured motorist off the highway and causing further injury d. Informing a visitor about a patient’s condition ANS: B Standards of care dictate that a nurse must be aware of all the properties of drugs administered. Prochlorperazine (Compazine) is a phenothiazine. Providing confidential information or refusing to give an excessively large narcotic dose is not considered malpractice. Good Samaritan laws generally protect a person giving aid to an injured motorist. DIF: Cognitive Level: Application REF: 26 TOP: Malpractice KEY: Nursing Process Step: N/A
OBJ: 2 MSC: NCLEX: N/A
22. A lumbar puncture was performed on a patient without a signed informed consent form. This patient might sue for: a. punitive damages. b. civil battery. c. assault.
d. nothing; no violation has occurred. ANS: B Civil battery charges can be brought against someone performing an invasive procedure without the patient’s informed consent legally documented. This patient could not sue for punitive damages or an assault. DIF: Cognitive Level: Comprehension TOP: Informed consent MSC: NCLEX: N/A
REF: 27 OBJ: 6 | 8 KEY: Nursing Process Step: N/A
23. A health care provider instructs the nurse to bladder train a patient. The nurse clamps the patient’s indwelling urinary catheter but forgets to unclamp it. The patient develops a urinary tract infection. What do the nurse’s actions exemplify? a. Malpractice b. Battery c. Assault d. Neglect of duty ANS: A A nurse is liable for acts of commission (doing an act) and omission (not doing an act) performed in the course of their professional duty. A charge of malpractice is likely when a duty exists, there is a breach of that duty, and harm has occurred to the patient. DIF: Cognitive Level: Application REF: 25 TOP: Malpractice KEY: Nursing Process Step: N/A
OBJ: 2 MSC: NCLEX: N/A
24. What is true about nurse practice acts? a. They informally define the scope of nursing practice. b. They provide for unlimited scope of nursing practice. c. Only some states have adopted a nurse practice act. d. The nurse must know the nurse practice act within his or her state. ANS: D The laws formally defining and limiting the scope of nursing practice are called nurse practice acts. All state, provincial, and territorial legislatures in the United States and Canada have adopted nurse practice acts, although the specifics they contain often vary. It is the nurse’s responsibility to know the nurse practice act that is in effect for her geographic region. DIF: Cognitive Level: Comprehension TOP: Nurse practice acts MSC: NCLEX: N/A
REF: 26 KEY: Nursing Process Step: N/A
MULTIPLE RESPONSE 1. How can the medical record be used in litigation? (Select all that apply.) a. Public record b. Proof of adherence to standards c. Evidence of omission of care
d. Documentation of time lapses e. Evidence by only the plaintiff ANS: A, B, C, D The information when used in court becomes a public record. The information can be used as proof of adherence to standards, omission of care, and documentation of time lapses. Both plaintiff and defendant can use the document. DIF: Cognitive Level: Comprehension REF: 24 OBJ: 1 | 4 TOP: Legal properties of medical record KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. During a lunch break, an emergency department (ED) nurse truthfully tells another nurse about the condition of a patient who came to the ED last night. What is the ED nurse guilty of? (Select all that apply.) a. HIPAA violation b. Slander c. Libel d. Invasion of privacy e. Defamation ANS: A, D The disclosure is an invasion of privacy and a violation of HIPAA. Because the information is true and verbal, it cannot be considered slander or libel. DIF: Cognitive Level: Application TOP: Disclosure of information MSC: NCLEX: N/A
REF: 30 OBJ: 7 KEY: Nursing Process Step: N/A
3. A nurse failed to monitor a patient’s respiratory status after medicating the patient with a narcotic analgesic. The patient’s respiratory status worsened, requiring intubation. The patient’s family claimed the nurse committed malpractice. What must be present for the nurse to be held liable? (Select all that apply.) a. A nurse-patient relationship exists. b. The nurse failed to perform in a reasonable manner. c. There was harm to the patient. d. The nurse was prudent in her performance. e. The nurse did not cause the patient harm. f. Duty does not exist. ANS: A, B, C For the court to uphold the charge of malpractice, and to find the nurse liable, the following elements must be present: duty exists, there is a breach of duty, and harm must have occurred. DIF: Cognitive Level: Application REF: 24 TOP: Malpractice KEY: Nursing Process Step: N/A COMPLETION
OBJ: 2 MSC: NCLEX: N/A
1. Personal beliefs about the worth of an object, idea, custom, or attitude that influence a person’s behavior in a given situation are referred to as . ANS: values Values are personal beliefs about the worth of an object, an idea, a custom, or an attitude. Values vary among people and cultures; they develop over time and undergo change in response to changing circumstances and necessity. Each of us adopts a value system that will govern what we feel is right or wrong (or good and bad) and will influence our behavior in a given situation. DIF: Cognitive Level: Knowledge REF: 34 TOP: Values KEY: Nursing Process Step: N/A
OBJ: 11 | 12 MSC: NCLEX: N/A
2. Acts whose performance is required, permitted, or prohibited are defined by of care. ANS: standards Standards of care define acts whose performance is required, permitted, or prohibited. DIF: Cognitive Level: Knowledge TOP: Standards of care MSC: NCLEX: N/A
REF: 26 OBJ: 4 KEY: Nursing Process Step: N/A
Chapter 03: Documentation Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. What does documentation of type of care, time of care, and signature of the person prove? a. The person who signed the documentation did all the work noted. b. No litigation can be brought against the person who signed. c. Interventions were implemented to meet the patient’s needs. d. The patient’s response to the intervention was positive. ANS: C Documenting type of care, time of care, and signature of the person results in recording the interventions that are implemented to meet the patient’s needs. Many charting entries include health care provider’s visits, presence of family, or interventions by other departments. Patient response to some interventions is not always positive. DIF: Cognitive Level: Comprehension TOP: Documentation Implementation MSC: NCLEX: N/A
REF: 40 OBJ: 1 KEY: Nursing Process Step:
2. Why is documentation especially significant in managed care? a. The hospital needs to show that employees care for patients. b. Institutions are reimbursed only for patient care that is documented. c. Patients might bring lawsuits if care was not given. d. Documents may become part of a lawsuit. ANS: B Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the prospective payment system of diagnosis-related groups (DRGs): a system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount. DIF: Cognitive Level: Comprehension TOP: Documentation MSC: NCLEX: N/A
REF: 41 OBJ: 1 KEY: Nursing Process Step: N/A
3. The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is this system of documentation? a. SOAP b. Block c. CBE d. Focus ANS: C
Charting additional treatments done, changes in a patient’s condition, and new concerns during the shift is charting by exception (CBE). DIF: Cognitive Level: Comprehension TOP: Documentation MSC: NCLEX: N/A
REF: 47-48 OBJ: 1 | 5 | 7 KEY: Nursing Process Step: N/A
4. What form explains the lapse when events are not consistent with facility or national standards of expected care? a. Subjective data b. Focus chart c. Incident report d. Nursing assessment ANS: C An incident report is completed when patient care was not consistent with facility or national standards. The form explains the event, time, extent of injury, and who was notified. DIF: Cognitive Level: Knowledge TOP: Documentation MSC: NCLEX: N/A
REF: 49 OBJ: 1 | 7 KEY: Nursing Process Step: N/A
5. The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This is known as a: a. nursing order. b. Kardex. c. nursing care plan. d. critical pathway. ANS: D Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type. DIF: Cognitive Level: Knowledge TOP: Documentation Implementation MSC: NCLEX: N/A
REF: 41 OBJ: 8 KEY: Nursing Process Step:
6. What makes home health care documentation unique? a. Some charting is retained at the hospital. b. The health care provider’s office needs separate charting. c. Different health care providers need access. d. The health care provider is the pivotal person in the charting. ANS: C Home health care documentation has unique problems because of the need for different health care workers to access the medical record. DIF:
Cognitive Level: Comprehension
REF: 55
OBJ: 9
TOP: Documentation MSC: NCLEX: N/A
KEY: Nursing Process Step: N/A
7. What regulates standards for long-term care documentation? a. OBRA b. Title XXII c. Patient problems d. The care plan ANS: A OBRA (Omnibus Budget Reconciliation Act) was a significant Medicare and Medicaid legislation for long-term health care documentation. DIF: Cognitive Level: Knowledge TOP: Documentation MSC: NCLEX: N/A
REF: 55 OBJ: 10 KEY: Nursing Process Step: N/A
8. What is the nurse required to do to adhere to the concept of confidentiality for the patient’s medical record? a. Provide information only to another nurse. b. Provide information only to an attorney. c. Share information only with the family. d. Have a clinical reason for reading the record. ANS: D The nurse should not read the patient’s medical record unless there is a clinical reason for doing so. DIF: Cognitive Level: Comprehension TOP: Confidentiality MSC: NCLEX: N/A
REF: 56 OBJ: 4 KEY: Nursing Process Step: N/A
9. Documentation is necessary for the evaluation of patient care. Of which phase of the nursing process is this an integral part? a. Assessment b. Planning c. Implementation d. Evaluation ANS: C Documentation is part of the implementation phase of the nursing process. DIF: Cognitive Level: Comprehension TOP: Documentation MSC: NCLEX: N/A
REF: 40 OBJ: 1 | 4 KEY: Nursing Process Step: N/A
10. What does the nurse use as a basis for documentation in focus charting? a. Problem list b. Nursing orders c. Patient problems
d. Evaluation ANS: C In focus charting, instead of using the problem list, modified patient problems are used as an index for nursing documentation. DIF: Cognitive Level: Knowledge TOP: Documentation MSC: NCLEX: N/A
REF: 47 OBJ: 7 KEY: Nursing Process Step: N/A
11. What is the purpose of QA (quality assurance)? a. To screen employment applications b. To evaluate care results against accepted standards c. To conduct in-services for “quality documentation” d. To report deviation from standards to the state health department ANS: B QA is an in-house department that evaluates care services and results against accepted standards. DIF: Cognitive Level: Comprehension TOP: Documentation MSC: NCLEX: N/A
REF: 41 OBJ: 1 KEY: Nursing Process Step: N/A
12. What is the process used to appraise the practice of an individual nurse known as? a. Quality assurance b. Incident reporting c. OBRA d. Peer review ANS: D Peer review is an in-house department study that may appraise the nursing practice of individual nurses. DIF: Cognitive Level: Knowledge REF: 41 TOP: Peer review KEY: Nursing Process Step: N/A
OBJ: 4 MSC: NCLEX: N/A
13. What is the documentation format that uses the acronym SOAPE? a. Problem-oriented b. Focused c. Traditional d. Crisis ANS: A The problem-oriented medical record uses the acronym SOAPE to format and for focus charting on a list of patient problems. DIF: Cognitive Level: Comprehension REF: 46 OBJ: 7 TOP: Problem-oriented medical record (POMR) KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
14. Who is the legal owner of the patient’s medical record? a. Patient b. Health care provider c. Institution d. State ANS: C Ownership of a medical record belongs to the institution in the case of a hospitalized patient, or the health care provider in the case of private office visits. DIF: Cognitive Level: Knowledge TOP: Legal ownership Implementation MSC: NCLEX: Psychosocial Integrity
REF: 56 OBJ: 4 KEY: Nursing Process Step:
15. When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered? a. Charting in code b. Logging off c. Charting in privacy d. Signing on with a password ANS: B Logging off closes the computer file that was opened with the nurse’s password. Any other data entry will require that person to sign on with their password. DIF: Cognitive Level: Comprehension TOP: Computer documentation MSC: NCLEX: N/A
REF: 57 OBJ: 2 KEY: Nursing Process Step: N/A
16. What is the system that classifies patients by age, diagnosis, and surgical procedure, and produces 300 different categories used for predicting the use of hospital resources? a. Quality assurance b. Resource assessment c. Quality improvement d. Diagnosis-related groups ANS: D Cost reimbursement rates under government plans are based on diagnosis-related groups (DRGs), which is a system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay. DIF: Cognitive Level: Knowledge TOP: Diagnostic-related groups MSC: NCLEX: N/A
REF: 41-42 OBJ: 5 KEY: Nursing Process Step: N/A
17. A nurse is using the data, action, response, education (DARE) system of charting, and is completing the data portion. What data are the nurse’s focus? a. Planning
b. Assessment c. Implementation d. Patient teaching ANS: B DARE is the acronym for four different aspects of charting using the focus format. Data (D) is both subjective and objective and is equivalent to the assessment step of the nursing process. Action (A) is a combination of planning and implementation. Response (R) of the patient is the same as evaluation of effectiveness. Some facilities include education/patient teaching (E). DIF: Cognitive Level: Comprehension REF: 47 TOP: Charting KEY: Nursing Process Step: Assessment
OBJ: 7 MSC: NCLEX: N/A
18. A new patient is being admitted to a long-term care facility. Who has primary responsibility for each patient’s initial admission nursing history, physical assessment, and development of the care plan based on the patient problem identified? a. Health care provider b. Registered nurse c. Unlicensed assistive personnel d. Licensed practical nurse/licensed vocational nurse ANS: B The registered nurse (RN) has primary responsibility for each patient’s initial admission nursing history, physical assessment, and development of the care plan based on the patient problem identified. DIF: Cognitive Level: Comprehension TOP: Scope of practice MSC: NCLEX: N/A
REF: 43 OBJ: 4 | 10 KEY: Nursing Process Step: N/A
19. What will the nurse implement when an error is made when documenting in a patient’s chart? a. Scratch out the error. b. Apply correction fluid. c. Erase the error completely. d. Draw a single line through the error. ANS: D A nurse should not erase, apply correction fluid, or scratch out errors made while recording in a patient’s chart. Instead, the nurse should draw a single line through the error, write the word “error” above it, and sign her name or initials. DIF: Cognitive Level: Application TOP: Documentation MSC: NCLEX: N/A
REF: 45 OBJ: 6 KEY: Nursing Process Step: N/A
20. What should the nurse be sure to do when documenting in a patient’s chart? a. Include speculation. b. Chart consecutively.
c. Leave blank spaces. d. Include retaliatory comments. ANS: B A nurse should not write retaliatory or critical comments about a patient or care by other health care professionals. The nurse should not leave blank spaces in the nurse’s notes. The nurse should be certain the entry is factual and not speculate or guess. The nurse should chart consecutively, line by line. DIF: Cognitive Level: Application TOP: Documentation MSC: NCLEX: N/A
REF: 45 OBJ: 6 KEY: Nursing Process Step: N/A
21. A nurse is receiving a telephone order from a health care provider. The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals. What is the second step of this method? a. Read back b. Background c. Recommendation d. Situation e. Assessment ANS: B SBAR (Situation, Background, Assessment, and Recommendation) is a method of communication among health care workers and a part of documentation (Kaiser Permanente, 2007). SBAR is considered a safety measure in preventing errors from poor communication during “hand-off” or “handover” interactions, the communication that occurs from one shift to the next or when a nurse phones a health care provider with information about a patient. An additional “R” is added. The additional “R” (SBARR) represents “read back” when the nurse reads back the order for clarification. DIF: Cognitive Level: Application REF: 43 TOP: SBARR KEY: Nursing Process Step: N/A
OBJ: 3 MSC: NCLEX: N/A
MULTIPLE RESPONSE 1. What are categories of inadequate documentation that may lead to a malpractice claim? (Select all that apply.) a. Incorrectly recording the time of an event b. Failing to record verbal orders c. Charting events in advance d. Documenting an incorrect date e. Marking out and initialing charting errors ANS: A, B, C, D Marking out with a single line and initialing is an acceptable method to indicate a charting error. DIF:
Cognitive Level: Application
REF: 45
OBJ: 4
TOP: Inadequate documentation MSC: NCLEX: N/A
KEY: Nursing Process Step: N/A
2. When documenting an incident in the nurse’s notes, what should the nurse include? (Select all that apply.) a. Description of injury, including diagrams of injury placement b. Date, time, and location of incident c. Name of health care provider and family members notified d. Chronologic order of events of the incident e. Confirmation that an incident report was initiated ANS: A, B, C, D The documentation of the initiation of an incident report should not be included in the nurse’s notes. Nurse’s notes are part of the legal medical record; the incident report is not. To note that an incident report was initiated is a red flag that a problem has occurred. DIF: Cognitive Level: Application TOP: Documenting incident reports MSC: NCLEX: N/A
REF: 49 KEY: Nursing Process Step: N/A
3. What are some problems associated with electronic (or computerized) charting? (Select all that apply.) a. Security b. Expense of training staff c. Legibility d. Easy retrieval e. New terminology ANS: A, B, E Security, expensive staff training, and learning new terminology are all problems of electronic charting. Legibility and easy retrieval are advantages. DIF: Cognitive Level: Comprehension TOP: Computer charting MSC: NCLEX: N/A
REF: 42-43 OBJ: 1 KEY: Nursing Process Step: N/A
4. What are the basic purposes of written patient records? (Select all that apply.) a. Teaching b. Legal record of care c. Written communication d. Research and data collection e. Permanent record for accountability f. Temporary record of hospitalization ANS: A, B, C, D, E There are five basic purposes for written patient records: (1) written communication, (2) permanent record for accountability, (3) legal record of care, (4) teaching, and (5) research and data collection.
DIF: Cognitive Level: Comprehension TOP: Medical record MSC: NCLEX: N/A
REF: 41 OBJ: 1 KEY: Nursing Process Step: N/A
5. What should a medical record provide for all health care providers? (Select all that apply.) a. Care given to the patient b. Care planned for the patient c. A patient’s nursing problems d. A patient’s medical problems e. Details about any incident reports f. The patient’s response to treatment ANS: A, B, C, D, F A medical record should furnish all health care providers with a concise, accurate, written picture of a patient’s medical and nursing problems, care planned and given, and the patient’s response to treatments. DIF: Cognitive Level: Comprehension TOP: Medical record MSC: NCLEX: N/A
REF: 43 OBJ: 1 KEY: Nursing Process Step: N/A
COMPLETION 1. The best defense against malpractice claims associated with nursing care is accurate . ANS: documentation Accurate documentation can guard against malpractice claims because it should describe when, what, and how events occurred. DIF: Cognitive Level: Comprehension TOP: Documentation MSC: NCLEX: N/A
REF: 41 | 42 OBJ: 4 KEY: Nursing Process Step: N/A
2. Twenty-four-hour charting is designed to establish staffing needs.
levels to help determine
ANS: acuity Patient acuity, which is reflected in 24-hour charting compilation, can dictate staffing needs. DIF: Cognitive Level: Comprehension TOP: 24-hour charting MSC: NCLEX: N/A
REF: 49 OBJ: 7 KEY: Nursing Process Step: N/A
3. Documentation using the DARE format (Data, Action, Response, Education) includes elements of the charting system. ANS: focused Focused charting uses the acronym DARE to direct and formalize charting. DIF: Cognitive Level: Comprehension TOP: Focused charting MSC: NCLEX: N/A
REF: 47 OBJ: 7 KEY: Nursing Process Step: N/A
4. A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as _ . ANS: quality assurance quality assessment quality improvement Quality assurance/assessment/improvement is an audit in health care that evaluates services provided and the results achieved compared with accepted standards. DIF: Cognitive Level: Knowledge REF: 41 OBJ: 1 TOP: Quality assurance | Assessment | Improvement KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
Chapter 04: Communication Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. Although the patient denies pain, the nurse observes the patient breathing rapidly with clenched fists and facial grimacing. What is the nurse’s best response to these observations? a. “I am glad you are feeling better and have no discomfort.” b. “Where do you hurt?” c. “What you are saying and what I am observing don’t seem to match.” d. “It makes me uncomfortable when you are not honest with me.” ANS: C The nonverbal communication should be clarified to prevent miscommunication. DIF: Cognitive Level: Application TOP: Communication MSC: NCLEX: Physiological Integrity
REF: 69 OBJ: 2 | 3 KEY: Nursing Process Step: Assessment
2. The nurse considers the feelings and needs of a patient by stating, “I know you are concerned about your surgery tomorrow. How can I help you?” What type of communication is this? a. Intrusive b. Aggressive c. Closed d. Assertive ANS: D Assertive communication takes a patient’s feelings and needs into account, yet honors the patient’s rights as an individual. DIF: Cognitive Level: Comprehension TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 63 OBJ: 4 KEY: Nursing Process Step:
3. If the nurse aggressively says to a patient, “Why couldn’t you have asked me to give you your pain medication when I was in here earlier?” What feeling is the patient most likely to demonstrate? a. Anger b. Satisfaction that his needs are met c. Humiliation and worthlessness d. Confidence that his request will be granted ANS: C Aggressive communication is highly destructive. Although anger may eventually come, the patient most likely feels humiliated first.
DIF: Cognitive Level: Application TOP: Communication MSC: NCLEX: Psychosocial Integrity
REF: 63 OBJ: 7 KEY: Nursing Process Step: Assessment
4. What does therapeutic communication accomplish? a. Facilitates the formation of a positive nurse-patient relationship. b. Manipulates the patient. c. Assigns the patient a passive role. d. Requires the patient to accept what the nurse says. ANS: A A positive nurse-patient relationship is facilitated by therapeutic communication. DIF: Cognitive Level: Comprehension TOP: Communication MSC: NCLEX: N/A
REF: 64 OBJ: 10 KEY: Nursing Process Step: N/A
5. The nurse is sitting in a chair near the patient’s bed, leaning forward to hear what the patient is saying, and does not interrupt. What is the nurse demonstrating? a. Support b. Caring c. Active listening d. Interest ANS: C When demonstrating active listening, the nurse must give his or her full attention and make an effort to understand both the verbal and nonverbal message. DIF: Cognitive Level: Comprehension TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 65 OBJ: 5 KEY: Nursing Process Step:
6. What therapeutic communication technique requires a great deal of skill and is not used as frequently as other communication techniques? a. Touch b. Silence c. Listening d. Summarizing ANS: B Silence is an extremely effective therapeutic communication skill that is frequently underused because the nurse feels uncomfortable applying it. DIF: Cognitive Level: Comprehension TOP: Communication MSC: NCLEX: N/A
REF: 65 OBJ: 5 KEY: Nursing Process Step: N/A
7. A patient does not speak English; therefore, the nurse cannot use words to provide comfort during a painful procedure. What is another intervention that may provide comfort to this patient? a. Silence b. Listening c. Touch d. Restating ANS: C Holding the hand of a non–English-speaking patient is effective and comforting. DIF: Cognitive Level: Application TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 76 OBJ: 9 KEY: Nursing Process Step:
8. A patient states, “I do cocaine when I feel things are out of my control.” The nurse responds by asking, “What else does cocaine do for you?” What communication skill does this exemplify? a. Summarization b. Restating c. Showing acceptance d. Stating observations ANS: C Acceptance is the willingness to listen and respond to what the patient is saying without passing judgment. DIF: Cognitive Level: Application TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 66 OBJ: 5 KEY: Nursing Process Step:
9. A patient states, “I’m really strung out about this pregnancy.” The nurse responds by asking, “What about this pregnancy worries you?” What communication technique is this? a. Closed inquiry b. Restating c. Open-ended question d. Minimal encouraging ANS: C Open-ended questions convey interest and do not require a specific response. DIF: Cognitive Level: Application TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 68 OBJ: 5 KEY: Nursing Process Step:
10. A grieving young widow cries out, “Why was my husband killed? Why wasn’t it me?” What is the nurse’s best response? a. Stating “You need to be strong for your children.” b. Silently placing her hand on the widow’s arm. c. Asking if there is anyone the widow needs to have notified. d. Stating “You are feeling overwhelmed about your husband’s death.” ANS: B The ability to listen and assist those who are newly grieving through the use of silence and a quiet presence is very effective. Stating “You need to be strong for your children” is a cliché. Asking if there is anyone the widow needs to have notified and stating “You are feeling overwhelmed about your husband’s death” are not therapeutic in this immediate grieving time. DIF: Cognitive Level: Application TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 73 OBJ: 5 KEY: Nursing Process Step:
11. A nurse is assessing a patient with a patient problem of impaired verbal communication. What is the lowest number of defining characteristics for this diagnosis? a. One b. Two c. Three d. Four ANS: A If one or more of the defining characteristics is present, a patient problem of impaired verbal communication can be determined. DIF: Cognitive Level: Comprehension TOP: Communication MSC: NCLEX: Psychosocial Integrity
REF: 74 OBJ: 9 KEY: Nursing Process Step: Assessment
12. What communication technique should the nurse use when communicating with an unresponsive patient? a. Avoid speaking directly to the patient. b. Assume verbal stimuli are heard. c. Speak in a loud voice. d. Use simple words. ANS: B A person interacting with an unresponsive patient should assume all sounds and verbal stimuli have the potential of being heard by the patient. DIF: Cognitive Level: Application TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 76 OBJ: 10 KEY: Nursing Process Step:
13. If in response to the patient statement, “I am upset about all this lab work” the nurse responds, “You’re upset?” What is this is an example of? a. An open-ended question b. Reflecting c. Restating d. Paraphrasing ANS: C Restating is one of the most effective methods of therapeutic communication to encourage the patient to offer more information. DIF: Cognitive Level: Application TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 69 OBJ: 5 KEY: Nursing Process Step:
14. What is one of the main characteristics of therapeutic communication? a. It allows the patient a passive role. b. It uses only verbal communication. c. It involves the patient as a person. d. It is directive. ANS: C Therapeutic communication actively involves the patient in all areas of the nursing process. DIF: Cognitive Level: Comprehension TOP: Communication MSC: NCLEX: N/A
REF: 64 OBJ: 1 KEY: Nursing Process Step: N/A
15. A nurse is standing at the bedside with the patient lying in bed. What can the nurse be construed as demonstrating? a. Interest b. Power c. Caring d. Support ANS: B Standing at the bedside with the patient in bed may imply that the nurse has power. DIF: Cognitive Level: Application TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 70 OBJ: 6 | 7 KEY: Nursing Process Step:
16. A nurse actively avoids the use of one-way communication. What is the major problem with one-way communication? a. The receiver is in control. b. Feedback is provided to the sender. c. Participation is not equal.
d. The communication is unstructured. ANS: C One-way communication is seldom effective because the sender is in control and gets very little feedback from the receiver. DIF: Cognitive Level: Comprehension TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 61 OBJ: 7 KEY: Nursing Process Step:
17. A nurse must violate the personal space of a patient to perform an invasive procedure. How can the nurse reduce the discomfort of the patient? a. By approaching the interaction in a professional manner b. By distracting the patient with jokes and humor c. By asking another nurse to be present at the bedside d. By assuring the patient that all people dislike invasion of personal space ANS: A The intimate zone can cause uneasiness for both patient and nurse; therefore, approach the interaction in a professional manner. DIF: Cognitive Level: Application TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 70 OBJ: 6 KEY: Nursing Process Step:
18. What would be the best method for a literate, English-speaking patient on a ventilator to communicate his or her needs? a. Eye blinking for “yes” and “no” b. Magic slate or paper and pencil c. Computer d. Message board or cards ANS: B Writing devices are preferred as they do not limit the patient’s messages compared to a message board or cards. Eye blinks are tiring and time-consuming. Computers require space and the ability to type. DIF: Cognitive Level: Application TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 76 OBJ: 10 KEY: Nursing Process Step:
19. A patient roughly asks the nurse to bring him some ice cream. What would be considered an assertive response by the nurse? a. “You are hungry and want a snack.” b. “I can do that in 10 minutes when I finish my rounds.” c. “Maybe I can get one of the aides to bring you something in a while.” d. “Call the nurses’ station and ask them to have the kitchen bring whatever you
want.” ANS: B Assertiveness is the most effective style of communication to be responsive to the patient and set limits. DIF: Cognitive Level: Application TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 63 OBJ: 4 KEY: Nursing Process Step:
20. A nurse tells a patient, “This PM you are going for an abdominal A&P, an H&H, as well as an IV pyelogram. Please sign these consent forms.” What may this use of medical jargon cause? a. Understanding b. Speed in communication c. Misinterpretation d. Clarity in the message ANS: C Jargon is terminology unique to people in a special type of work and is not understood by everyone. Although jargon does speed communication and is clear to those who know it, it may be misinterpreted and not understood by all people. DIF: Cognitive Level: Comprehension TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 61 OBJ: 7 KEY: Nursing Process Step:
21. During a complete assessment, which type of questioning is not usually conducive to fostering communication? a. Open-ended b. Focused c. Closed d. Clarifying ANS: C Closed questions are types of questions that the nurse may choose to use that are not usually conducive to fostering communication. DIF: Cognitive Level: Comprehension TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 67 OBJ: 7 KEY: Nursing Process Step:
22. A patient states, “My husband has told me how he feels about my having a mastectomy.” The nurse nods and says, “Go on.” This is an example of: a. clarifying. b. restating. c. focusing.
d. minimal encouraging. ANS: D The nurse uses minimal encouragement to lead the patient to provide more information. DIF: Cognitive Level: Application TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 66 OBJ: 5 KEY: Nursing Process Step:
23. A nurse is communicating with an older adult. How might the nurse enhance communication? a. Speak in a rapid manner to accommodate the patient’s short attention span. b. Speak in a lower voice tone to accommodate hearing loss. c. Speak in a simple manner as if speaking to a child. d. Speak in a loud voice directly at ear level. ANS: B Older adults lose their ability to hear higher frequency sound. Speaking in a lower tone enhances communication. Speaking overly loud and as if to a child may be irritating and demeaning. Rapid speech may be difficult for older adults to understand. DIF: Cognitive Level: Application REF: 73 TOP: Physiologic factors affecting communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
OBJ: 6
24. What does maintaining eye contact for 2 to 6 seconds during communication with a patient do? a. Keeps the nurse’s attention on the conversation b. Counteracts shyness in the patient c. Indicates continuous focused attention d. Assesses if the patient is involved in the conversation ANS: C Maintaining eye contact for 2 to 6 seconds involves the person in what is being said, is indicative of continued interest, and conveys to the patient an accepting attitude. DIF: Cognitive Level: Comprehension TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 62 OBJ: 2 KEY: Nursing Process Step:
25. The nurse recognizes that a patient experiencing stress feels vulnerable. What would be the most appropriate way for the nurse to intervene? a. Use technical language. b. Direct the conversation. c. Modify communication methods. d. Offer all the information. ANS: C
When the patient is experiencing stress, the nurse should modify communication methods. DIF: Cognitive Level: Application TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 73 OBJ: 6 KEY: Nursing Process Step:
26. A nurse communicates with a patient by maintaining eye contact and through the use of touch. What type of communication technique is the nurse demonstrating? a. Verbal b. Persuasive c. Directive d. Nonverbal ANS: D Messages transmitted without the use of words (either oral or written) constitute nonverbal communication. Nonverbal cues include tone and rate of voice, volume of speech, eye contact, physical appearance, and use of touch. DIF: Cognitive Level: Comprehension TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 61 OBJ: 5 KEY: Nursing Process Step:
27. A nurse frequently looks at her watch when giving a patient a bed bath. What message is most likely conveyed to the patient from the nurse? a. She desires to spend more time with the patient. b. She is anxious to listen to the patient’s concerns. c. She is feeling hurried. d. She likes her watch. ANS: C Frequently looking at one’s watch while interacting with a patient conveys to the patient that the nurse is in a hurry and really has no desire to spend time with him or her. DIF: Cognitive Level: Application REF: 62 | 66 OBJ: 8 TOP: Gestures KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 28. When listening to a patient, what action by the nurse demonstrates disinterest and coldness? a. Tightly crossing her arms b. Uncrossing her arms c. Uncrossing her legs d. Facing the patient ANS: A
The way that an individual sits, stands, and moves is called posture. Posture has the potential to convey warmth and acceptance, or distance and disinterest. An open posture is demonstrated with a relaxed stance with uncrossed arms and legs while facing the other individual. A slight shift in body position toward an individual, a smile, and direct eye contact are all consistent with open posturing and convey warmth and caring. Closed posture is a more formal, distant stance, generally with the arms, and possibly the legs, tightly crossed. A person will often interpret closed posture as disinterest, coldness, and even nonacceptance. DIF: Cognitive Level: Comprehension REF: 62 OBJ: 1 | 7 | 8 TOP: Posture KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 29. How can the nurse demonstrate warmth and acceptance when listening to a patient? a. Tightly crossing her arms b. Uncrossing her arms c. Tightly crossing her legs d. Facing away from the patient ANS: B The way that an individual sits, stands, and moves is called posture. Posture has the potential to convey warmth and acceptance, or distance and disinterest. An open posture is demonstrated with a relaxed stance with uncrossed arms and legs while facing the other individual. A slight shift in body position toward an individual, a smile, and direct eye contact are all consistent with open posturing and convey warmth and caring. Closed posture is a more formal, distant stance, generally with the arms, and possibly the legs, tightly crossed. A person will often interpret closed posture as disinterest, coldness, and even nonacceptance. DIF: Cognitive Level: Application REF: 62 OBJ: 1 | 5 | 8 TOP: Posture KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 30. How may a nurse caring for a pediatric patient best be perceived as nonthreatening? a. Tightly crossing her arms b. Maintaining an open posture c. Maintaining a tense posture d. Standing at the bedside ANS: B Standing at the bedside looking down at the patient in the bed places the nurse in a position of authority and control. The patient is likely to experience this as intimidating and condescending. Whenever possible, the nurse should be level with the patient; this is especially important with pediatric patients. Sitting at the bedside in a relaxed and open posture is one example. DIF: Cognitive Level: Application REF: 62-63 OBJ: 1 | 5 TOP: Posture KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
31. A nurse is caring for a patient who is experiencing excruciating pain and requires frequent administration of analgesics. What statement would be an example of the nurse demonstrating aggressive communication? a. “Please let me know when you start to have pain.” b. “Let’s practice some guided imagery.” c. “Let’s try repositioning you.” d. “I will only medicate you every 4 hours.” ANS: D Aggressive communication is when a person interacts with another in an overpowering and forceful manner to meet his or her own personal needs at the expense of the other. By only medicating a patient every 4 hours for excruciating pain, the nurse meets his or her own needs at the expense of the patient. DIF: Cognitive Level: Application TOP: Communication Implementation MSC: NCLEX: Psychosocial Integrity
REF: 63 OBJ: 7 KEY: Nursing Process Step:
32. A nurse is caring for a newly admitted diabetic patient and is performing the initial assessment. What statement made by the nurse demonstrates the use of a closed question? a. “What time do you take your insulin?” b. “How do you feel about taking insulin?’ c. “Tell me about your support system.” d. “How do you feel about having diabetes?” ANS: A Much of the information gathered from a patient comes from questioning them directly. A closed question is focused and seeks a particular answer. For example, when interviewing a newly admitted patient with diabetes, the nurse asks, “What time do you take your insulin?” A specific question with a specific answer is a typical closed question, which generally requires only one or two words in response. DIF: Cognitive Level: Application TOP: Closed questioning Implementation MSC: NCLEX: Psychosocial Integrity
REF: 67 OBJ: 7 KEY: Nursing Process Step:
33. A nurse is caring for a patient experiencing respiratory distress. The health care provider places an endotracheal tube. What is the most appropriate patient problem for this patient? a. Ineffective coping b. Risk for infection c. Altered nutrition: less than body requirements d. Impaired verbal communication ANS: D Because of the placement of an endotracheal tube, the patient is unable to speak. The patient problem of impaired verbal communication is most appropriate.
DIF: Cognitive Level: Application TOP: Patient problem MSC: NCLEX: Psychosocial Integrity
REF: 74 OBJ: 9 KEY: Nursing Process Step: Diagnosis
34. A nurse examines whether patient interventions have been appropriate and expected outcomes have been met. The nurse is demonstrating which step in the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation ANS: D A nurse evaluates the effectiveness of interventions based on the patient’s ability to meet established goals and outcomes. DIF: Cognitive Level: Application TOP: Nursing process MSC: NCLEX: Evaluation
REF: 74 OBJ: 9 KEY: Nursing Process Step: Evaluation
35. Which question below is open-ended? a. “Are you going to Europe this fall?” b. “Are you sailing to Europe?” c. “What are you most looking forward to in Europe?” d. “Have you been to Europe before?” e. “Where in Europe are you going?” ANS: C Only the question “What are you most looking forward to in Europe?” allows an unlimited answer. DIF: Cognitive Level: Comprehension TOP: Open-ended communication MSC: NCLEX: N/A
REF: 67 OBJ: 5 KEY: Nursing Process Step: N/A
MULTIPLE RESPONSE 1. Which are true regarding communicating while using eye contact? (Select all that apply.) a. Eye contact is responsible for much communication. b. Eye contact is responsible for much miscommunication. c. Making eye contact generally indicates an intention to interact. d. Eye contact always results in a positive outcome. e. Extended eye contact can imply aggression. f. Extended eye contact can lead to heightened anxiety. ANS: A, B, C, E, F
Eye contact is responsible for much communication and much miscommunication. Generally, making eye contact communicates an intention to interact. However, the nature of the interaction and the results of eye contact are not necessarily always positive. Extended eye contact sometimes implies aggression and arouses anxiety. DIF: Cognitive Level: Comprehension REF: 61 OBJ: 3 TOP: Eye contact KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 2. Which are examples of passive listening? (Select all that apply.) a. The nurse nods frequently while the patient speaks. b. The nurse maintains eye contact while listening to the patient. c. The nurse occasionally interjects, “I see,” when listening to the patient. d. The nurse gives verbal feedback to the patient. e. The nurse verbally interprets the meaning of what the patient has said. ANS: A, B, C, D Listening is sometimes active and sometimes passive. Active listening requires full attention to what the patient is saying. The message is heard, its meaning is interpreted, and the patient is given feedback, indicating understanding of the message. Verbally interpreting the meaning of what the patient has said is an example of active listening. In passive listening, the nurse indicates that they are listening to what the patient is saying either nonverbally, through eye contact and nodding, or verbally through encouraging phrases such as “Uh-huh” and “I see.” All of the other options are examples of passive listening. DIF: Cognitive Level: Comprehension REF: 65 OBJ: 5 TOP: Listening KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 3. What is true about the use of touch in therapeutic communication? (Select all that apply.) a. Touch is a form of nonverbal communication. b. Touch is a form of verbal communication. c. Touch should be used with indiscretion. d. Touch can convey warmth and caring. e. Touch can convey support and understanding. f. Touch should be used sincerely and genuinely. ANS: A, D, E, F Touch is a form of nonverbal communication that is inherent in the practice of nursing. Nearly every nursing intervention for the purpose of providing physical care calls for touch. Touch is frequently highly personal or of an intimate nature (e.g., giving a bed bath, assisting a patient on or off a bedpan, inserting a urinary catheter). Because of the intimate nature of touch in the nursing context, it is necessary to use it with great discretion to fit into sociocultural norms and guidelines. Some nurses are uncomfortable with touch because of a fear of it seeming inappropriate or being misinterpreted. When a nurse feels comfortable with physical contact with a patient, touch has great potential for conveying warmth, caring, support, and understanding. For the nurse to convey warmth, it is absolutely necessary for the nature of their touch to be sincere and genuine.
DIF: Cognitive Level: Comprehension REF: 65-66 OBJ: 5 TOP: Touch KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 4. When speaking to a person of a different culture, how should the nurse consider modifying his or her communication style? (Select all that apply.) a. Speak slowly and with increased volume b. Use of touch c. Use of eye contact d. Reference of address e. Meaning of gestures ANS: B, C, D, E Use of touch, eye contact, reference of address, and meaning of gestures all may have cultural significance and connotation. Slow, loud speech would not assist with speaking to a person of a different culture. DIF: Cognitive Level: Application REF: 66 TOP: Culture KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 7
5. Which defining characteristics support the patient problem of impaired verbal communication? (Select all that apply.) a. Aphasia b. Geriatric patients c. Profoundly deaf d. Legally blind e. Severe COPD ANS: A, C, D, E Difficulty speaking, attending, disorientation, dyspnea, and sensory deficits are all defining characteristics that warrant a diagnosis of impaired verbal communication. Being a geriatric patient does not necessarily support the patient problem of impaired verbal communication. DIF: Cognitive Level: Application TOP: Impaired communication MSC: NCLEX: Psychosocial Integrity
REF: 73 OBJ: 9 KEY: Nursing Process Step: Assessment
6. What is true about the use of silence in therapeutic communication? (Select all that apply.) a. Maintaining silence is an effective therapeutic communication technique. b. Maintaining silence is generally overused in therapeutic communication. c. The sender often becomes uncomfortable when using silence. d. The ability to use silence effectively requires skill and timing. e. Prolonged periods of misunderstood silence can cause tension. f. Purposeful use of silence often conveys lack of respect. ANS: A, C, D, E
Maintaining silence is an extremely effective therapeutic communication technique, and yet tends to be quite underused. Because silence often feels awkward in American society, people tend to feel the need to “fill” it. This impulse does not always allow the people involved in an interaction time to organize their thoughts sufficiently to communicate what they would like. It is common for a person to need several seconds after hearing a verbal message to interpret what has been stated and to formulate the most appropriate response. Unfortunately, the receiver often does not get this amount of time before a response is necessary. In many cases, the sender becomes uncomfortable with the silence and begins speaking again before the receiver has had an opportunity to formulate a response and is really ready to deliver it. The ability to use silence effectively requires skill and timing. It is easy for prolonged periods of misunderstood silence to cause uneasiness and tension. However, in many cases, purposeful use of silence conveys respect, understanding, caring, and support, and it is often used in conjunction with therapeutic touch. DIF: Cognitive Level: Comprehension REF: 65 OBJ: 5 TOP: Silence KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity COMPLETION 1. The nurse explains to a patient that based on the description of “personal space,” the area within 18 in of the patient is designated as the zone. ANS: intimate Personal space zones: 0 to 18 in = intimate, 18 in to 4 ft = personal zone, 4 to 12 ft = social zone, more than 12 ft = public zone. DIF: Cognitive Level: Knowledge TOP: Space and territoriality Implementation MSC: NCLEX: Psychosocial Integrity
REF: 70 OBJ: 8 KEY: Nursing Process Step:
2. A patient with aphasia who cannot understand a spoken or written message is said to have aphasia. ANS: receptive Aphasic patients who do not understand verbal exchanges are classified as receptive aphasics. DIF: Cognitive Level: Comprehension REF: 76 TOP: Aphasia KEY: Nursing Process Step: N/A
OBJ: 7 MSC: NCLEX: N/A
3. The term that describes an individual’s perception or understanding of a particular word or phrase is .
ANS: connotation Connotation is the meaning an individual applies to a word or phrase. DIF: Cognitive Level: Knowledge REF: 61 TOP: Connotation KEY: Nursing Process Step: N/A
OBJ: 2 MSC: NCLEX: N/A
4. When a nurse lectures to a large group, the method of communication is usually in the form of communication. ANS: one-way One-way communication allows the sender to be in control with little expectation of or desire for feedback. DIF: Cognitive Level: Comprehension TOP: Communication MSC: NCLEX: N/A
REF: 61 OBJ: 5 KEY: Nursing Process Step: N/A
5. As the nurse listens to a supervisor, the nurse has a smile on her face but has crossed her arms in front of her chest and has crossed her legs. This is an example of a posture. ANS: closed A posture with crossed limbs frequently is indicative of nonacceptance. DIF: Cognitive Level: Comprehension REF: 62 TOP: Posture KEY: Nursing Process Step: N/A 6.
OBJ: 6 | 7 MSC: NCLEX: N/A
is described as the exchange of information. ANS: Communication Communication is described as the exchange of information. DIF: Cognitive Level: Knowledge TOP: Communication MSC: NCLEX: N/A
REF: 60 OBJ: 1 KEY: Nursing Process Step: N/A
7. The is the person conveying the message, whereas the receiver is the individual or individuals to whom the message is conveyed. ANS:
sender For communication to occur, a sender and a receiver of a message are both necessary. The sender is the person conveying the message, whereas the receiver is the individual or individuals to whom the message is conveyed. DIF: Cognitive Level: Knowledge TOP: Communication MSC: NCLEX: N/A
REF: 60 OBJ: 1 KEY: Nursing Process Step: N/A
Chapter 05: Nursing Process and Critical Thinking Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. What best defines the nursing process? a. A method to ensure that the health care provider’s orders are implemented
correctly. b. A series of assessments that isolate a patient’s health problem. c. A framework for the organization of individualized nursing care. d. A preset formula for the design of nursing care. ANS: C
The nursing process is a framework by which to organize individualized nursing care. DIF: Cognitive Level: Comprehension TOP: Nursing process MSC: NCLEX: N/A
REF: 80 OBJ: 1 KEY: Nursing Process Step: N/A
2. All of the following patients have been admitted to the acute care setting. On admission,
which patient should receive a focused assessment? a. 53-year-old admitted with a perforated ulcer b. 5-year-old admitted for the implant of grommets in the middle ear c. 76-year-old admitted for a knee replacement d. 40-year-old admitted for possible bowel obstruction ANS: A
A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should receive a focused assessment. The remaining options are not considered critical illnesses. DIF: Cognitive Level: Application REF: 81 | 82 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 2
3. What subjective data does the nurse record following a head-to-toe examination? a. Rash on back b. Prolonged nausea c. Blood pressure of 190/100 d. White blood cell count of 19,000 ANS: B
Another term for subjective data is symptoms, which cannot be observed or measured. This data must come from the patient. DIF: Cognitive Level: Application TOP: Subjective data MSC: NCLEX: Physiological Integrity
REF: 82 OBJ: 3 KEY: Nursing Process Step: Assessment
4. What objective data should the nurse include after a patient assessment? a. Headache of 3 days’ duration
b. Severe stomach cramps c. Flatulence d. Anxiety ANS: C
Objective data are observable and measurable by people other than the patient. DIF: Cognitive Level: Application TOP: Objective data MSC: NCLEX: Physiological Integrity
REF: 82 OBJ: 3 KEY: Nursing Process Step: Assessment
5. What is classified as information provided by the family when a patient is unable to
provide data during assessment? a. Primary b. Secondary c. Unreliable d. Biased ANS: B
Secondary sources include family members. DIF: Cognitive Level: Comprehension REF: 82 TOP: Assessment KEY: Nursing Process Step: Assessment
OBJ: 3 MSC: NCLEX: N/A
6. What are the two primary methods used to collect data? a. Written report by patient and family b. Review of the chart and the nurse’s notes c. Interview and physical examination d. Review of the health care provider’s orders and the Kardex ANS: C
The two primary methods of collecting data are interviewing and physical examination. DIF: Cognitive Level: Comprehension REF: 82 TOP: Assessment KEY: Nursing Process Step: Assessment
OBJ: 3 MSC: NCLEX: N/A
7. The nurse writes two patient problems: (1) inadequate nutritional intake related to
vomiting as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition. What is the major difference between these diagnoses? a. The second diagnosis needs no defined nursing interventions. b. The second diagnosis needs medical intervention. c. The second diagnosis will not need to be evaluated. d. The second diagnosis reflects a problem that does not yet exist. ANS: D
The actual patient problem represents a condition that is currently present. “Risk for” diagnoses are those that the patient is susceptible to, but not yet troubled by. DIF: Cognitive Level: Comprehension TOP: Patient problem MSC: NCLEX: Physiological Integrity
REF: 84 OBJ: 4 KEY: Nursing Process Step: Assessment
8. What framework does the establishment of priorities of care during the planning phase of
the nursing process often use? a. Erikson’s developmental tasks b. Piaget’s cognitive table c. Maslow’s hierarchy of needs d. Freud’s classifications ANS: C
A useful framework to guide prioritization is Maslow’s hierarchy of needs. DIF: Cognitive Level: Comprehension TOP: Priorities of care MSC: NCLEX: Physiological Integrity
REF: 86 OBJ: 9 KEY: Nursing Process Step: Planning
9. What is an appropriate outcome statement for a patient with a patient problem of
ineffective airway clearance related to thick secretions? a. The patient will increase intake to 1000 mL daily to liquefy secretions. b. The patient will cough more frequently within 3 days. c. The patient will breathe better within 3 days. d. The patient will perform deep-breathing exercises four times daily. ANS: A
The patient goal would be to improve airway clearance. Coughing more frequently within 3 days and performing deep-breathing exercises four times daily do not directly relate to the problem of thick secretions. Breathing better within 3 days is too vague. DIF: Cognitive Level: Comprehension TOP: Patient problem MSC: NCLEX: Physiological Integrity
REF: 90 OBJ: 6 KEY: Nursing Process Step: Planning
10. What is the primary purpose of nursing interventions? a. To support health care provider’s orders b. To provide direction for all caregivers c. To provide broad, general statements d. To clarify nursing principles ANS: B
Nursing orders are necessary to provide instructions for all caregivers. DIF: Cognitive Level: Comprehension TOP: Nursing interventions MSC: NCLEX: N/A
REF: 87 | 88 OBJ: 7 KEY: Nursing Process Step: Planning
11. What documentation reflects implementation? a. “Patient selected low-sugar snacks independently.” b. “Patient was medicated with Tylenol 500 mg PO for pain.” c. “Patient was ambulated for 15 minutes after lunch.” d. “Patient participated in group therapy session without reminder.” ANS: C
Implementation is the nurse carrying out nursing orders to promote outcome achievement.
DIF: Cognitive Level: Comprehension TOP: Implementation MSC: NCLEX: N/A
REF: 89 OBJ: 2 KEY: Nursing Process Step: Implementation
12. Which nursing intervention is complete and correct? a. “May 10: Unlicensed assistive personnel will ambulate patient. A. Nurse” b. “Day nurse will cleanse wound and change dressings every day. May 10, A.
Nurse” c. “Unlicensed assistive personnel will serve 8 oz glass of juice at each meal, 5/10.” d. “P.M. nurse will ensure that heel protectors are in place before bedtime.” ANS: B
Nursing orders must be signed, dated, and have specific designation as to who will perform intervention and specifics about time or frequency of the intervention. DIF: Cognitive Level: Application TOP: Nursing interventions MSC: NCLEX: Physiological Integrity
REF: 87 | 88 OBJ: 7 KEY: Nursing Process Step: Implementation
13. A patient with a urinary tract infection is assessed using a clinical pathway. When a
projected outcome is not met by a predetermined date, it is determined that what has occurred? a. Omission b. Variance c. Failure d. Error ANS: B
A variance occurs when a projected outcome is not met. DIF: Cognitive Level: Comprehension TOP: Critical pathways MSC: NCLEX: Physiological Integrity
REF: 91 OBJ: 8 | 11 KEY: Nursing Process Step: Evaluation
14. During a physical examination, the nurse discovers that the patient demonstrates signs of
flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a patient problem plan. What does this data represent? a. Symptoms b. Data clustering c. Signs of fluid overload d. Urinary retention ANS: B
The nurse organizes data, and those that are related are referred to as clustering. DIF: Cognitive Level: Comprehension REF: 82 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 3 | 12
15. What type of assessment is performed continuously throughout nurse-patient contact? a. Complete b. Body systems
c. Focused d. Subjective ANS: C
Focused assessments are performed continuously throughout nurse-patient contact based on the nursing care plan. DIF: Cognitive Level: Comprehension REF: 81-82 TOP: Assessment KEY: Nursing Process Step: Assessment
OBJ: 1 MSC: NCLEX: N/A
16. What assists the nurse in the identification of patient problems? a. Objective data b. Subjective data c. Data clustering d. Validated data ANS: C
Data clustering assists the nurse in determining patient problems. DIF: Cognitive Level: Comprehension TOP: Patient problem MSC: NCLEX: N/A
REF: 82 OBJ: 4 KEY: Nursing Process Step: Assessment
17. What organized approach might the nurse use when performing a complete physical
examination? a. Maslow’s hierarchy of needs b. A head-to-toe assessment c. Subjective data collection d. Objective data collection ANS: B
A head-to-toe format provides a systematic approach. DIF: Cognitive Level: Application REF: 82 TOP: Assessment KEY: Nursing Process Step: Assessment
OBJ: 3 MSC: NCLEX: N/A
18. Who is the person responsible for analyzing and interpreting data to arrive at a patient
problem? a. Health care provider b. LPN/LVN c. RN d. Technician ANS: C
The RN is responsible for analyzing and interpreting data. DIF: Cognitive Level: Knowledge TOP: Role responsibility MSC: NCLEX: N/A
REF: 81 OBJ: 4 KEY: Nursing Process Step: N/A
19. What is the basis for designing and selecting nursing interventions to meet patient needs? a. Patient problem b. Care plan
c. Health care provider’s orders d. Nurse’s notes ANS: A
The patient problem is the basis for developing nursing interventions. DIF: Cognitive Level: Knowledge TOP: Patient problem MSC: NCLEX: N/A
REF: 87 OBJ: 4 KEY: Nursing Process Step: Planning
20. The patient is confined to bed rest, which contributes to immobility. What is bed rest
considered in this situation? a. Contributing to the patient’s recovery b. A risk factor c. Difficult to maintain d. A nursing responsibility ANS: B
Risk factors are those that increase the susceptibility of a patient to a problem. DIF: Cognitive Level: Application REF: 84 TOP: Risk factors KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
OBJ: 5
21. What is a patient problem considered when a problem is suspected but data to support it
are lacking? a. A syndrome patient problem b. An actual patient problem c. A “risk for” diagnosis d. A possible patient problem ANS: D
A possible patient problem requires additional data to confirm a problem or to complete a data cluster so that it can be related to a NANDA-I label. DIF: Cognitive Level: Comprehension TOP: Patient problem MSC: NCLEX: N/A
REF: 81 | 86 OBJ: 4 | 10 KEY: Nursing Process Step: Assessment
22. When a nurse selects interventions to assist the patient to meet the needs demonstrated, the
nurse is in which phase of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation ANS: B
During the planning phase, the nurse connects nursing interventions to nursing orders. DIF: Cognitive Level: Comprehension TOP: Nursing process MSC: NCLEX: N/A
REF: 86 OBJ: 2 KEY: Nursing Process Step: Planning
23. What is an important consideration when developing the care plan? a. Ensure the number of interventions is limited. b. Ensure the patient is involved in the process. c. Ensure interventions will be easy to implement. d. Ensure evaluation of the patient problems is possible. ANS: B
Plans are more effective when the patient is involved in the process. The care plan is not limited in terms of the number of interventions, nor do they have to be easy. The patient problems are not evaluated; the patient’s progress toward the outcome is. DIF: Cognitive Level: Comprehension REF: 86 TOP: Care plan KEY: Nursing Process Step: Planning
OBJ: 6 | 9 MSC: NCLEX: N/A
24. From where are the “risk for” patient problems identified? a. The care plan b. The interventions c. The assessment d. The evaluation ANS: C
Patient problems should be identified from the assessment. DIF: Cognitive Level: Knowledge TOP: Nursing process MSC: NCLEX: Physiological Integrity
REF: 80-81 OBJ: 2 KEY: Nursing Process Step: Assessment
25. What expected outcome exemplifies accepted criteria? a. Nurse will assess vital signs every day b. Resident will observe safety guidelines while smoking c. Resident will take part in one activity daily for the next 90 days d. Nurse will monitor O2 saturation to maintain at greater than 90% ANS: C
Expected outcomes must be patient-centered, measurable, and refer to a time frame. DIF: Cognitive Level: Application TOP: Nursing process MSC: NCLEX: Physiological Integrity
REF: 85 OBJ: 6 KEY: Nursing Process Step: Planning
26. During an admission assessment, the nurse collects objective and subjective data. What is
an example of subjective data? a. The patient complains of nausea. b. The patient is vomiting. c. The patient experiences tachycardia. d. The patent is pacing the halls. ANS: A
Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of nausea is an example of subjective data. All other options are examples of objective data.
DIF: Cognitive Level: Application TOP: Subjective data MSC: NCLEX: Physiological Integrity
REF: 82 OBJ: 1 | 3 KEY: Nursing Process Step: Assessment
27. During an admission assessment, the nurse collects objective and subjective data. What is
an example of subjective data? a. The patient is asleep. b. The patient is tearful. c. The patient has facial grimacing. d. The patient states, “I hurt all over.” ANS: D
Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Stating “I hurt all over” is an example of subjective data. All other options are examples of objective data. DIF: Cognitive Level: Application TOP: Nursing process MSC: NCLEX: Physiological Integrity
REF: 82 OBJ: 1 | 3 KEY: Nursing Process Step: Planning
28. During an admission assessment, the nurse collects objective and subjective data. What is
an example of subjective data? a. The patient is coughing. b. The patient has cyanosis of the lips. c. The patient experiences tachypnea. d. The patient complains of generalized discomfort. ANS: D
Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of generalized discomfort is an example of subjective data. All other options are examples of objective data. DIF: Cognitive Level: Application TOP: Subjective data MSC: NCLEX: Physiological Integrity
REF: 82 OBJ: 1 | 3 KEY: Nursing Process Step: Assessment
29. During an admission assessment, the nurse collects objective and subjective data. What is
an example of objective data? a. The patient complains of chest pain. b. The patient states, “I feel nauseous.” c. The patient complains of feeling faint. d. The patient is short of breath on exertion. ANS: D
Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Shortness of breath on exertion is an example of objective data. All other options are examples of subjective data.
DIF: Cognitive Level: Application TOP: Objective data MSC: NCLEX: Physiological Integrity
REF: 82 OBJ: 1 | 3 KEY: Nursing Process Step: Assessment
30. During an admission assessment, the nurse collects objective and subjective data. What is
an example of objective data? a. The patient is jaundiced. b. The patient states, “I am nervous.” c. The patient complains of palpitations. d. The patient denies dizziness when ambulating. ANS: A
Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. The patient is jaundiced is an example of objective data. All other options are examples of subjective data. DIF: Cognitive Level: Application TOP: Objective data MSC: NCLEX: Physiological Integrity
REF: 82 OBJ: 1 | 3 KEY: Nursing Process Step: Assessment
31. During an admission assessment, the nurse collects objective and subjective data. What is
an example of objective data? a. The patient complains of feeling depressed. b. The patient states, “I hear voices in my head.” c. The patient complains of auditory hallucinations. d. The patient is pacing back and forth while chanting. ANS: D
Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Pacing back and forth while chanting is an example of objective data. All other options are examples of subjective data. DIF: Cognitive Level: Application TOP: Objective data MSC: NCLEX: Physiological Integrity
REF: 82 OBJ: 1 | 3 KEY: Nursing Process Step: Assessment
32. What is an example of an appropriate Patient problem? a. Impaired skin integrity b. Skin breakdown noted c. Turn patient every 2 hours d. The patient has scabies on his back ANS: A
“Impaired skin integrity” is an example of a patient problem. “Skin breakdown noted” is an example of a charting entry, “turn patient every 2 hours” is a nursing intervention, and “scabies” is a medical diagnosis.
DIF: Cognitive Level: Comprehension TOP: Patient problem MSC: NCLEX: Physiological Integrity
REF: 81 | 83 OBJ: 4 KEY: Nursing Process Step: Diagnosis
33. What is an example of an appropriate patient problem? a. Constipation b. Patient complains of constipation c. Need for laxatives d. Patient has a duodenal ulcer ANS: A
Constipation is an example of a patient problem, a patient complaining of constipation is an example of a charting entry, a need for laxatives is an example of a patient need, and a patient has a duodenal ulcer is an example of a medical diagnosis. DIF: Cognitive Level: Comprehension TOP: Patient problem MSC: NCLEX: Physiological Integrity
REF: 84 OBJ: 4 KEY: Nursing Process Step: Diagnosis
34. A nurse is formulating a patient problem. What is an example of an appropriately written
patient problem? a. Risk for impaired skin integrity related to physical immobilization b. Physical immobilization secondary to risk for impaired skin integrity c. Risk for impaired skin integrity related to diagnosis of decubitus ulcers d. Physical immobilization secondary to decreased cognitive ability ANS: A
Risk for impaired skin integrity related to physical immobilization is the only appropriately written patient problem. All other options are not listed as NANDA-I approved patient problems. DIF: Cognitive Level: Application TOP: Patient problem MSC: NCLEX: Physiological Integrity
REF: 83-85 OBJ: 4 KEY: Nursing Process Step: Diagnosis
35. Which is an example of a patient problem? a. Pneumonia b. Diabetes mellitus c. Impaired skin integrity d. Congestive heart failure ANS: C
Impaired skin integrity is the only example of a patient problem; all other options are examples of medical diagnoses. DIF: Cognitive Level: Comprehension TOP: Patient problem MSC: NCLEX: Physiological Integrity
REF: 83-85 OBJ: 4 KEY: Nursing Process Step: Diagnosis
36. Which is an example of a medical diagnosis? a. Constipation b. Diabetes mellitus
c. Impaired skin integrity d. Altered nutrition: less than body requirements ANS: B
Diabetes mellitus is the only example of a medical diagnosis; all other options are examples of patient problems. DIF: Cognitive Level: Comprehension TOP: Medical diagnosis MSC: NCLEX: Physiological Integrity
REF: 85 OBJ: 4 KEY: Nursing Process Step: Diagnosis
37. Which is an example of a medical diagnosis? a. Pain b. Anxiety c. Pneumonia d. Impaired skin integrity ANS: C
Pneumonia is the only example of a medical diagnosis; all other options are examples of patient problems. DIF: Cognitive Level: Comprehension TOP: Medical diagnosis MSC: NCLEX: Physiological Integrity
REF: 85 OBJ: 4 KEY: Nursing Process Step: Diagnosis
MULTIPLE RESPONSE 1. Which are acceptable secondary sources for data? (Select all that apply.) a. Patient b. Family members c. Other health professionals d. Diagnostic reports e. Textbooks ANS: B, C, D, E
A patient is not a secondary source. The patient is the primary data source. DIF: Cognitive Level: Comprehension REF: 82 TOP: Data sources KEY: Nursing Process Step: N/A
OBJ: 3 MSC: NCLEX: N/A
2. Which are official categories of patient problems? (Select all that apply.) a. Actual b. Risk c. Wellness d. Syndrome e. Potential ANS: A, B, C, D
Actual, risk, wellness, and syndrome are the four categories of patient problems. DIF: Cognitive Level: Comprehension TOP: Patient problem
REF: NIT OBJ: 4 KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A 3. Which are considered phases of the nursing process? (Select all that apply.) a. Diagnosis b. Prediction c. Assessment d. Evaluation e. Implementation f. Outcome identification ANS: A, C, D, E, F
The nursing process consists of six dynamic and interrelated phases: diagnosis, assessment, outcome identification, planning, implementation, and evaluation. Prediction is not a phase of the nursing process. DIF: Cognitive Level: Comprehension TOP: Nursing process MSC: NCLEX: N/A
REF: 89 OBJ: 2 KEY: Nursing Process Step: All
COMPLETION 1. NANDA International meets to reorganize diagnosis labels and language every 2
. ANS:
years NANDA International meets every two years to revise language, form, and diagnosis labels. DIF: Cognitive Level: Knowledge REF: 83 TOP: NANDA KEY: Nursing Process Step: N/A 2. The standards that name and measure patient
OBJ: 10 MSC: NCLEX: N/A
are referred to as NOC (Nursing
Outcome Classification). ANS:
outcomes NOC sets up outcome criteria based on a patient problem. DIF: Cognitive Level: Knowledge REF: 90 TOP: NOC KEY: Nursing Process Step: N/A 3. The document that outlines a
OBJ: 10 MSC: NCLEX: N/A
_ plan for care interventions over a specified time frame is called a clinical pathway, critical path, action plan, or care map. ANS:
multidisciplinary
A clinical pathway is an organized multidisciplinary plan over a specified time frame, which outlines aspects of patient care. They are also called critical paths, action plans, and care maps. DIF: Cognitive Level: Knowledge TOP: Clinical pathways MSC: NCLEX: N/A
REF: 91 OBJ: 11 KEY: Nursing Process Step: N/A
4. A systematic method by which nurses plan and provide care for patients is known as the
nursing
.
ANS:
process The nursing process serves as the organizational framework for the practice of nursing. It is a systematic method by which nurses plan and provide care for patients. DIF: Cognitive Level: Knowledge TOP: Nursing process MSC: NCLEX: N/A
REF: 80 OBJ: 2 KEY: Nursing Process Step: N/A
5. A systemic, dynamic way to collect and analyze data about a patient that includes
physiologic data as well as psychological, sociocultural, spiritual, economic, and lifestyle factors is known as . ANS:
assessment The American Nurses Association (ANA) defines assessment as “a systematic, dynamic way to collect and analyze data about a patient, the first step in delivering nursing care. Assessment includes not only physiologic data, but also psychological, sociocultural, spiritual, economic, and lifestyle factors as well.” DIF: Cognitive Level: Knowledge TOP: Nursing process MSC: NCLEX: N/A
REF: 80 OBJ: 2 KEY: Nursing Process Step: Assessment
6. Any health care condition that requires diagnostic, therapeutic, or educational actions is
known as a
.
ANS:
problem A problem is any health care condition that requires diagnostic, therapeutic, or educational actions. DIF: Cognitive Level: Knowledge REF: 83 TOP: A problem KEY: Nursing Process Step: N/A
OBJ: 2 MSC: NCLEX: N/A
7. A clinical judgment concerning a human response to health conditions/life processes, or a
vulnerability for that response, by an individual, family, group or community is known as a nursing . ANS:
diagnosis A patient problem is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community. DIF: Cognitive Level: Knowledge TOP: Patient problem MSC: NCLEX: N/A
REF: 83 OBJ: 4 KEY: Nursing Process Step: Diagnosis
8. The human responses to health conditions/life processes that exist in an individual, family,
or community are known as a(n)
patient problem.
ANS:
actual An actual patient problem is described as the human responses to health conditions/life processes that exist in an individual, family, or community. DIF: Cognitive Level: Knowledge TOP: Actual patient problem MSC: NCLEX: N/A
REF: 84 OBJ: 4 KEY: Nursing Process Step: Diagnosis
9. Human responses to health conditions and life processes that may develop in a vulnerable
individual, family, or community are known as a(n)
patient problem.
ANS:
risk A risk patient problem is defined as the human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community. DIF: Cognitive Level: Knowledge TOP: Risk patient problem MSC: NCLEX: N/A
REF: 84 OBJ: 4 KEY: Nursing Process Step: Diagnosis
10. Human responses to levels of wellness in an individual, family, or community that have a
readiness for enhancement are known as a
patient problem
ANS:
wellness A wellness patient problem is defined as human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement. DIF: Cognitive Level: Knowledge
REF: 83
OBJ: 4
TOP: Wellness patient problem MSC: NCLEX: N/A
KEY: Nursing Process Step: Diagnosis
11. The identification of a disease or condition by a scientific evaluation of physical signs,
symptoms, history, laboratory tests, and procedures is known as a
diagnosis.
ANS:
medical A medical diagnosis is the identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures. DIF: Cognitive Level: Knowledge TOP: Medical diagnosis MSC: NCLEX: N/A
REF: 85 OBJ: 4 KEY: Nursing Process Step: N/A
12. A health care system that provides control over health care services for a specific group of
individuals in an attempt to control cost is known as
care.
ANS:
managed Managed care is a health care system that provides control over health care services for a specific group of individuals in attempts to control cost. DIF: Cognitive Level: Knowledge TOP: Risk managed care MSC: NCLEX: N/A
REF: 91 OBJ: 6 | 11 KEY: Nursing Process Step: N/A
13. A multidisciplinary plan that schedules clinical
over an anticipated time frame for high-risk, high-volume, and high-cost types of cases is known as a critical pathway. ANS:
interventions A critical pathway is a multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases. DIF: Cognitive Level: Knowledge TOP: Clinical pathways MSC: NCLEX: N/A
REF: 91 OBJ: 11 KEY: Nursing Process Step: N/A
Chapter 06: Cultural and Ethnic Considerations Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. Culture varies from patient to patient. Why is it important that the nurse understand and
accept each person as an individual? a. To develop a plan of care b. To provide holistic care c. To identify differences d. To support each patient ANS: B
Accepting each person as an individual is the first step in providing holistic care. DIF: Cognitive Level: Comprehension REF: 95 TOP: Culture KEY: Nursing Process Step: N/A
OBJ: 2 MSC: NCLEX: N/A
2. What is a fixed concept of how all members of an ethnic group act or think? a. Variations within a cultural group b. Identical practices c. Holistic nursing d. Ethnic stereotypes ANS: D
Ethnic stereotypes are fixed concepts of how all members of an ethnic group act or think. DIF: Cognitive Level: Knowledge REF: 96 TOP: Culture KEY: Nursing Process Step: N/A
OBJ: 4 MSC: NCLEX: N/A
3. All nurses should work to provide culturally appropriate nursing care. What is the
integration of cultural knowledge into all aspects of care? a. Cultural competence b. Transcultural nursing c. Nursing process d. Team nursing ANS: B
All nurses should provide transcultural nursing, which is the integration of cultural knowledge into all aspects of care. DIF: Cognitive Level: Knowledge REF: 96 TOP: Culture KEY: Nursing Process Step: N/A
OBJ: 1 | 2 MSC: NCLEX: N/A
4. What is the term for when members of a particular ethnic group believe that their beliefs
and practices are the best? a. Prejudice b. Separatism c. Ethnocentrism d. Bias
ANS: C
When members of a particular ethnic group believe that their practices and beliefs are the best, it is referred to as ethnocentrism. DIF: Cognitive Level: Knowledge REF: 96 TOP: Culture KEY: Nursing Process Step: N/A
OBJ: 4 MSC: NCLEX: N/A
5. What is the term used to describe cultures in which women make decisions about health
care and provide the care and discipline to the children? a. Biological b. Matriarchal c. Cultural d. Patriarchal ANS: B
In a matriarchal society, women make the decisions about health care. In patriarchal society, the men make decisions about health care. There is no such thing as biological or cultural cultures. DIF: Cognitive Level: Knowledge REF: 101 TOP: Culture KEY: Nursing Process Step: N/A
OBJ: 4 MSC: NCLEX: N/A
6. What basic philosophy in the United States is relevant to health care? a. Folk remedies b. Biomedical therapy c. Holistic therapy d. Spiritual intervention ANS: B
Most people in the United States believe biomedical therapy is the best way to treat disease. DIF: Cognitive Level: Comprehension REF: 106 TOP: Culture KEY: Nursing Process Step: N/A
OBJ: 4 MSC: NCLEX: N/A
7. What is a set of learned values, beliefs, customs, and practices shared by a group? a. Race b. Ethnicity c. Culture d. Religion ANS: C
Culture is a set of learned values, beliefs, customs, and practices shared by a group. DIF: Cognitive Level: Knowledge REF: 95 TOP: Culture KEY: Nursing Process Step: N/A
OBJ: 4 MSC: NCLEX: N/A
8. A nurse is American-born and works in a large hospital with patients from many cultures.
What must this nurse develop to provide the best care? a. Another language b. Assessment skills c. Cultural competence
d. Care planning ability ANS: C
To provide care to patients from different cultures, the nurse must develop cultural competence. DIF: Cognitive Level: Comprehension REF: 96 TOP: Culture KEY: Nursing Process Step: N/A
OBJ: 3 MSC: NCLEX: N/A
9. The nurse from New York City is caring for a patient from Atlanta, Georgia. What
difference between the nurse and patient may cause them to experience difficulty in communicating? a. Race b. Subculture c. Ethnic group d. Culture ANS: B
Subcultures have characteristic patterns that distinguish them from the rest of the culture. DIF: Cognitive Level: Comprehension REF: 95 TOP: Subculture KEY: Nursing Process Step: N/A
OBJ: 2 MSC: NCLEX: N/A
10. The father of an American Indian has just died. What should the nurse do immediately
after death? a. Provide privacy so that the family may touch and kiss the deceased goodbye b. Ask about providing help with the death ceremony c. Carefully wrap the deceased’s clothing for the family to take home d. Mention the deceased by name frequently ANS: B
In the American Indian culture it is taboo to touch the deceased or any of the belongings of the deceased. After death, the name of the deceased is not spoken. DIF: Cognitive Level: Application TOP: American Indian MSC: NCLEX: Psychosocial Integrity
REF: 113 OBJ: 1 | 4 | 6 KEY: Nursing Process Step: Implementation
11. What is the term for a generalization about a form of behavior, an individual, or a group? a. Dialect b. Religion c. Ethnicity d. Stereotype ANS: D
A stereotype is a generalization about a form of behavior, an individual, or a group. DIF: Cognitive Level: Knowledge REF: 96 TOP: Stereotype KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity
OBJ: 4
12. What is the term for a group of people who share biological physical characteristics? a. Race
b. Culture c. Religion d. Social organization ANS: A
A race is a group of people who share biological physical characteristics. DIF: Cognitive Level: Knowledge REF: 96-97 TOP: Race KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity
OBJ: 4
13. What is the term for a group of people who share a common social and cultural heritage
based on shared traditions, national origin, and physical and biological characteristics? a. Race b. Culture c. Religion d. Ethnicity ANS: D
Ethnicity refers to a group of people who share a common social and cultural heritage based on shared traditions, national origin, and physical and biological characteristics. DIF: Cognitive Level: Knowledge REF: 96-97 TOP: Ethnicity KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity
OBJ: 4
14. A nurse is caring for a neonate born to observant Orthodox Jewish parents. Who can the
nurse anticipate will name the neonate? a. Father b. Mother c. Grandfather d. Grandmother ANS: A
For observant Jews, babies are named by the father. DIF: Cognitive Level: Knowledge TOP: Religious practices MSC: NCLEX: Psychosocial Integrity
REF: 104 OBJ: 2 | 3 KEY: Nursing Process Step: N/A
15. A nurse is caring for a male neonate born to observant Orthodox Jewish parents. Who will
the nurse anticipate will circumcise the neonate? a. A bishop b. A mohel c. His father d. His health care provider ANS: B
Male children are named 8 days after birth, when ritual circumcision is done. A mohel performs the circumcision. DIF: Cognitive Level: Knowledge TOP: Religious practices
REF: 104 OBJ: 2 | 4 KEY: Nursing Process Step: N/A
MSC: NCLEX: Psychosocial Integrity 16. A nurse is caring for a female neonate born to observant Orthodox Jewish parents. What
book does the nurse know will be used when naming this neonate? a. Bible b. Koran c. Holy Torah d. Book of Mormon ANS: C
For observant Jews, female babies are usually named during a reading of the Holy Torah. DIF: Cognitive Level: Knowledge TOP: Religious practices MSC: NCLEX: Psychosocial Integrity
REF: 104 OBJ: 2 | 4 KEY: Nursing Process Step: N/A
17. A nurse is caring for an Orthodox Jewish woman immediately after she has given birth.
What can the nurse expect regarding the spouse’s participation in his wife’s care? a. He will share a bed with the patient. b. He will ask to bathe with the patient. c. He will touch the patient frequently. d. He will avoid physical contact with the patient. ANS: D
For observant Jews, a woman is considered to be in a ritual state of impurity whenever blood is coming from her uterus, such as during menstrual periods and after the birth of a child. During this time, her husband will not have physical contact with her. When this time is completed, she will bathe herself in a pool called a mikvah. Nurses need to be aware of this practice and be sensitive to the husband and wife because the husband will not touch his wife. DIF: Cognitive Level: Comprehension TOP: Religious practices MSC: NCLEX: Psychosocial Integrity
REF: 104 OBJ: 4 | 5 KEY: Nursing Process Step: N/A
18. A nurse is caring for an Orthodox Jewish patient. What is the most appropriate dietary
requirement for the nurse to implement? a. Mixing of milk and meat at a meal b. Use of separate cooking utensils for meat and milk products c. Use of one set of cooking utensils for meat and milk products d. Consumption of food not slaughtered in accordance with Jewish law ANS: B
For observant Jews, Kosher dietary laws include the following: no mixing of milk and meat at a meal; no consumption of food or any derivative thereof from animals not slaughtered in accordance with Jewish law; use of separate cooking utensils for meat and milk products; if a patient requires milk and meat products for a meal, the dairy foods should be served first, followed later by the meat. DIF: Cognitive Level: Application TOP: Religious practices MSC: NCLEX: Psychosocial Integrity
REF: 104 OBJ: 4 KEY: Nursing Process Step: N/A
19. The nurse is preparing an Orthodox Jewish patient’s tray during Passover. What
intervention is appropriate for this patient? a. Avoid fish dishes. b. Encourage time for prayer. c. Offer the patient leavened products. d. Encourage the use of loud music in celebration. ANS: B
Orthodox Jews say prayers over the bread and wine before meals. Time and a quiet environment should be provided for this. During Passover, no leavened products are eaten. DIF: Cognitive Level: Application TOP: Religious practices MSC: NCLEX: Psychosocial Integrity
REF: 104 OBJ: 4 KEY: Nursing Process Step: N/A
20. A nurse is preparing to discuss birth control options for a Roman Catholic patient. What is
the most appropriate method for the nurse to discuss with this patient? a. Abstinence b. Vasectomy c. Tubal ligation d. Oral contraceptives ANS: A
Birth control for Roman Catholics is prohibited except for abstinence or natural family planning. Referral to a priest for questions about this can be of great help. Nurses can teach the techniques of natural family planning if they are familiar with them; otherwise, this should be referred to the health care provider or to a support group of the Church that instructs couples in this method of birth control. Sterilization is prohibited unless there is an overriding medical reason. DIF: Cognitive Level: Application TOP: Religious practices MSC: NCLEX: Psychosocial Integrity
REF: 104 OBJ: 3 | 5 | 7 KEY: Nursing Process Step: N/A
21. A nurse is preparing a meal tray for a patient who is a Latter-Day Saint. What beverage
should the nurse prepare? a. Tea with all meals b. Coffee each morning c. Cola beverages d. Fruit juice ANS: D
For observant Latter-Day Saints, beverages with caffeine such as cola, coffee, and tea; alcohol; and other substances are considered injurious. DIF: Cognitive Level: Application TOP: Religious practices MSC: NCLEX: Psychosocial Integrity
REF: 102 OBJ: 4 | 7 KEY: Nursing Process Step: N/A
22. A nurse is caring for a patient who is a Latter-Day Saint. The nurse is aware members of
this faith may wear sacred undergarments. What intervention is appropriate for the nurse caring for this patient? a. Instruct the patient to remove the undergarments. b. Allow the patient to wear the undergarments only at night. c. Allow the patient to wear the undergarments only during the day. d. Remove the undergarments in emergency situations only. ANS: D
For observant Latter-Day Saints, a sacred undergarment may be worn at all times and should be removed only in emergency situations. DIF: Cognitive Level: Application TOP: Religious practices MSC: NCLEX: Psychosocial Integrity
REF: 102 OBJ: 4 | 5 KEY: Nursing Process Step: N/A
23. Which statement about the biomedical health belief system is true? a. Life processes can be manipulated by humans by mechanical interventions. b. Life processes cannot be manipulated by humans by mechanical interventions. c. Disease has a nonspecific cause, onset, course, and treatment. d. Disease is only caused by failure of body parts and chemical imbalances. ANS: A
Characteristic of the biomedical health belief system includes the beliefs that life is regulated by biomedical and physical processes. Life processes can be manipulated by humans by mechanical interventions. Health is the absence of disease or signs and symptoms of disease. Disease is an alteration of the structure and function of the body. Disease has a specific cause, onset, course, and treatment. It is caused by trauma, pathogens, chemical imbalances, or failure of body parts. Treatment focuses on the use of physical and chemical treatments. DIF: Cognitive Level: Comprehension TOP: Health belief systems MSC: NCLEX: Psychosocial Integrity
REF: 106-108 OBJ: 4 KEY: Nursing Process Step: N/A
24. Which health belief system is commonly referred to as “third-world” beliefs and practices? a. Folk health belief system b. Holistic health belief system c. Biomedical health belief system d. Alternative/complementary belief system ANS: A
The folk health belief system is commonly referred to as “third-world” beliefs and practices. It is often called strange or weird by nurses and other health professionals who are unfamiliar with folk medicine beliefs. DIF: Cognitive Level: Knowledge TOP: Health belief systems MSC: NCLEX: Psychosocial Integrity
REF: 108 OBJ: 4 KEY: Nursing Process Step: N/A
25. Which health belief system includes a belief of a supernatural force exerting influence to
cause health or illness?
a. b. c. d.
Folk Holistic Biomedical Alternative/complementary
ANS: A
The folk health belief system is commonly referred to as “third-world” beliefs and practices. It is often called strange by nurses and other health professionals who are unfamiliar with folk medicine beliefs. DIF: Cognitive Level: Knowledge TOP: Health belief systems MSC: NCLEX: Psychosocial Integrity
REF: 108 OBJ: 4 KEY: Nursing Process Step: N/A
26. Which health belief system focuses on restoring balance with physical, social, and
metaphysical worlds? a. Folk health belief system b. Holistic health belief system c. Biomedical health belief system d. Alternative/complementary belief system ANS: B
The treatment based on the holistic health belief system is designed to restore balance with physical, social, and metaphysical worlds. DIF: Cognitive Level: Knowledge TOP: Health belief systems MSC: NCLEX: Psychosocial Integrity
REF: 108 OBJ: 4 KEY: Nursing Process Step: N/A
27. The nurse is caring for a patient who fasts during daylight hours during Ramadan. The
nurse recognizes that the patient is adhering to the cultural beliefs of which culture? a. Muslims b. African Americans c. Chinese Americans d. Mexican Americans ANS: A
Muslims practice fasting during daylight hours during Ramadan. DIF: Cognitive Level: Knowledge REF: 103 | 113 | 114 OBJ: 4 | 5 TOP: Health belief systems KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 28. The nurse is caring for a Muslim patient. What dietary selection should the nurse serve to
this patient? a. Bacon, eggs, and toast b. Pork fried rice c. Ham and cheese sandwich d. Chicken and rice ANS: D
Muslims practice avoidance of foods that include pork products. Bacon, pork, and ham are all pork products. Only the chicken and rice meal does not include a pork product. DIF: Cognitive Level: Application TOP: Health belief systems MSC: NCLEX: Psychosocial Integrity
REF: 114 OBJ: 1 | 2 | 4 KEY: Nursing Process Step: N/A
29. A patient requests a consultation between the health care provider and a religious leader
known as an Imam. What is this patient’s cultural belief? a. Muslim b. African American c. Chinese American d. Mexican American ANS: A
Muslims may wish to have their health care provider consult with an Imam, a religious leader. DIF: Cognitive Level: Comprehension TOP: Health belief systems MSC: NCLEX: Psychosocial Integrity
REF: 111 OBJ: 4 KEY: Nursing Process Step: N/A
30. The nurse is delivering a meal tray to a female Muslim patient. What intervention is most
appropriate for this patient? a. Offering her a ham and cheese sandwich b. Providing her with a male nurse c. Providing her with a female nurse d. Offering her bacon and eggs ANS: C
When caring for Muslims, same-sex health care providers should be used if at all possible. Ham and bacon are not appropriate items to offer a Muslim patient, since they do not consume pork products. DIF: Cognitive Level: Application TOP: Health belief systems MSC: NCLEX: Psychosocial Integrity
REF: 111 OBJ: 4 KEY: Nursing Process Step: N/A
31. The nurse is caring for a Chinese American patient. How should this nurse demonstrate
cultural awareness? a. Maintain eye contact with the patient. b. Hold the patient’s hand while conversing. c. Touch the patient’s arm when speaking to the patient. d. Sit side-to-side when speaking with the patient. ANS: D
Chinese Americans view maintaining eye contact as ill-mannered and disrespectful. They are uncomfortable when face-to-face, and prefer to sit side-to-side or at a right angle to carry on conversation. Touching is not usual during conversation; it is regarded as disrespectful or impolite. DIF: Cognitive Level: Application
REF: 112
OBJ: 4 | 5
TOP: Health belief systems MSC: NCLEX: Psychosocial Integrity
KEY: Nursing Process Step: N/A
32. The nurse is caring for a Mexican American patient. What nursing intervention would best
demonstrate cultural sensitivity? a. Encouraging consultation of male members of the family regarding health care decisions b. Discouraging consultation of male members of the family regarding health care decisions c. Insisting on providing all personal care required by the patient d. Asking only female family members about health care decisions ANS: A
When caring for Mexican Americans, families may expect to help care for the patient. Male family members usually are consulted before health care decisions are made. DIF: Cognitive Level: Application TOP: Health belief systems MSC: NCLEX: Psychosocial Integrity
REF: 112 OBJ: 4 | 5 | 7 KEY: Nursing Process Step: N/A
33. The nurse is caring for an African-American patient. Who would the nurse expect to be the
primary decision maker in the patient’s family? a. Men b. Women c. Clergy d. Grandparents ANS: B
When caring for African Americans, women are primarily the decision makers in the family and are frequently the head of the household. DIF: Cognitive Level: Comprehension TOP: Health belief systems MSC: NCLEX: Psychosocial Integrity
REF: 112 OBJ: 1 | 4 KEY: Nursing Process Step: N/A
34. The nurse is caring for a Mexican American patient who is in labor. How can this nurse
best demonstrate cultural sensitivity? a. Encouraging female family members to be present for the delivery b. Encouraging the patient’s spouse to be present for the delivery c. Asking the patient’s spouse to see his baby before cutting the umbilical cord d. Asking the patient’s spouse to hold the neonate before bathing the neonate ANS: A
When caring for Mexican Americans, it is considered inappropriate for the husband to be present during birth. The father is not expected to see his wife or baby until both are cleaned and dressed. DIF: Cognitive Level: Application TOP: Health belief systems MSC: NCLEX: Psychosocial Integrity
REF: 113 OBJ: 4 KEY: Nursing Process Step: N/A
35. The nurse is caring for a postpartum patient who requests to dry and bury the umbilical
cord near an object or in a place that symbolizes what the parents want for the child’s future. Which cultural beliefs does the nurse recognize this patient adhering to? a. American Indian b. African American c. Chinese American d. Mexican American ANS: A
After delivery, American Indians practice taking the umbilical cord from the newborn, drying and burying it near an object or place that symbolizes what the parents want for the child’s future. DIF: Cognitive Level: Comprehension TOP: Health belief systems MSC: NCLEX: Psychosocial Integrity
REF: 113 OBJ: 4 KEY: Nursing Process Step: N/A
MULTIPLE RESPONSE 1. What are some characteristics that cultures have in common? (Select all that apply.) a. Economic practices b. Survival modes c. Transportation systems d. Language e. Family systems ANS: A, B, C, E
Language may differ within cultures; the rest are shared characteristics. DIF: Cognitive Level: Comprehension TOP: Common traits MSC: NCLEX: N/A
REF: 97 OBJ: 1 | 4 KEY: Nursing Process Step: N/A
2. What should the culturally sensitive nurse do for a Muslim woman being treated in the
hospital? (Select all that apply.) a. Assign only female staff to care for her. b. Keep her head and extremities covered as much as possible. c. Arrange for family to bring specially prepared pork dishes. d. Let her make decisions relative to her care. e. Allow privacy for prayer. ANS: A, B, E
Muslim women are not accustomed to making decisions, leaving it to the head of the house or the family as a whole. Muslims do not eat pork. DIF: Cognitive Level: Application REF: 111-114 OBJ: 4 | 5 TOP: Muslims KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
3. A nurse working in a long-term care facility is admitting an 85-year-old resident of
Hispanic descent diagnosed with Alzheimer’s disease. What should this nurse take into consideration when caring for the resident? (Select all that apply.) a. Cultural background has an important role in determining the resident’s status b. The resident will be culturally sensitive to caregivers c. Home remedies may have value even if harmful d. The resident will have a strong sense of trust for health care workers e. Communication should involve gesturing whenever possible ANS: A, C
Cultural background has an impact on family dynamics and plays an important role in determining the role and the status of the older person. Some older adults are less tolerant of other cultures as a result of influences or experiences early in their lives, which raises the possibility of misunderstandings and distrust when the caregiver is of a cultural group different than that of the older person. Communication should suit the individual needs of the resident and does not necessarily involve gesturing. DIF: Cognitive Level: Application REF: 98 OBJ: 6 TOP: Older adult KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity COMPLETION 1. The nurse should not maintain eye contact with a Korean patient because many Asians
believe prolonged eye contact is
or rude.
ANS:
impolite Many Asians avoid eye contact, believing it to be impolite or rude. DIF: Cognitive Level: Comprehension REF: 112 OBJ: 2 | 4 TOP: Asians KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 2. The cultural characteristic of unwillingness to leave a current activity—which may result
in late or missed appointments—is called
.
ANS:
elasticity Elasticity is the ethnic characteristic of being late or missing an appointment altogether because of involvement in a current activity. DIF: Cognitive Level: Knowledge REF: 101 TOP: Elasticity KEY: Nursing Process Step: N/A
OBJ: 4 MSC: NCLEX: N/A
3. Following the death of a Presbyterian infant, the nurse should help arrange for
. ANS:
baptism Presbyterians believe in infant baptism. DIF: Cognitive Level: Application TOP: Infant baptism MSC: NCLEX: Psychosocial Integrity
REF: 105 OBJ: 4 KEY: Nursing Process Step: Implementation
4. While caring for a Mexican American family in the home, the home health nurse
recognizes that the family may also consult the curandero or advice.
for health
ANS:
folk healer The curandero or folk healer is an important figure in the health care of Mexican Americans. DIF: Cognitive Level: Application TOP: Mexican Americans MSC: NCLEX: Psychosocial Integrity
REF: 109 OBJ: 4 KEY: Nursing Process Step: Implementation
5. A nation, community, or broad group of people who establish particular aims, beliefs, or
standards of living and conduct is known as a
.
ANS:
society A society is a nation, community, or broad group of people who establish particular aims, beliefs, or standards of living and conduct. DIF: Cognitive Level: Knowledge REF: 95 TOP: Society KEY: Nursing Process Step: N/A
OBJ: 4 MSC: NCLEX: N/A
6. A set of learned values, beliefs, customs, and practices that are shared by a group and are
passed from one generation to another is known as
.
ANS:
culture Culture is a set of learned values, beliefs, customs, and practices that are shared by a group and are passed from one generation to another. DIF: Cognitive Level: Knowledge REF: 96 TOP: Culture KEY: Nursing Process Step: N/A
OBJ: 4 MSC: NCLEX: N/A
7. A generalization about a form of behavior, an individual, or a group is known as a
. ANS:
stereotype
A stereotype is a generalization about a form of behavior, an individual, or a group. DIF: Cognitive Level: Knowledge REF: 96 TOP: Stereotype KEY: Nursing Process Step: N/A
OBJ: 4 MSC: NCLEX: N/A
Chapter 07: Asepsis and Infection Control Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. What is true regarding surgical asepsis? a. It inhibits growth of pathogenic organisms. b. It is known as a cleaning technique. c. It includes hand hygiene. d. It is known as a sterile technique. ANS: D
Surgical asepsis is known as a sterile technique. DIF: Cognitive Level: Knowledge REF: 118 TOP: Infection KEY: Nursing Process Step: N/A
OBJ: 1 MSC: NCLEX: N/A
2. What action exemplifies a nurse practicing medical asepsis in performing daily care? a. Lifting a sterile swab from a sterile field b. Using disposable sterile gowns c. Washing hands for 5 minutes between patients d. Keeping bed linens off the floor ANS: D
Keeping the bed linens off the floor is an example of medical asepsis; all other options are examples of surgical asepsis. DIF: Cognitive Level: Comprehension REF: 123 OBJ: 1 | 2 TOP: Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 3. What bacteria can lie dormant when conditions for growth are not favorable? a. Residue b. Capsules c. Spores d. Flagella ANS: C
Spore formation occurs when conditions are unfavorable, causing the bacteria to take a dormant form. DIF: Cognitive Level: Comprehension REF: 119 OBJ: 2 | 4 TOP: Bacteria KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 4. A patient with a respiratory infection reports that he is not yet on an antibiotic. The nurse
explains that the health care provider is waiting on the results of the culture and sensitivity. What does this test determine? a. What media the bacteria requires to grow b. How fast the bacteria grow c. Which antibiotics stop bacterial growth
d. When the bacteria colonize ANS: C
Sensitivity tests are done to determine which antibiotics will stop growth. DIF: Cognitive Level: Comprehension TOP: Laboratory tests MSC: NCLEX: Physiological Integrity
REF: 119 OBJ: 6 KEY: Nursing Process Step: Implementation
5. What bacterium is responsible for more diseases than any other organism? a. Staphylococcus b. Pseudomonas aeruginosa c. Haemophilus influenzae d. Streptococcus ANS: D
The Streptococcus bacterium is responsible for more diseases than any other organism. DIF: Cognitive Level: Knowledge REF: 137 OBJ: 3 TOP: Bacteria KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 6. What additional complication does a disease caused by a virus have compared to a disease
caused by bacteria? a. Multiplies rapidly. b. Returns frequently. c. Is not killed by antibiotics. d. Is unable to be cultured. ANS: C
Antibiotics do not alter the course of a disease caused by a virus. DIF: Cognitive Level: Comprehension REF: 121 TOP: Virus KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 3
7. What should the nurse be diligent in to provide a safe environment for the patient? a. Keeping a light on at night to prevent falls b. Hand hygiene between patient contacts c. Regulating the temperature to avoid drafts d. Changing the bed linen to diminish microorganisms ANS: B
One of the most important actions is hand hygiene before caring for another patient. DIF: Cognitive Level: Application REF: 122 OBJ: 5 | 8 | 9 TOP: Safe environment KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 8. What does the nurse describe when giving an example of a fomite vehicle? a. Rabid dog b. Person with AIDS c. Contaminated stethoscope
d. Infected wound ANS: C
If a vehicle is an inanimate (nonliving) object, it is called a fomite. DIF: Cognitive Level: Application REF: 123 OBJ: 2 TOP: Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 9. The nurse is concerned when a patient admitted with a diagnosis of pneumonia suddenly
develops a urinary tract infection (UTI). What type of infection is this UTI considered? a. Viral infection b. Bacterial infection c. Health care–associated infection d. Spore infection ANS: C
More than 40 million people are admitted to hospitals each year and as many as 10% of them acquire a health care–associated infection while there. Criteria for health care– associated infections require that the infection manifest at least 48 hours after hospitalization or contact with another health agency. DIF: Cognitive Level: Comprehension TOP: Health care–associated infection MSC: NCLEX: Physiological Integrity
REF: 125 OBJ: 2 KEY: Nursing Process Step: Assessment
10. The nurse prioritizes the care of four patients. Which patient has a systemic infection? a. 14-year-old with acute appendicitis b. 80-year-old with a urinary tract infection c. 40-year-old with AIDS d. 50-year-old with arthritis ANS: C
AIDS is a systemic viral infection. Acute appendicitis and urinary tract infections are local infections. Arthritis is not an infection. DIF: Cognitive Level: Application TOP: Systemic infection MSC: NCLEX: Physiological Integrity
REF: 124 | 125 OBJ: 6 KEY: Nursing Process Step: Assessment
11. What assessment does the nurse recognize as an inflammatory response in a surgical
wound on the leg of a patient? a. A foul drainage is coming from the wound. b. The affected leg is cooler than the other leg. c. There are raised, red, pruritic welts on the leg. d. Rubor and edema appear around the wound. ANS: D
Rubor and edema are two of the cardinal signs of an inflammatory response. Foul drainage suggests infection, the affected leg being cooler than the other leg suggests circulatory disorder, and raised, red, pruritic welts on the leg suggest allergy.
DIF: Cognitive Level: Application TOP: Inflammatory response MSC: NCLEX: Physiological Integrity
REF: 125 OBJ: 7 KEY: Nursing Process Step: Assessment
12. The infection control health care provider plans an in-service on control of health
care–associated infections. What should be the focus of this program? a. Observing nurses caring for patients b. Screening patients who are admitted to the hospital c. Educating hospital personnel about aseptic practices d. Discharging infectious patients from the hospital ANS: C
Duties of the infection control health care provider include staff education on infection control. DIF: Cognitive Level: Application REF: 126 TOP: Infection KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment
OBJ: 5 | 13
13. A health care worker is stuck by a needle left on the patient’s bedside table. The staff
member appropriately reports the needlestick. What will the indicated treatment be combatting? a. Hepatitis B b. Streptococcal infections c. Staphylococcal infections d. Influenza ANS: A
Workers who have had a needlestick need to complete an injury report and seek treatment in the event of exposure to hepatitis B. DIF: Cognitive Level: Comprehension REF: 126 TOP: Needlesticks KEY: Nursing Process Step: N/A
OBJ: 3 | 5 MSC: NCLEX: N/A
14. What technique should the nurse use when disposing of linens contaminated with feces? a. Don gown, gloves, and mask b. Wash hands for 5 minutes after disposal c. Don gloves only d. Double-bag the sheets ANS: C
All health care workers should follow Standard Precautions to prevent infection from pathogens. Standard Precautions for the disposal of ordinary feces require only that the nurse don gloves. DIF: Cognitive Level: Application REF: 131 OBJ: 13 TOP: Standard precautions KEY: Nursing Process Step: Analysis MSC: NCLEX: Safe, Effective Care Environment 15. The nurse is instructing a patient about the most important preventive technique for
breaking the chain of infection. What technique is the patient learning about? a. Sterilization
b. Standard Precautions c. Hand hygiene d. Medical asepsis ANS: C
Hand hygiene is the most important preventive measure for interrupting the infection process. DIF: Cognitive Level: Comprehension REF: 118 OBJ: 2 | 9 TOP: Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 16. A nurse is observing isolation precautions by wearing a mask while performing complex
patient care. How often should the nurse change masks? a. 5 to 10 minutes b. 10 to 20 minutes c. 20 to 30 minutes d. 30 to 40 minutes ANS: C
The mask should be changed every 20 to 30 minutes. DIF: Cognitive Level: Comprehension REF: 133 OBJ: 8 TOP: Mask KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 17. A major threat to health care workers is blood-contaminated sharps. What should the nurse
use to discard the used syringe? a. Wastebasket b. Sink c. Puncture-proof container d. Disinfecting soap ANS: C
All patient care areas where sharps are used require puncture-proof containers. DIF: Cognitive Level: Comprehension REF: 122 | 136 OBJ: 8 TOP: Sharps KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 18. The nurse is transporting a patient in respiratory isolation to the radiology department.
What intervention should the nurse implement? a. Cover the patient with a sheet. b. Take the patient down the service elevator. c. Apply a mask to the patient. d. Call x-ray to come and get the patient. ANS: C
If a patient requiring respiratory isolation must be transported to another area, the patient must don a mask. DIF: Cognitive Level: Application REF: 133 | 135 OBJ: 5 | 8 TOP: Isolation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment 19. The patient in isolation may experience psychological or emotional deprivation. What
should the nurse do to help minimize these feelings? a. Be cheerful. b. Spend extra time with the patient. c. Protect the patient from additional infection. d. Answer the call light quickly. ANS: B
To minimize feelings of psychological or emotional deprivation, the nurse should spend extra time with the patient. DIF: Cognitive Level: Application REF: 138 OBJ: 13 TOP: Isolation KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 20. The infection control officer is observing hospital staff for appropriate use of aseptic
technique. What observation demonstrates the need for more instruction on surgical asepsis? a. Facing the sterile field b. Placing a sterile dressing on a sterile field c. Touching the edges of the sterile field with sterile gloves d. Keeping gloved hands above the waist ANS: C
The edges of a sterile field are not considered sterile. DIF: Cognitive Level: Application REF: 143 OBJ: 1 TOP: Sterile technique KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment 21. The nurse is pouring a sterile solution from a bottle. What direction should the label on the
bottle be in for appropriate technique? a. Facing outward b. Covered c. Facing downward d. In the palm of the hand ANS: D
The bottle should be held with the label in the palm of the hand. DIF: Cognitive Level: Application REF: 147 OBJ: 11 | 12 TOP: Sterile technique KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 22. What is a method used to kill all microorganisms, including spores? a. Disinfecting b. Using an antiseptic c. Using chlorine bleach d. Sterilizing
ANS: D
Sterilization refers to methods used to kill all microorganisms and spores. DIF: Cognitive Level: Knowledge REF: 142 | 143 TOP: Pathogens KEY: Nursing Process Step: N/A
OBJ: 12 MSC: NCLEX: N/A
23. The nurse accidently spills blood from a specimen container. The first action the nurse
takes is to don gloves. What should the nurse then spray the fluid with? a. Liquid detergent b. 20% bleach solution c. 10% bleach solution d. Warm soapy water ANS: C
Any accidental body fluid spill should be cleaned up as soon as possible. The person cleaning the spill should wear gloves. One cup of bleach diluted with 10 cups of water should be used as a disinfectant to spray over the spill and clean up with paper towels. The paper towels should then be placed in the plastic-lined waste container. DIF: Cognitive Level: Knowledge REF: 153 OBJ: 12 TOP: Body fluids KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 24. When assessing a patient for signs of an infection, the nurse recognizes which laboratory
result as indicative of an infection? a. Lowered red blood cell count b. Increased white blood cell count c. Lowered white blood cell count d. Increased red blood cell count ANS: B
Increased white blood cell count may indicate an infection. DIF: Cognitive Level: Application REF: 155 TOP: Lab results KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 3 | 4
25. What can result from the nurse consistently performing hand hygiene and using sterile
supplies when caring for patients in the hospital setting? a. Hospital stay is shortened b. Sense of self-worth is improved c. Risk of infection is reduced d. Nursing care needed is reduced ANS: C
Hand hygiene is the most important measure for interrupting the infectious process. DIF: Cognitive Level: Comprehension REF: 118 OBJ: 5 TOP: Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment
26. Recognizing the stages of an infection assists the nurse in identifying the progression of an
infection. What is the nonspecific to specific symptom stage of an infection? a. Convalescent b. Illness c. Prodromal d. Incubation ANS: C
The prodromal stage progresses from onset of nonspecific signs and symptoms to more specific signs and symptoms. DIF: Cognitive Level: Knowledge REF: 125 TOP: Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4 | 6
27. What is the most dependable and practical method to use when sterilizing instruments for
the operating room? a. Chemical solution b. Boiling water c. Steam under pressure d. Dry heat ANS: C
Steam under pressure is the most practical and dependable method for destruction of all microorganisms. DIF: Cognitive Level: Comprehension REF: 153 TOP: Sterilization KEY: Nursing Process Step: N/A
OBJ: 12 MSC: NCLEX: N/A
28. What contribution did Joseph Lister introduce to medical practice? a. Isolation of infected patients b. Iodine and alcohol use as disinfectants c. The autoclave d. Aseptic technique ANS: D
Joseph Lister contributed to medical practice through the introduction of the aseptic technique. DIF: Cognitive Level: Knowledge TOP: Joseph Lister MSC: NCLEX: N/A
REF: 117 OBJ: 1 KEY: Nursing Process Step: N/A
29. The nurse is providing instruction to an anxious mother of a child with Rocky Mountain
spotted fever. When discussing this diagnosis, what information will the nurse relay about this disease? a. It is extremely contagious among humans. b. It is contracted from handling unvaccinated animals. c. It is a hemolytic B Streptococcus infection spread by droplet transmission. d. It is a serious disease contracted from the bite of a tick. ANS: D
Rocky Mountain spotted fever is contracted through the bite of a tick vector. It is not contagious among humans. DIF: Cognitive Level: Comprehension TOP: Vector transmission MSC: NCLEX: Physiological Integrity
REF: 120 OBJ: 2 | 3 KEY: Nursing Process Step: Implementation
30. The emergency department nurse is assessing a puncture wound of the foot. What is the
most likely type of infection in this wound? a. Aerobic bacterial infection b. Anaerobic bacterial infection c. Viral infection d. Fungal infection ANS: B
An anaerobic bacterial infection is one that grows in an oxygenated environment. DIF: Cognitive Level: Comprehension TOP: Anaerobic infections MSC: NCLEX: Physiological Integrity
REF: 119 OBJ: 6 KEY: Nursing Process Step: Assessment
31. The nurse is instructing a bioterrorism class regarding anthrax. How can anthrax be
transmitted? a. From person to person b. Through microscopic skin punctures c. Through inhalation of the spores d. By exposure to animals that have anthrax ANS: C
Anthrax is contracted by inhaling the spores. DIF: Cognitive Level: Comprehension REF: 119 | 120 OBJ: 3 TOP: Anthrax KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 32. The nurse is providing teaching to elementary students regarding vectors. What example
will the nurse provide as an example of a vector? a. Child with measles giving it to his sister b. Tick whose bite causes Lyme disease c. Woman with syphilis infecting her partner d. Dog whose bite causes rabies ANS: B
A vector is a person or animal not sick with the disease harboring an organism that is contagious. DIF: Cognitive Level: Comprehension REF: 122 OBJ: 3 TOP: Vector KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. What type of organism causes malaria? a. Bacterium
b. Virus c. Protozoan d. Fungus ANS: C
Malaria is caused by the introduction of protozoa from the bite of a mosquito. DIF: Cognitive Level: Knowledge TOP: Protozoan infections MSC: NCLEX: Physiological Integrity
REF: 122 OBJ: 4 KEY: Nursing Process Step: Implementation
34. A nurse is performing an admission assessment on a patient with suspected tuberculosis.
What assessment findings by the nurse are consistent with tuberculosis? a. Hemoptysis b. Weight gain c. Night terrors d. Hypothermia ANS: A
Suspicious symptoms consistent with tuberculosis include fatigue, unexplained weight loss, dyspnea, fever, night sweats, and hemoptysis (a cough that can be productive of blood). DIF: Cognitive Level: Comprehension TOP: Tuberculosis MSC: NCLEX: Physiological Integrity
REF: 138 OBJ: 6 KEY: Nursing Process Step: Assessment
35. A nurse is performing an admission assessment on a patient with suspected tuberculosis.
What is the greatest risk of exposure to tuberculosis? a. After a diagnosis is made b. Before a diagnosis is made c. After the patient has begun medication therapy d. After implementation of isolation precautions ANS: B
The risk of exposure to tuberculosis is greatest before a diagnosis is made and isolation precautions are implemented. DIF: Cognitive Level: Comprehension TOP: Tuberculosis MSC: NCLEX: Physiological Integrity
REF: 139 OBJ: 8 KEY: Nursing Process Step: Assessment
MULTIPLE RESPONSE 1. A person can spread a bacterial infection by which actions? (Select all that apply.) a. Kissing others b. Sneezing at work c. Donating blood d. Coming in contact with blood products e. Leaving used tissue on the lavatory ANS: A, B, E
Bacteria can be spread by direct, indirect, or airborne transmission. DIF: Cognitive Level: Comprehension REF: 122 | 155 OBJ: 14 TOP: Bacterial transmission KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. What are some characteristics of microorganisms? (Select all that apply.) a. Involved in a life process of their own. b. Pathogens that cause disease. c. Nonpathologic organisms that cause disease. d. May be infectious. e. Can enter the body via skin, air, or blood. ANS: A, B, D, E
Microorganisms are involved in a life process of their own, pathogens cause disease, may be infectious, and can enter the body via skin, air, or blood. Nonpathologic organisms do not cause disease. DIF: Cognitive Level: Comprehension REF: 122-126 OBJ: 3 TOP: Characteristics of microorganisms KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment COMPLETION 1. A patient is distressed that an antibiotic has not been effective for the control of the
infection. The nurse explains that some bacteria are capable of defending against antibiotics by the formation of a . ANS:
capsule Some bacteria can protect themselves by the formation of a capsule of sticky protein that prevents antibiotics from entering the cell. DIF: Cognitive Level: Comprehension TOP: Bacterial capsules MSC: NCLEX: Physiological Integrity
REF: 119 OBJ: 4 KEY: Nursing Process Step: Implementation
2. The nurse reminds a group of nursing students that the type of asepsis that destroys all
microorganisms and their spores is
asepsis.
ANS:
surgical Surgical asepsis destroys all microorganisms and their spores. DIF: Cognitive Level: Comprehension REF: 118 OBJ: 1 TOP: Surgical asepsis KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment
Chapter 08: Body Mechanics and Patient Mobility Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse instructs a unlicensed assistive personnel to use large muscle groups when
lifting. What is the rationale for this instruction? a. Workers’ compensation claims will be prevented. b. Big muscles work more effectively. c. It guarantees no muscle strain. d. It distributes workload more evenly. ANS: D
Proper body mechanics provide for even distribution of workload. DIF: Cognitive Level: Comprehension REF: 161 OBJ: 1 | 2 TOP: Body mechanics KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 2. What should the nurse do to reduce the effort of moving a heavy object? a. Bring the feet close together and flex the knees. b. Keep the back straight and bend at the waist. c. Widen the base of support in the direction of movement. d. Broaden the base of support and twist toward the direction of movement. ANS: C
The base of support should be broadened in the direction of movement. DIF: Cognitive Level: Application REF: 161 OBJ: 1 | 2 TOP: Body mechanics KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 3. What should the nurse do to protect his or her back when lifting or moving a patient? a. Lowering the height of the bed b. Holding the back straight with locked knees c. Bending knees and hips d. Getting the patient to the side of the bed ANS: C
The nurse’s back can be well protected when he or she bends knees and hips. DIF: Cognitive Level: Application REF: 161 OBJ: 11 TOP: Body mechanics KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 4. Where should the nurse place the load when carrying heavy objects? a. In a low position b. To the side of the body c. Close to the body midline d. With another’s assistance
ANS: C
The nurse should carry objects close to the midline of the body. DIF: Cognitive Level: Comprehension REF: 163 OBJ: 11 TOP: Body mechanics KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 5. The nurse is educating a patient on ways to regain the ability to perform ADLs and
maintain normal physiologic activities. What will the nurse relay as a requirement? a. Strength b. Wellness c. Alertness d. Mobility ANS: D
The purpose of mobility is completing ADLs and maintaining physiologic activities. DIF: Cognitive Level: Comprehension REF: 167 TOP: Mobility KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
6. The nurse counsels the immobilized patient in regard to prevention of muscle atrophy and
contractures. What will the nurse be sure to include when counseling this patient? a. The need for additional calcium b. The need for additional protein c. The need for some type of exercise d. The need for a special protective bed ANS: C
The immobilized patient must receive some type of exercise to prevent atrophy and contractures. DIF: Cognitive Level: Application REF: 171 OBJ: 6 TOP: Immobility KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. What is the term for range of motion (ROM) when it is performed by the patient? a. Assisted b. Passive c. Active d. Coordinated ANS: C
ROM performed actively by the patient is designated as active ROM. DIF: Cognitive Level: Knowledge TOP: Range of motion (ROM) MSC: NCLEX: Physiological Integrity
REF: 183 OBJ: 9 KEY: Nursing Process Step: Implementation
8. The nurse is performing passive range of motion (ROM) for the patient. How will the
nurse move the joint through ROM? a. The fullest extent.
b. Place the joint in normal position. c. The point of pain. d. Relax the patient. ANS: C
The joints are moved to the point of resistance or pain. DIF: Cognitive Level: Application TOP: Range of motion (ROM) MSC: NCLEX: Physiological Integrity
REF: 171 OBJ: 9 KEY: Nursing Process Step: Implementation
9. How should the nurse assist the patient with moving when pain is anticipated? a. Be supportive. b. Apply heat before moving them. c. Administer medication before ambulation. d. Obtain assistance if the patient is heavy. ANS: C
The nurse may want to administer medication before an activity that may be painful. DIF: Cognitive Level: Application TOP: Body mechanics MSC: NCLEX: Physiological Integrity
REF: 180 OBJ: 6 KEY: Nursing Process Step: Implementation
10. The 125-lb nurse is preparing to lift a heavy object. What is the maximum amount of
weight considered safe for the nurse to lift? a. 75 lb b. 50 lb c. 100 lb d. 125 lb ANS: B
The suggested maximum weight considered safe to lift by a single person is 50 lb. DIF: Cognitive Level: Knowledge REF: 163 OBJ: 11 TOP: Body mechanics KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 11. What is the site of the most common strain injury acquired by the nurse when working? a. Trapezius muscle group b. Thoracic muscle group c. Lumbar muscle group d. Thigh muscle group ANS: C
The most common back injury is strain of the lumbar muscle group. DIF: Cognitive Level: Knowledge TOP: Body mechanics MSC: NCLEX: N/A
REF: 163 | 164 OBJ: 2 KEY: Nursing Process Step: N/A
12. What implementation might the nurse use to improve safety during a transfer? a. Weighing the patient first
b. Using a transfer belt c. Putting shoes on the patient d. Supporting a flaccid arm ANS: B
As a general rule, the nurse should use a transfer belt. DIF: Cognitive Level: Application REF: 178 OBJ: 5 TOP: Body mechanics KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 13. What is considered to be the minimum number of hours of daily activity necessary to
prevent the negative consequences of immobility? a. 2 hours b. 4 hours c. 6 hours d. 8 hours ANS: A
The amount of exercise required to prevent physical disuse syndrome is 2 hours in 24 hours. DIF: Cognitive Level: Knowledge REF: 167 | 183 OBJ: 6 TOP: Immobility KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse is performing passive range-of-motion exercises on a patient following a
traumatic injury. What is the number of times the nurse should move each joint when performing passive range-of-motion (ROM) exercises? a. Three b. Four c. Five d. Six ANS: C
Each movement should be repeated five times. DIF: Cognitive Level: Application TOP: Range of motion (ROM) MSC: NCLEX: Physiological Integrity
REF: 174 OBJ: 6 KEY: Nursing Process Step: Implementation
15. What profession has the highest workers’ compensation claim rates of any occupation or
industry? a. Firefighters b. Truck drivers c. Law enforcement d. Nursing personnel ANS: D
Studies of workers’ compensation claims show that nursing personnel have the highest claim rates of any occupation or industry.
DIF: Cognitive Level: Knowledge TOP: Workers’ compensation MSC: NCLEX: Physiological Integrity
REF: 161 OBJ: 2 KEY: Nursing Process Step: N/A
16. A nurse instructs a unlicensed assistive personnel about moving older adult patients in bed.
When should the nurse intervene when observing the unlicensed assistive personnel perform a return demonstration? a. The unlicensed assistive personnel is using simple language. b. The unlicensed assistive personnel is avoiding jerky movements. c. The unlicensed assistive personnel is avoiding sudden movements. d. The unlicensed assistive personnel is pulling the patient across bed linens. ANS: D
The skin of older adults is more fragile and susceptible to injury. When moving or transferring older adults, it is essential to avoid pulling them across bed linens because this may cause shearing or tearing of the skin. The nurse should explain each step in simple language and avoid jerky, sudden movements. DIF: Cognitive Level: Application TOP: Moving patients MSC: NCLEX: Physiological Integrity
REF: 162 OBJ: 10 | 11 KEY: Nursing Process Step: Implementation
17. The LPN/LVN assists a patient into the semi-Fowler’s position per health care provider
order. What would indicate that this patient is in the correct position? a. Patient is leaning over the bedside table b. Head of bed is at a 30-degree angle c. Knee is drawn toward the chest d. Arms are flexed toward the head ANS: B
The semi-Fowler’s position is when the head of the bed is raised approximately 30 degrees. Orthopneic position is when the patient is leaning over the bedside table. Sims position is when the knee is drawn toward the chest. Arms are not flexed toward the head in the semi-Fowler’s position. DIF: Cognitive Level: Comprehension TOP: Positioning patients MSC: NCLEX: Physiological Integrity
REF: 165 OBJ: 7 KEY: Nursing Process Step: Implementation
MULTIPLE RESPONSE 1. A newly hired group of graduate practical/vocational nurses are attending orientation at a
long-term care facility. What information will be included regarding considerations of mobility and the older adult? (Select all that apply.) a. The skin of older adults is more fragile and susceptible to injury. b. Always support older adults under the soft tissue when moving them in bed. c. Weakness and hypertension are common signs and symptoms noted in an older adult on bed rest. d. Aging tends to result in loss of flexibility and joint mobility. e. Older adults sometimes become fearful when hydraulic lifts are used for transfers.
ANS: A, D, E
The skin of older adults is more fragile and susceptible to injury. Aging tends to result in the loss of flexibility and joint mobility and older adults sometimes do become fearful with use of hydraulic lifts. Older adults should be supported under the joints when moving in bed. Weakness and hypotension are common signs and symptoms noted in an older adult on bed rest. DIF: Cognitive Level: Comprehension REF: 162 TOP: Older adult KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 3
2. The nurse receives a patient from the recovery room following total hip replacement
surgery. What will the nurse include when assessing neurovascular status on this patient? (Select all that apply.) a. Pupils b. Pain c. Sensation d. Color e. Skin temperature ANS: B, C, D, E
One of the responsibilities of the nurse is to frequently monitor the patient’s neurovascular function, or circulation, movement, and sensation (CMS) assessment. The LPN/LVN checks for skin color, temperature, movement, sensation, pulses, capillary refill, and pain. Pupil assessment is part of a neurologic assessment. DIF: Cognitive Level: Comprehension TOP: Neurovascular function MSC: NCLEX: Physiological Integrity
REF: 168-169 OBJ: 8 | 13 KEY: Nursing Process Step: Assessment
COMPLETION 1. The most common cause of musculoskeletal disorders in nurses involves a movement that
requires the nurse to
and lift at the same time.
ANS:
twist The motion of twisting and lifting at the same time frequently strains the muscles of the lower back. DIF: Cognitive Level: Comprehension TOP: Muscle strain MSC: NCLEX: N/A
REF: 161 | 162 OBJ: 1 | 2 KEY: Nursing Process Step: N/A
2. To maintain a wide base of support, the nurse should stand with the feet separated by the
distance of ANS:
shoulder
width apart.
Actions to promote proper body mechanics include positioning feet shoulder width apart to create a wide base of support. DIF: Cognitive Level: Knowledge REF: 161 OBJ: 1 TOP: Base of support KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 3. When a fall occurs, the nurse should document the incident and initiate a(n)
_
report. ANS:
incident The nurse must initiate an incident report describing the events of a patient’s fall. DIF: Cognitive Level: Knowledge REF: 168 OBJ: 6 TOP: Incident report KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 4. Continuous
motion machines flex and extend joints to mobilize them passively without the strain of active exercises. ANS:
passive Continuous passive motion (CPM) machines flex and extend joints to mobilize them passively without the strain of active exercises. It is imperative that the CPM machine be set according to the health care provider’s orders for the degree and the speed of flexion and extension for each individual patient to prevent damage to the joint or surgical site. DIF: Cognitive Level: Knowledge REF: 174 TOP: Continuous passive motion machines KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 12
5. Acute
syndrome occurs in the extremities, especially the legs, where a sheath of inelastic fascia partitions blood vessel, nerve, and muscle tissue. ANS:
compartment Acute compartment syndrome occurs in the extremities, especially the legs, where a sheath of inelastic fascia partitions blood vessel, nerve, and muscle tissue. DIF: Cognitive Level: Knowledge TOP: Compartment syndrome MSC: NCLEX: Physiological Integrity OTHER
REF: 169 OBJ: 8 KEY: Nursing Process Step: Assessment
1. Place the initial nursing activities in priority order for preparing to move a patient. Put a
comma and space between each answer choice (A, B, C, D, etc.). a. Explain procedure. b. Preform hand hygiene. c. Prepare patient. d. Introduce self. e. Identify patient. ANS:
D, E, A, B, C The order that is most organized is introduce self, identify patient, explain procedure, perform hand hygiene, and prepare patient. DIF: Cognitive Level: Application REF: 181 OBJ: 6 TOP: Preparation to move KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment
Chapter 09: Hygiene and Care of the Patient’s Environment Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse is preparing to bathe a patient. What should the room temperature be set at? a. No warmer than 67°F (19.4°C) b. No cooler than 68°F (20°C) c. No cooler than 70°F (21.1°C) d. 75°F or warmer (23.8°C) ANS: B
The recommended room temperature is 68° to 74°F (20° to 23.3°C). DIF: Cognitive Level: Application TOP: Patient's environment MSC: NCLEX: Physiological Integrity
REF: 188 OBJ: 1 | 2 | 4 KEY: Nursing Process Step: Implementation
2. The nurse explains that the purpose of a sitz bath is to reduce inflammation in the perineal
and anal area. What is the least amount of time the nurse will instruct for a sitz bath? a. 10 to 15 minutes b. 20 to 30 minutes c. 30 to 40 minutes d. 1 hour ANS: B
The sitz bath should last 20 to 30 minutes. DIF: Cognitive Level: Application TOP: Therapeutic baths MSC: NCLEX: Physiological Integrity
REF: 192 OBJ: 2 | 3 KEY: Nursing Process Step: Implementation
3. A patient is recovering from a hemorrhoidectomy and experiences dizziness within 5
minutes when taking a sitz bath. What action should the nurse implement? a. Cover the patient to prevent chilling. b. Stay with the patient until the full time for the bath has elapsed. c. Remove the patient from the sitz bath and return to bed. d. Assess vital signs every 5 minutes during the remainder of the sitz bath. ANS: C
The patient may become dizzy during a sitz bath due to dilation of the large vessels in the abdomen. If this occurs, the patient should be removed from the sitz bath and returned to bed. Vital signs should be assessed until they return to normal. DIF: Cognitive Level: Application REF: 193 OBJ: 3 TOP: Sitz bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. What should the water temperature be when preparing a tepid bath for a patient? a. 98.6°F (37°C) b. 100.2°F (37.8°C)
c. 104.8°F (40.4°C) d. 110.4°F (43.5°C) ANS: A
The tepid bath is taken in water that is 98.6°F (37°C). DIF: Cognitive Level: Knowledge REF: 193 OBJ: 4 TOP: Tepid bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is assessing a patient’s skin for signs of impaired skin integrity. Which finding
by the nurse is considered a major manifestation? a. Burn b. Laceration c. Pressure injury d. Infection ANS: C
A major manifestation of impaired skin integrity is a pressure injury. DIF: Cognitive Level: Comprehension TOP: Pressure injuries MSC: NCLEX: Physiological Integrity
REF: 202 OBJ: 5 KEY: Nursing Process Step: Assessment
6. A nurse assesses an area of sustained redness on the coccyx area of a resident in long-term
care. What is the most likely cause of this pressure area? a. Heat from pressure b. Collapse of blood vessels c. Friction from pressure d. Collapse of skin tissue ANS: B
A pressure injury occurs when there is sufficient pressure to collapse the blood vessels. DIF: Cognitive Level: Comprehension TOP: Pressure injuries MSC: NCLEX: Physiological Integrity
REF: 202 OBJ: 5 KEY: Nursing Process Step: Evaluation
7. The nurse is caring for an unconscious patient with a risk for skin impairment. How often
will the nurse plan to change the position of this patient? a. Every 30 minutes b. Every 60 minutes c. Every 120 minutes d. Every 180 minutes ANS: C
The bedfast patient should have a position change every 2 hours (120 minutes) because skin compromise can occur if there is unrelieved pressure during that amount of time. DIF: Cognitive Level: Application TOP: Pressure injuries MSC: NCLEX: Physiological Integrity
REF: 231 OBJ: 5 KEY: Nursing Process Step: Implementation
8. The nurse assesses a red blister over the right superior iliac area of a patient. What stage is
this decubitus injury? a. 1 b. 2 c. 3 d. 4 ANS: B
A pressure injury demonstrating blisters is a stage 2 decubitus injury. DIF: Cognitive Level: Application TOP: Pressure injuries MSC: NCLEX: Physiological Integrity
REF: 203 OBJ: 5 KEY: Nursing Process Step: Assessment
9. The nursing assessment of a pressure injury includes size, depth, pain, odor, and color of
tissue. What does this evaluate? a. Treatment needed b. Effectiveness of implementation c. Whether improvement is occurring d. Need for additional interventions ANS: C
Ongoing assessment of a pressure injury will evaluate whether improvement is occurring. DIF: Cognitive Level: Comprehension TOP: Pressure injuries MSC: NCLEX: Physiological Integrity
REF: 202 | 203 OBJ: 5 KEY: Nursing Process Step: Assessment
10. The nurse attempts to avoid a pressure injury for a bedridden patient by turning the patient
frequently. What is the most favorable position for the nurse to move this patient into? a. Back-lying b. Full lateral c. 30-degree lateral d. Full prone ANS: C
It is preferable to use the 30-degree lateral incline position. DIF: Cognitive Level: Application TOP: Pressure injuries MSC: NCLEX: Physiological Integrity
REF: 205 OBJ: 5 KEY: Nursing Process Step: Implementation
11. One reason the nurse focuses on oral hygiene is to maintain a healthy state of the oral
cavity. What is another reason to promote oral hygiene? a. To improve self-esteem b. To stimulate appetite c. To restore tooth destruction d. To assist with periodontitis ANS: B
A sense of well-being can stimulate appetite.
DIF: Cognitive Level: Comprehension TOP: Oral hygiene MSC: NCLEX: Physiological Integrity
REF: 211 OBJ: 6 KEY: Nursing Process Step: Implementation
12. How will the nurse correctly replace a patient’s dentures after cleaning? a. Inserting the lower denture first b. Asking the patient to insert them c. Inserting both dentures together d. Inserting the upper denture first ANS: D
When reinserting dentures, replace the upper dentures first. DIF: Cognitive Level: Application TOP: Oral hygiene MSC: NCLEX: Physiological Integrity
REF: 213 OBJ: 6 KEY: Nursing Process Step: Implementation
13. Proper hair care is important for the patient’s self-image. What is the proper water
temperature when shampooing a patient’s hair? a. 101°F (38.3°C) b. 105°F (40.5°C) c. 110°F (43.3°C) d. 120°F (48.8°C) ANS: C
Water at 110°F (38.3°C) should be used to shampoo a patient’s hair. DIF: Cognitive Level: Knowledge REF: 193 OBJ: 6 TOP: Hair care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. When must the nurse remember to use an electric razor when shaving a patient? a. When a bleeding tendency is present b. When there is a risk for suicide c. When the facial hair is fine d. When speed is essential ANS: A
A patient with a bleeding disorder should use an electric razor. DIF: Cognitive Level: Application REF: 214 OBJ: 6 TOP: Shaving KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is bathing a patient with a deep vein thrombosis in the left leg. What
modification will the nurse make when attending to the left leg? a. Washing the leg with long, firm strokes and drying with a towel b. Omitting washing the leg at all c. Gently washing the leg and patting dry with a towel d. Applying lotion in long, smooth strokes ANS: C
The lower extremities of people with circulatory disorders are gently washed and patted dry, omitting any stroking or massaging. DIF: Cognitive Level: Application REF: 196 OBJ: 3 TOP: Bathing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is providing hand and foot care to a patient and notices the patient has extremely
hard nails. Who is the person best prepared to provide nail care for patients with extremely hard nails? a. Health care provider b. RN c. CNA d. Podiatrist ANS: D
If the patient’s nails are extremely hard, a podiatrist should provide care. DIF: Cognitive Level: Comprehension REF: 216 TOP: Foot care KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 6
17. How often should the nurse cleanse the meatal-catheter junction of a patient with an
indwelling catheter? a. At least once a day b. At least twice a day c. At bedtime d. Each shift ANS: B
Catheter care should be performed at least two times daily. DIF: Cognitive Level: Comprehension TOP: Catheter care MSC: NCLEX: Physiological Integrity
REF: 214 OBJ: 8 KEY: Nursing Process Step: Implementation
18. The nurse is preparing to perform perineal care for the female patient. What is the best
method for using a bath blanket to drape the patient? a. Square position b. Long position c. Diamond position d. Rectangular position ANS: C
Drape the patient with a bath blanket in the diamond position. DIF: Cognitive Level: Application TOP: Perineal care MSC: NCLEX: Physiological Integrity
REF: 218 OBJ: 8 KEY: Nursing Process Step: Implementation
19. Clear water is used to cleanse the eyes. It is important to use proper technique when
cleansing the eyes to prevent infection. What direction will the water flow when cleansing a patient’s eyes? a. Upward toward the forehead b. Downward toward the chin c. From the outer toward the inner canthus d. From the inner toward the outer canthus ANS: D
The eye is cleansed from the inner to outer canthus. DIF: Cognitive Level: Comprehension REF: 219 OBJ: 6 TOP: Eye care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. How frequently should the nurse clean the nares of patients who have a nasogastric tube or
are receiving oxygen by nasal cannula? a. At least every 2 hours b. At least every 6 hours c. At least every 8 hours d. At least every 10 hours ANS: C
When receiving oxygen by a nasal cannula or when a nasogastric tube is in place, the nurse should cleanse the nares every 8 hours. DIF: Cognitive Level: Application REF: 221 OBJ: 6 TOP: Nasal care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse must follow the principles of medical asepsis while making a patient’s bed,
including procedures for handling linens. How should the nurse handle soiled linens? a. Place on the floor b. Fan in the air c. Hold away from the uniform d. Place at the end of the bed ANS: C
Soiled linen should not come into contact with a uniform. DIF: Cognitive Level: Application REF: 224 | 225 OBJ: 10 TOP: Bed making KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 22. How should the nurse cleanse the meatal opening when performing male perineal care? a. From the meatus outward b. With an alcohol swab c. In a circular motion d. With a cotton-tipped applicator ANS: A
The nurse should cleanse the meatal opening from the meatus outward.
DIF: Cognitive Level: Application TOP: Perineal care MSC: NCLEX: Physiological Integrity
REF: 214 | 219 OBJ: 8 KEY: Nursing Process Step: Implementation
23. The nurse lowers the bed to place the patient on the bedpan. The angle of the head of the
bed should be raised to: a. 20 degrees. b. 45 degrees. c. 90 degrees. d. 30 degrees. ANS: D
Elimination is facilitated with the head of the bed elevated 30 degrees. DIF: Cognitive Level: Application REF: 225 OBJ: 12 TOP: Elimination KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. What does the nurse recognize is important to consider when using the nursing process to
plan hygiene care of the patient? a. Nurse’s orders b. Health care provider’s orders c. Patient’s preferences d. Outcome goals ANS: C
Individual patients will have individual desires and choices. DIF: Cognitive Level: Application REF: 228 TOP: Hygiene KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 2
25. The nurse is providing personal hygiene for a Hindu patient from India. What intervention
should the nurse implement? a. Not serve meat b. Shampoo the patient’s hair weekly c. Give a daily bath d. Cut nails monthly ANS: C
A daily bath is part of the religious duty of Indian Hindus. DIF: Cognitive Level: Application REF: 188 TOP: Hygiene KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 2
26. The nurse is assisting a patient to perform personal hygiene. What is the most important
focus of the nurse when assisting this patient? a. Nursing care b. Independence c. Repetition
d. Performance ANS: B
The nurse should encourage the patient’s independence as much as possible. DIF: Cognitive Level: Comprehension REF: 187 OBJ: 2 TOP: Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The nurse discovers a reddened area over a patient’s hip. What should be the nurse’s first
intervention? a. Cover the area with an occlusive dressing. b. Apply mild ointment with a cotton-tipped applicator. c. Press the area gently to assess for blanching. d. Rub gently to increase circulation. ANS: C
If the area is a stage 1 decubitus injury, the area will not blanch. DIF: Cognitive Level: Application TOP: Pressure injuries MSC: NCLEX: Physiological Integrity
REF: 203 OBJ: 5 KEY: Nursing Process Step: Assessment
28. The nurse is educating a patient regarding a tub bath. What is the maximum length of time
the nurse should instruct the patient to remain in the water? a. 5 to 10 minutes b. 10 to 20 minutes c. 20 to 30 minutes d. 30 to 40 minutes ANS: B
A patient should not stay in the water for more than 20 minutes. DIF: Cognitive Level: Comprehension REF: 216 OBJ: 3 TOP: Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. Where should a nurse performing a backrub begin? a. Shoulder b. Base of the neck c. Sacral area d. Lumbar area ANS: C
The nurse should begin a massage in the sacral area. DIF: Cognitive Level: Comprehension REF: 200 OBJ: 7 TOP: Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. The nurse is caring for a patient experiencing presbycusis. What intervention should the
nursing personnel be instructed to implement? a. Speak quickly to the patient.
b. Speak in loud tones to the patient. c. Speak slowly and clearly to the patient. d. Tell the patient they must purchase a hearing aid. ANS: C
Age-related hearing loss, presbycusis, is a common finding in older adults. It is important to speak slowly and clearly to the patient with presbycusis. Not all patients with this type of hearing loss require a hearing aid. DIF: Cognitive Level: Application REF: 220 OBJ: 6 TOP: Hearing loss KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 31. A health care provider orders a patient to be placed in the Trendelenburg’s position. How
will the nurse position the bed? a. On the floor b. Parallel with the floor c. Tilted with the head of the bed down d. Tilted with the foot of the bed down ANS: C
The entire bed is tilted downward with the head of the bed down when placing a patient in the Trendelenburg’s position. DIF: Cognitive Level: Application REF: 191 OBJ: 1 TOP: Positioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 32. The health care provider orders a patient to be placed in the reverse Trendelenburg’s
position. How should the nurse place the bed? a. On the floor b. Parallel with the floor c. Tilted with the head of the bed down d. Tilted with the foot of the bed down ANS: D
The entire bed is tilted downward with the foot of the bed down when placing a patient in the reverse Trendelenburg’s position. DIF: Cognitive Level: Application REF: 191 OBJ: 1 TOP: Positioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. Which guideline should be followed when giving a backrub? a. Observing the skin for abnormalities b. Massaging for at least 10 minutes c. Following massage with a brisk alcohol rub d. Conversing with patient continually throughout the backrub e. Using alcohol-based lotion for disinfection ANS: A
The backrub should last for about 3 to 5 minutes, giving the nurse an opportunity to observe for skin abnormalities. Conversation should be kept to a minimum to enhance relaxation. Alcohol either as a rub or used as disinfectant is drying to the skin. DIF: Cognitive Level: Application REF: 201 OBJ: 7 TOP: Backrub KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is preparing to make an occupied bed. What procedure will the nurse follow to
correctly complete this task? (Select all that apply.) a. Remove spread and blanket separately. b. Place soiled sheet at end of bed. c. Place bath blanket over patient on top sheet. d. Slide mattress to bottom of bed. e. Position patient to far side of bed. ANS: A, C, E
When making an occupied bed the nurse will remove the spread and blanket separately. The bath blanket is placed over the patient on the top sheet and the patient is positioned to the far side of the bed. Soiled linen is placed in the laundry bin, not at the end of the bed. The mattress is slid to the top of the bed. DIF: Cognitive Level: Application REF: 222 OBJ: 11 TOP: Making occupied bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment COMPLETION 1. The nurse avoids dragging the patient across the bed linen to decrease the potential risk of
skin injury by
.
ANS:
friction Dragging the patient across bed linen rather than lifting can cause skin damage from friction. DIF: Cognitive Level: Comprehension REF: 202 OBJ: 5 | 9 TOP: Friction KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 2. Because of its effect on epithelization, the LPN/LVN should confirm the order to use
or alcohol on a stage 3 pressure injury. ANS:
peroxide Peroxide and alcohol have a negative effect on epithelization of a pressure injury.
DIF: Cognitive Level: Knowledge REF: 205 OBJ: 5 TOP: Pressure injuries KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 3. To prevent skin breakdown in a wheelchair-bound patient, the nurse teaches the patient to
shift the patient’s weight every
minutes.
ANS:
15 People who are wheelchair-bound should shift their weight by pushing on the arms of their chair every 15 minutes to prevent skin breakdown. DIF: Cognitive Level: Knowledge REF: 205 OBJ: 5 TOP: Skin breakdown KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 4. As a safety precaution against breakage of dentures, the nurse should place
the emesis basin before cleaning the dentures. ANS:
water Water in the basin will break the fall of the dentures if they are dropped. DIF: Cognitive Level: Knowledge REF: 213 OBJ: 6 TOP: Oral hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment
in
Chapter 10: Safety Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse manager is providing an in-service regarding a “safe hospital environment.”
What will this education mainly focus on preventing? a. Falls b. Exposure to contaminants c. Injury d. Electric hazard ANS: C
A safe environment implies freedom from injury. DIF: Cognitive Level: Knowledge REF: 235 OBJ: 6 TOP: Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 2. What is important for the nurse to determine in order to decrease the risk for injury to a
patient? a. If patient can read English b. If patient is left-handed c. If patient ambulates with assistive device d. If patient can dress independently ANS: B
Patients requiring an assistive device to ambulate are at an increased risk for injury. DIF: Cognitive Level: Comprehension REF: 237 TOP: Safety KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment
OBJ: 1
3. What skills should health care workers frequently attend in-services about to ensure that
staff has competent skills and risk for falls can be decreased? a. Bathing b. Feeding c. Transferring d. Ambulating ANS: C
The majority of patient falls occur during transfer. DIF: Cognitive Level: Comprehension REF: 236 OBJ: 3 TOP: Falls KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 4. What important safety precaution should the home health nurse teach parents in order to
prevent burns to small children? a. Never leave them unattended. b. Turn pot handles on stoves away from reach.
c. Turn hot water on first when filling the bathtub. d. Keep side rails up on the crib. ANS: B
To protect infants and children from burns, turn the pot handles on stoves away from the child’s reach. DIF: Cognitive Level: Application REF: 237 OBJ: 2 TOP: Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 5. What must the nurse do before applying a safety reminder device (SRD)? a. Get permission from the family. b. Assess patient’s skin condition. c. Get a health care provider’s order. d. Explain the SRD to the patient. ANS: C
Initially, an order is necessary that specifies the type of SRD and the duration of its application. DIF: Cognitive Level: Application REF: 243 OBJ: 4 TOP: Safety reminder devices (SRDs) KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 6. What should the nurse do when offering a cup of hot coffee to a frail, older adult patient? a. Give the patient a straw. b. Dilute the coffee with cold water. c. Fill the cup half full. d. Offer a bib or an apron. ANS: C
Filling the cup half full promotes safety and does not change the flavor of the beverage, nor does it demean the patient as would making him or her wear a bib or apron. DIF: Cognitive Level: Application REF: 236 | 237 | 241 OBJ: 2 TOP: Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 7. What type of fire extinguisher should the nurse use when the oxygen concentrator machine
malfunctions and causes an electric fire? a. Type A b. Type B c. Type C d. Type D ANS: C
Electric fires require type C fire extinguishers. DIF: Cognitive Level: Application REF: 249 OBJ: 7 TOP: Fires KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment
8. A disaster situation occurs and involves an explosion in a hospital laundry. What would
this be classified as? a. Active b. External c. Life-threatening d. Internal ANS: D
Internal disaster often threatens the safety of patients and staff. DIF: Cognitive Level: Analysis REF: 252 | 253 TOP: Disaster KEY: Nursing Process Step: N/A
OBJ: 9 MSC: NCLEX: N/A
9. The emergency department nurse admits a victim of poisoning. Who should the nurse call
to receive the best assistance for dealing with this victim? a. American Red Cross b. Fire department paramedics c. Poison control center d. Civil defense office ANS: C
The nurse can access the local poison control center for assistance in caring for a victim of poisoning. DIF: Cognitive Level: Knowledge REF: 250 | 251 OBJ: 8 TOP: Poisoning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. A nurse instructs a unlicensed assistive personnel about the proper use of a gait belt and is
observing a return demonstration. What action by the unlicensed assistive personnel should cause the nurse to intervene? a. Unlicensed assistive personnel is walking on the patient’s strong side. b. Unlicensed assistive personnel is walking to the side of the patient. c. Unlicensed assistive personnel is securing the gait belt securely around the patient’s waist. d. Unlicensed assistive personnel is grasping the handles of the gait belt while the patient ambulates. ANS: A
A gait belt should be securely applied around the patient’s waist. It has handles attached for the nurse to grasp while the patient ambulates. The nurse should walk on the patient’s weaker side so that assistance may be given if the patient starts to fall. DIF: Cognitive Level: Application REF: 236-237 TOP: Gait belt KEY: Nursing Process Step: N/A 11. What should a nurse do when encountering a mercury spill? a. Vacuum the spill. b. Open interior doors. c. Close all outside windows. d. Open any outside windows.
OBJ: 4 MSC: NCLEX: N/A
ANS: D
In the event of a mercury spill, interior doors should be closed and outside windows should be opened. The spill should not be vacuumed. DIF: Cognitive Level: Application TOP: Mercury spill MSC: NCLEX: N/A
REF: 245 OBJ: 9 KEY: Nursing Process Step: N/A
MULTIPLE RESPONSE 1. When the nurse ambulates with a patient who has left-sided weakness, what actions should
the nurse take? (Select all that apply.) a. Walk on the patient’s right side. b. Keep the patient away from heavy furniture. c. Hold the patient’s arm securely. d. Keep the leg nearest the patient behind the patient’s knee. e. Use a gait belt. ANS: D, E
Ambulating with a person who has an identified weakness requires that the nurse walk on the same side as the weakness, slightly behind the patient, with the nurse’s near leg behind the patient’s knee. The nurse should use a gait belt and hold the patient at the waist and the gait belt. Furniture can be used as support. DIF: Cognitive Level: Application REF: 236-237 OBJ: 3 TOP: Ambulating KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 2. The nurse assesses a patient in a Posey safety reminder device (SRD) for which problem
that may increase because of the use of SRDs? (Select all that apply.) a. Immobility b. Lethargy c. Risk for impaired circulation d. Risk for skin impairment e. Incontinence ANS: A, C, D, E
The use of SRDs increases a patient’s immobility, risk for skin impairment, risk for impaired circulation, and incontinence. A SRD would not increase lethargy. DIF: Cognitive Level: Comprehension TOP: Problems associated with SRDs MSC: NCLEX: Physiological Integrity
REF: 240 OBJ: 4 KEY: Nursing Process Step: Assessment
3. A long-term care facility is committing to a restraint-free environment. What will the
health care workers implement to encourage this environment? (Select all that apply.) a. Frequent orientation to surroundings. b. Explain all procedures and treatments. c. Discourage visitors. d. Maintain toileting routines. e. Minimize exercise and ambulation.
ANS: A, B, D
To encourage a restraint-free environment, health care workers should provide frequent orientation to surroundings, thoroughly explain all procedures and treatments, and maintain toileting routines. Visitors should be encouraged so they may sit with the residents, and frequent exercise and ambulation also should be encouraged. DIF: Cognitive Level: Application REF: 257 OBJ: 5 TOP: Restraint-free environment KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment COMPLETION 1.
is a violent or dangerous act used to intimidate or coerce a person or government to further a political or social agenda. ANS:
Terrorism Terrorism is a violent or dangerous act used to intimidate or coerce a person or government to further a political or social agenda. DIF: Cognitive Level: Knowledge REF: 252 TOP: Terrorism KEY: Nursing Process Step: N/A
OBJ: 9 MSC: NCLEX: N/A
2. When reinforcing the PASS acronym for fire extinguisher use, the nurse reminds the staff
that the final “S” stands for
.
ANS:
sweep The acronym stands for: P = pull pin, A = aim, S = squeeze, S = sweep. DIF: Cognitive Level: Knowledge REF: 250 OBJ: 7 TOP: Fire extinguisher use KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 3. The nurse conducting a seminar on bioterrorism reviews several types of agents that may
be used as weapons. An agent that does not seriously damage or kill the target population but only impairs it is classified as . ANS:
incapacitating The agent that only impairs the target rather than killing or seriously damaging it is classified as an incapacitating agent. DIF: Cognitive Level: Knowledge REF: 256 OBJ: 11 TOP: Bioterrorism KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
4. The nurse explains that the measurement of radiation exposure is in multiples of Gy. The
number of Gy an individual may absorb before becoming ill with radiation syndrome is . ANS:
0.75 The amount of radiation absorbed is measured by the Gy. 1 Gy is equal to 100 rad. Absorption of 0.75 Gy will cause the individual to develop acute radiation syndrome. DIF: Cognitive Level: Comprehension TOP: Radiation syndrome MSC: NCLEX: Physiological Integrity
REF: 255 OBJ: 11 KEY: Nursing Process Step: Implementation
Chapter 11: Admission, Transfer, and Discharge Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. When admitting a patient to the hospital, the nurse observes that the patient is distracted
and tense. What does this behavior suggest as a common reaction to hospitalization? a. Relief about being cared for b. Fear of the unknown c. Feeling of powerlessness d. Concern about cost ANS: B
Fear of the unknown may be the most common reaction to hospitalization. DIF: Cognitive Level: Comprehension REF: 260 TOP: Admission KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 3 | 5
2. A nurse is admitting a patient to an acute care facility. During the admission procedure,
what nursing intervention would best help reduce patient anxiety? a. Transport the patient by wheelchair. b. Inform the health care provider that the patient is admitted. c. Greet the patient by name. d. Collect financial information during the interview. ANS: C
Greeting the patient by name is one of the most important aspects of admission. DIF: Cognitive Level: Application REF: 262 OBJ: 1 | 4 | 5 TOP: Admission KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 3. What essential part of the admission procedure is performed by the RN? a. Securing the patient’s valuables b. Confirming the type of insurance coverage c. Obtaining a health history d. Familiarizing the patient with the room ANS: C
Admission assessment is performed by the RN. DIF: Cognitive Level: Knowledge REF: 266 TOP: Admission KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 4. When should discharge planning begin? a. The day before discharge b. On the first day postoperatively c. Shortly after admission d. When the health care provider orders it
OBJ: 5 | 6
ANS: C
Discharge planning begins shortly after admission. DIF: Cognitive Level: Knowledge REF: 269 OBJ: 5 | 8 TOP: Discharge KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 5. Where can a nurse refer the family of a patient to find a source of financial aid to meet
medical expenses? a. A local bank b. A clinical nurse specialist c. The hospital administration d. Social services ANS: D
Often a patient will require services of various disciplines within the hospital. Social services can assist with meeting medical financial obligations. DIF: Cognitive Level: Comprehension REF: 273 OBJ: 8 TOP: Social services KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 6. When a patient demands to be discharged without a health care provider’s order and is
leaving the unit with his belongings, what should the nurse ask the patient to sign? a. A form exercising the patient’s rights b. A discharge against medical advice form c. An informed consent d. An advanced directive ANS: B
If a health care provider cannot convince the patient to stay, the patient should sign an against medical advice form. DIF: Cognitive Level: Application REF: 273 | 274 OBJ: 10 TOP: Discharge KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 7. The nurse must be sensitive to an older adult patient experiencing separation anxiety when
admitted to the hospital. When a child experiences separation anxiety, they will usually cry. What will an older adult often demonstrate when experiencing separation anxiety? a. Withdrawal b. Anger c. Depression d. Regression ANS: C
The older adult may demonstrate depression as a result of separation anxiety entering the hospital. DIF: Cognitive Level: Comprehension REF: 260 TOP: Admission KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 3
8. Upon admission, the nurse notes that a patient without family members present has a
billfold filled with cash. Where can the nurse suggest the money be placed? a. In a sealed envelope in the bedside table b. In the care of hospital security c. Locked in the narcotic cupboard d. In the hospital safe ANS: D
Valuables should be locked in the hospital safe. DIF: Cognitive Level: Application REF: 263 OBJ: 6 TOP: Care of valuables KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 9. If a patient has an order for an interagency transfer, where does the nurse explain that the
patient will be moved? a. A double room to a private room b. One unit of the hospital to another c. One room of the unit to another d. One facility to another ANS: D
The interagency transfer moves a patient from one health care agency to another. DIF: Cognitive Level: Comprehension REF: 268 OBJ: 7 TOP: Transfer KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 10. Before the actual discharge occurs, what must the nurse ensure? a. The patient is well enough to go home. b. The patient has not been overly medicated. c. The patient understands the discharge instructions. d. The patient has adequate transportation. ANS: C
It is essential that the patient be fully aware of the discharge instructions before being discharged. DIF: Cognitive Level: Application REF: 268-269 OBJ: 5 | 9 TOP: Discharge KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 11. A patient who is alert and oriented is threatening to leave the hospital against medical
advice (AMA). What action should the nurse take? a. Forcibly detain and restrain the patient. b. Administer a sedative hypnotic medication. c. Prevent patient from leaving until an AMA form is signed. d. Notify the health care provider that the patient is threatening to leave AMA. ANS: D
When a patient threatens to leave AMA, the health care provider should be notified immediately. If the health care provider fails to convince the patient to remain in the facility, the health care provider will ask the patient to sign an AMA form releasing the facility from legal responsibility for any medical problems the patient may experience after discharge. If the health care provider is not available, the nurse should discuss the discharge form with the patient and obtain the patient’s signature. If the patient refuses to sign the AMA form, the patient should not be detained. This violates the patient’s legal rights. After the patient leaves, the nurse should document the incident thoroughly in the nurse’s notes and notify the health care provider. A rational adult patient who will not sign the AMA form cannot be forcibly detained. DIF: Cognitive Level: Application REF: 275 OBJ: 10 TOP: Against medical advice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 12. How can the nurse demonstrate cultural sensitivity to a Haitian American patient? a. By providing a well-lit room 24 hours a day b. By writing out all instructions given to the patient c. By allowing the patient to keep leaves in her room d. By asking the health care provider to provide all directions to the patient ANS: C
Many Haitians believe that leaves have a special significance in healing. Leaves may be found in the clothes and on various parts of the body. Leaves are thought to have mystical power related to regaining or keeping health. DIF: Cognitive Level: Application TOP: Cultural awareness MSC: NCLEX: Psychological Integrity
REF: 262 OBJ: 4 KEY: Nursing Process Step: Implementation
13. A nurse is caring for a Haitian American patient. How might the nurse demonstrate
cultural sensitivity? a. Discarding any leaves the patient may have brought with them b. Assigning the patient to a room with any Haitian American patient c. Instructing the patient to ride in a wheelchair when discharged d. Allowing the patient to walk out of the hospital when discharged ANS: D
Some Haitian Americans associate wheelchairs with being sick. Therefore, on discharge, the patient who is allowed to walk out of the hospital will be more likely to feel that care has been effective. A poor patient with a Haitian background and a wealthy patient with a Haitian background, although from the same country, may find the same room assignment together in the hospital very distasteful. DIF: Cognitive Level: Application TOP: Cultural awareness MSC: NCLEX: Psychological Integrity
REF: 262 OBJ: 4 KEY: Nursing Process Step: Implementation
MULTIPLE RESPONSE 1. How can the nurse help reduce the stress of a hospital admission? (Select all that apply.)
a. b. c. d. e.
Show the patient how bedside equipment works. Explain the need to establish a clear source of reimbursement. Give simple explanation of policies. Involve the patient in the plan of care. Keep family interventions to a minimum.
ANS: A, C, D
An empathic reception reduces anxiety of admission; for instance, demonstrating how bedside equipment works, explaining hospital policies, and involving the patient in the plan of care from the start all help to reduce the stress of a hospital admission. Securing financial information is not a role of the nurse, and family interventions are frequently helpful in reducing stress. DIF: Cognitive Level: Comprehension REF: 261 KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
TOP: Stress reduction
2. The nurse adheres to the discharge standards set by The Joint Commission (TJC), which
include that patients will receive instruction regarding which aspects of care? (Select all that apply.) a. Medications b. Rehabilitation techniques c. Referral to community agencies d. Medical equipment to be used e. Obtaining health insurance ANS: A, B, C, D
The Joint Commission (TJC) standards require that a patient have information pertinent to medication, rehabilitation instructions, referral to community agencies, instruction in using any medical equipment, family care responsibility, diet, and how to obtain further treatment if necessary. DIF: Cognitive Level: Comprehension REF: 270 OBJ: 9 TOP: TJC standards for discharge KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment COMPLETION 1. The nurse completes thorough documentation before, during, and after a
ensure continuity of care. ANS:
transfer Clear documentation before, during, and after a transfer ensures that the patient’s condition is being monitored and maintains the continuity of care. DIF: Cognitive Level: Comprehension REF: 269 OBJ: 5 | 7 TOP: Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment
to
2. Some Orthodox Jewish patients consider sundown Friday to sundown
to be
the Sabbath, which is a time of rest. ANS:
Saturday Some Orthodox Jewish patients consider sundown Friday to sundown Saturday to be the Sabbath, which is a time of rest. These patients may avoid the use of any electronic equipment, so the nurse should find alternatives to the use of this equipment if possible. DIF: Cognitive Level: Knowledge TOP: Orthodox Jewish culture MSC: NCLEX: Psychosocial Integrity
REF: 262 OBJ: 3 KEY: Nursing Process Step: Implementation
3. Because of the stress caused by hospitalization, the nurse assesses a newly admitted older
adult patient for
.
ANS:
disorientation In a normally alert and oriented older adult, medical conditions that necessitate hospitalization often result in some level of disorientation. DIF: Cognitive Level: Application TOP: Disorientation in older adults MSC: NCLEX: Psychosocial Integrity
REF: 261 OBJ: 3 | 5 KEY: Nursing Process Step: Assessment
Chapter 12: Vital Signs Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. What part of the body maintains a balance between heat production and heat loss, regulating body temperature? a. Thymus b. Thyroid c. Hypothalamus d. Adrenal glands ANS: C Body temperature is regulated by the hypothalamus. DIF: Cognitive Level: Knowledge REF: 282 TOP: Vital signs KEY: Nursing Process Step: N/A
OBJ: 9 | 13 MSC: NCLEX: N/A
2. What type of body temperature remains relatively constant? a. Surface b. Rectal c. Oral d. Core ANS: D The core body temperature remains relatively constant. DIF: Cognitive Level: Knowledge REF: 282 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 2
3. The nurse uses cooling techniques to keep the body temperature below 105°F (40.6°C). What can result from an elevated temperature? a. Excessive thirst b. Excessive perspiration c. Damage to body cells d. Increased heart rate ANS: C If the temperature exceeds 105°F (40.6°C), normal body cells may be damaged. DIF: Cognitive Level: Comprehension REF: 283 OBJ: 8 TOP: Vital signs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures. What temperature is the nurse aware of that can lead to death? a. 95.2°F (35.1°C)
b. 93.0°F (33.8°C) c. 93.2°F (34°C) d. 90.8°F (32.6°C) ANS: C Death can occur if the temperature falls below 93.2° F (34°C). DIF: Cognitive Level: Comprehension REF: 283 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 9
5. What is the term for a fever that rises and falls but does not return to normal until the patient is well? a. Constant b. Intermittent c. Remittent d. Elevated ANS: C A remittent fever does not return to normal until the patient becomes well. DIF: Cognitive Level: Knowledge TOP: Remittent fever MSC: NCLEX: Physiological Integrity
REF: 283 OBJ: 9 KEY: Nursing Process Step: Assessment
6. How should the nurse position the ear pinna when using the tympanic thermometer on a child? a. Upward and back b. Parallel c. Downward and back d. Upward and forward ANS: C Using the tympanic thermometer for a child, the nurse will tug the ear pinna down and back. DIF: Cognitive Level: Application TOP: Tympanic thermometer for a child Implementation MSC: NCLEX: Physiological Integrity
REF: 287 OBJ: 3 | 9 KEY: Nursing Process Step:
7. How should the nurse position the earpieces on a stethoscope to ensure optimum reception? a. Backward b. Parallel to the ears c. Toward the face d. Downward ANS: C To ensure the best reception of sound, place earpieces pointing toward the face.
DIF: Cognitive Level: Application REF: 289 OBJ: 9 | 12 TOP: Vital signs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. What does the nurse use the diaphragm of the stethoscope to best assess? a. Carotid sounds b. Lung sounds c. Vascular sounds d. Low-pitched sounds ANS: B Lung sounds are auscultated by using the diaphragm of the stethoscope. DIF: Cognitive Level: Comprehension TOP: Stethoscope use Implementation MSC: NCLEX: Physiological Integrity
REF: 300 OBJ: 6 | 9 KEY: Nursing Process Step:
9. What is the pulse—the expansion and contraction of an artery— produced by? a. Contraction of the right atrium b. Contraction of the right ventricle c. Contraction of the left atrium d. Contraction of the left ventricle ANS: D Expansion and contraction of an artery is caused by the ejection of blood from the left ventricle. DIF: Cognitive Level: Knowledge REF: 290 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
10. When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of 120 beats/min. What is this pulse interpreted as by the nurse? a. Normal b. Bradycardic c. Arrhythmic d. Tachycardic ANS: D If the pulse is faster than 100 beats/min on an adult patient, it is considered to be tachycardic. DIF: Cognitive Level: Analysis REF: 290 TOP: Tachycardia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
11. The patient’s pulse is below 60 beats/min. The nurse is aware that the patient is not receiving digoxin. What does the nurse suspect is causing the bradycardia? a. Low exercise tolerance
b. Unrelieved severe pain c. Excessive bed rest d. A prone position ANS: B Bradycardia can result from unrelieved severe pain. DIF: Cognitive Level: Analysis REF: 290 TOP: Bradycardia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
12. What site should be selected if a peripheral pulse needs to be assessed quickly? a. Radial pulse b. Brachial pulse c. Carotid pulse d. Pedal pulse ANS: C The carotid site is the best for finding a pulse quickly. DIF: Cognitive Level: Application REF: 293 TOP: Carotid KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
13. What is the term for the exchange of carbon dioxide and oxygen that takes place at the alveolar level? a. Tachypnea b. Internal respiration c. External respiration d. Bradypnea ANS: B Internal respiration is the exchange of gas at the alveolar level. DIF: Cognitive Level: Knowledge TOP: Internal respiration Implementation MSC: NCLEX: Physiological Integrity
REF: 294 OBJ: 6 KEY: Nursing Process Step:
14. A patient is suspected of having a cardiac arrhythmia. The nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. What is the term for the difference between these two rates? a. Pulse pressure b. Unequal pulses c. Pulse deficit d. Tachycardia ANS: C The difference between radial and apical pulses is called a pulse deficit. DIF:
Cognitive Level: Knowledge
REF: 293
OBJ: 5
TOP: Pulse deficit KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. The nurse is alarmed when a patient with a severe head injury of the occipital lobe has a respiratory rate of 10 breaths/min. Where might this finding indicate that there is an injury? a. Cerebellum b. Medulla oblongata c. Cortex d. Cerebrum ANS: B Rate of respiration is controlled by the medulla oblongata. DIF: Cognitive Level: Analysis TOP: Respiratory rate MSC: NCLEX: Physiological Integrity
REF: 294 OBJ: 6 KEY: Nursing Process Step: Assessment
16. The nurse assesses respirations of a patient demonstrating pursed-lip breathing, flared nostrils, and retractions. How will the nurse describe these respirations? a. Tachypnea b. Stertorous c. Dyspnea d. Cheyne-Stokes ANS: C The patient who is using ancillary muscles to breathe is exhibiting dyspnea. DIF: Cognitive Level: Analysis REF: 295 TOP: Dyspnea KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
17. A nurse assesses a neonate’s temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonate’s temperature is 96°F (35.5°C)? a. Record the findings. b. Notify the health care provider. c. Check the axillary temperature. d. Check the tympanic temperature. ANS: A The neonate’s temperature normally ranges from 96° to 99.5°F (35.5° to 37.5°C). Temperature regulation is labile (unstable) during infancy because of immature physiologic mechanisms. Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic membrane thermometer. Tympanic thermometer readings are suitable for patients of all ages, except infants. DIF: Cognitive Level: Application REF: 283 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 8
18. A nurse assesses a neonate’s temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonate’s temperature is 99.5°F (37.5°C)? a. Record the findings. b. Notify the health care provider. c. Check the axillary temperature. d. Check the tympanic temperature. ANS: A The neonate’s temperature normally ranges from 96° to 99.5°F (35.5° to 37.5°C). Temperature regulation is labile (unstable) during infancy because of immature physiologic mechanisms. Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic membrane thermometer. Tympanic thermometer readings are suitable for patients of all ages, except infants. DIF: Cognitive Level: Application REF: 283 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 8
19. A nurse assesses a patient’s dorsalis pedis pulse. The pulse is difficult to feel and not palpable when only slight pressure is applied. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse ANS: C A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied. A bounding pulse feels full and springlike even under moderate pressure. DIF: Cognitive Level: Analysis REF: 291 TOP: Pulses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4 | 15
20. A nurse assesses a patient’s dorsalis pedis pulse. The pulse is not palpable when light pressure is applied. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse ANS: A A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied. A bounding pulse feels full and springlike even under moderate pressure.
DIF: Cognitive Level: Analysis REF: 291 TOP: Pulses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4 | 15
21. A nurse assesses a patient’s dorsalis pedis pulse. The pulse is easily felt but not palpable when moderate pressure is applied. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse ANS: B A normal pulse is easily felt but not palpable when moderate pressure is applied. A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A bounding pulse feels full and springlike even under moderate pressure. DIF: Cognitive Level: Analysis REF: 291 TOP: Pulses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4 | 15
22. A nurse assesses a patient’s dorsalis pedis pulse. The pulse feels full and springlike even under moderate pressure. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse ANS: D A bounding pulse feels full and springlike even under moderate pressure. A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied. DIF: Cognitive Level: Analysis REF: 291 TOP: Pulses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4 | 15
MULTIPLE RESPONSE 1. When instructing a primary caregiver about keeping a daily log of blood pressure readings, what instructions should the nurse include? (Select all that apply.) a. Take the reading at different times during the day. b. Apply the cuff approximately 2 in above the antecubital fossa. c. If unable to get a reading the first time, immediately reinflate the cuff. d. Assess pulse with the bell of the stethoscope. e. Apply the cuff snugly.
ANS: B, E Readings for a blood pressure log should be taken at the same time every day on the same arm. The cuff should be applied 2 in above the antecubital fossa and snugly secured. The pulse should be assessed with the diaphragm of the stethoscope. If unable to get a reading the first time, the cuff should be deflated completely and reinflated after several minutes. DIF: Cognitive Level: Application TOP: Blood pressure MSC: NCLEX: Physiological Integrity
REF: 279 | 280 OBJ: 7 KEY: Nursing Process Step: Assessment
2. When assessing factors that may influence the patient’s pulse rate, what should the nurse take into consideration? (Select all that apply.) a. Age b. Sex c. Emotion d. Temperature e. Religion ANS: A, B, C, D All the options listed can affect the pulse rate, except religion. DIF: Cognitive Level: Application TOP: Influences on pulse rate MSC: NCLEX: Physiological Integrity
REF: 290 OBJ: 5 KEY: Nursing Process Step: Assessment
3. A patient is admitted to a medical surgical unit. What factors will determine how frequently vital signs will be assessed? (Select all that apply.) a. Desire of the patient b. Judgment of need by the nurse c. Discretion of the family d. Orders of the health care provider e. Patient’s condition ANS: B, D, E Whether and how frequently vital signs are measured depends on the nurse’s judgment of need, orders of the health care provider, and patient’s condition. Desire of the patient and family members cannot override these factors, but can be taken into consideration within reason of these factors. DIF: Cognitive Level: Comprehension REF: 280 TOP: Frequency of vital signs measurement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 11
4. The home health nurse is preparing to educate a patient regarding electronic self-blood pressure measurement. What information should the nurse provide regarding this procedure? (Select all that apply.) a. Expect precise values. b. Proper measurement techniques are necessary.
c. Cuff fits over clothing. d. Stethoscope is not required. e. Recalibration is not necessary. ANS: B, C, D Self-blood pressure monitoring requires proper measurement techniques, cuff is made to fit over clothing, and stethoscopes are not required. Values may be inaccurate and recalibration is necessary at least once a year. DIF: Cognitive Level: Application TOP: Self-blood pressure measurement Implementation MSC: NCLEX: Physiological Integrity
REF: 305 OBJ: 14 KEY: Nursing Process Step:
5. The health care provider orders daily weights on a patient residing in a long-term care setting. What actions should the nurse implement to assess weight accurately? (Select all that apply.) a. Weigh patient at the same time each day. b. Schedule weighing immediately after breakfast. c. Encourage patient to void before being weighed. d. Ensure same amount of clothing is worn by patient. e. Calibrate by setting scale at zero after each weight. ANS: A, C, D Accurate assessment of weight should occur at the same time each day, preferably at 6 a.m. before breakfast. The patient should be encouraged to void before being weighed and the same amount of clothing should be worn each day. The scale should be calibrated to zero before (not after) each weight is taken. DIF: Cognitive Level: Application TOP: Weight measurement Implementation MSC: NCLEX: Physiological Integrity
REF: 306 OBJ: 10 KEY: Nursing Process Step:
COMPLETION 1. The nurse assesses for the fifth vital sign, which is
.
ANS: pain Pain is considered the fifth vital sign. DIF: Cognitive Level: Knowledge TOP: Pain as a vital sign MSC: NCLEX: Physiological Integrity
REF: 280 OBJ: 1 KEY: Nursing Process Step: Assessment
2. If a patient has an axillary temperature of 96.2°F (35.6°C), the nurse understands that the true temperature is .
ANS: 97.2°F (35.6°C) 97.2°F 35.6°C Axillary temperatures are considered to be 1°F (–17.2°C) below core temperature. DIF: Cognitive Level: Comprehension TOP: Axillary temperature MSC: NCLEX: Physiological Integrity
REF: 288 OBJ: 3 KEY: Nursing Process Step: Assessment
3. The nurse assesses the blood pressure as 192/86, noting that the patient has a pulse pressure of . ANS: 106 The pulse pressure is the difference between the diastolic and systolic readings. DIF: Cognitive Level: Analysis TOP: Pulse pressure MSC: NCLEX: Physiological Integrity
REF: 297 OBJ: 7 KEY: Nursing Process Step: Assessment
Chapter 13: Physical Assessment Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse is collecting data during an initial assessment. What can be seen, heard, measured, or felt and is objective? a. Symptom b. Observation c. Sign d. Assessment ANS: C A sign can be seen, heard, measured, or felt. DIF: Cognitive Level: Knowledge REF: 311 TOP: Assessment KEY: Nursing Process Step: Assessment
OBJ: 1 MSC: NCLEX: N/A
2. As part of an assessment, the nurse asks the patient for subjective information related to the present illness. What are the subjective findings perceived by the patient? a. Assessments b. Symptoms c. Signs d. Observations ANS: B Symptoms are subjective indications of illness that are perceived by the patient. DIF: Cognitive Level: Knowledge REF: 312 TOP: Assessment KEY: Nursing Process Step: Assessment
OBJ: 1 MSC: NCLEX: N/A
3. Any disturbance of a structure or function of the body is a pathologic condition. What is the term for this condition? a. Injury b. Condition c. Disease d. Pathology ANS: C A disease is any disturbance of a structure or function of the body. DIF: Cognitive Level: Knowledge REF: 312 TOP: Disease KEY: Nursing Process Step: Assessment
OBJ: 2 MSC: NCLEX: N/A
4. The nurse is assessing a patient for collection of subjective and objective data. What will this data provide the basis for making? a. Care plan b. Medical diagnosis c. Nursing assessment
d. Patient problem ANS: D Nurses rely on assessment of signs and symptoms to formulate a patient problem. DIF: Cognitive Level: Comprehension REF: 313 TOP: Assessment KEY: Nursing Process Step: Assessment
OBJ: 11 MSC: NCLEX: N/A
5. The nurse is discussing the origin of diabetes with a diabetic patient. What will the nurse discuss as the most appropriate explanation for the cause of this disease? a. Pituitary b. Adrenals c. Pancreas d. Thyroid ANS: C Diabetes mellitus results from dysfunction of the pancreas. DIF: Cognitive Level: Comprehension REF: 312 TOP: Disease KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
OBJ: 2
6. There are four categories of factors that increase an individual’s vulnerability to develop a disease: genetic, physiologic, age, and lifestyle. What is the term for these factors? a. Risk factors b. Causative factors c. Etiologic factors d. Hazardous factors ANS: A Risk factors are placed into four categories. DIF: Cognitive Level: Knowledge REF: 313 TOP: Disease KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
OBJ: 3
7. When discussing diabetes with a patient, the nurse describes this disease as falling into which group in terms of duration? a. Acute b. Organic c. Chronic d. Functional ANS: C Diabetes mellitus is an example of a chronic disease. DIF: Cognitive Level: Comprehension REF: 313 TOP: Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
8. What is the term used to describe a disease where there has been a partial or complete disappearance of clinical and subjective characteristics of the disease? a. Acute b. Functional c. Chronic d. Remission ANS: D Remission means there has been partial or complete disappearance of the clinical and subjective characteristics. DIF: Cognitive Level: Knowledge REF: 313 TOP: Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
9. What type of disease results in a structural change in an organ that interferes with its functioning? a. Functional disease b. Organic disease c. Acute disease d. Chronic disease ANS: B An organic disease results in a structural change in an organ. DIF: Cognitive Level: Knowledge REF: 313 TOP: Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 2
10. The signs and symptoms of both infection and inflammation include erythema, edema, and pain. What is considered the major difference between infection and inflammation? a. Inflammation is a result of bacteria. b. Inflammation is a protective response. c. Inflammation is a disease process. d. Inflammation produces tissue damage. ANS: B Inflammation is a protective response. DIF: Cognitive Level: Comprehension REF: 313 TOP: Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
11. A nursing assessment is a process of collecting data to establish a database. The information contained in the database is a basis for: a. a complete physical examination. b. a medical assessment. c. an individualized plan of care. d. writing nursing orders. ANS: C
The information contained in the database is the basis for an individualized plan of care. DIF: Cognitive Level: Comprehension REF: 316 TOP: Assessment KEY: Nursing Process Step: Assessment
OBJ: 13 MSC: NCLEX: N/A
12. The nurse is meeting a patient for the first time. What is the first thing the nurse will do to initiate a nurse-patient relationship? a. Appear interested. b. Introduce herself/himself. c. Provide support. d. Communicate trust. ANS: B The first step in a nurse-patient relationship is for the nurse to introduce herself/himself. DIF: Cognitive Level: Application TOP: Nurse-patient relationship Implementation MSC: NCLEX: Psychosocial Integrity
REF: 318 OBJ: 9 KEY: Nursing Process Step:
13. What should a patient interview being conducted by the nurse convey to the patient? a. The nurse has feelings of concern. b. The nurse has limited time. c. The nurse is very intelligent. d. The nurse has answers to problems. ANS: A The nurse must convey feelings of concern. DIF: Cognitive Level: Comprehension REF: 319 TOP: Interview KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 9
14. What does the nurse recognize as the initial step in conducting an assessment of a patient? a. A body systems review b. The nursing health history c. Biographic data d. The present illness ANS: B The nursing health history is the initial step in the assessment process. DIF: Cognitive Level: Comprehension REF: 318 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 11
15. When collecting data related to the present illness, the nurse must obtain detailed and comprehensive data. What does this data help to establish? a. A patient problem
b. A nursing care plan c. Appropriate interventions d. Nursing orders ANS: C The data collected related to the present illness must be detailed and comprehensive to allow planning of appropriate interventions. DIF: Cognitive Level: Comprehension REF: 320 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 10
16. During the nursing interview, several histories are taken. What is the history that involves data concerning habits and lifestyle patterns? a. Family history b. Environmental history c. Past health history d. Psychosocial history ANS: C The nurse identifies habits and lifestyle patterns under the past health history. DIF: Cognitive Level: Knowledge REF: 320 TOP: Interview KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 10
17. The nurse uses a systematic method for collecting data on all body systems, including normal functioning and any noted changes. What is this method? a. Nursing interview b. Review of systems c. Nursing assessment d. Health history ANS: B A review of systems is a systematic method. DIF: Cognitive Level: Knowledge REF: 321 TOP: Interview KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 11
18. The nurse is developing a nursing care plan for a newly admitted patient. What is the first step the nurse will take in developing this care plan? a. Health history b. Review of systems c. Family history d. Nursing assessment ANS: D The nursing assessment is the critical step in forming the nursing care plan. DIF:
Cognitive Level: Application
REF: 325
OBJ: 11
TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. The patient should be assessed as soon as possible after admission. Who performs this initial assessment? a. Health care provider b. Charge nurse c. LPN/LVN d. RN ANS: D The initial assessment is done by the registered nurse. DIF: Cognitive Level: Knowledge REF: 324 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 8
20. A patient was admitted with a complaint of abdominal pain. Later, the nurse observed the patient demonstrating dyspnea. What type of assessment does this change in condition require? a. Individualized b. Focused c. Specialized d. Systematic ANS: B When the nurse observes a change in the patient’s condition, the assessment is focused. DIF: Cognitive Level: Application REF: 324 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
21. When performing a nursing physical assessment, the nurse uses a head-to-toe approach. Where will the nurse begin when using this method? a. Skin assessment b. Neurologic assessment c. Circulatory assessment d. Respiratory assessment ANS: B When performing a head-to-toe assessment, the nurse begins with a neurologic assessment. DIF: Cognitive Level: Application REF: 325 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 11
22. An older adult patient is being assessed for skin turgor. The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised. What can the nurse conclude is responsible for this assessment?
a. b. c. d.
Dehydration Edema Skin breakdown Malnutrition
ANS: A Dehydration results in decreased skin turgor. DIF: Cognitive Level: Analysis REF: 327 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
23. During a physical assessment, the nurse listens for adventitious lung sounds. Crackles are classified as fine, medium, or coarse. When are these sounds most often auscultated? a. During expiration b. Following expiration c. During inspiration d. Following inspiration ANS: C Crackles are usually heard during inspiration. DIF: Cognitive Level: Comprehension REF: 328-329 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
24. Auscultating the heart sounds should result in a “lub-dup” sound when using the bell and the diaphragm of the stethoscope. What causes the “lub” sound? a. Opening of the AV valves b. Opening of the semilunar valves c. Closing of the AV valves d. Closing of the semilunar valves ANS: C The “lub-dup” sound of the heart is caused by the closing of the AV and semilunar valves, respectively. DIF: Cognitive Level: Comprehension REF: 330 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
25. The nurse assesses a patient for capillary refill after the fingernail is compressed for 5 seconds. What should the nurse expect the refill time to be? a. 1 second b. 2 seconds c. 3 seconds d. 4 seconds ANS: C Capillary refill should take fewer than 3 seconds.
DIF: Cognitive Level: Application REF: 332 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
26. Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope. What is the normal rate of bowel sounds per minute? a. 2 to 10 b. 3 to 20 c. 4 to 32 d. 5 to 40 ANS: C The normal rate of bowel sounds per minute is 4 to 32. DIF: Cognitive Level: Knowledge REF: 332 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
27. A patient has edema of the lower extremities. The nurse is assessing whether it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 2+ pitting edema. When did the edema disappear? a. 10 to 15 seconds b. 20 to 25 seconds c. 30 to 35 seconds d. 40 to 45 seconds ANS: A The 2+ pitting edema is identified because the pitting edema disappears in 10 to 15 seconds. DIF: Cognitive Level: Application REF: 331 | 334 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
28. Various techniques are used by the nurse when performing a physical assessment. One of these techniques is percussion. What is percussion used to determine? a. Sounds for auscultation b. Data about physical features c. Changes in structural integrity d. Density of underlying tissue ANS: D The sounds indicate the density of the underlying tissue. DIF: Cognitive Level: Comprehension REF: 334 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
29. The nurse is obtaining a history of a patient’s present illness. The PQRST system is used for the interview. What does the R stand for in this system?
a. b. c. d.
Random Region Result Recent
ANS: B In the PQRST system, the R stands for region. DIF: Cognitive Level: Knowledge REF: 320 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 10
30. When performing a physical examination of a patient, the nurse uses a technique that is particularly useful in identifying areas of tenderness or masses of the abdomen. What is this technique? a. Auscultation b. Deep palpation c. Light palpation d. Percussion ANS: B Deep palpation is used to detect tenderness or masses of the abdomen. DIF: Cognitive Level: Comprehension REF: 333 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 8
31. The nurse is performing auscultation of breath sounds on a respiratory patient. The sounds heard on inspiration and expiration are low-pitched, coarse, gurgling, and have a snoring sound. What best identifies these sounds? a. Crackles b. Plural friction rub c. Rhonchi d. Sonorous wheezes ANS: D Sonorous wheezes have a low-pitched, coarse, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and large airways. DIF: Cognitive Level: Analysis REF: 329 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
32. What is the suggested sequence for a systematic approach to begin auscultating the thorax? a. Anterior thorax b. Apices c. Left lateral thorax d. Right lateral thorax ANS: B
The suggested sequence for a systematic auscultation of the thorax is to begin with the apices. DIF: Cognitive Level: Comprehension REF: 328 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 11
33. A nurse is gathering objective data when admitting a patient. Which assessment finding reported by the patient is considered objective? a. Complains of nausea b. States, “I hurt all over.” c. Complains of feeling anxious d. Appears to be anxious ANS: D Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Anxiety is the only objective assessment finding. All other options are examples of subjective data. DIF: Cognitive Level: Application REF: 312 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
34. A nurse is gathering objective data when admitting a patient. Which assessment finding is considered objective data? a. The patient complains of chest pain. b. The patient states, “I am having trouble breathing.” c. The patient complains of coughing up sputum. d. The patient expectorates red-tinged sputum. ANS: D Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Expectoration of red-tinged sputum is the only objective assessment finding. All other options are examples of subjective data. DIF: Cognitive Level: Application REF: 312 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
35. A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data? a. Complains of chest pain. b. Is experiencing dyspnea. c. Appears to be anxious. d. Expectorates red-tinged sputum. ANS: A
Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Chest pain is the only subjective assessment finding. All other options are examples of objective data. DIF: Cognitive Level: Application REF: 312 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
36. A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data? a. Complains of pruritus. b. Is experiencing erythema. c. Appears to be experiencing pruritus. d. Has a generalized rash. ANS: A Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Pruritus is the only subjective assessment finding. All other options are examples of objective data. DIF: Cognitive Level: Application REF: 312 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
37. A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data? a. Complains of diplopia b. Is experiencing nystagmus c. Demonstrates facial grimacing d. Has a generalized rash ANS: A Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Diplopia is the only subjective assessment finding. All other options are examples of objective data. DIF: Cognitive Level: Application REF: 312 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
38. What should the nurse begin by assessing when performing a head-to-toe assessment? a. Support system b. Skin integrity c. Pain level
d. Neurologic status ANS: D When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order. DIF: Cognitive Level: Comprehension REF: 325 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 11
39. During a head-to-toe assessment, the nurse assesses the patient’s abdomen. Which area should the nurse assess next? a. Chest b. Arms c. Legs and feet d. Perineal area ANS: D When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order. DIF: Cognitive Level: Application REF: 325 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 11
40. During a head-to-toe assessment, the nurse assesses the patient’s perineal area. Which area should the nurse assess next? a. Chest b. Arms c. Abdomen d. Legs and feet ANS: D When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order. DIF: Cognitive Level: Application REF: 325 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 11
41. During a neurologic assessment, the nurse notes a patient has a unilateral, dilated, and nonreactive pupil. This is a sign that the patient is experiencing pressure on which cranial nerve? a. I
b. II c. III d. IV ANS: C The third cranial nerve runs parallel to the brainstem. The function of the oculomotor nerve is essential for eye movements. A traumatic brain injury can result in increased intracranial pressure, edema to the brainstem with pressure on cranial nerve III, causing the ominous sign of a unilateral, dilated, and nonreactive pupil. DIF: Cognitive Level: Analysis REF: 325 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
42. A health care provider needs to insert a vaginal speculum into a patient for a vaginal examination. In what position should the nurse place the patient? a. Sims b. Prone c. Lithotomy d. Dorsal recumbent ANS: C The lithotomy position provides maximal exposure of genitalia and facilitates insertion of a vaginal speculum. DIF: Cognitive Level: Application REF: 317 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
43. A health care provider needs to assess extension of a patient’s hip joint. In what position should the nurse place the patient? a. Sims b. Prone c. Lithotomy d. Dorsal recumbent ANS: B Prone position is used to assess extension of a patient’s hip joint. DIF: Cognitive Level: Application REF: 317 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
44. A health care provider needs to assess a patient for a heart murmur. In what position should the nurse place the patient? a. Sims b. Prone c. Lithotomy d. Lateral recumbent ANS: D
The lateral recumbent position aids in detecting heart murmurs. DIF: Cognitive Level: Application REF: 317 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
45. A health care provider needs to assess a patient’s rectal area. In what position should the nurse place the patient? a. Sims b. Prone c. Lithotomy d. Knee-chest ANS: D Knee-chest position provides maximum exposure of the rectal area. DIF: Cognitive Level: Application REF: 317 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
46. A nurse needs to auscultate a patient’s lung sounds. In what position should the nurse place the patient? a. Sims b. Prone c. Sitting d. Lithotomy ANS: C Sitting upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts. DIF: Cognitive Level: Application REF: 317 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 11
47. During a physical assessment, the nurse notes a patient has a bluish discoloration of the skin and mucous membranes. How should the nurse document this finding? a. Dyspnea b. Cyanosis c. Diaphoresis d. Ecchymosis ANS: B Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood. DIF: Cognitive Level: Knowledge REF: 314 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
48. During a physical assessment, the nurse notes a patient has a lack of appetite resulting in an inability to eat. What should the nurse document that the patient is experiencing? a. Dyspnea b. Asthenia c. Anorexia d. Ecchymosis ANS: C Anorexia is a lack of appetite resulting in the inability to eat. This symptom can occur in many disease conditions. DIF: Cognitive Level: Knowledge REF: 314 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
49. During a physical assessment, the nurse notes a patient has a loss of strength and energy. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Asthenia d. Ecchymosis ANS: C Asthenia is a condition of debility, loss of strength and energy, and depleted vitality. DIF: Cognitive Level: Knowledge REF: 314 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
50. During a physical assessment, the nurse notes that a patient’s heart rate is 56 beats/min. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Diaphoresis d. Bradycardia ANS: D Bradycardia is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute. DIF: Cognitive Level: Application REF: 314 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
51. During a physical assessment, the patient complains of difficulty in passing stools. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Constipation d. Ecchymosis
ANS: C Constipation is difficulty in passing stools or an incomplete or infrequent passage of hard stools. There are many causes, both organic and functional. DIF: Cognitive Level: Knowledge REF: 314 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
52. During a physical assessment, the nurse observes a patient experiencing a sudden audible expulsion of air from the lungs. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Coughing d. Ecchymosis ANS: C Coughing is a sudden audible expulsion of air from the lungs. Coughing is an essential protective response that serves to clear the lungs, bronchi, or trachea of irritants and secretions or to prevent aspiration of foreign material into the lungs. It is a common sign of diseases of the larynx, bronchi, and lungs. DIF: Cognitive Level: Knowledge REF: 314 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
53. During a physical assessment, the nurse notes a patient has profuse secretions of sweat. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Diaphoresis d. Ecchymosis ANS: C Diaphoresis is the secretion of sweat, especially the profuse secretion associated with an elevated body temperature, physical exertion, exposure to heat, and mental or emotional stress. DIF: Cognitive Level: Knowledge REF: 314 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
54. During a physical assessment, the nurse notes a patient passes frequent loose liquid stools. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Diaphoresis d. Diarrhea ANS: D
Diarrhea is the frequent passage of loose liquid stools. It generally results from increased motility in the colon. This is usually a sign of an underlying disorder. The characteristics of the diarrhea give evidence as to the source. Dark black, tarry stools can mean there is bleeding in the intestines. Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract. DIF: Cognitive Level: Knowledge REF: 314 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
55. During a physical assessment, the nurse notes that a patient has bright red blood in the feces. What does the nurse recognize as the most likely cause of this bleeding? a. Bleeding in the upper intestinal tract b. Bleeding in the lower intestinal tract c. Bleeding in the entire intestinal tract d. Consumption of cranberry juice ANS: B Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract. DIF: Cognitive Level: Application REF: 314 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
56. A nurse is caring for a patient with congestive heart failure. During the physical assessment, the nurse notes the patient is experiencing difficulty breathing. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Diaphoresis d. Ecchymosis ANS: A Dyspnea is shortness of breath or difficulty in breathing that may be caused by certain heart and lung conditions, strenuous exercise, or anxiety. DIF: Cognitive Level: Knowledge REF: 314 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
57. A patient has discoloration of an area of their mucous membrane caused by extravasation of blood into the subcutaneous tissue. What should the nurse document that the patient has? a. Dyspnea b. Cyanosis c. Diaphoresis d. Ecchymosis ANS: D
Ecchymosis is discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls (also called a bruise). DIF: Cognitive Level: Application REF: 314 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
58. When admitting a patient to the hospital, the nurse notes the patient has mild sunburn. How should the nurse document this finding? a. Dyspnea b. Cyanosis c. Erythema d. Ecchymosis ANS: C Erythema is redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries; erythema is seen in mild sunburn. DIF: Cognitive Level: Application REF: 314 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
59. When assessing a patient with hepatitis, the nurse notes a yellow tinge to the patient’s skin. What does the nurse understand as the most likely cause of the jaundice? a. Heart b. Liver c. Brain d. Intestines ANS: B Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver. DIF: Cognitive Level: Comprehension REF: 314 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
60. When assessing a patient, the nurse notes a yellow tinge to the patient’s skin. How should the nurse document this finding? a. Dyspnea b. Cyanosis c. Jaundice d. Ecchymosis ANS: C Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver. DIF:
Cognitive Level: Application
REF: 314
OBJ: 13
TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 61. When assessing a patient, the nurse notes that the patient is unable to lie flat to breathe. When the nurse assists the patient into a sitting position, the patient is able to breathe more easily. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Jaundice d. Orthopnea ANS: D Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably. It occurs in many disorders of the respiratory and cardiac systems. DIF: Cognitive Level: Application REF: 315 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
62. When assessing a patient, the nurse notes that the patient has an unnatural paleness of color to the skin. How should the nurse document this finding? a. Skin pallor b. Pruritus c. Sallow skin d. Jaundice ANS: A Pallor is an unnatural paleness or absence of color in the skin; it may result from a decrease in hemoglobin and erythrocytes. DIF: Cognitive Level: Application REF: 315 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
63. When assessing a patient, the patient complains of an uncomfortable sensation leading to an urge to scratch. The nurse notes the patient scratches frequently. How should the nurse document this finding? a. Dyspnea b. Cyanosis c. Jaundice d. Pruritus ANS: D Pruritus is a symptom of itching and an uncomfortable sensation leading to an urge to scratch. Some causes are allergy, infection, jaundice, elevated serum urea, and skin irritation. DIF: Cognitive Level: Application REF: 315 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
64. A health care provider documents that a patient is having purulent drainage from a wound. What does the nurse understand is most likely the cause? a. Ringworm b. Viral infection c. Fungal infection d. Bacterial infection ANS: D Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues. Bacterial infection is the most common cause. The character of the pus, including its color, consistency, quantity, or odor, may be of diagnostic significance. DIF: Cognitive Level: Comprehension REF: 315 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
65. A health care provider documents that a patient has a sallow complexion. How does the nurse interpret this information? a. Yellow color to the skin b. Blue color to the skin c. Red color to the skin d. Gray color to the skin ANS: A Sallow is an unhealthy, yellow color; usually said of a complexion or skin. DIF: Cognitive Level: Application REF: 315 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
66. A health care provider documents that a patient has a scleral icterus. How does the nurse describe the color of the patient’s sclera? a. Red b. Blue c. Green d. Yellow ANS: D Scleral icterus means the color of the sclera is yellow. The jaundice is due to coloring of the sclera with bilirubin that infiltrates all tissues of the body. DIF: Cognitive Level: Application REF: 315 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
67. A health care provider documents that a patient has a scleral icterus. What is the cause of this coloring? a. Bilirubin
b. Hemoglobin c. Serum potassium d. Serum magnesium ANS: A Scleral icterus means the color of the sclera is yellow. The jaundice is due to coloring of the sclera with bilirubin that infiltrates all tissues of the body. DIF: Cognitive Level: Comprehension REF: 315 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
68. What is the third assessment technique in a standard physical examination? a. Auscultation b. Percussion c. Inspection d. Palpation ANS: A The usual sequence of assessment is inspection, palpation, auscultation, and lastly percussion. DIF: Cognitive Level: Comprehension TOP: Physical examination series MSC: NCLEX: Physiological Integrity
REF: 317 OBJ: 11 KEY: Nursing Process Step: Assessment
MULTIPLE RESPONSE 1. When assessing a female for risk factors associated with coronary artery disease, what information should the nurse include? (Select all that apply.) a. Family history of illness b. Diet c. Smoking d. Exercise e. Number of pregnancies ANS: A, B, C, D With the exception of information relative to pregnancies, all options would be informative about risk for heart disease. DIF: Cognitive Level: Comprehension REF: 313 TOP: Risk factors KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Which are infectious diseases? (Select all that apply.) a. Measles b. Pneumonia c. Hay fever d. Tuberculosis e. Osteoarthritis
OBJ: 3
f. Acquired immunodeficiency syndrome ANS: A, B, D, F Infectious diseases result from the invasion of microorganisms into the body. Examples of infectious diseases include acquired immunodeficiency syndrome (AIDS), tuberculosis, measles, and pneumonia. Hay fever is a manifestation of an allergic reaction, and osteoarthritis is an example of a degenerative disease. DIF: Cognitive Level: Knowledge TOP: Infectious disease MSC: NCLEX: Physiological Integrity
REF: 312 OBJ: 2 KEY: Nursing Process Step: Assessment
3. The nurse is preparing to perform a physical assessment. What essential supplies should this nurse gather? (Select all that apply.) a. Flashlight b. Gloves c. Red pen d. Thermometer e. Scissors ANS: A, B, D, E Items essential to the nurse’s assessment are a penlight or flashlight, a stethoscope, a blood pressure cuff, a thermometer, gloves, gait belt, watch with second hand, scissors, black pen, and a tongue blade. DIF: Cognitive Level: Application TOP: Physical assessment MSC: NCLEX: Physiological Integrity
REF: 324 OBJ: 7 KEY: Nursing Process Step: Assessment
COMPLETION 1. An unpleasant sensation caused by noxious (extremely destructive or harmful) stimulation of the sensory nerve endings is . ANS: pain Pain is an unpleasant sensation caused by noxious (extremely destructive or harmful) stimulation of the sensory nerve endings. It is a cardinal symptom of inflammation and is valuable in the diagnosis of many disorders and conditions. Pain has varied manifestations: mild or severe, chronic, acute, burning, dull or sharp, precisely or poorly localized, or referred. DIF: Cognitive Level: Knowledge REF: 315 TOP: Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
2. When auscultating the chest, a nurse hears crackles in both lower lobes. To further assess this finding, the nurse should ask the patient to .
ANS: cough It is a useful assessment to determine that the patient can clear the secretions by coughing. DIF: Cognitive Level: Application REF: 314 TOP: Crackles KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 11
3. The nurse observes that an older adult patient has no hair on the lower legs. The nurse should assess further for the sufficiency of arterial . ANS: flow Reduced arterial flow causes lack of hair on the lower extremities due to inadequate blood flow. DIF: Cognitive Level: Application TOP: Vascular assessment MSC: NCLEX: Physiological Integrity
REF: 327 OBJ: 12 KEY: Nursing Process Step: Assessment
4. Signs that are perceived by an examiner and can be seen, are known as objective data.
, measured, or felt
ANS: heard Objective data is a sign that can be seen, heard, measured, or felt by the examiner. DIF: Cognitive Level: Knowledge TOP: Objective data MSC: NCLEX: Physiological Integrity
REF: 311 OBJ: 2 KEY: Nursing Process Step: Assessment
5. Symptoms that are perceived by the patient are known as
data.
ANS: subjective Symptoms are subjective indications of illness that are perceived by the patient. Symptoms are referred to as subjective data. DIF: Cognitive Level: Knowledge TOP: Subjective data MSC: NCLEX: Physiological Integrity
REF: 312 OBJ: 2 KEY: Nursing Process Step: Assessment
6. A condition in which there is a lack of appetite resulting in the inability to eat is known as . ANS: anorexia Anorexia is a lack of appetite resulting in the inability to eat. It can occur in many disease conditions. DIF: Cognitive Level: Knowledge REF: 314 TOP: Anorexia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
7. A condition of debility, loss of strength and energy, and depleted vitality is known as . ANS: asthenia Asthenia is a condition of debility, loss of strength and energy, and depleted vitality. DIF: Cognitive Level: Knowledge REF: 314 TOP: Asthenia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
8. A circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute is known as . ANS: bradycardia Bradycardia is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute. DIF: Cognitive Level: Knowledge REF: 314 TOP: Bradycardia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
9. A condition in which a patient experiences bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood is known as . ANS: cyanosis Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood. DIF:
Cognitive Level: Knowledge
REF: 314
OBJ: 4
TOP: Cyanosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. Discoloration of an area of the skin or mucous membrane that is caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls is known as . ANS: ecchymosis Ecchymosis is discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls. DIF: Cognitive Level: Knowledge REF: 314 TOP: Ecchymosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
11. Redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries is known as . ANS: erythema Erythema is redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries. DIF: Cognitive Level: Knowledge REF: 314 TOP: Erythema KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
12. A yellow tinge to the skin that may indicate obstruction in the flow of bile from the liver is known as . ANS: jaundice Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver. DIF: Cognitive Level: Knowledge REF: 314 TOP: Jaundice KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
13. An abnormal condition in which a person must sit or stand to breathe deeply or comfortably is known as . ANS:
orthopnea Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably. DIF: Cognitive Level: Knowledge REF: 315 TOP: Orthopnea KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
14. A symptom of itching and an uncomfortable sensation leading to an urge to scratch is known as _. ANS: pruritus Pruritus is a symptom of itching and an uncomfortable sensation leading to an urge to scratch. DIF: Cognitive Level: Knowledge REF: 315 TOP: Pruritus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
15. A creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of is known as purulent drainage. ANS: tissues Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues. DIF: Cognitive Level: Knowledge TOP: Purulent drainage MSC: NCLEX: Physiological Integrity
REF: 315 OBJ: 4 KEY: Nursing Process Step: Assessment
16. An abnormal condition in which the heart contracts regularly but at a rate greater than 100 beats/min is known as . ANS: tachycardia Tachycardia is an abnormal condition in which the heart contracts regularly but at a rate greater than 100 beats/min. DIF: Cognitive Level: Knowledge REF: 315 TOP: Tachycardia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
17. An abnormally rapid rate of breathing that is seen in many disease conditions is known as . ANS: tachypnea Tachypnea is an abnormally rapid rate of breathing that is seen in many disease conditions. DIF: Cognitive Level: Knowledge REF: 315 TOP: Tachypnea KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
18. A condition in which there is a temporary loss of consciousness associated with an increased rate of respiration, tachycardia, pallor, perspiration, and coolness of the skin is known as . ANS: syncope Syncope is a temporary loss of consciousness (partial or complete) associated with an increased rate of respiration, tachycardia, pallor, perspiration, and coolness of skin. DIF: Cognitive Level: Knowledge REF: 326 TOP: Syncope KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
19. Cultural beliefs and personal characteristics determine behavior in individuals and families. More than half of all health problems are the result of behavior and lifestyle. ANS: health Cultural beliefs and personal characteristics determine health behavior in individuals and families. More than half of all health problems are the result of behavior and lifestyle. DIF: Cognitive Level: Knowledge TOP: Cultural sensitivity MSC: NCLEX: Physiological Integrity
REF: 322 OBJ: 14 KEY: Nursing Process Step: Assessment
Chapter 14: Oxygenation Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. When an older adult patient with chronic emphysema comes to the emergency department in respiratory distress, at what rate should the nurse begin oxygen per nasal cannula? a. 2 L/min b. 3 L/min c. 4 L/min d. 5 L/min ANS: A Administering O2 at more than 2 L/min to a person with chronic pulmonary disease may cause respiratory failure. DIF: Cognitive Level: Application TOP: O2 administration Implementation MSC: NCLEX: Physiological Integrity
REF: 340 OBJ: 1 KEY: Nursing Process Step:
2. The nurse instructs a patient receiving home O2 therapy to drink plenty of fluids to help keep bronchial secretions liquefied. What is the recommended fluid? a. Milk b. Water c. Tea with artificial sweetener d. Coffee ANS: B Water is the best option. Drinks with caffeine, sugar, or dairy products are not helpful to liquefy secretions. DIF: Cognitive Level: Application REF: 345 OBJ: 1 TOP: Fluids KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The wife of a patient with a cuffed tracheostomy asks why the cuff is inflated intermittently. What is the purpose of the inflated cuff? a. Prevent regurgitation after meals. b. Hold the trachea open until it is completely healed. c. Dilate the tracheal opening for passage of secretions. d. Prevent aspiration when eating. ANS: D The cuff is inflated to prevent aspiration while eating or when cleaning the tracheostomy tube. DIF:
Cognitive Level: Analysis
REF: 346
OBJ: 7
TOP: Cuffed tracheostomy tubes KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 4. Which of the following is an appropriate nursing measure when performing tracheostomy care? a. Wear clean gloves. b. Insert the catheter without suction. c. Suction for 1 minute before removing the catheter. d. Place the used catheter in a plastic shield for later use. ANS: B Insertion of the suction catheter without suction reduces the probability of tissue injury. Sterile gloves should be used for tracheostomy care. Suctioning should be done for a maximum of 10 seconds at a time. A used catheter should be disposed of appropriately. DIF: Cognitive Level: Application TOP: Tracheal suction Implementation MSC: NCLEX: Physiological Integrity
REF: 347 OBJ: 7 KEY: Nursing Process Step:
5. An 80-year-old male patient has been admitted to the acute care facility with the diagnosis of pneumonia. He is receiving oxygen via nasal cannula at 2 L/min. The nurse assesses respirations at 24/min, PaO2 level 88 mm Hg, and pink skin tone. What action should the nurse implement? a. Notify thehealth care provider. b. Increase oxygen to 4 L/min. c. Record PaO2 level. d. Administer nebulizer treatment. ANS: C The nurse would document PaO2 level. Normal arterial oxygen levels sometimes decrease with age, but not usually low enough to fall outside the normal range. It may be possible for an 80-year-old person to have an arterial partial pressure oxygen (PaO2) level (the amount of oxygen found in the arterial circulation) between 80 and 85 mm Hg (normal range is 80 to 100 mm Hg) without experiencing significant alterations in health. DIF: Cognitive Level: Comprehension REF: 344 TOP: PaO2 levels KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. What is the appropriate value for the venturi mask? Oxygen delivery devices with percent of oxygen delivered Delivery device Amount of delivered FiO2 Nasal cannula 1–6 L/min = 24%–44% O2 Simple face mask 5–8 L/min = 35%–55% O2 Venturi mask Partial rebreather mask 6–12 L/min = 60%–90% O2 Nonrebreather mask 6–15 L/min = 70%–100% O2
OBJ: 1
a. 1–6 L/min = 24%–44% O2 b. 5–8 L/min = 35%–55% O2 c. 4–10 L/min = 24%–55% O2 d. 6–12 L/min = 60%–90% O2 e. 6–15 L/min = 70%–100% O2 ANS: C DIF: Cognitive Level: Knowledge REF: 340 OBJ: 1 TOP: O2 administration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. A patient has a new health care provider’s order for oxygen administration at 2 L via nasal cannula. Who can initiate implementation of this order? (Select all that apply.) a. RN b. UAP c. Respiratory therapist d. EMT e. Nutritional specialist ANS: A, C, D Oxygen therapy may be initiated by a respiratory therapist, a nurse, an emergency medical technician (EMT), or any other licensed health care provider with an appropriate order for the oxygen. In some facilities, there is a respiratory care department, staffed by respiratory therapists who assume the responsibility of administering oxygen and delivering treatments that will improve a patient’s ventilation and oxygenation. Adjustment of the oxygen flow rate is not delegated to UA nor nutritional specialist. DIF: Cognitive Level: Comprehension TOP: O2 administration Implementation MSC: NCLEX: Physiological Integrity
REF: 340 OBJ: 1 KEY: Nursing Process Step:
2. The nurse is caring for a patient with an endotracheal tube. What interventions will the nurse implement? (Select all that apply.) a. Change or clean all respiratory therapy equipment every 24 hours. b. Turn and reposition the patient every 2 hours. c. Provide constant airway humidification. d. Encourage intake of fruits and vegetables. e. Elevate the head of the bed. ANS: B, C, E Nursing interventions for the patient with an endotracheal tube include turning and repositioning every 2 hours for maximal ventilation and lung expansion, constant airway humidification and elevation of the head of the bed to assist with ventilation. Equipment should be changed or cleaned at least every 8 hours. Patients with endotracheal tubes are allowed nothing by mouth (NPO). It is necessary to provide parenteral or enteral nourishment.
DIF: Cognitive Level: Application TOP: Endotracheal care Implementation MSC: NCLEX: Physiological Integrity
REF: 350 OBJ: 7 KEY: Nursing Process Step:
COMPLETION 1. A cannula is a device consisting of small tubes inserted into the nares and is the most common way to administer oxygen. ANS: nasal A nasal cannula is device consisting of small tubes inserted into the nares and is the most common way to administer oxygen. DIF: Cognitive Level: Knowledge TOP: O2 administration MSC: NCLEX: Physiological Integrity
REF: 340 OBJ: 1 KEY: Nursing Process Step: Assessment
2. When suctioning a tracheostomy suction may be applied for a maximum of at a time never longer.
seconds
ANS: 10 ten Suctioning should be done for a maximum of 10 seconds at a time. Prolonged suctioning depletes oxygen supply. DIF: Cognitive Level: Application TOP: Tracheal suction Implementation MSC: NCLEX: Physiological Integrity
REF: 348 OBJ: 7 KEY: Nursing Process Step:
Chapter 15: Elimination and Gastric Intubation Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. After a Foley catheter has been removed, the nurse should assess the patient for: a. hemorrhage. b. constipation. c. urinary retention. d. bladder spasm. ANS: C While an indwelling urinary catheter is in place, the bladder loses tone and can retain urine after the removal of the catheter. DIF: Cognitive Level: Application TOP: Catheter removal MSC: NCLEX: Physiological Integrity
REF: 364 OBJ: 1 KEY: Nursing Process Step: Assessment
2. What would be the correct explanation of catheter care? a. Cleansing the first 2 in of the catheter with soap and water every shift b. Disinfecting the entire catheter with alcohol every shift c. Lubricating the catheter with antiseptic lotion every 24 hours d. Cleansing the meatal-catheter junction every 24 hours ANS: A The first 2 in of the catheter should be cleaned with soap and water every shift or more often if the patient is incontinent. Alcohol and lotions are contraindicated. Catheter care should be done every shift. DIF: Cognitive Level: Application REF: 368 OBJ: 1 TOP: Catheter care KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 3. During insertion of a Foley catheter, the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse? a. Withdraw the catheter. b. Ask the patient to bear down. c. Continue to inflate the balloon. d. Advance the catheter into the bladder. ANS: D Grimacing is a sign of pain indicating that the balloon might be in the urethra instead of the bladder. The catheter should be advanced before inflation. DIF: Cognitive Level: Application TOP: Catheterization MSC: NCLEX: Physiological Integrity
REF: 360 OBJ: 1 KEY: Nursing Process Step: Assessment
4. When explaining the difference between a colostomy and an ileostomy, the nurse explains which of the following about an ileostomy? a. It is always permanent. b. It drains semiliquid stool. c. It has a much larger stoma. d. It does not need a pouch. ANS: B The ileostomy is higher in the GI tract and drains semiliquid stool. The ileostomy is very similar in appearance to the colostomy, may not be permanent, and needs a pouch. DIF: Cognitive Level: Comprehension REF: 383 OBJ: 7 TOP: Ileostomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. Before inserting a nasogastric tube, what measurement should the nurse take? a. Tip of the nose to the earlobe to the xiphoid process b. Bridge of the nose to the xiphoid process c. Nose to the top of the ear to the stomach d. Clavicular notch to the stomach ANS: A The measurement is from the tip of the nose to the ear lobe to the xiphoid process. DIF: Cognitive Level: Application TOP: Nasogastric (NG) tube Implementation MSC: NCLEX: Physiological Integrity
REF: 376 OBJ: 3 KEY: Nursing Process Step:
MULTIPLE RESPONSE 1. Bladder training is initiated on a patient preparing for discharge to home from an acute care setting. When should voiding times be scheduled? (Select all that apply.) a. At least every hour b. At patients request c. Before each meal d. At bedtime e. Upon waking up in morning ANS: C, D, E Typical voiding times are upon rising, before each meal, and at bedtime. When initiating bladder training the nurse should assist the patient to void as scheduled, check the patient for wetness periodically, and remind or assist the patient to the toilet as scheduled. DIF: Cognitive Level: Application TOP: Bladder training Implementation MSC: NCLEX: Physiological Integrity
REF: 373 OBJ: N/A KEY: Nursing Process Step:
2. The nurse administers an enema to a patient as ordered. What should be documented? (Select all that apply.) a. Date b. Time c. Type and volume of enema d. Temperature of solution e. Characteristics of results f. How patient tolerates procedure ANS: A, B, C, D, E, F Following an enema date, time, type and volume of enema, temperature of solution, characteristics of results and how patient tolerated procedure should all be documented. DIF: Cognitive Level: Application REF: 385 OBJ: 6 TOP: Enemas KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1.
is the inability to control urine or bowel elimination and can be a psychologically distressing and socially disruptive problem, especially among older adults. ANS: Incontinence Incontinence is the inability to control urine or bowel elimination. It can be a psychologically distressing and socially disruptive problem, especially among older adults. DIF: Cognitive Level: Knowledge REF: 370 TOP: Incontinence KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. A the nasopharynx.
OBJ: N/A
tube is a flexible, hollow tube that is passed into the stomach via
ANS: nasogastric A nasogastric tube is a flexible, hollow tube that is passed into the stomach via the nasopharynx. DIF: Cognitive Level: Knowledge TOP: Nasogastric (NG) tube MSC: NCLEX: Physiological Integrity
REF: 373 OBJ: 3 KEY: Nursing Process Step: Assessment
3. A is the diversion of urine away from a diseased or defective bladder through a surgically created opening or stoma in the skin.
ANS: urostomy A urostomy is the diversion of urine away from a diseased or defective bladder through a surgically created opening or stoma in the skin. DIF: Cognitive Level: Knowledge REF: 383 TOP: Urostomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 8
Chapter 16: Care of Patients Experiencing Urgent Alterations in Health Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. When administering first aid in emergency situations, the nurse must first survey victims for severity of injuries. What term correctly describes this process? a. The Good Samaritan law b. An emergency interview c. Triage d. Taking vital signs ANS: C This process of patient classification is called triage. DIF: Cognitive Level: Knowledge REF: 393 | 394 TOP: First aid KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
2. The Good Samaritan law will protect all people who offer assistance. What is necessary for this protection? a. A license b. The person acts prudently c. Licensed supervision d. The patient improves ANS: B The Good Samaritan law will protect any person who follows a prudent course of action. DIF: Cognitive Level: Comprehension TOP: Good Samaritan law MSC: NCLEX: N/A
REF: 394 OBJ: 2 KEY: Nursing Process Step: N/A
3. A nurse is assessing victims in an emergency situation. What will the nurse assess for first? a. Hemorrhage b. Fractures c. Mobility d. Abnormal breathing ANS: D A life-threatening situation of the highest priority is arrested or abnormal breathing. DIF: Cognitive Level: Application TOP: ABC of assessment MSC: NCLEX: Physiological Integrity
REF: 394 OBJ: 1 KEY: Nursing Process Step: Assessment
4. CPR has been initiated at an accident site. When can CPR be terminated? a. Victim is clinically dead.
b. Victim is brain dead. c. Paramedics arrive. d. Rescuer perceives CPR is futile. ANS: C There is a moral obligation to continue CPR once it has been initiated unless the rescuer is exhausted and cannot continue, trained medical personnel take over CPR, or a licensed health care provider pronounces the victim dead. DIF: Cognitive Level: Comprehension REF: 394 TOP: Cardiopulmonary resuscitation (CPR) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 4
5. The nurse determines clinical death and initiates CPR immediately. How long is resuscitation considered possible? a. If cardiopulmonary arrest has existed for no more 2 minutes b. If cardiopulmonary arrest has existed for no more 3 minutes c. If cardiopulmonary arrest has existed for no more 4 minutes d. If cardiopulmonary arrest has existed for no more 5 minutes ANS: C CPR can reverse clinical death if initiated before 4 minutes. DIF: Cognitive Level: Comprehension REF: 395 TOP: Cardiopulmonary resuscitation (CPR) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 3
6. When assessing the adult victim for pulselessness, the CPR rescuer should palpate the most reliable and accessible pulse. Which pulse will be palpated? a. Radial b. Brachial c. Carotid d. Femoral ANS: C When assessing the adult victim for pulselessness, the most reliable and accessible pulse is the carotid. DIF: Cognitive Level: Application REF: 396 OBJ: 4 TOP: Cardiopulmonary resuscitation (CPR) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. When a patient suddenly experiences respiratory difficulty in the cafeteria, the nurse begins assessment for foreign-body airway obstruction. What is the most appropriate question to ask the victim? a. “What did you swallow?” b. “Are you choking?” c. “Are you OK?”
d. “Can I help you?” ANS: B With complete airway obstruction, the victim cannot speak. Ask, “Are you choking?” With this question the nurse pinpoints the problem and can perform the Heimlich maneuver with no wasted time. DIF: Cognitive Level: Application TOP: Heimlich maneuver Implementation MSC: NCLEX: Physiological Integrity
REF: 400 OBJ: 1 KEY: Nursing Process Step:
8. The patient arrived at the emergency department in pain and bleeding profusely with the following vital signs: BP 80/54, P 102, RR 22. What does the nurse recognize that these symptoms indicate? a. Inadequate perfusion b. Circulatory shock c. Massive vasodilation d. Heart failure ANS: B Shock results from failure of the circulatory system to provide sufficient blood circulation. DIF: Cognitive Level: Analysis REF: 402 TOP: Shock KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 7
9. CPR has been initiated on an adult patient. How will the nurse confirm the effectiveness of CPR? a. Assessing an EKG pattern with each compression b. Assessing a palpable carotid pulse during each compression c. Assuring a compression depth of to 2 in d. Observing pupils that change from pinpoint to dilated ANS: B During effective CPR, a carotid pulse is palpable during each compression. DIF: Cognitive Level: Application REF: 396 TOP: Cardiopulmonary resuscitation (CPR) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 4
10. A patient with multiple serious injuries sustained in a motorcycle accident is lying beside his wrecked motorcycle unconscious and bleeding when the rescuer arrives at the scene. What will be the rescuer’s priority action? a. Assessing blood loss b. Assessing respiratory status c. Obtaining vital signs d. Organizing laypeople at the scene
ANS: B Priority intervention is to assess respiratory status. DIF: Cognitive Level: Application REF: 417 TOP: First aid KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
11. The worried mother of an accident victim asks the nurse how much circulating blood an average adult male is supposed to have. What will the nurse reply? a. 8 pints b. 10 pints c. 12 pints d. 14 pints ANS: C An average adult male has 12 pints of blood. DIF: Cognitive Level: Knowledge TOP: Circulating blood volume Implementation MSC: NCLEX: Physiological Integrity
REF: 403 OBJ: 8 KEY: Nursing Process Step:
12. The nurse is assessing a patient who is severely bleeding and at risk for hypovolemic shock. What can the nurse anticipate? a. Slow, labored breathing b. Hot, flushed skin c. Edematous extremities d. Weak, thready pulse ANS: D The pulse becomes weak and thready with hypovolemic shock. DIF: Cognitive Level: Application TOP: Symptoms of shock MSC: NCLEX: Physiological Integrity
REF: 402 OBJ: 7 KEY: Nursing Process Step: Assessment
13. A nurse assesses an accident victim who has bright red blood spurting from a laceration on his right forearm. Where will the nurse apply pressure after applying direct pressure and elevating the limb? a. Right subclavian artery b. Right radial artery c. Right ulnar artery d. Right brachial artery ANS: D Arterial bleeding is characterized by the spurting of bright red blood and can be controlled by direct pressure, elevation, and indirect pressure on the appropriate pressure point. The brachial artery is the closest pressure point to the injury. DIF:
Cognitive Level: Application
REF: 403-404
OBJ: 10
TOP: Pressure points Implementation MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step:
14. The nurse is attempting to control bleeding in a patient with a profusely bleeding scalp wound. What is the most effective initial treatment of this bleeding? a. Elevate the head. b. Apply direct pressure. c. Apply an ice pack. d. Apply indirect pressure. ANS: B The most effective general treatment of bleeding is to apply direct pressure. DIF: Cognitive Level: Application TOP: Control of bleeding Implementation MSC: NCLEX: Physiological Integrity
REF: 404 OBJ: 10 KEY: Nursing Process Step:
15. When other methods have failed to stop the bleeding and the victim’s life is in danger, the rescuer at the scene applies a tourniquet to a young woman’s leg above the knee. What is another step that is essential for the rescuer to follow? a. Never release the tourniquet. b. Wrap the tourniquet around the limb twice. c. Mark the patient with a “T.” d. Leave the limb elevated. ANS: A A tourniquet must never be released once it is in place. All other options are enhancements to the procedure of the tourniquet application, but not essential. DIF: Cognitive Level: Application REF: 404 | 405 OBJ: 8 TOP: Tourniquet KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is teaching a patient with epistaxis about the best way to control bleeding. What information will the nurse relay to this patient? a. Place ice on the nose and pinch the nostrils. b. Maintain a flat position. c. Pack nostrils with cotton. d. Lean backward. ANS: A Apply steady pressure to both nostrils while applying ice to the nose is the best way to attempt to control the bleeding of epistaxis. DIF: Cognitive Level: Application REF: 405 OBJ: 8 TOP: Epistaxis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
17. A farm worker who has been kicked in the stomach by a mule passes a foul, black, tarry stool. What is this called? a. Loose stool b. Melena c. Hematuria d. Hemoptysis ANS: B When internal bleeding occurs, the patient may demonstrate hemoptysis (bloody sputum), hematemesis (bloody vomit), melena (foul black tarry stool), or hematuria (bloody urine). DIF: Cognitive Level: Knowledge REF: 406 TOP: Melena KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 2
18. A machinist visits the industrial nurse’s clinic with a deep laceration of the thigh. What should be the nurse’s first action? a. Splint the thigh and apply tape to approximate the edges. b. Apply ice and a pressure dressing to the thigh. c. Give a tetanus booster injection. d. Wash the laceration with an antiseptic. ANS: D Lacerations should be cleaned thoroughly and bandaged to approximate the edges. DIF: Cognitive Level: Application REF: 419 OBJ: 9 TOP: Wounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The patient’s lower chest has been punctured with a knife that is still in place. What should the nurse’s first action be? a. Remove the knife. b. Apply an airtight dressing over the wound. c. Place the patient in a modified Trendelenburg’s position. d. Immobilize the knife with dressings and tape. ANS: D When the patient’s lower chest has been punctured with the weapon still in place, the nurse should immobilize the weapon with dressings and tape. DIF: Cognitive Level: Application REF: 408 OBJ: 9 TOP: Wounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. A patient arrives in the emergency department with a sucking wound to the left chest. What is the first action the nurse should take? a. Place several layers of gauze dressing over the wound. b. Place the patient in a supine position. c. Cover the wound with an airtight dressing taped on three sides.
d. Turn the patient to the left side. ANS: C Sucking chest wounds should be dressed with a flutter dressing so that air can escape the pleural space, but no more air can be sucked in. DIF: Cognitive Level: Application TOP: Sucking chest wounds Implementation MSC: NCLEX: Physiological Integrity
REF: 408 OBJ: 9 KEY: Nursing Process Step:
21. The nurse is assisting a victim of an accident who requires bandaging of the right lower extremity. What should the nurse do when applying the bandage? a. Use sterile material. b. Leave the toes exposed. c. Bandage the extremity tightly. d. Bend the knee after bandaging. ANS: B The tips of the toes should remain exposed to assess circulation. DIF: Cognitive Level: Application REF: 408 OBJ: 1 TOP: Bandaging KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. A patient who had taken a poisonous substance is brought to the emergency department. What is the first action the nurse should take? a. Give syrup of ipecac. b. Contact the poison control center. c. Give milk to coat the stomach. d. Observe for symptoms. ANS: B The nurse should immediately call the poison control center. DIF: Cognitive Level: Application REF: 409 | 410 OBJ: 11 TOP: Poison KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. A patient has been stung by a bee and is brought to the emergency department. The nurse observes the sting site and identifies that the stinger is still in the skin. What action should the nurse take? a. Remove it with sterile tweezers. b. Soak the area with a cold compress. c. Scrape the stinger with the side of a knife. d. Squeeze the surrounding tissue to expel the stinger. ANS: C The stinger should be removed with the side of a knife by scraping to avoid forcing more venom into the skin.
DIF: Cognitive Level: Application REF: 411 OBJ: 1 TOP: Wounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. The patient with heatstroke has been undressed and treated with cold packs and a fan. The patient’s temperature is now down to 101.2°F (38.4°C). The patient starts to shiver. What action should the emergency department nurse take? a. Raise the head of the bed. b. Offer warm liquids. c. Remove cold packs and fan. d. Continue with cooling interventions. ANS: C The cooling techniques have caused the patient to shiver, which will increase the patient’s temperature. DIF: Cognitive Level: Application REF: 413 OBJ: 12 TOP: Heatstroke KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. The patient is admitted to the emergency department, having suffered frostbite to the hands, which are grayish-white in color. What action should the nurse implement when attempting to warm the hands? a. Have the patient rub the hands together briskly. b. Wipe the hands vigorously with a warm towel. c. Run tepid water over the hands to warm slowly. d. Wrap the hands in hot, moist towels. ANS: D Warming the hands in moist towels will warm the hands slowly. Friction of frozen body parts should be avoided. DIF: Cognitive Level: Application REF: 414 OBJ: 12 TOP: Frostbite KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. A visitor in the hospital slips and falls. The patient’s arm appears dislocated and the visitor is unable to move it. What is the first action the nurse should implement? a. Apply cold packs. b. Check range of motion. c. Splint the arm. d. Apply an Ace bandage. ANS: C The nurse should splint the arm where it lies and not attempt to move or rearrange the limb. DIF: Cognitive Level: Application REF: 415 OBJ: 13 TOP: Fracture KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
27. The patient is brought to the emergency department after having fractured an arm 12 hours ago. The arm is very edematous from the fingers to the elbow, and the patient cannot move it. What should be the initial action of the nurse? a. Test range of motion. b. Take the vital signs. c. Place ice packs on the arm. d. Check fingers for capillary refill. ANS: D Swelling from the fracture can impede circulation. DIF: Cognitive Level: Application REF: 414-415 TOP: Injuries KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
28. When assessing a patient who has suffered a burn injury, the nurse classifies the burn as a deep partial-thickness burn. What is this observation most likely based upon? a. Painful reddened skin b. Charred skin with milky-white areas c. Erythema and blisters d. Erythema, pain, and swelling ANS: C With deep partial-thickness burns, blister formation may be seen with erythema. DIF: Cognitive Level: Comprehension REF: 417 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
29. The nurse arrives on the scene of a fire. What is the first thing the nurse will do for a burn victim? a. Apply dressings. b. Cover with a blanket. c. Cool the burn immediately. d. Apply topical ointment. ANS: C The burn should be cooled immediately to stop the burning process. DIF: Cognitive Level: Application REF: 417 OBJ: 12 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. A patient is admitted to the hospital after receiving a blow to the head. The patient begins to show signs of shock. How should the patient be positioned? a. With the head lower than the body b. Flat with the legs elevated c. Flat on the back d. In a side-lying position
ANS: C If head injuries are suspected, the victim must be kept flat. DIF: Cognitive Level: Application REF: 403 OBJ: 1 TOP: Shock KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 31. While on break in the hospital cafeteria a nurse witnesses her pregnant coworker start to choke. The coworker is conscious, but unable to breathe. Where should the nurse administer thrusts? a. Below the navel b. The chest c. At the xiphoid process d. The upper back ANS: B If the victim is pregnant or obese, chest thrusts are acceptable instead of abdominal thrusts. To provide chest thrusts, the nurse should place his or her hands in the same position that is used for chest compressions during CPR. DIF: Cognitive Level: Knowledge REF: 401 OBJ: 5 TOP: Choking KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 32. A burn patient is brought into the emergency department with the following burns: half of the front torso, entire left arm, and front of left leg. The nurse should record that the patient has a % burn. a. 27 b. 25 c. 50 d. 43 ANS: A Half of the front torso = 9, entire left arm = 9, front of the left leg = 9. DIF: Cognitive Level: Analysis TOP: Rule of nines MSC: NCLEX: Physiological Integrity
REF: 417 OBJ: 12 KEY: Nursing Process Step: Assessment
COMPLETION 1. When treating an infant choking on a foreign body, the nurse should use a combination of back and chest thrusts. ANS: blows
If the nurse is assisting a child who has aspirated a foreign body, the nurse may treat the child in a manner similar to the adult with performance of abdominal thrusts. However, there is a potential for injury if the nurse uses this maneuver in the infant. The nurse should use a combination of back blows and chest thrusts with an infant. DIF: Cognitive Level: Application REF: 401 OBJ: 6 TOP: Choking KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. If a spinal injury is suspected, before the rescuer starts CPR, the trachea should be opened with a jaw maneuver. ANS: thrust The jaw-thrust maneuver does not hyperextend the neck. DIF: Cognitive Level: Application REF: 397 TOP: Cardiopulmonary resuscitation (CPR) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 14
3. When two nurses perform two-person CPR, there should be two slow breaths for every 30 . ANS: compressions Two slow breaths are given after every 30 compressions. DIF: Cognitive Level: Application TOP: Two-person CPR Implementation MSC: NCLEX: Physiological Integrity
REF: 398 OBJ: 4 KEY: Nursing Process Step:
4. The acronym RICE directs the nurse in the care of a sprain. The “C” in the acronym stands for . ANS: compression The acronym stands for Rest, Ice, Compression, and Elevation. DIF: Cognitive Level: Knowledge REF: 415-416 TOP: Sprain KEY: Nursing Process Step: Application MSC: NCLEX: Physiological Integrity
OBJ: 13
5. When performing on an infant, the breastbone is depressed approximately one-third of the chest diameter or in.
ANS: CPR The breastbone is depressed one-third the chest diameter or an infant. DIF: Cognitive Level: Application REF: 399 TOP: Cardiopulmonary resuscitation (CPR) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
in when doing CPR on
OBJ: 4
Chapter 17: Dosage Calculation and Medication Administration Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. What is the correct conversion for the improper fraction a. b.
?
7 8
c. 7.79 d. 79.7 ANS: B
Divide the numerator by the denominator. The correct conversion for the improper fraction is 8 . DIF: Cognitive Level: Comprehension REF: 425 TOP: Math KEY: Nursing Process Step: N/A 2. What is the fraction
OBJ: 3 MSC: NCLEX: N/A
when reduced to lowest terms?
a. b. c. d. 3 ANS: C
Find a number that will evenly divide into the numerator and the denominator. DIF: Cognitive Level: Comprehension REF: 425 TOP: Math KEY: Nursing Process Step: N/A 3. Which of the following fractions is the largest? a. b. c. d.
ANS: A
The smaller the denominator, the larger the fraction.
OBJ: 3 MSC: NCLEX: N/A
DIF: Cognitive Level: Knowledge REF: 424 TOP: Math KEY: Nursing Process Step: N/A
OBJ: 3 MSC: NCLEX: N/A
4. Which of the following fractions is the smallest? a. b. c. d. ANS: A
The larger the denominator, the smaller the fraction. DIF: Cognitive Level: Knowledge REF: 425 TOP: Math KEY: Nursing Process Step: N/A 5. What is the sum of
and
OBJ: 3 MSC: NCLEX: N/A
?
a. b. c. d.
1
ANS: D
Find the common denominator and add.
will equal
. Add
. Reduce to
lowest terms = 1 . DIF: Cognitive Level: Comprehension REF: 425 TOP: Math KEY: Nursing Process Step: N/A 6. What is the product of
?
a. b. c. d.
ANS: A
Multiply the numerators. Multiply the denominators.
OBJ: 3 MSC: NCLEX: N/A
DIF: Cognitive Level: Comprehension REF: 425 TOP: Math KEY: Nursing Process Step: N/A 7. What is
divided by
OBJ: 3 MSC: NCLEX: N/A
?
a. b. c. d. ANS: B
Write the problem down correctly, invert the second number, and multiply. DIF: Cognitive Level: Comprehension REF: 427 TOP: Math KEY: Nursing Process Step: N/A
OBJ: 3 MSC: NCLEX: N/A
8. What is 2.34 + 0.77? a. 0.01 b. 90.4 c. 2.417 d. 3.11 ANS: D
Align the decimal point of each decimal fraction in a column and add. DIF: Cognitive Level: Comprehension REF: 428 TOP: Math KEY: Nursing Process Step: N/A
OBJ: 3 MSC: NCLEX: N/A
9. What is 6.147 rounded to the nearest tenth? a. 6.2 b. 6.15 c. 6.14 d. 6.1 ANS: D
A subsequent number that is 5 or larger can increase the previous number by one whole number. A subsequent number that is less than 5 will leave the number unchanged. DIF: Cognitive Level: Application REF: 424 TOP: Math KEY: Nursing Process Step: N/A 10. What is 2.5 2? a. 1.25 b. 5 c. 50 d. 22.5 ANS: B
OBJ: 3 MSC: NCLEX: N/A
When multiplying, decimal points do not have to be aligned. The decimal point in the answer is determined by the number of decimal points found to the right of the decimal point in the numbers multiplied. DIF: Cognitive Level: Application REF: 428 TOP: Math KEY: Nursing Process Step: N/A
OBJ: 3 MSC: NCLEX: N/A
11. What is 4.5 divided by 3? a. 0.75 b. 1.5 c. 5 d. 0.66 ANS: B
In the divisor, move the decimal point all the way to the right and move the decimal point in the dividend the same number of places as moved in the divisor. DIF: Cognitive Level: Application REF: 428 TOP: Math KEY: Nursing Process Step: N/A
OBJ: 3 MSC: NCLEX: N/A
12. What is 0.9% expressed as a decimal? a. 9 b. 0.9 c. 0.09 d. 0.009 ANS: D
Remove the % and move the decimal point two places to the left. DIF: Cognitive Level: Application REF: 429 TOP: Math KEY: Nursing Process Step: N/A 13. What is a. b. c. d.
OBJ: 3 MSC: NCLEX: N/A
expressed as a percent?
50% 20% 10% 5%
ANS: B
Change a fraction to a percent by dividing the numerator by the denominator and multiplying by 100. DIF: Cognitive Level: Application REF: 429 TOP: Math KEY: Nursing Process Step: N/A 14. Which is the same ratio as 2:100? a. 1:50 b. 5:300 c. 1:20 d. 4:25
OBJ: 3 MSC: NCLEX: N/A
ANS: A
The value of a ratio is not changed if both sides are multiplied or divided by the same number. DIF: Cognitive Level: Application REF: 429 TOP: Math KEY: Nursing Process Step: N/A
OBJ: 3 MSC: NCLEX: N/A
15. The medication order reads “Ibuprofen 600 mg PO tid.” The bottle is labeled “Ibuprofen
200 mg/tab.” How many tablets should the nurse administer? a. 1 b. 2 c. 3 d. 6 ANS: C
Desired dose over available dose times the unit. The unit is what the available dose is contained in. DIF: Cognitive Level: Application REF: 428-429 OBJ: 3 TOP: Math KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 16. The health care provider has ordered furosemide 20 mg stat. The ampule is labeled 40
mg/mL. What dose should the nurse administer? a. 0.8 mL b. 0.5 mL c. 2.0 mL d. 8.0 mL ANS: B
Desired dosage over the available dosage times the unit. The unit is what the available dosage is contained in.
DIF: Cognitive Level: Analysis REF: 428-429 TOP: Math KEY: Nursing Process Step: Assessment
OBJ: 3 MSC: NCLEX: N/A
17. 6 mg is equal to how many grams? a. 6.0 g b. 0.6 g c. 0.06 g d. 0.006 g ANS: D
Small to big, move decimal point three places to the left. DIF: Cognitive Level: Application REF: 424 TOP: Math KEY: Nursing Process Step: N/A 18. 0.5 L is equal to how many mL?
OBJ: 3 MSC: NCLEX: N/A
a. b. c. d.
0.0005 mL 0.05 mL 50 mL 500 mL
ANS: D
Big to small, move decimal point three places to the right. DIF: Cognitive Level: Application REF: 424 TOP: Math KEY: Nursing Process Step: N/A
OBJ: 3 MSC: NCLEX: N/A
19. The average adult dose of Phenergan is 50 mg. Using the Young rule for a 10-year-old,
what is the correct dosage for the child? a. 23 mg b. 25 mg c. 30 mg d. 35 mg ANS: A
[Age of the child over age of the child + 12] the average adult dose = child’s dose.
DIF: Cognitive Level: Analysis REF: 426-427 OBJ: 4 TOP: Math KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 20. A 35-lb child is to receive an IM medication. The average adult dose is 75 mg. Using the
Clark rule, what dosage should the nurse administer? a. 30.5 mg b. 25.5 mg c. 20.5 mg d. 17.5 mg ANS: D
[Weight of child in pounds ÷ 150] average adult dose = child’s dose.
DIF: Cognitive Level: Application REF: 426-427 OBJ: 4 TOP: Math KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 21. Tylenol gr V is ordered. The available tablet is 0.3 g. What dosage should the nurse
administer? a. 1 tablet b. 1.5 tablets c. tablet
d. 2 tablets ANS: A
Gram to grain, multiply by 15. (0.3 15 = 4.5 grains). DIF: Cognitive Level: Application REF: 426-427 OBJ: 2 TOP: Math KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 22. Lanoxin 0.125 mg is to be given. The nurse converts the dose to how many grams? a. 1.250 g b. 1250 g c. 0.000125 g d. 0.00125 g ANS: C
Small, arrow to big, move the decimal point three places in the direction the arrow points; move decimal three places to the left. DIF: Cognitive Level: Application REF: 424 OBJ: 1 TOP: Math KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 23. Atropine 0.4 mg is to be given. Ampule is labeled gr 1/150/mL. What dose should the
nurse administer? a. 1.5 mL b. 0.25 mL c. 0.5 mL d. 1 mL ANS: D
To convert mg to gr, divide by 60. DIF: Cognitive Level: Application REF: 425 OBJ: 2 TOP: Math KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 24. A 150-lb man is to receive a medication based on milligrams/kilograms. He is to receive 1
mg/kg. What dosage should the nurse administer? a. 50 mg b. 68 mg c. 75 mg d. 80 mg ANS: B
2.2 lb equals 1 kg. DIF: Cognitive Level: Application REF: 423 OBJ: 1 TOP: Math KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 25. 0.5 g of medication is ordered. The label reads 125 mg/mL. What is the correct dose to be
administered?
a. b. c. d.
1 mL 2 mL 3 mL 4 mL
ANS: D
Desired dose over available dose the unit. Unit is what the available dose is contained in. DIF: Cognitive Level: Application REF: 423 OBJ: 3 TOP: Math KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 26. What is the main organ that inactivates and metabolizes drugs? a. Spleen b. Liver c. Lungs d. Pancreas ANS: B
The liver is the main organ that inactivates and metabolizes drugs. DIF: Cognitive Level: Comprehension REF: 432 OBJ: 8 TOP: Pharmacology KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 27. When giving a subcutaneous injection to a very thin patient, how does the nurse alter the
injection technique? a. Using a 23-gauge needle b. Spreading the skin before injection c. Pinching up the skin and inserting the needle at a 45-degree angle d. Injecting the medicine quickly to reduce pain ANS: C
The subcutaneous technique changes when injecting a thin patient. The selection of needles is the same ( -in needle of 27 or 28 gauge), the site selection is the same, but the technique changes to pinch up the skin and inject at a 45-degree angle. DIF: Cognitive Level: Application REF: 473 OBJ: 11 TOP: Subcutaneous injections KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 28. The nurse cautions a patient taking an anticoagulant that he should avoid taking aspirin
because one drug may increase the action of the other drug. What is the correct term for this effect? a. Compatibility b. Antagonism c. Synergism d. Cooperation ANS: C
When one drug increases the action of another drug, it is called synergism.
DIF: Cognitive Level: Comprehension REF: 433 OBJ: 7 TOP: Pharmacology KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 29. When a patient comes into the emergency department with a narcotic overdose, the nurse
anticipates that the patient will be treated with Narcan. What drug classification is Narcan? a. Enhancer b. Substitute c. Control d. Antagonist ANS: D
An antagonist is a drug that will block the action of another drug, such as Narcan with Demerol. DIF: Cognitive Level: Comprehension TOP: Pharmacology MSC: NCLEX: Physiological Integrity
REF: 433 OBJ: 7 KEY: Nursing Process Step: Planning
30. The nurse administered a sedative to an older adult who was having difficulty sleeping.
Later, the patient was walking the halls and becoming agitated. What is this drug response known as? a. Expected b. Untoward c. Idiosyncratic d. Hypersensitive ANS: C
An unexpected response to a medication is termed idiosyncratic. DIF: Cognitive Level: Application TOP: Pharmacology MSC: NCLEX: Physiological Integrity
REF: 433 OBJ: 8 KEY: Nursing Process Step: Assessment
31. In some health care facilities, the LPN/LVN is allowed to take telephone orders from a
health care provider. What is one precaution the nurse must take when receiving a verbal order? a. Write quickly. b. Repeat the order to the health care provider. c. Have another nurse listen on an extension. d. Sign and initial the health care provider’s name on the order. ANS: B
The nurse should always repeat the order to the health care provider. The nurse should write slowly to avoid making a mistake. It is not necessary to have another nurse listen to the verbal order. The nurse should not sign the health care provider’s name to the order. DIF: Cognitive Level: Application REF: 437 OBJ: 13 TOP: Pharmacology KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment
32. The nurse who was going off shift had prepared the medications for the nurse who was
going to relieve her to save the oncoming nurse time. What would be the correct action of the oncoming nurse? a. Give the medications when ordered. b. Recheck the medications. c. Never give medications another person has prepared. d. Identify each medication as it is given. ANS: C
The nurse should never give a medication that has been prepared by another person. DIF: Cognitive Level: Application REF: 439 OBJ: 9 TOP: Pharmacology KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment 33. What important principle should be taken to prevent medication errors? a. Placing an unlabeled syringe on the medication cart b. Following the six rights of medication administration c. Leaving a medication with the patient only when family is there d. Always charting medications before the end of the shift ANS: B
Following the six rights ensures excellent drug administration practice. Unlabeled syringes should never be left on a medication cart. Medications should never be left in a patient’s room. Medications should be charted immediately after they are administered. DIF: Cognitive Level: Application REF: 438 OBJ: 10 TOP: Pharmacology KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment 34. When the patient complains about his IV lines and asks if he can have the medication by
mouth, what is the most appropriate response by the nurse? a. “Pills are difficult for many patients to swallow.” b. “Medication by mouth is absorbed more slowly than by any other route.” c. “It takes more time for the nurse to prepare and administer oral medications.” d. “It leads to more errors to give pills, because the pills all look alike.” ANS: B
Medications that enter the GI tract are absorbed more slowly than by any other route. It is not known whether or not this particular patient has difficulty swallowing. The decision to give IV medications does not depend on the time of administration. It is not true that all pills look alike. DIF: Cognitive Level: Application TOP: Pharmacology MSC: NCLEX: Physiological Integrity
REF: 442 OBJ: 11 KEY: Nursing Process Step: Implementation
35. What landmarks are used for the administration of an intramuscular injection into the
gluteal site? a. The tip of the coccyx and the greater trochanter b. Between the center of the gluteus and the iliac spine c. Between the posterior iliac crest and the greater trochanter
d. On an imaginary line between the center of the gluteus and the greater trochanter ANS: C
The gluteal site is marked by the greater trochanter and the posterior iliac crest. DIF: Cognitive Level: Application REF: 469 OBJ: 16 TOP: Pharmacology KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 36. What screening test is accomplished by performing an intradermal injection? a. Diabetes b. Tuberculosis c. Hepatitis d. Meningitis ANS: B
Intradermal injection absorption is slow, which makes it the best route for tuberculosis screening. DIF: Cognitive Level: Comprehension REF: 472 OBJ: 11 TOP: Pharmacology KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1. What should the nurse do with an injection of 2 mL of Demerol that the patient has
refused? (Select all that apply.) a. Independently waste the drug in a secure place. b. Record in the narcotic log that the drug was wasted. c. Chart in the patient’s record the reason the medication was refused. d. Get any staff member to sign the narcotic log as witness to the drug being wasted. e. Confirm the count is correct on the narcotic log. ANS: B, C, E
When a controlled substance is wasted, the actual wasting must be witnessed by a licensed person, the narcotic log must be signed by both the nurse wasting the drug and the witness, and the narcotic count is confirmed by both people. DIF: Cognitive Level: Analysis REF: 480 OBJ: 9 TOP: Wasting a controlled drug KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment COMPLETION 1. To help relax the anal sphincter during the insertion of a suppository, the nurse should ask
the patient to
.
ANS:
exhale Exhaling will help relax the anal sphincter.
DIF: Cognitive Level: Application REF: 447 OBJ: 8 TOP: Rectal suppository KEY: Nursing Process Step: Intervention MSC: NCLEX: Safe, Effective Care Environment 2. When giving a tubal medication, the nurse should flush the tubing with 30 to 50
of water. ANS:
mL The water will enhance the absorption of the drug and also clear the tubing. DIF: Cognitive Level: Application REF: 446 OBJ: 8 TOP: Tubal administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 3. The following information is included in a health care provider’s order:
Jane Doe September 23 Amoxicillin 250 mg PO every 6 hours for 10 days Dr. John Smith The essential component missing is the
.
ANS:
time The health care provider’s order should include the patient’s name, date, time, medication, dose, route, frequency, and health care provider’s signature. DIF: Cognitive Level: Analysis TOP: Health care provider’s order MSC: NCLEX: N/A
REF: 480 OBJ: 13 KEY: Nursing Process Step: N/A
4. The order is for 100 mL to run over 8 hours as a “piggyback.” The drop factor of the
secondary unit is 15. The nurse should set the drop control to deliver 3 gtts/
.
ANS:
min 100 mL divided by 8 = 12.5 mL/h
DIF: Cognitive Level: Application REF: 425 OBJ: 3 TOP: Pharmacology KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment
Chapter 18: Fluids and Electrolytes Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. What percentage of an adult’s body weight consists of water? a. 10% to 20% b. 30% to 40% c. 50% to 60% d. 70% to 80% ANS: C
The percentage of water declines to 50% to 60% in adults. DIF: Cognitive Level: Knowledge REF: 483 OBJ: 1 TOP: Fluids KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. When administering intravenous (IV) fluids, the nurse ensures that the IV fluids are
infusing as ordered to prevent dehydration in an adult. When could dehydration become lethal? a. If the patient loses 5% of body fluid b. If the patient loses 10% of body fluid c. If the patient loses 15% of body fluid d. If the patient loses 20% of body fluid ANS: D
A loss of 20% of body fluid in an adult is fatal. DIF: Cognitive Level: Knowledge REF: 483 OBJ: 1 TOP: Fluids KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse uses a diagram to show that fluids in the interstitial and intravascular
compartments are combined. What do they combine to form? a. Intercellular compartment b. Circulating compartment c. Vertical compartment d. Extracellular compartment ANS: D
The fluids in the interstitial and intravascular compartments are combined to form the extracellular compartment. DIF: Cognitive Level: Knowledge TOP: Fluid compartments MSC: NCLEX: Physiological Integrity
REF: 483 OBJ: 1 KEY: Nursing Process Step: Implementation
4. The nurse encourages a patient who has been vomiting to drink fluids because the body
fluid lost daily must match the amount of fluid taken in to maintain homeostasis. What is the recommended daily amount of fluid for an adult?
a. b. c. d.
1000 mL 1500 mL 2050 mL 2500 mL
ANS: D
Daily fluid intake and output is about 2200 to 2700 mL/day, and urinary output is about 1000 to 2000 mL/day. DIF: Cognitive Level: Knowledge REF: 489 TOP: Fluids KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
5. The nurse must keep an accurate intake and output record to assess kidney efficiency. In
order for the kidneys to remove waste, what is the least amount of hourly urine output the kidneys must produce to remove waste? a. 10 mL b. 20 mL c. 30 mL d. 40 mL ANS: C
The kidneys must excrete a minimum of 30 mL/h to eliminate waste products. DIF: Cognitive Level: Knowledge REF: 485 TOP: Fluids KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
6. The nurse weighs a patient at the same time of day with the same scale and same clothing.
What is this a simple and accurate method of determining? a. An accurate weight b. Water balance c. Adequate nutrition d. Urinary output ANS: B
A simple and accurate method of determining water balance is to weigh the patient under the same conditions each day. DIF: Cognitive Level: Comprehension REF: 485 TOP: Fluids KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 8
7. When a patient takes substances into the body, they first enter the extracellular
compartment. What must the substances enter to carry out their function? a. Horizontal compartment b. Intracellular compartment c. Compartmental d. Vertical compartment ANS: B
To carry out their function, substances must enter the cell.
DIF: Cognitive Level: Comprehension REF: 483-484 TOP: Fluids KEY: Nursing Process Step: N/A
OBJ: 2 MSC: NCLEX: N/A
8. What is the method by which inhaled oxygen is moved into the intravascular compartment
called? a. Active transport b. Oxygenation c. Passive transport d. Mass movement ANS: C
Passive transport occurs when the patient inhales oxygen into the lungs, with the oxygen passing by diffusion into the intravascular compartment. DIF: Cognitive Level: Comprehension TOP: Transport process MSC: NCLEX: Physiological Integrity
REF: 485-486 OBJ: 4 KEY: Nursing Process Step: Intervention
9. The nurse explains to a patient that the drug Lasix reduces edema by drawing water from
the interstitial space into the intravascular space. What is this process called? a. Diffusion b. Filtration c. Osmosis d. Homeostasis ANS: C
Osmosis is the movement of water from an area of lower concentration to an area of higher concentration. DIF: Cognitive Level: Knowledge TOP: Transport process MSC: NCLEX: Physiological Integrity
REF: 486 OBJ: 2 KEY: Nursing Process Step: Intervention
10. What does actively transporting electrolytes from an area of higher concentration to an
area of lower concentration require? a. Hydrostatic pressure b. Osmotic pressure c. Blood pressure d. Pulse pressure ANS: A
Electrolytes are moved by hydrostatic pressure, which is a form of active transport. DIF: Cognitive Level: Comprehension TOP: Transport process MSC: NCLEX: Physiological Integrity
REF: 487 OBJ: 4 KEY: Nursing Process Step: Assessment
11. Electrolytes are not measured by weight; their chemical activity is expressed in
milliequivalents. What does 1 mEq of potassium have the same combining power as? a. 1 mEq of nitrogen b. 1 mEq of oxygen
c. 1 mEq of hydrogen d. 1 mEq of magnesium ANS: C
Electrolytes are measured in milliequivalents: 1 mEq of any electrolyte is equal to 1 mEq of hydrogen. DIF: Cognitive Level: Knowledge REF: 487 OBJ: 5 TOP: Electrolytes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. Sodium is the most abundant electrolyte in the body. The location of electrolytes is
important for maintaining homeostasis. Sodium is the major electrolyte in which fluid compartment? a. Intracellular b. Intravascular c. Extracellular d. Interstitial ANS: C
Sodium is the major extracellular electrolyte. DIF: Cognitive Level: Knowledge REF: 487 TOP: Electrolytes KEY: Nursing Process Step: N/A
OBJ: 5 MSC: NCLEX: N/A
13. The lactating mother is counseled by the nurse to eat adequate amounts of meat and
legumes. What level will this help to increase? a. Potassium b. Chloride c. Magnesium d. Phosphorus ANS: D
Phosphorus should be increased during pregnancy and lactation. DIF: Cognitive Level: Knowledge REF: 493 OBJ: 5 TOP: Electrolytes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. A nurse assesses an edematous cardiac patient. The nurse is aware that this condition is a
result of retained fluid. What is the patient considered to be? a. Hyponatremic b. Hypokalemic c. Hypernatremic d. Hypercalcemic ANS: C
Hypernatremia is a greater-than-normal concentration of sodium, which leads to retained fluids and edema. DIF: Cognitive Level: Comprehension REF: 488 TOP: Electrolytes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
15. What is the nurse closely assessing for in a patient with hypokalemia? a. Systemic edema b. Cardiac complications c. Muscle cramping d. Impaired kidney function ANS: B
Hypokalemia can affect cardiac function. DIF: Cognitive Level: Application REF: 489 TOP: Electrolytes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
16. The nurse modifies the care plan for the immobilized patient after assessing a calcium
level of 6.2 mEq/L. What nursing assessment should the nurse include when modifying this care plan? a. Osteoporosis b. Tooth loss c. Renal calculi d. Contractures ANS: C
Hypercalcemia occurs when calcium levels exceed 5.8 mEq/L. It may occur when calcium stored in the bone enters the circulation, for example, in patients who are immobilized. Renal calculi may develop because of high levels of calcium. DIF: Cognitive Level: Application REF: 492-493 TOP: Electrolytes KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 5
17. Homeostasis of the hydrogen ion concentration in body fluids depends on the ratio of
carbonic acid to bicarbonate in the extracellular fluid. What is this ratio? a. 1:5 b. 1:10 c. 1:15 d. 1:20 ANS: D
The ratio needed for homeostasis is 1 part carbonic acid to 20 parts bicarbonate. DIF: Cognitive Level: Knowledge REF: 494 TOP: Electrolytes KEY: Nursing Process Step: N/A
OBJ: 3 MSC: NCLEX: N/A
18. When reading the laboratory report of a patient with excessive diarrhea, the nurse notes
that the pH is 7.10, and the PaCO2 and the PaO2 are normal. What should the nurse recognize as this patient’s state from this information alone? a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis
ANS: B
The profile of a patient in metabolic acidosis is that the blood pH will be below 7.35 and the oxygen readings are within normal limits. DIF: Cognitive Level: Comprehension REF: 498 TOP: Electrolytes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 7
19. What should the nurse expect when assessing a patient with respiratory alkalosis? a. Slow respirations b. Muscle weakness c. Strong, even heart rate d. Flushed face ANS: B
Tetany and muscle weakness, tachypnea, and cardiac arrhythmias are symptomatic of respiratory alkalosis. DIF: Cognitive Level: Application REF: 497 TOP: Electrolytes KEY: Nursing Process Step: Analysis MSC: NCLEX: Physiological Integrity
OBJ: 7
20. Three body systems work at different speeds to keep the pH in the narrow range of normal.
What is the order of effectiveness for these three systems? a. Blood buffers, kidneys, and lungs b. Kidneys, lungs, and blood buffers c. Blood buffers, lungs, and kidneys d. Lungs, kidneys, and blood buffers ANS: C
The three systems are blood buffers, lungs, and kidneys. The blood buffers’ speed is a fraction of a second, the lungs take minutes, and the kidneys take hours to days. DIF: Cognitive Level: Comprehension TOP: Acid-base balance MSC: NCLEX: Physiological Integrity
REF: 495 OBJ: 6 KEY: Nursing Process Step: Assessment
21. A patient admitted in a state of extreme anxiety has vital signs of T 98.6°F (37°C), P 81,
BP 130/86, R 32. What will result if this hyperventilation continues? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: D
Respiratory alkalosis is caused by hyperventilation as the lungs blow off large amounts of CO2. DIF: Cognitive Level: Application TOP: Acid-base balance MSC: NCLEX: Physiological Integrity
REF: 497 OBJ: 7 KEY: Nursing Process Step: Assessment
22. A patient began vomiting and continued to do so for several hours. What is the result of
this loss of stomach contents? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: B
The most common cause of metabolic alkalosis is vomiting gastric contents. DIF: Cognitive Level: Application TOP: Acid-base balance MSC: NCLEX: Physiological Integrity
REF: 498 OBJ: 7 KEY: Nursing Process Step: Assessment
23. What should the nurse focus on when creating a nursing care plan for a patient with
metabolic acidosis? a. Frequent periods of ambulation b. Increasing fluid intake c. Decreasing fluid intake d. Deep-breathing exercises ANS: D
Deep breathing will cause the patient to blow off CO2 and assist in increasing the pH and reduce the acidity. DIF: Cognitive Level: Application TOP: Acid-base balance MSC: NCLEX: Physiological Integrity
REF: 495 | 496 OBJ: 8 KEY: Nursing Process Step: Planning
24. The nurse is educating a patient regarding the need to avoid foods high in potassium. What
food choices led the nurse to conclude that teaching was not effective? a. Apples and green beans b. Kiwis and onions c. Apricots and asparagus d. Grapes and lima beans ANS: C
Apricots and asparagus are potassium-rich. DIF: Cognitive Level: Application TOP: Nursing process MSC: NCLEX: Physiological Integrity
REF: 489 OBJ: 8 KEY: Nursing Process Step: Planning
MULTIPLE RESPONSE 1. What are the three types of passive transport? (Select all that apply.) a. Diffusion b. Titration c. Osmosis d. Distillation e. Filtration
ANS: A, C, E
The three types of passive transport are diffusion, osmosis, and filtration. DIF: Cognitive Level: Knowledge REF: 485 OBJ: 4 TOP: Passive transport KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. What are the three buffer systems of the body? (Select all that apply.) a. Bicarbonate/carbonic acid system b. Respiratory system c. Renal system d. GI system e. Integumentary system ANS: A, B, C
The bicarbonate/carbonic acid system, the respiratory system, and the renal system are the buffer systems of the body. DIF: Cognitive Level: Knowledge REF: 495 OBJ: 6 TOP: Buffer systems KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1. The nurse expects an adult with normal
function to void a minimum of
120 mL of urine in 4 hours. ANS:
kidney The norm is to excrete at least 30 mL/h. In 4 hours, the urine output is expected to be 120 mL. DIF: Cognitive Level: Comprehension TOP: Kidney output MSC: NCLEX: Physiological Integrity
REF: 496 OBJ: 8 KEY: Nursing Process Step: Assessment
2. A child has been having an asthma attack for the last 8 hours. Because of the child’s
inability to exhale effectively, the nurse assesses for respiratory
_.
ANS:
acidosis Retained CO2 will lead to respiratory acidosis. DIF: Cognitive Level: Application TOP: Respiratory acidosis MSC: NCLEX: Physiological Integrity
REF: 496-497 OBJ: 7 KEY: Nursing Process Step: Assessment
3. The nurse explains that a normal adult will lose approximately 350 mL of water through
respiration in the course of a(n)
.
ANS:
day Adults lose about 350 mL of water daily through respiration. DIF: Cognitive Level: Knowledge REF: 484 OBJ: 8 TOP: Insensible loss KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
Chapter 19: Nutritional Concepts and Related Therapies Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse makes nutrition a focus in the care plan. Where does nutrition play the most
important role? a. Weight control b. Sustained appetite c. Building strong bones d. Health maintenance ANS: D
Nutrition is the total of all processes involved in taking in and using food substances for proper growth, functioning, and maintenance of health. DIF: Cognitive Level: Comprehension REF: 523 TOP: Nutrition KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
OBJ: 1
2. The nurse is explaining the activity recommendations from the USDA’s new MyPlate
plan. What is the minimum amount of moderate weekly exercise needed to balance nutritional intake? a. 15 minutes b. 1 hour and 15 minutes c. 2 hours and 30 minutes d. 60 minutes ANS: C
MyPlate recommends a minimum of 2 hours and 30 minutes of moderate aerobic physical activity a week to balance nutritional intake and 1 hour and 15 minutes of vigorous physical activity a week. DIF: Cognitive Level: Knowledge REF: 549 OBJ: 2 TOP: MyPlate KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. What are elements that are found in food and necessary for good health but that the body
cannot make? a. Important nutrients b. Lifesaving nutrients c. Essential nutrients d. Necessary nutrients ANS: C
Elements found in food that our bodies cannot make are essential nutrients. DIF: Cognitive Level: Knowledge REF: 526 OBJ: 3 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
4. To demonstrate the energy-producing potential of different foods, the nurse explains that 3
g of lean meat produces 12 kcal/g. How many kcal/g does 3 g of fish oil produce? a. 6 kcal/g b. 15 kcal/g c. 21 kcal/g d. 27 kcal/g ANS: D
Fat provides 9 kcal/g. DIF: Cognitive Level: Analysis REF: 526 OBJ: 3 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. What has replaced the USDA’s Recommended Dietary Allowance (RDA)? a. Nutrition Recommended Allowance (NRA) b. National Bionutritional Allowance (NBA) c. Dietary Reference Intake (DRI) d. Dietary Guidelines for Americans (DGA) ANS: C
The Dietary Reference Intake (DRI) has replaced the Recommended Dietary Allowance (RDA). DIF: Cognitive Level: Knowledge REF: 524 OBJ: 2 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. How many kcal/g does 1 g of alcohol provide? a. 4 kcal/g b. 5 kcal/g c. 6 kcal/g d. 7 kcal/g ANS: D
Alcohol provides 7 kcal/g of energy. DIF: Cognitive Level: Knowledge REF: NIT OBJ: 3 TOP: Alcohol KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. The nurse is educating a group of high school students regarding nutrition. How should the
nurse respond when the students ask what occurs when protein, mineral, iron, and fat combine? a. Body processes are regulated. b. Energy is provided. c. Tissue is built and repaired. d. Body function is restored. ANS: C
Many nutrients are necessary to build and repair tissue, including protein, minerals, iron, and fat.
DIF: Cognitive Level: Comprehension REF: 526 TOP: Nutrition KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance
OBJ: 4
8. When reviewing a patient’s dietary intake, the nurse recommends that sugar consumption
be reduced to the recommended daily level. What is this level? a. No more than 24% of total daily kilocalories b. No more than 16% of total daily kilocalories c. No more than 8% of total daily kilocalories d. No more than 4% of total daily kilocalories ANS: C
DRIs relating to carbohydrates indicate that 45% to 65% of an adult’s total calorie intake should be in the form of carbohydrates and that added sugars should be limited to no more than 8% (approximately 40 g) of the total number of calories consumed daily. DIF: Cognitive Level: Knowledge REF: 527 OBJ: 3 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. What is the body’s storage form of carbohydrates, usually found in the liver with some
storage in the muscles? a. Sugar b. Glucose c. Lipids d. Glycogen ANS: D
Glycogen is not generally consumed in the diet but is the body’s storage form of carbohydrate. It is found mainly in the liver, with some storage in the muscles. DIF: Cognitive Level: Knowledge REF: 528 OBJ: 4 TOP: Glycogen KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 10. What is the term for stored fat that insulates the body and serves as a cushion to protect
organs? a. Subcutaneous tissue b. Adipose tissue c. Cohesive tissue d. Lipid tissue ANS: B
Fat is stored in the body as adipose tissue. DIF: Cognitive Level: Knowledge REF: 529 OBJ: 4 TOP: Adipose tissue KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 11. The nurse is providing information about high cholesterol levels. What is the rationale for
avoiding saturated fats?
a. b. c. d.
They block absorption of nutrients. They interfere with metabolism. They increase blood cholesterol. They must be hydrogenated.
ANS: C
Saturated fats tend to increase blood cholesterol. DIF: Cognitive Level: Comprehension REF: 529 OBJ: 6 TOP: Saturated fats KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. When discussing the digestion and metabolism of fat, the nurse tells the patient who has a
history of cholecystitis and who is on a low-fat diet that fat must be emulsified to be digested. What is the substance necessary for emulsification? a. Sugar b. Cholesterol c. Bile d. Protein ANS: C
Bile is necessary to emulsify fat. DIF: Cognitive Level: Knowledge REF: 530 OBJ: 6 TOP: Function of bile KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 13. The body uses 22 common amino acids, but 9 of them must be obtained from protein in
the diet. What are these proteins considered? a. Essential b. Basic c. Fundamental d. Primary ANS: A
Essential amino acids must be consumed in the diet, because the body cannot make them. DIF: Cognitive Level: Knowledge REF: 531 OBJ: 4 TOP: Essential amino acids KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 14. The nurse is educating a patient on a vegan diet. What supplement will the nurse
encourage this patient to take to avoid a deficiency? a. B6 b. B12 c. K d. D ANS: B
B12 is almost exclusively found in animal products, but it can be supplemented with fortified cereals or vitamins.
DIF: Cognitive Level: Application REF: 531 | 535 TOP: B12 deficit KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 7
15. A fit, young woman was at zero nitrogen balance. The nurse discovers that this patient is
now pregnant with her first child. For what is this patient at risk? a. Embolism b. Anabolism c. Catabolism d. Metabolism ANS: B
When more nitrogen is consumed than is excreted, anabolism occurs. This is also called a positive nitrogen balance. DIF: Cognitive Level: Application REF: 531 OBJ: 8 TOP: Nitrogen balance KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 16. The nurse explains that a patient with a heart problem should follow a decreased sodium
diet. What will this diet help reduce the risk for or prevent? a. Stroke b. Fluid excretion c. Heart attacks d. Obesity ANS: C
Sodium attracts water and causes fluid retention. Hypervolemia increases the heart’s workload, which can lead to a heart attack. DIF: Cognitive Level: Comprehension REF: 556 OBJ: 2 TOP: Fluid retention KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 17. The patient complains to the nurse that he feels terrible since he has been taking several
different kinds of vitamin preparations. What should the nurse assess for indications of vitamin toxicity? a. Edema b. Hypertension c. Fatigue d. Diarrhea ANS: C
Toxicity usually occurs from the use of large supplemental doses of vitamins and minerals and presents as fatigue, nausea, vomiting, and headache. DIF: Cognitive Level: Application REF: 532 OBJ: 7 TOP: Vitamin toxicity KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 18. The nurse cautions a patient with a pancreatic disorder that will interfere with the digestion
of fats and may lead to a clotting disorder. What is the cause of these potential problems?
a. b. c. d.
Inability to use vitamin B Inability to use vitamin C Inability to use vitamin D Inability to use vitamin K
ANS: D
Vitamins A, D, E, and K are fat-soluble. Difficulty with fat metabolism will result in the inability to use fat-soluble vitamins. Vitamin K plays a role in blood clotting. It is important in maintaining four of the eleven clotting factors found in the blood. DIF: Cognitive Level: Comprehension REF: 532 OBJ: 7 TOP: Fat-soluble vitamins KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 19. The home health nurse is caring for a patient that has undergone removal of a part of the
stomach. For what should the nurse carefully assess this patient? a. A stomach ulcer b. Digestive problems c. Pernicious anemia d. Malabsorption ANS: C
Pernicious anemia results when the intrinsic factor is missing due to surgery on the stomach. DIF: Cognitive Level: Application REF: 535 OBJ: 17 TOP: Pernicious anemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 20. A patient taking a diuretic is assessed by the nurse as having an erratic pulse and muscle
weakness. What should the nurse suspect is deficient? a. Sodium b. Potassium c. Chloride d. Iron ANS: B
Diuretics can deplete potassium through urine excretion and lead to muscle weakness and cardiac arrhythmias. DIF: Cognitive Level: Application REF: 538 OBJ: 9 TOP: Potassium depletion KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 21. A patient who has hypertension is complaining about the lack of taste with the low-sodium
diet that has been prescribed. What should the nurse emphasize that sodium may do? a. Contribute to hypertension. b. Interfere with blood clotting. c. Produce stomach ulcers. d. Decrease calcium in the bones. ANS: A
Sodium may contribute to hypertension. DIF: Cognitive Level: Comprehension REF: 538 OBJ: 1 TOP: Sodium-induced hypertension KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 22. The young woman who is breastfeeding will need an increase of calories and protein.
What foods should the nurse suggest as sources of protein? a. Green, leafy vegetables b. Citrus fruits c. Asparagus d. Nuts ANS: D
Nuts are a safe source of protein for lactating women. DIF: Cognitive Level: Comprehension REF: 538 OBJ: 4 TOP: Protein source KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 23. At approximately 4 to 6 months of age, solid food is introduced to a baby. What foods
with high iron content should be recommended by the nurse? a. Pureed fruit b. Fortified cereals c. Fruit juice d. Rice ANS: B
At approximately 4 to 6 months, iron-rich foods, such as fortified cereal and pureed meat, are introduced to a baby. DIF: Cognitive Level: Comprehension REF: 536 OBJ: 8 TOP: Iron-rich foods KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 24. A school nurse is teaching a group of adolescents about adequate nutrition. What increased
intake should the nurse encourage? a. Potassium and sodium b. Chloride and magnesium c. Iron and calcium d. Vitamins and minerals ANS: C
Dietary inadequacies in adolescence include iron and calcium. DIF: Cognitive Level: Application REF: 537 | 539 OBJ: 8 TOP: Adolescent nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 25. A nurse caring for a patient who is prescribed a full-liquid diet recognizes that this diet
lacks some nutrients. What nutrients are lacking? a. Fat-soluble vitamins
b. Potassium c. Iron and fiber d. Water-soluble vitamins ANS: C
A full-liquid diet is deficient in iron and fiber. DIF: Cognitive Level: Comprehension REF: 547 OBJ: 10 TOP: Full-liquid diets KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 26. The nurse has assessed a patient’s body mass index (BMI) to be 19.6. This assessment of
weight versus height indicates that this patient’s weight category is in which category? a. Low health risk b. Overweight c. Obese d. Morbidly obese ANS: A
A BMI between 18.5 and 24.9 is associated with the lowest health risk. Those with BMIs between 25 and 29.9 are considered overweight, and those with BMIs of 30 or greater are considered obese. A BMI of less than 18.5 is considered underweight and is also associated with health risks. DIF: Cognitive Level: Analysis REF: 549 OBJ: 12 TOP: Body mass index (BMI) KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 27. The nurse is counseling a patient about the difference between type 1 and type 2 diabetes.
What should the nurse stress that patients with type 2 diabetes are required to receive on a daily basis? a. Regular carbohydrate-controlled meals b. Oral hyperglycemic agents c. Insulin injections d. Stringent low-calorie diets ANS: A
People with type 2 diabetes must take daily regulated meals with controlled carbohydrate content. Type 1 diabetics must have insulin injections. DIF: Cognitive Level: Comprehension REF: 552 OBJ: 1 TOP: Nutrition in type 2 diabetes KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 28. Careful attention to carbohydrate consumption can improve metabolic control of diabetes.
The nurse teaches a meal planning approach that focuses on the total amount of carbohydrates eaten at a meal. What is this meal planning approach called? a. Carbohydrate splitting b. Reduced caloric intake c. Carbohydrate counting d. Carbohydrate balancing
ANS: C
Carbohydrate counting is a meal planning approach that focuses on the total amount of carbohydrates eaten. DIF: Cognitive Level: Knowledge REF: 552 OBJ: 13 TOP: Carbohydrate counting KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 29. The patient who had a gastrostomy complains to the nurse about frequent episodes of
dumping syndrome. What can the nurse recommend to this patient to decrease this problem? a. Eat small, frequent meals. b. Include more fiber in meals. c. Increase seasoning on food. d. Limit intake to semiliquids. ANS: A
The symptoms of dumping syndrome can be reduced by consuming small frequent meals of mildly seasoned food; extra fiber is not essential. DIF: Cognitive Level: Application REF: 552-553 OBJ: 2 TOP: Dumping syndrome KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 30. The nurse reminds the male patient with lactose intolerance that he can avoid the
unpleasant symptoms of nausea, bloating, flatulence, and diarrhea, if he will avoid certain foods. What product should the patient be instructed to avoid? a. Soy beans b. Rice c. Milk d. High fiber ANS: C
Lactose intolerance occurs as a result of a lack of lactase that makes it impossible to break down milk sugar. DIF: Cognitive Level: Application REF: 553 OBJ: 2 TOP: Lactose intolerance KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 31. A patient diagnosed with renal failure is unable to excrete protein waste products and
develops a condition that requires a protein-restricted diet. The nurse instructs the patient that azotemia can be diminished by substituting other food groups for protein. What is an example of a food that this patient can substitute for protein? a. Potatoes b. Beans c. Cheese d. Soy products ANS: A
The foods that a patient with renal disease can substitute for energy are in the carbohydrate group. Potatoes are the only carbohydrate listed.
DIF: Cognitive Level: Comprehension REF: 556 OBJ: 11 TOP: Azotemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 32. What is a nursing intervention to decrease the thirst of a patient who is on a fluid
restriction? a. Rinsing the mouth with warm water b. Sipping carbonated drinks c. Sucking on occasional ice chips d. Limiting tooth brushing to once per day ANS: C
Sucking on occasional ice chips is a way to decrease thirst without adding a large amount of fluid. Rinsing the mouth with cool water and frequent tooth brushing are helpful also. Carbonated drinks contain sodium and will enhance fluid retention. DIF: Cognitive Level: Application REF: 557 OBJ: 16 TOP: Fluid restrictions KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 33. The nurse recognizes that when a patient is unable to consume adequate nutrition by
mouth, an alternative route such as a feeding ostomy may be used. What is the proper term for feeding a patient by this method? a. Total parenteral nutrition (TPN) b. Nasogastric c. Enteral d. Parenteral ANS: C
The administration of nutritionally balanced liquid foods through a feeding ostomy is called enteral nutrition. DIF: Cognitive Level: Knowledge REF: 557 OBJ: 2 TOP: Enteral feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 34. The nurse teaches a patient who has a nonfunctioning or dysfunctional GI tract that total
parenteral nutrition (TPN) will be infused. Where will the infusion occur? a. Through the carotid artery b. Through the superior vena cava c. Through the femoral vein d. Through the inferior vena cava ANS: B
TPN solution is usually infused through the superior vena cava. DIF: Cognitive Level: Comprehension REF: 565 OBJ: 2 TOP: Total parenteral nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE
1. Which are the energy-providing food groups? (Select all that apply.) a. Carbohydrates b. Fats c. Proteins d. Vitamins e. Minerals ANS: A, B, C
The food groups that provide energy are carbohydrates, fats, and proteins. DIF: Cognitive Level: Application REF: 526 OBJ: 3 TOP: Energy-producing food groups KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1. To simplify food values, the measurement of energy obtained by food is defined as the
. ANS:
kilocalorie The kilocalorie is the energy value by which foods are measured for their energy-producing potential. DIF: Cognitive Level: Knowledge REF: 526 TOP: Kilocalorie KEY: Nursing Process Step: Intervention MSC: NCLEX: Health Promotion and Maintenance
OBJ: 3
2. The body mass index (BMI) of a man 6 ft tall weighing 250 lb is
.
ANS:
33.9 The BMI is calculated by dividing the pounds expressed as kilograms by the height in meters squared. 6 ft = 72 in ÷ 39.37 = 1.83 m 250 lb ÷ 2.2 = 113.6 kg 113.6 ÷ (1.83 1.83) = 33.9 DIF: Cognitive Level: Analysis REF: 548 | 549 OBJ: 12 TOP: Calculating body mass index (BMI) KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. Insoluble
softens stools, speeds transit of foods through the digestive tract, and reduces pressure in the colon. ANS:
fiber
Insoluble fiber softens stools, speeds transit of foods through the digestive tract, and reduces pressure in the colon. Thus it may help relieve constipation and reduce the risk of certain gastrointestinal (GI) disorders, such as diverticulosis or hemorrhoids. DIF: Cognitive Level: Knowledge REF: 528 TOP: Fiber KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance
OBJ: 5
Chapter 20: Complementary and Alternative Therapies Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient recovering from a hip replacement and is providing
education regarding exercises in physical therapy. What type of therapy should the nurse call these exercises? a. Alternative therapies b. Complementary therapies c. Comfort therapies d. Body therapies ANS: B
Complementary therapies are used in addition to conventional therapies. DIF: Cognitive Level: Knowledge TOP: Complementary therapies MSC: NCLEX: Physiological Integrity
REF: 570 OBJ: 1 KEY: Nursing Process Step: Implementation
2. An older adult patient tells the home health nurse, “My health care provider hasn’t helped
my arthritis at all. I am using the chiropractor now.” What change has the patient made? a. Western medicine to complementary therapy b. Complementary therapy to alternative therapy c. Alternative therapy to allopathic medicine d. Allopathic medicine to alternative therapy ANS: D
Alternative therapies may become the primary treatment modality; for instance, the patient switching from traditional (allopathic) medicine to chiropractic (alternative). DIF: Cognitive Level: Comprehension REF: 587 TOP: Therapies KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
3. What is the responsibility of the National Center for Complementary and Alternative
Medicine (NCCAM)? a. To certify alternative medical health care providers b. To evaluate effectiveness of alternative medical treatments c. To set standards for the practice of alternative medicine d. To train alternative medical health care providers ANS: B
The National Center for Complementary and Alternative Medicine was established to facilitate the evaluation of alternative medical treatment. DIF: Cognitive Level: Comprehension REF: 571 OBJ: 1 TOP: National Center for CAM KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment
4. What is the importance of the nurse asking about the patient’s use of alternative therapies
when obtaining a health history? a. Alternative therapies can be covered by insurance. b. Alternative therapies have unfortunate interactions with traditional therapies. c. Alternative therapies can be substituted for allopathic medicine. d. Alternative therapies have curative and healing power. ANS: B
Some alternative therapies may have serious side effects. As a rule, complementary and alternative (CAM) therapies are not curative or healing as is allopathic medicine. Some complementary therapies are covered by insurance, but alternative remedies are not. DIF: Cognitive Level: Comprehension REF: 571 OBJ: 3 TOP: Complementary and alternative (CAM) therapies KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The nurse is obtaining health history information on a new patient at a health care
provider’s office and he or she records a barbiturate medication on the current list. What herb should the nurse ask if the patient is taking? a. St. John’s wort b. Aloe vera c. Valerian d. Ginkgo ANS: C
Valerian enhances the effect of barbiturates. DIF: Cognitive Level: Application REF: 574 TOP: Valerian KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 3 | 5
6. What should the nurse instruct a patient who takes tincture of rosemary to do several times
a day? a. Assess pulse frequently. b. Avoid constipation. c. Watch for hypoglycemia. d. Wear sunscreen. ANS: D
Rosemary can cause photosensitivity. DIF: Cognitive Level: Application REF: 576 OBJ: 2 | 5 TOP: Rosemary KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. What is true regarding manufacturers of herbal remedy products? a. They do extensive field testing on the products. b. They must show dosage equivalents. c. They must adhere to standards of strength. d. They do not have to demonstrate their safety. ANS: D
Herbal remedy manufacturers are not required by law to demonstrate the safety of their products. DIF: Cognitive Level: Comprehension REF: 572 | 575 OBJ: 4 TOP: Herbal remedies KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 8. Herbs have not been approved for use as drugs. How are herbs allowed to be sold? a. For pain relief b. To improve body strength c. To prolong life d. As diet supplements ANS: D
Herbs are sold as food supplements. DIF: Cognitive Level: Comprehension TOP: Herbal remedies MSC: NCLEX: N/A
REF: 572 OBJ: 4 KEY: Nursing Process Step: N/A
9. What is the goal of herbal therapy? a. Treat symptoms. b. Restore balance. c. Treat disease. d. Improve nutrition. ANS: B
The goal of herbal therapy is to restore balance. DIF: Cognitive Level: Comprehension TOP: Herbal therapy MSC: NCLEX: N/A
REF: 572 OBJ: 4 KEY: Nursing Process Step: N/A
10. Confusion and misinformation relative to herbal medicine can make patients reluctant to
disclose their herbal use to health care providers. What should be the nurse’s approach? a. Instructive b. Nonjudgmental c. Inquisitive d. Determined ANS: B
A nonjudgmental open attitude will encourage the patient to share information about the use of CAM (complementary and alternative medicine). DIF: Cognitive Level: Application TOP: Health interview MSC: NCLEX: Psychosocial Integrity
REF: 575 OBJ: 2 KEY: Nursing Process Step: Implementation
11. What will placing an herb in alcohol or vinegar make? a. A suspension b. An emulsion c. An infusion
d. A tincture ANS: D
Tinctures are made by placing the herb in alcohol or vinegar. DIF: Cognitive Level: Knowledge TOP: Making herbal remedies MSC: NCLEX: Physiological Integrity
REF: 575 OBJ: 5 KEY: Nursing Process Step: Implementation
12. During a follow-up visit with a patient recently started on Coumadin, the home health
nurse is concerned after seeing an herbal remedy that enhances the effect of anticoagulants by the patient’s bedside. What is this herbal remedy? a. Cayenne b. Aloe vera c. Asian ginseng d. Kava ANS: C
Asian ginseng may enhance the effect of Coumadin. DIF: Cognitive Level: Comprehension REF: 572 TOP: Ginseng KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment
OBJ: 5
13. Acupuncture is a complementary therapy that uses fine needles placed in acupoints. What
is the believed purpose of these acupoints? a. “Close the gate” for pain transmission. b. Align the internal organs. c. Open meridians to release qi. d. Stimulate the “centering” of qi. ANS: C
Acupuncture therapy uses needles placed in acupoints to open meridians to release qi (life force). DIF: Cognitive Level: Comprehension REF: 577 TOP: Acupuncture KEY: Nursing Process Step: N/A
OBJ: 7 MSC: NCLEX: N/A
14. The nurse is educating a patient with phlebitis of the left leg. What alternative therapy
should this patient avoid until the condition is resolved? a. Acupuncture b. Therapeutic massage c. Yoga d. Acupressure ANS: B
Therapeutic massage is contraindicated in conditions such as thrombosis, phlebitis, and infective skin diseases. DIF: Cognitive Level: Application REF: 579 OBJ: 9 TOP: Therapeutic massage KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment
15. What type of alternative therapy is the nurse practicing when using essential oils to
provide inhalation treatments? a. Magnet therapy b. Respiratory therapy c. Herbal therapy d. Aromatherapy ANS: D
Aromatherapy uses pure essential oils to provide health benefits. DIF: Cognitive Level: Comprehension TOP: Aromatherapy MSC: NCLEX: Physiological Integrity
REF: 580 OBJ: 10 KEY: Nursing Process Step: Implementation
16. The nurse is educating a patient regarding reflexology. Information includes that
reflexology is a therapy based on the theory that the entire body can be reached by applying pressure to specific areas. Where is pressure mainly applied? a. Hands b. Head c. Back d. Feet ANS: D
In reflexology it is thought that the entire body can be reached by applying pressure to specific areas on the feet. DIF: Cognitive Level: Comprehension REF: 580-581 OBJ: 2 | 11 TOP: Reflexology KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychological Integrity 17. What type of therapy is contraindicated in patients with pacemakers? a. Relaxation therapy b. Magnetic therapy c. Yoga therapy d. Imagery therapy ANS: B
Magnet therapy interferes with pacemaker function. DIF: Cognitive Level: Knowledge TOP: Magnetic therapy MSC: NCLEX: N/A
REF: 581 OBJ: 12 KEY: Nursing Process Step: N/A
18. Which term describes using the conscious mind to create situations that evoke physical
changes in the body? a. Imagination b. Self-hypnosis c. Imagery d. Visualization ANS: C
Imagery uses the conscious mind to create images that evoke physical changes in the body.
DIF: Cognitive Level: Knowledge REF: 581 OBJ: 1 TOP: Imagery KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The nurse describes a therapy that can produce a state of decreased cognitive, physiologic,
and/or behavioral arousal. To what alternative therapy is the nurse referring? a. Subconscious b. Imagery c. Sleep d. Relaxation ANS: D
Relaxation is the state of general decreased cognitive, physiologic, and/or behavior arousal. DIF: Cognitive Level: Knowledge REF: 581-582 OBJ: 1 | 2 TOP: Relaxation KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 20. What is a therapeutic treatment that joins the mind and body and increases muscle tone
and flexibility? a. Acupressure b. Spiritual enrichment c. Yoga therapy d. Therapeutic massage ANS: C
Yoga therapy is the joining of the mind, body, and spirit to enrich the quality of one’s life. Yoga also increases muscle tone and flexibility. DIF: Cognitive Level: Knowledge REF: 583 OBJ: 14 TOP: Yoga KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. What training system may help prevent osteoporosis? a. Acupressure b. Yoga c. Therapeutic massage d. Tai chi ANS: D
Tai chi, although a martial arts skill, increases balance and timing and may prevent osteoporosis. DIF: Cognitive Level: Knowledge REF: 584 OBJ: 15 TOP: Tai chi KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. A patient wants to use aromatherapy to treat pneumonia, but the hospital policy will not
allow burning of eucalyptus-scented candles. What should the nurse suggest the patient use instead?
a. b. c. d.
Another essential oil Prescribed medications A topical eucalyptus product Massage therapy
ANS: C
Eucalyptus oils can be used for inhalation or may be applied topically. DIF: Cognitive Level: Application TOP: Aromatherapy MSC: NCLEX: Physiological Integrity
REF: 576 OBJ: 10 KEY: Nursing Process Step: Implementation
23. A patient admitted with lower back pain is not sure that the prescribed treatment is helping
and asks what alternative therapies might help. What should the nurse suggest? a. Herbal therapy b. Chiropractic therapy c. Acupressure d. Reflexology ANS: B
Chiropractic therapy is currently viewed as an acceptable treatment for certain disorders, including back pain. DIF: Cognitive Level: Application REF: 577 OBJ: 6 TOP: Chiropractic KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Herbal remedies vary from pharmaceutical remedies in what ways? (Select all that apply.) a. Herbal remedies use the whole plant. b. Herbal remedies have no quality control. c. Herbal remedies have no standard dose. d. Herbal remedies are sold as food supplements. e. Herbal remedies are always safe and effective. ANS: A, B, C, D
Herbal remedies are not always safe and effective. DIF: Cognitive Level: Comprehension TOP: Herbal remedies MSC: NCLEX: Physiological Integrity
REF: 575 OBJ: 1 KEY: Nursing Process Step: Implementation
2. Founded in 1992, the National Center for Complementary and Alternative Medicine
(NCCAM) has the responsibility for what actions? (Select all that apply.) a. Evaluating alternative treatments b. Distributing information to the public c. Coordinating and conducting research d. Removing defective products from the market e. Regulating third-party reimbursement ANS: A, B, C
The National Center for Complementary and Alternative Medicine has the responsibility to evaluate treatments, distribute information, and conduct research. It has no power to remove defective products from the market or deal with insurance payments. DIF: Cognitive Level: Knowledge TOP: National Center for CAM MSC: NCLEX: N/A
REF: 572 OBJ: 1 KEY: Nursing Process Step: N/A
3. The nurse recommends that a patient have animal-assisted therapy (AAT) sessions because
this therapy has been found to have what effects? (Select all that apply.) a. Improvement in mood b. Decrease in blood pressure c. Decrease in blood sugar d. Reduction of allergies e. Increase in socialization skills ANS: A, B, E
Animal-assisted therapy (AAT) has been found to improve mood, decrease blood pressure, and increase socialization skills. AAT has not been found to decrease blood sugar or reduce allergies. DIF: Cognitive Level: Comprehension TOP: Animal-assisted therapy (AAT) MSC: NCLEX: Psychosocial Integrity
REF: 583 OBJ: 13 KEY: Nursing Process Step: Implementation
4. Why do people often choose complementary and alternative medicine (CAM)? (Select all
that apply.) a. CAM is less invasive. b. CAM is more holistic. c. CAM is focused on treatment of disease. d. CAM is dedicated to health maintenance. e. CAM is within the control of the patient. ANS: A, B, D, E
CAM is less invasive, more holistic, dedicated to health maintenance, and within control of the patient. CAM is focused on prevention, not treatment. DIF: Cognitive Level: Comprehension REF: 571 TOP: CAM KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
COMPLETION 1. The nurse reassures a patient that
CAM therapy each year. ANS:
one-third
of all adults in the United States take some form of
It is estimated that one-third of all adults in the United States take some form of herbal or natural product supplement alone or in combination with conventional medicines but rarely report this practice to their health care providers. DIF: Cognitive Level: Knowledge TOP: Herbal supplements MSC: NCLEX: Physiological Integrity
REF: 571 OBJ: 3 KEY: Nursing Process Step: Implementation
2. People with fractures, rheumatoid arthritis, and osteoporosis are not candidates for
therapy. ANS:
chiropractic Contraindications for chiropractic therapy include acute myelopathy, fractures, dislocations, rheumatoid arthritis, and osteoporosis. DIF: Cognitive Level: Comprehension REF: 577 TOP: Chiropractic KEY: Nursing Process Step: N/A 3.
OBJ: 6 MSC: NCLEX: N/A
is a noninvasive method an individual can employ to learn control of the body to manage certain conditions. Monitoring equipment is used to measure vital signs and muscle tension. The messages are sent back to the individual. ANS:
Biofeedback Biofeedback is a noninvasive method an individual can employ to learn control of the body to manage certain conditions. It may be considered when other therapies have not been successful or in conjunction with other treatments. Health concerns such as anxiety, stress, irritable bowel syndrome, and asthma may be managed using biofeedback. DIF: Cognitive Level: Knowledge REF: 585 TOP: Biofeedback KEY: Nursing Process Step: N/A
OBJ: 16 MSC: NCLEX: N/A
Chapter 21: Pain Management, Comfort, Rest, and Sleep Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. A patient reports to the nurse that he is experiencing a moderate amount of back pain rated
6 out of 10 on the pain scale. What should the nurse recognize about this assessment? a. Pain is objective for the nurse. b. Pain is easy to recognize. c. Pain is subjective for the patient. d. Pain is easily relieved if found early. ANS: C
Pain is subjective. Pain is exactly what the patient says it is. DIF: Cognitive Level: Comprehension REF: 592 TOP: Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 3 | 5
2. A patient has pain in the left arm secondary to coronary insufficiency. This is an example
of what type of pain? a. Acute pain b. Chronic pain c. Referred pain d. Subacute pain ANS: C
An example of referred pain is coronary insufficiency manifested by pain in the left arm, which is a distant location from the real source of discomfort. DIF: Cognitive Level: Comprehension REF: 593 TOP: Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1 | 2
3. The nurse reassures a patient that most acute pain is intense and of short duration. How
long does can acute pain usually last? a. 1 week b. Less than 6 months c. At least 9 months d. More than 1 year ANS: B
Acute pain lasts less than 6 months. DIF: Cognitive Level: Comprehension REF: 593 OBJ: 1 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. What is the defining term for continuous or intermittent pain that does not serve as a
warning of tissue damage? a. Acute
b. Unrelieved c. Chronic d. Subacute ANS: C
Chronic pain can be continuous or intermittent and may not be indicative of tissue damage. DIF: Cognitive Level: Knowledge REF: 593 OBJ: 1 | 2 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is planning interventions for a patient experiencing pain. For what type of
synergistic relationship should the nurse assess? a. Inflammatory process b. Circulatory disorder c. Food allergy d. Fatigue ANS: D
Fatigue, sleep disturbance, and depression act in a synergistic relationship. DIF: Cognitive Level: Comprehension REF: 593 TOP: Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 2 | 7
6. The nurse is giving a backrub to a patient to relieve pain. What pain theory is the nurse
using? a. Synergism b. Gate control c. Distraction d. Guided imagery ANS: B
The pressure of a backrub will close the gate, according to the gate control theory of pain. DIF: Cognitive Level: Comprehension REF: 595 OBJ: 4 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. A young athlete asks the nurse why he felt little pain when he broke his leg during a game.
What does the nurse describe as having an effect on this patient’s perception of pain? a. Hormones b. Enzymes c. Adrenaline d. Endorphins ANS: D
Endorphins found in the pituitary gland and other areas of the central nervous system create the same effect as morphine, producing an analgesic effect. DIF: Cognitive Level: Comprehension REF: 593 OBJ: 1 | 2 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
8. Where does the nurse recognize that many institutions are now including pain assessment
in implementing patient care? a. The initial assessment b. Discharge planning c. Assessing vital signs d. Care planning ANS: C
Making pain a vital sign would ensure that pain is monitored on a regular basis. DIF: Cognitive Level: Comprehension REF: 594 OBJ: 6 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. Why should a nurse promptly administer a prescribed analgesic after a pain assessment? a. The health care provider has ordered it. b. It is an efficient use of time. c. Unrelieved pain can cause setbacks. d. It meets the goals of the nursing care plan. ANS: C
Appropriate pain management can bring about quicker recoveries, shorter hospital stays, fewer readmissions, and can improve the quality of life. DIF: Cognitive Level: Comprehension REF: 595 OBJ: 10 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse obtains information from a patient about the site, severity, and duration of the
pain. What type of data is this considered? a. Patient data b. Objective data c. Focused data d. Subjective data ANS: D
Information from the patient concerning site, severity, and duration of the pain is subjective data that only the patient knows. DIF: Cognitive Level: Comprehension REF: 596 TOP: Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
11. The nurse is assessing pain reported by a Latino male patient. What is important for the
nurse take into consideration when observing objective data? a. Latino men are suspicious of female caregivers. b. Latino men have a cultural bias against use of narcotics. c. Latino men believe pain is necessary for cure. d. Latino men feel it is unmanly to admit to pain. ANS: D
Many Latino men feel that to admit to being in pain is unmanly. DIF: Cognitive Level: Application TOP: Latino culture MSC: NCLEX: Psychosocial Integrity
REF: 603 OBJ: 10 KEY: Nursing Process Step: Assessment
12. To share assessment findings and pain relief interventions, which documentation sample is
the most helpful? a. 1600: Patient reports chest pain. Medicated with morphine sulfate. b. 1600: Patient reports sharp chest pain. Morphine sulfate given IM. c. 1600: Patient reports sharp pain in left chest radiating to neck. Morphine sulfate 5 mg administered IM in right deltoid. d. 1600: Patient requested medication for pain in left chest. Morphine sulfate 10 mg PO given. ANS: C
The nurse should record subjective information relative to the pain, as well as the intervention and administration route. DIF: Cognitive Level: Application REF: 603 OBJ: 10 TOP: Pain medication documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 13. The nurse teaches noninvasive pain relief techniques, such as guided imagery,
biofeedback, and relaxation. What is the primary advantage of these techniques? a. Can be done any time. b. Does not require a nurse. c. Gives the patient some control. d. Is most effective. ANS: C
The greatest advantage of noninvasive pain relief techniques is that they give the patient some control. DIF: Cognitive Level: Comprehension TOP: Noninvasive pain control MSC: NCLEX: Psychosocial Integrity
REF: 595 OBJ: 11 KEY: Nursing Process Step: Implementation
14. The nurse explains that transcutaneous electric nerve stimulation (TENS) provides a
continuous mild electric current to the skin. How does the TENS unit act to reduce pain? a. Distracts the patient. b. Blocks endorphin production. c. Warms the skin. d. Blocks pain impulses. ANS: D
TENS works by blocking pain impulses. DIF: Cognitive Level: Comprehension REF: 595 OBJ: 11 TOP: TENS KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
15. An American Indian patient requests that an egg yolk be placed in a saucer and put under
his bed to absorb the pain. What should the nurse do? a. Explain that medication will relieve the pain better. b. Place the egg in a saucer under the bed. c. Ask the health care provider for permission. d. Warn that housekeeping staff will remove the egg. ANS: B
The nurse should use methods of pain control that the patient believes will work. DIF: Cognitive Level: Application TOP: Cultural considerations MSC: NCLEX: Psychosocial Integrity
REF: 606 OBJ: 10 KEY: Nursing Process Step: Implementation
16. The home health nurse is caring for a patient with an implanted pacemaker. What type of
pain management would be contraindicated? a. Peripheral analgesics b. A TENS unit c. Opioid analgesics d. Adjuvant analgesics ANS: B
A TENS unit may interfere with the function of the pacemaker. DIF: Cognitive Level: Application REF: 595 TOP: Pain control KEY: Nursing Process Step: Analysis MSC: NCLEX: Physiological Integrity
OBJ: 10
17. The nurse is trying to reassure a patient who is concerned about receiving addictive drugs.
What percentage of patients become addicted to analgesics? a. Less than 0.1% b. Less than 1% c. Less than 5% d. Less than 6% ANS: B
Research findings suggest that less than 1% of patients receiving analgesics become addicted. DIF: Cognitive Level: Knowledge REF: 596 OBJ: 10 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 18. The nurse is caring for a patient using patient-controlled analgesia (PCA). What is a major
advantage to this method? a. Less expensive b. More effective c. Less addictive d. Quicker ANS: D
The use of the PCA gives quicker relief as there is no delay in waiting for the nurse to respond to the request for analgesia. DIF: Cognitive Level: Comprehension REF: 600 OBJ: 10 TOP: Patient-controlled analgesia (PCA) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. A patient tearfully declares the use of relaxation techniques does not work for her. What is
the best action for the nurse to implement? a. Give up on the idea. b. Encourage the patient to try again. c. Assure the patient that not everyone is successful. d. Give the patient a sedative. ANS: B
Some alternative approaches to pain control require practice. Encouragement to try again is appropriate. DIF: Cognitive Level: Application TOP: Alternate methods of pain control MSC: NCLEX: Physiological Integrity
REF: 606 OBJ: 11 KEY: Nursing Process Step: Implementation
20. A patient is receiving an opioid narcotic. What common side effect should the nurse be
aware of when assessing this patient? a. Addiction b. Vomiting c. Constipation d. Diarrhea ANS: C
Constipation is the most common opioid narcotic side effect for which patients do not develop a tolerance. DIF: Cognitive Level: Comprehension REF: 598 TOP: Constipation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 10
21. A male patient reports to the home health nurse that he does not feel rested although he has
slept 8 hours. For what should the nurse assess? a. Having vivid dreams b. Eating a heavy meal before going to bed c. Consuming an excessive amount of alcohol d. Taking an anxiolytic medication ANS: D
Anxiolytic (antianxiety) medications interfere with REM sleep, which is when people achieve full rest. DIF: Cognitive Level: Application REF: 608-609 TOP: Sleep KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 14 | 15
22. Although denying pain, a patient is irritable, responds slowly, and exhibits periods of
tachycardia. What should the nurse assess for in this patient? a. Electrolyte imbalance b. Allergic response c. Sleep deprivation d. Constipation ANS: C
With sleep deprivation, patients may experience a variety of physiologic and psychological symptoms. DIF: Cognitive Level: Application TOP: Sleep deprivation MSC: NCLEX: Physiological Integrity
REF: 609 OBJ: 16 KEY: Nursing Process Step: Assessment
23. When preparing a patient for sleep, diming the lights and decreasing the noise levels are
examples of nursing interventions. What are these interventions designed to do? a. Mimic usual sleep patterns. b. Decrease environmental stimuli. c. Prepare the patient for sleep. d. Provide for more rest. ANS: B
Environmental stimuli should be decreased when preparing the patient for sleep. DIF: Cognitive Level: Comprehension REF: 610 OBJ: 13 TOP: Sleep KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. What is the best approach for a nurse to use when planning pain relief measures? a. Use a variety of pain relief methods. b. Use only nonopioid analgesics. c. Use at least three alternating methods. d. Use only one method at a time. ANS: A
A variety of methods applied simultaneously have an additive effect on pain control. DIF: Cognitive Level: Comprehension REF: 606 OBJ: 10 TOP: Pain control KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. The nurse is trying to establish an effective relationship with a patient in pain. What is the
best statement for the nurse to make when beginning the assessment? a. “I’ll check to see if you can have anything.” b. “Let me give you a backrub and see if it helps.” c. “I believe you are in pain.” d. “When was your last medication for pain?” ANS: C
A nursing intervention to establish an effective relationship is to believe the patient. Although the other options are not wrong, they do not help establish an effective relationship. DIF: Cognitive Level: Application REF: 593 | 602 OBJ: 10 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 26. What action should the nurse take when evaluating the effectiveness of new or revised
therapies for pain relief? a. Observe the patient performing activities of daily living. b. Observe the patient’s facial expressions. c. Frequently assess subjective data. d. Perform evaluation of outcome goals. ANS: D
Continuous evaluation allows the nurse to determine if new or revised therapies are required. DIF: Cognitive Level: Application REF: 611 TOP: Pain KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
OBJ: 10
27. The home health nurse is instructing the family of an older adult patient with arthritis
about sleep promotion. What intervention can best promote sleep for the older adult patient? a. Giving nonsteroidal anti-inflammatory drugs (NSAIDs) in the mornings b. Administering diuretics in the mornings c. Encouraging daytime sleeping d. Avoiding the stimulation of backrubs or warm drinks before bedtime ANS: B
Older adults sleep lightly. Give NSAIDs before bedtime for comfort. Diuretics should be given in the mornings to reduce having to wake up to go to the bathroom during the night. Daytime sleeping may negatively affect nighttime sleep. Nonpharmacologic interventions are helpful to induce sleep. DIF: Cognitive Level: Comprehension TOP: Sleep promotion MSC: NCLEX: Physiological Integrity
REF: 598 OBJ: 13 KEY: Nursing Process Step: Implementation
28. The nurse is using a pain scale of 0 to 10 to assess pain in a postoperative patient. What is
considered the maximum pain level at which a patient can usually function effectively? a. 2 b. 3 c. 4 d. 5 ANS: C
Most patients do not function effectively if the pain level exceeds 4 on a scale of 10. DIF: Cognitive Level: Knowledge
REF: 605
OBJ: 8
TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. A patient is receiving epidural analgesics. What should the nurse monitor closely in this
patient? a. Temperature elevation from 98° to 99.2°F (36.6° to 37.3°C) b. Increase in pulse rate from 88 to 99 c. Decrease in respirations from 16 to 14 d. Decrease in blood pressure from 120/80 to 110/68 ANS: C
Administering epidural analgesics requires close monitoring for respiratory depression. None of the other options is indicative of opiate toxicity. DIF: Cognitive Level: Application TOP: Opiate toxicity MSC: NCLEX: Physiological Integrity
REF: 601 OBJ: 10 KEY: Nursing Process Step: Assessment
30. When should a nurse administer prescribed analgesic medication when treating a
postoperative patient? a. Before activity b. Only when requested by the health care provider c. Only when requested by the family d. Only when requested by the patient ANS: A
To control pain early, an analgesic should be given 30 to 40 minutes before a patient must walk or perform an activity. PRN medications should be given around the clock to effectively control moderately severe to severe pain. Waiting for the patient or family to request analgesics results in delays in administration and inadequate pain control. DIF: Cognitive Level: Application REF: 606 OBJ: 10 TOP: Pain control KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 31. What action should the nurse implement when assisting a postoperative patient with pain
control and comfort? a. Pull the patient up in bed. b. Lift the patient up in bed. c. Tighten constricting bandages. d. Restrict fluid and dietary intake. ANS: B
Pain control and comfort measures include loosening constricting bandages, lifting, not pulling the patient up in bed, and preventing constipation by encouraging appropriate fluid and dietary intake. DIF: Cognitive Level: Application REF: 605 OBJ: 10 TOP: Pain control KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
32. A nurse is caring for a patient who requires long-term management for severe pain. What
should be the drug of choice for this patient? a. Aspirin b. Morphine c. Oxycodone d. Acetaminophen ANS: B
Morphine and hydromorphone are the opioids of choice for long-term management of severe pain. DIF: Cognitive Level: Analysis REF: 599 OBJ: 9 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. The pain relief intervention that stimulates large cutaneous nerve fibers to “close the gate”
is the a. PRI b. TENS c. CTG d. UTI
unit.
ANS: B
TENS (transcutaneous electric nerve stimulator) stimulates cutaneous nerve fibers with electric impulses, which follow the same spinal pathway as do pain impulses. The cutaneous nerves “close the gate” to the pain impulses. DIF: Cognitive Level: Knowledge REF: 595 OBJ: 4 | 11 TOP: TENS KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse should administer an analgesic to an unconscious patient after observing which
signs? (Select all that apply.) a. Increased heart rate from 82 to 94 b. Decreased systolic blood pressure c. Increased muscle tension d. Perspiration on upper lip e. Facial grimacing ANS: A, C, D, E
Pain indicators in the unconscious patient might include increased heart rate, blood pressure, and muscle tension; diaphoresis; and grimacing. DIF: Cognitive Level: Application REF: 591 | 605 OBJ: 10 TOP: Assessing pain in the unconscious patient KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. A patient tells the nurse he is reluctant to report his pain because he does not want to be a
bother. What problems is the nurse aware that unrelieved pain can cause? (Select all that apply.) a. Decreased oxygen demand b. Depression c. Respiratory dysfunction d. Decreased GI motility e. Irritability ANS: B, C, D, E
Pain, which is unrelieved, can cause many physical and psychological symptoms, including depression, respiratory dysfunction, decreased GI motility, and irritability. Pain causes increased oxygen demand. DIF: Cognitive Level: Comprehension TOP: Unrelieved pain MSC: NCLEX: Physiological Integrity
REF: 595 OBJ: 10 KEY: Nursing Process Step: Implementation
COMPLETION 1. The nurse clarifies that the term peripheral analgesics describes the group of drugs also
referred to as
.
ANS:
NSAIDs Peripheral analgesics are also the group of drugs referred to as NSAIDs. DIF: Cognitive Level: Knowledge REF: 599 TOP: Nonsteroidal anti-inflammatory drugs (NSAIDs) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 10
2. The nurse is aware that the state at which a person is mentally relaxed, free from worry,
and is physically calm is
.
ANS:
rest When a person is mentally relaxed, free from worry, and is physically calm, he or she is at rest. DIF: Cognitive Level: Knowledge REF: 606 TOP: Rest KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
Chapter 22: Surgical Wound Care Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse is instructing a patient who has a drain in a surgical wound. How will the nurse
indicate that the wound will heal? a. Primary intention b. Secondary intention c. Tertiary intention d. Deliberate intention ANS: C
When wounds are kept open by a drain, they heal by tertiary intention. DIF: Cognitive Level: Comprehension TOP: Tertiary intention MSC: NCLEX: Physiological Integrity
REF: 616 OBJ: 4 KEY: Nursing Process Step: Implementation
2. What technique will the nurse implement to assist the postoperative patient to cough? a. Support the patient’s back. b. Offer an antitussive. c. Splint the abdomen with a pillow. d. Lean patient against the bedside table. ANS: C
To assist a postoperative patient to cough, splinting the abdomen with pillow, hands, or a towel roll is helpful to relieve stress on the suture line. DIF: Cognitive Level: Application REF: 617 OBJ: 8 TOP: Suture lines KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The day following surgery, the nurse notes bloody drainage on the dressing. How will the
nurse describe this drainage when documenting? a. Serosanguineous b. Sanguineous c. Serous d. Purulent ANS: B
The term sanguineous means bloody. It is indicative of active bleeding. DIF: Cognitive Level: Application REF: 619 TOP: Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. What is the advantage of an occlusive dressing? a. Allows air to the incision. b. Keeps the incision moist. c. Delays epithelialization.
OBJ: 1
d. Does not have to be changed. ANS: B
Occlusive dressings keep the incision moist and increase epithelialization. DIF: Cognitive Level: Comprehension TOP: Occlusive dressings MSC: NCLEX: Physiological Integrity
REF: 620 OBJ: 7 KEY: Nursing Process Step: Implementation
5. When removing the dressing on a patient, the nurse discovers that the gauze dressing has
adhered to the wound. What intervention should the nurse implement? a. Call the RN. b. Gently remove the gauze with sterile forceps. c. Cover with occlusive dressing. d. Moisten the dressing with sterile water. ANS: D
When a dressing has adhered to the wound, the nurse may moisten the dressing with sterile water or sterile normal saline to loosen it. DIF: Cognitive Level: Application TOP: Dry dressings MSC: NCLEX: Physiological Integrity
REF: 621 OBJ: 7 KEY: Nursing Process Step: Implementation
6. The nurse is providing instruction to a patient regarding home wound irrigation. How far
should the patient hold the handheld showerhead from the wound when irrigating the wound? a. 2.5 in b. 6 in c. 12 in d. 18 in ANS: C
When wound irrigation is done at home with a handheld showerhead, the showerhead should be held approximately 12 in from the wound. DIF: Cognitive Level: Comprehension TOP: Wound irrigation MSC: NCLEX: Physiological Integrity
REF: 628 OBJ: 11 KEY: Nursing Process Step: Implementation
7. The nurse is irrigating a leg wound of a patient on the trauma unit. Where should the nurse
direct the flow of the irrigant? a. From the area of least contamination to the area of most contamination b. Forcefully into the wound c. Gently over the skin into the wound d. From a distance of about 12 in ANS: A
The irrigant should flow from the least contaminated area to the most contaminated area to prevent microorganisms from entering the wound. DIF: Cognitive Level: Application TOP: Wound irrigation
REF: 625 OBJ: 11 KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 8. The nurse observes a loop of bowel protruding from the surgical incision. What is the first
intervention the nurse should implement? a. Call the RN. b. Cover the bowel with a sterile saline dressing. c. Turn the patient to the side of the evisceration. d. Raise the patient up to a high Fowler’s position. ANS: B
Although the RN must be notified, covering the loop of the bowel takes priority. The patient may be raised to a semi-Fowler’s position to relieve strain on the suture line. DIF: Cognitive Level: Application REF: 632 OBJ: 8 TOP: Evisceration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse is removing every other staple from a surgical wound, which has been closed
with 15 staples. The wound begins to separate after removal of 3 of the 15. What nursing action should be implemented? a. Remove 7 more alternate staples and securely tape with Steri-Strips. b. Cover with moist dressing and apply a binder. c. Continue to remove staples as ordered because this is an expected outcome. d. Leave the 12 staples in place and record the separation. ANS: D
If the wound separates during the removal of staples, cease the removal, cover with a dry dressing, and record the separation. DIF: Cognitive Level: Application TOP: Staple removal MSC: NCLEX: Physiological Integrity
REF: 629 | 630 OBJ: 9 KEY: Nursing Process Step: Implementation
10. The health care provider has not ordered a dressing change for a draining wound on a
patient in an acute care setting. How should the nurse assess the amount of drainage? a. Weigh the patient to estimate the weight of the saturated dressing. b. Reinforce the dressing. c. Circle and date the outline of the exudate on the dressing. d. Count each dressing as 1 mL of drainage. ANS: C
Without an order to change the dressing, the drainage should be circled and dated. Should the dressing become saturated, the dressing can be reinforced but the exudate should still be circled. DIF: Cognitive Level: Application TOP: Draining wounds MSC: NCLEX: Physiological Integrity
REF: 633 OBJ: 7 KEY: Nursing Process Step: Assessment
11. The Centers for Disease Control and Prevention (CDC) classifies wounds according to the
amount of contamination. What is the classification for an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively?
a. b. c. d.
Dirty wound Clean-contaminated wound Contaminated wound Clean wound
ANS: D
A clean wound is an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively. DIF: Cognitive Level: Comprehension REF: 615 TOP: Wounds KEY: Nursing Process Step: N/A
OBJ: 5 MSC: NCLEX: N/A
12. Hemostasis begins as soon as the injury occurs and a clot begins to form. What is the
substance in the clot that holds the wound together? a. Fibrin b. Thrombin c. Protime d. Calcium ANS: A
Fibrin in the clot begins to hold the wound together. DIF: Cognitive Level: Knowledge REF: 616 OBJ: 1 TOP: Wounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. What phase is a wound in when blood and fluid flow into the vascular space and produce
edema, erythema, heat, and pain? a. Healing b. Inflammatory c. Reconstruction d. Maturation ANS: B
During the inflammatory phase, blood and fluid leak out of the blood vessels into the vascular space. DIF: Cognitive Level: Comprehension REF: 633 TOP: Wounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
14. What marked advantage does primary intention have over other phases of wound healing? a. Healing is rapid. b. Healing rarely becomes infected. c. Minimal scarring results. d. Healing is painless. ANS: C
Wounds that heal by primary intention have minimal scarring. DIF: Cognitive Level: Comprehension REF: 616 OBJ: 4 TOP: Wounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
15. The nurse is caring for a patient during the first 24 hours following surgery. How often
will the nurse assess for bleeding under the dressing? a. Every 30 minutes b. Every 60 minutes c. Every 2 to 4 hours d. Every 5 to 8 hours ANS: C
The nurse inspects the dressing every 2 to 4 hours for the first 24 hours. DIF: Cognitive Level: Application REF: 619 TOP: Wounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
16. The nurse is preparing to perform a dressing change on a patient following a total hip
replacement. When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change? a. After the dressing change b. At least 15 minutes before the dressing change c. At least 30 minutes before the dressing change d. At least 1 hour before the dressing change ANS: C
It may help to give an analgesic at least 30 minutes before exposing the wound. DIF: Cognitive Level: Application REF: 621 OBJ: 7 TOP: Wounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry.
This drying process causes it to adhere to the wound. What is the result of this intervention when the dressing is removed? a. Destruction of tissue b. Bleeding c. Mechanical débridement d. Prevention of infection ANS: C
The primary purpose of a wet-to-dry dressing is to débride a wound mechanically. DIF: Cognitive Level: Comprehension REF: 623 OBJ: 7 TOP: Wounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse assessing a postoperative patient discovers that the pulse is rapid, blood pressure
has decreased, urinary output has decreased, and the dressing is dry. What can the nurse determine is indicated by these findings? a. Pain shock b. Dehydration c. Internal hemorrhage d. Acute infection
ANS: C
If a patient has a rapid pulse, decreased blood pressure, decreased urinary output, and the dressing is dry, then the diagnosis is most likely an internal hemorrhage. DIF: Cognitive Level: Analysis TOP: Postoperative MSC: NCLEX: Physiological Integrity
REF: 628-629 OBJ: 3 KEY: Nursing Process Step: Assessment
19. What is the usual length of time before suture removal? a. 2 to 3 days b. 4 to 5 days c. 5 to 6 days d. 7 to 10 days ANS: D
Sutures are generally removed within 7 to 10 days. DIF: Cognitive Level: Knowledge REF: 629 OBJ: 9 TOP: Wounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. The nurse carefully measures drainage during the first 24 hours after surgery on a patient
with a Jackson-Pratt drain. What is the maximum amount of drainage considered normal? a. 50 mL b. 100 mL c. 200 mL d. 300 mL ANS: D
Drainage greater than 300 mL in 24 hours is considered abnormal. DIF: Cognitive Level: Comprehension REF: 633 TOP: Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 3
21. What is the classification for the Jackson-Pratt drainage removal system? a. Sterile drainage system b. Closed drainage system c. Open drainage system d. Self-measuring drainage system ANS: B
The Jackson-Pratt removal system is a type of closed drainage system. DIF: Cognitive Level: Knowledge REF: 633 OBJ: 10 TOP: Drainage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The nurse is caring for a patient with a surgical wound. How can the nurse promote
healing? a. Offer fluids every 4 hours. b. Encourage the consumption of large meals.
c. Encourage up to 1000 mL of daily fluid intake. d. Encourage the consumption of small frequent meals. ANS: D
To promote wound healing, dietary services can provide small frequent feedings. Fluids, when tolerated, should be offered hourly. Unless contraindicated, the nurse should encourage an intake of 2000 to 2400 mL in 24 hours. DIF: Cognitive Level: Application TOP: Wound healing MSC: NCLEX: Physiological Integrity
REF: 616 OBJ: 2 KEY: Nursing Process Step: Implementation
23. The nurse is instructing a patient about the effects of smoking. What accurate information
does the nurse provide? a. Smoking increases the amount of tissue oxygenation. b. Smoking increases the amount of functional hemoglobin in blood. c. Smoking may decrease platelet aggregation and cause hypercoagulability. d. Smoking interferes with normal cellular mechanisms that promote release of oxygen. ANS: D
Smoking reduces the amount of functional hemoglobin in blood, thus decreasing tissue oxygenation. Smoking may increase platelet aggregation and hypercoagulability. Smoking interferes with normal cellular mechanisms that promote release of oxygen to tissues. DIF: Cognitive Level: Comprehension REF: 618 OBJ: 6 TOP: Smoking KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. The nurse is preparing a presentation regarding the effects of diabetes mellitus. What will
the nurse include regarding the effects of diabetes mellitus? a. Improves overall tissue perfusion. b. Promotes release of oxygen to tissues. c. Causes hemoglobin to have a greater affinity for oxygen. d. Causes hemoglobin to have a decreased affinity for oxygen. ANS: C
Diabetes mellitus is a chronic disease that causes small blood vessel disease that impairs tissue perfusion. It also causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues. DIF: Cognitive Level: Comprehension TOP: Diabetes mellitus MSC: NCLEX: Physiological Integrity
REF: 618 OBJ: 6 KEY: Nursing Process Step: Implementation
25. The nurse assessing a patient’s wound notes a clear watery drainage. How will the nurse
most accurately document this finding? a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage
ANS: A
Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is bright red and indicates active bleeding. Serosanguineous drainage is pale, red, and watery, and is a mixture of serous and sanguineous drainage. DIF: Cognitive Level: Comprehension REF: 619 TOP: Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
26. The nurse assessing a patient’s wound notes thick, yellow drainage. How will the nurse
most accurately document this finding? a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage ANS: B
Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Serous drainage has the appearance of clear, watery plasma. Sanguineous drainage is bright red and indicates active bleeding. Serosanguineous drainage is pale, red, and watery, and is a mixture of serous and sanguineous drainage. DIF: Cognitive Level: Comprehension REF: 616 TOP: Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
27. The nurse assessing a patient’s wound notes pale red watery drainage. How will the nurse
most accurately document this finding? a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage ANS: D
Serosanguineous drainage is pale, red, and watery, and is a mixture of serous and sanguineous drainage. Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is bright red and indicates active bleeding. DIF: Cognitive Level: Comprehension REF: 619 TOP: Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
28. The nurse assessing a patient’s wound notes bright red drainage. How will the nurse most
accurately document this finding? a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage ANS: C
Sanguineous drainage is bright red and indicates active bleeding. Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage. DIF: Cognitive Level: Comprehension REF: 619 TOP: Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
29. The nurse is assisting a patient to a sitting position when the patient suddenly complains of
feeling that his surgical incision has separated. What does the nurse recognize that this indicates? a. Cellulitis b. Dehiscence c. Evisceration d. Extravasation ANS: B
Dehiscence is separation of a surgical incision or rupture of a wound closure. DIF: Cognitive Level: Comprehension REF: 629 TOP: Dehiscence KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 8
30. The nurse is preparing to redress a wound and will secure the dressing using a gauze
bandage as ordered by the health care provider. What is an advantage of gauze bandages? a. Provision of warmth. b. Applies strong pressure. c. Antibacterial effects. d. Prevents skin maceration. ANS: D
Gauze bandages are lightweight and inexpensive, mold easily around contours of the body, and permit air circulation that helps prevent skin maceration (the softening and breaking down of skin from prolonged exposure to moisture). Flannel bandages provide warmth. Elastic bandages are effective for pressure application. Gauze bandages do not have antibacterial effects. DIF: Cognitive Level: Comprehension TOP: Bandages and binders MSC: NCLEX: Physiological Integrity
REF: 638 OBJ: 13 KEY: Nursing Process Step: Assessment
31. A patient with a diagnosis of insulin-dependent diabetes mellitus is being treated for a
stage 2 foot injury. The patient refuses to follow an ADA diet as ordered by a health care provider and is morbidly obese. The nurse assesses the injury to be healing, free from signs and symptoms of infection, with a positive pedal pulse and warm to touch. What patient problem will be identified as a priority? a. Infection b. Altered nutrition: more than body requirements c. Impaired skin integrity d. Altered peripheral tissue perfusion
ANS: B
The nurse’s assessment identifies no signs of infection, that the wound is healing with positive pedal pulse and skin warm to touch ruling out infection, impaired skin integrity, and altered peripheral tissue perfusion as priorities at this time. The priority patient problem for this patient is altered nutrition: more than body requirements related to diet noncompliance. DIF: Cognitive Level: Analysis TOP: Patient problem MSC: NCLEX: Physiological Integrity
REF: 616 | 642 OBJ: 14 KEY: Nursing Process Step: Diagnosis
MULTIPLE RESPONSE 1. The nurses employed at a wound therapy clinic are preparing an educational in-service
about the vacuum-assisted closure (VAC) device for hospital nurses. What accurate information will be included in this in-service? (Select all that apply.) a. Positive pressure is applied by this device. b. Healing is facilitated by decrease in drainage. c. Promotes formulation of granulation tissue. d. Reduces local and peripheral edema. e. Drops bacterial level in wound. ANS: C, D, E
Vacuum-assisted closure (VAC) devices apply negative pressure and increase drainage. Healing is facilitated by promotion of granulation tissue, decreased local and peripheral edema, and in 3 to 4 days following application a drop in bacterial level in the wound should be observed. DIF: Cognitive Level: Comprehension TOP: Vacuum-assisted device MSC: NCLEX: Physiological Integrity
REF: 633 OBJ: 12 KEY: Nursing Process Step: Implementation
2. Which are the phases of wound healing? (Select all that apply.) a. Reconstruction b. Hemostasis c. Inflammation d. Granulation e. Maturation ANS: A, B, C, E
The steps in wound healing are hemostasis, inflammation, reconstruction, and maturation. DIF: Cognitive Level: Knowledge TOP: Wound healing MSC: NCLEX: Physiological Integrity
REF: 616 OBJ: 1 KEY: Nursing Process Step: Implementation
3. Which solutions can be used on a wet-to-dry dressing? (Select all that apply.) a. Normal saline b. Lactated Ringer c. Acetic acid d. Dakin
e. Lysol ANS: A, B, C, D
Normal saline, sterile water, lactated Ringer, acetic acid, or Dakin solution are all acceptable for use on wet-to-dry dressings. DIF: Cognitive Level: Comprehension TOP: Wet-to-dry dressings MSC: NCLEX: Physiological Integrity
REF: 623 OBJ: 7 KEY: Nursing Process Step: Implementation
4. What are the advantages of a transparent dressing? (Select all that apply.) a. Adheres to undamaged skin. b. Contains the exudate. c. Reduces wound contamination. d. Serves as a barrier to external bacteria. e. Slows epithelial growth. ANS: A, B, C, D
Transparent dressings have the advantages of adhering to undamaged skin, containing the exudate, reducing wound contamination, serving as a barrier to external bacteria, and speeding epithelial growth. DIF: Cognitive Level: Comprehension TOP: Transparent dressings MSC: NCLEX: Physiological Integrity
REF: 625 OBJ: 7 KEY: Nursing Process Step: Planning
COMPLETION 1. The nurse assures a patient that the purple, raised, immature scar of a surgical wound is
normal and caused by
formation.
ANS:
collagen Collagen forms as an immature scar over a new surgical wound. DIF: Cognitive Level: Knowledge TOP: Immature scarring MSC: NCLEX: Physiological Integrity
REF: 616 OBJ: 1 KEY: Nursing Process Step: Implementation
2. The nurse encourages a patient recovering from a hysterectomy to drink at least
mL of fluid a day. ANS:
2000 A recovering surgical patient should drink between 2000 and 2400 mL of fluid daily. DIF: Cognitive Level: Comprehension REF: 617 OBJ: 2 TOP: Fluid intake KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
3. When preparing to remove a dressing, the nurse should don
gloves.
ANS:
clean To remove a dressing, clean gloves are appropriate. DIF: Cognitive Level: Comprehension REF: 620 OBJ: 7 TOP: Removal of a dressing KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment
Chapter 23: Specimen Collection and Diagnostic Testing Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. New health care provider orders are transcribed for a patient to receive a colonoscopy.
What must be completed before the colonoscopy to indicate the patient has been given full knowledge about what will be done along with its risks and complications? a. Patients’ rights b. Advance directive c. Informed consent d. Patient protection ANS: C
Informed consent states that the patient must fully understand and be aware of the risks and complications of what is to be done. DIF: Cognitive Level: Comprehension REF: 648 OBJ: 1 TOP: Proper preparation KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 2. The nurse is preparing a patient for a diagnostic examination. What can the nurse
implement to assist with reducing anxiety? a. Explain the costs of the examination. b. Demonstrate use of equipment. c. Answer questions for clarification. d. Fill out required paperwork. ANS: C
The nurse must be prepared to answer questions that the patient may have to reduce anxiety and give valid information. DIF: Cognitive Level: Application TOP: Proper preparation MSC: NCLEX: Psychosocial Integrity
REF: 648 OBJ: 2 KEY: Nursing Process Step: Implementation
3. A patient is required to provide a sample of body excretions per health care provider order.
What action can the nurse take when providing proper instructions to lessen the patient’s embarrassment? a. Instruct patient to provide the specimen behind a screen. b. Instruct patient to obtain his or her own specimen. c. Instruct patient to return later when he or she is more comfortable. d. Instruct patient to use a CNA for assistance to obtain the specimen. ANS: B
With proper instruction, many patients may obtain their own specimen. DIF: Cognitive Level: Application TOP: Specimen collection MSC: NCLEX: Psychosocial Integrity
REF: 666 OBJ: 3 KEY: Nursing Process Step: Implementation
4. What health care professional has the responsibility for notifying the health care provider
when laboratory and diagnostic studies deviate from the norm? a. Laboratory technician b. Cooperating health care provider c. Nurse d. Supervisor ANS: C
It is the nurse’s responsibility to notify the health care provider when laboratory and diagnostic studies deviate from the norm. DIF: Cognitive Level: Knowledge REF: 666 OBJ: 4 TOP: Diagnostic studies KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 5. What is the term for the cleanest part of a voided urine specimen that is collected after
voiding is initiated and before it is finished? a. Sterile specimen b. “Caught” specimen c. Midstream specimen d. Patient-collected specimen ANS: C
A midstream urine specimen is collected after voiding is initiated and before it is completed. DIF: Cognitive Level: Knowledge REF: 667 OBJ: 5 | 6 TOP: Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 6. The patient is to be catheterized for residual urine. The nurse must perform this
catheterization within how many minutes following voiding? a. 40 minutes b. 30 minutes c. 20 minutes d. 10 minutes ANS: D
Catheterization is performed within 10 minutes of the patient voiding to check for residual urine. DIF: Cognitive Level: Knowledge REF: 667 OBJ: 8 TOP: Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 7. The process for collecting a blood specimen for measuring blood glucose levels begins by
asking the patient to hold the selected arm at his or her side for 30 seconds. From what anatomic location is the specimen obtained? a. Tip of the finger b. Cubital fossa c. Side of the finger d. Center of the thumb
ANS: C
The specimen should be collected from the side of the selected finger to avoid painful fingertip sticks. DIF: Cognitive Level: Knowledge REF: 671 OBJ: 9 TOP: Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. What type of stool specimen must be sent to the laboratory immediately? a. Occult blood b. Ova and parasites c. Infection d. Fats ANS: B
A stool specimen for the presence of ova or parasites must be taken to the laboratory immediately. DIF: Cognitive Level: Knowledge REF: 670 OBJ: 10 TOP: Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 9. What is the probable source of bright red blood in the stool? a. Stomach b. Small intestine c. Lower gastrointestinal tract d. Higher intestinal tract ANS: C
When blood in the stool is bright red, the site of bleeding is most likely from the lower gastrointestinal tract. DIF: Cognitive Level: Comprehension REF: 670 | 673 TOP: Specimen KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4 | 10
10. A sputum specimen is ordered on a patient diagnosed with pneumonia. When is the best
time for the nurse to the attempt to collect this specimen? a. At bedtime b. After lunch c. In the early morning d. After breakfast ANS: C
Early morning before a meal is the best time to collect a sputum specimen. DIF: Cognitive Level: Knowledge REF: 673 OBJ: 11 TOP: Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 11. A patient is unable to obtain a sputum specimen by coughing and expectorating. What is
the best way for the nurse to collect this specimen?
a. b. c. d.
Ask the patient to spit. Direct the patient to turn, cough, and breathe deeply. Perform tracheal suctioning. Perform a bronchoscopy.
ANS: C
Some patients cannot expectorate and must have the trachea suctioned to obtain a specimen. DIF: Cognitive Level: Application REF: 673 OBJ: 11 TOP: Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 12. The nurse is collecting a specimen for a wound culture. What should be avoided when
collecting this specimen? a. A dressing b. Deep in the wound c. The outer edge of the wound d. Old drainage ANS: D
The nurse should not collect a wound culture from old drainage. DIF: Cognitive Level: Application REF: 673 OBJ: 5 TOP: Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 13. Anaerobic organisms tend to grow within body cavities. What will the nurse use to collect
an anaerobic specimen? a. Sterile cotton applicator b. Sterile culture tube c. Sterile syringe tip d. Sterile glass rod ANS: C
To collect an anaerobic specimen deep in a body cavity, the nurse uses a sterile syringe tip. DIF: Cognitive Level: Application REF: 673 OBJ: 5 TOP: Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 14. The nurse is obtaining a throat culture. What area will the nurse swab with a cotton-tipped
applicator? a. Larynx b. Oral mucosa c. Pharynx d. Trachea ANS: C
The nurse should swab the tonsillar area (pharynx) with a sterile cotton-tipped applicator to obtain a specimen for a throat culture.
DIF: Cognitive Level: Application REF: 678-679 OBJ: 4 TOP: Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 15. The nurse explains that electrocardiograms are graphic representations of electric impulses
generated by the heart. What type of abnormalities can an electrocardiogram identify? a. Those that produce a cardiac cycle b. Those that interfere with electric conduction c. Those that result from an interrupted blood flow d. Those that interfere with heart contraction ANS: B
Electrocardiograms identify abnormalities that interfere with electric conduction. DIF: Cognitive Level: Comprehension REF: 683 OBJ: 13 TOP: Electrocardiogram KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 16. What is the rationale for the nurse to assess a patient’s knowledge of an ordered
procedure? a. To determine difficulties the patient may encounter b. To determine the nurse’s role in the procedure c. To determine health teaching required d. To determine anxiety the patient has ANS: C
The nurse will need to assess the patient’s knowledge of the procedure to determine the level of health care teaching needed. DIF: Cognitive Level: Comprehension TOP: Teaching needs MSC: NCLEX: Psychosocial Integrity
REF: 683 OBJ: 2 KEY: Nursing Process Step: Assessment
17. What should the nurse assess the patient for before administration of contrast media? a. Has been NPO. b. Is allergic to iodine. c. Has emptied the bladder. d. Has taken medication. ANS: B
The patient should always be assessed for allergies to iodine before administration of contrast media. DIF: Cognitive Level: Application REF: 650 OBJ: 2 TOP: Diagnostic examination KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 18. The nurse should administer Telepaque in preparation for a cholecystogram. How
frequently will the nurse administer 1 tablet of Telepaque before this procedure? a. Every 5 minutes b. Every 10 minutes c. Every 15 minutes
d. Every 20 minutes ANS: C
Telepaque should be taken one at a time, waiting 15 minutes after each tablet. DIF: Cognitive Level: Application REF: 658 OBJ: 2 TOP: Diagnostic examination KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 19. Following a liver biopsy, the nurse should observe for hemorrhage and ensure that the
patient is kept on bed rest for 24 hours. How should the nurse keep the patient for the first 1 to 2 hours? a. On his or her left side b. On his or her back c. On his or her right side d. In high Fowler’s position ANS: C
The nurse should keep the patient on his or her right side for 1 to 2 hours. DIF: Cognitive Level: Application REF: 660 OBJ: 1 | 2 TOP: Diagnostic examination KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 20. The patient has undergone a lumbar puncture. What position will the nurse place the
patient in for up to 12 hours to avoid discomfort from postpuncture spinal headache? a. Supine b. Lateral c. Sims d. Prone ANS: A
The nurse should place the patient in the supine position and keep in reclining position for 12 hours. DIF: Cognitive Level: Application REF: 660 OBJ: 1 | 2 TOP: Diagnostic examination KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 21. The procedure for collecting a sterile urine specimen via a catheter port includes clamping
the Foley catheter tubing below the catheter port. How long will the clamp remain in place? a. 5 minutes b. 10 minutes c. 20 minutes d. 30 minutes ANS: D
Clamp just below the catheter port for 30 minutes. DIF: Cognitive Level: Comprehension REF: 669 OBJ: 1 TOP: Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment
22. The nurse is caring for a patient following a bronchoscopy and maintains NPO status for 2
hours. What additional assessment will indicate to the nurse that this patient’s risk for aspiration has decreased? a. Patient is fully awake. b. Patient asks for a drink. c. Gag reflex has returned. d. Preoperative medication has worn off. ANS: C
The nurse should not allow the patient to eat or drink after a bronchoscopy until the gag reflex has returned. DIF: Cognitive Level: Application REF: 654 OBJ: 1 TOP: Diagnostic examination KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 23. The nurse has an order to perform occult blood testing on a patient’s emesis. What color
will the sample turn to indicate that the test is positive for occult blood? a. Red b. Blue c. Green d. Yellow ANS: B
If the sample turns blue, the test is positive for occult blood; if it turns green, it is negative for occult blood. DIF: Cognitive Level: Comprehension TOP: Occult blood testing MSC: NCLEX: Physiological Integrity
REF: 673 OBJ: 1 KEY: Nursing Process Step: Implementation
24. What should the nurse do when preparing the patient for an abdominal scan? a. Assess laboratory results only for liver function. b. Assess patient for allergies to dye or shellfish. c. Instruct patient to limit fluid intake immediately following procedure. d. Instruct patient to be NPO for 1 hour before scan if contrast medium is used. ANS: B
The patient should be assessed for allergies to dye or shellfish. When a patient has an abdominal scan, laboratory results should be assessed for kidney function. The patient should be instructed to be NPO for 4 hours before the examination if contrast medium is to be used. The patient should be encouraged to consume fluids after the examination. DIF: Cognitive Level: Application TOP: Diagnostic examination MSC: NCLEX: Physiological Integrity
REF: 651 OBJ: 1 | 2 KEY: Nursing Process Step: Implementation
25. What should the nurse do when preparing the patient for an arteriography? a. Verify if the patient has been taking anticoagulants. b. Keep the patient NPO for 24 hours before the procedure. c. Instruct the patient to have a full bladder for the procedure.
d. Inform the patient that a coldness may be felt when dye is injected. ANS: A
When a patient has an arteriography, the nurse should assess if the patient has been taking anticoagulants. The patient is kept NPO for 2 to 8 hours before the procedure. The nurse informs the patient that a warm flush may be felt when dye is injected. The patient is instructed to void before the arteriography. DIF: Cognitive Level: Application TOP: Diagnostic examination MSC: NCLEX: Physiological Integrity
REF: 651 OBJ: 1 | 2 KEY: Nursing Process Step: Implementation
26. The nurse is preparing a patient for a barium enema. What color will the nurse inform the
patient his stools will be following this procedure? a. Blue b. White c. Green d. Brown ANS: B
Immediately following a barium enema, a patient’s stools are white until all of the barium is expelled. DIF: Cognitive Level: Comprehension TOP: Diagnostic examination MSC: NCLEX: Physiological Integrity
REF: 652 OBJ: 2 | 3 KEY: Nursing Process Step: Implementation
27. What should the nurse do when preparing the patient for an amniocentesis? a. Restrict food intake. b. Restrict fluid intake. c. Monitor fetal heart tones. d. Inform patient results will be available immediately. ANS: C
When a patient has an amniocentesis, fetal heart tones should be monitored. There are no fluid or food restrictions, and the patient should be told to contact her health care provider to obtain results, which are usually available after 2 weeks. DIF: Cognitive Level: Application TOP: Diagnostic examination MSC: NCLEX: Physiological Integrity
REF: 651 OBJ: 2 KEY: Nursing Process Step: Implementation
28. What should the nurse do when preparing the patient for a bone scan? a. Sedate the patient. b. Restrict food intake. c. Restrict fluid intake. d. Encourage water intake. ANS: D
Before a bone scan, the patient is encouraged to drink several glasses of water. No fasting or sedation is required before a bone scan.
DIF: Cognitive Level: Application TOP: Diagnostic examination MSC: NCLEX: Physiological Integrity
REF: 653 OBJ: 2 KEY: Nursing Process Step: Implementation
29. What should the nurse do when preparing the patient for a brain scan? a. Allow the patient to wear a wig during the scan. b. Allow the patient to wear a partial denture plate during the scan. c. Inform the patient that a clicking noise will be heard during the scan. d. Keep the patient NPO for 12 hours before scan if contrast dye is used. ANS: C
Before a brain scan, the patient is kept NPO for 4 hours if contrast dye is to be used, the patient is instructed not to wear a wig, hairpins, clips, or partial denture plates, and the nurse informs the patient that a clicking noise is made as the scanner moves. DIF: Cognitive Level: Application TOP: Diagnostic examination MSC: NCLEX: Physiological Integrity
REF: 653 OBJ: 2 KEY: Nursing Process Step: Implementation
30. What should the nurse do when preparing the patient for a bronchoscopy? a. Instruct the patient to hold his or her breath during the procedure. b. Instruct the patient to remain NPO 24 hours before the procedure. c. Obtain informed consent after premedicating the patient. d. Reassure the patient that he or she will be able to breathe during the procedure. ANS: D
The nurse should reassure a patient before a bronchoscopy that they will be able to breathe during the procedure. The patient is instructed to remain NPO after midnight (4 to 8 hours) before the procedure. Informed consent must be obtained before the patient is premedicated. DIF: Cognitive Level: Application TOP: Diagnostic examination MSC: NCLEX: Physiological Integrity
REF: 654 OBJ: 2 KEY: Nursing Process Step: Implementation
31. What should the nurse encourage the patient to consume when preparing for an
electroencephalogram (EEG)? a. Tea b. Food c. Cola d. Coffee ANS: B
Food intake should be encouraged, but coffee, tea, and colas should be eliminated before an EEG. DIF: Cognitive Level: Application TOP: Diagnostic examination MSC: NCLEX: Physiological Integrity
REF: 656 OBJ: 2 KEY: Nursing Process Step: Implementation
32. What intervention should the nurse implement when preparing the patient for a glucose
tolerance test (GTT)?
a. b. c. d.
Restrict water intake before the test. Encourage exercise before the test. Keep patient NPO 8 hours before the test. Instruct patient to have a full bladder for the test.
ANS: C
A patient having a glucose tolerance test should be kept NPO for 8 hours before the test except for water consumption so that they can provide urine samples. The patient should empty their bladder before the examination. DIF: Cognitive Level: Application TOP: Diagnostic examination MSC: NCLEX: Physiological Integrity
REF: 658 OBJ: 2 KEY: Nursing Process Step: Implementation
33. What should the nurse do when preparing the patient for an exercise tolerance test
(treadmill)? a. Withhold all foods and fluids before the test. b. Withhold all heart medications before the test. c. Allow the patient to drink water before the test. d. Allow the patient to consume food before the test. ANS: C
A patient having an exercise tolerance test is kept NPO, except for water, for 4 hours until after the test. The nurse should never withhold the patient’s heart medications before this test. DIF: Cognitive Level: Application TOP: Diagnostic examination MSC: NCLEX: Physiological Integrity
REF: 657 OBJ: 2 KEY: Nursing Process Step: Implementation
34. A patient has just had a liver biopsy. What should the nurse do immediately following this
procedure? a. Assist the patient up to a chair. b. Keep the patient on his or her left side. c. Assist the patient with ambulation. d. Tell the patient to avoid coughing. ANS: D
The nurse should tell the patient to avoid coughing or straining, which may cause increased intraabdominal pressure. Immediately following a liver biopsy, the patient is kept on bed rest for 24 hours. The patient should lie on his or her right side for about 1 to 2 hours. DIF: Cognitive Level: Application TOP: Diagnostic examination MSC: NCLEX: Physiological Integrity
REF: 660 OBJ: 1 KEY: Nursing Process Step: Implementation
MULTIPLE RESPONSE 1. The nurse is preparing to collect a urine specimen. What will this nurse include when
labeling this specimen? (Select all that apply.)
a. b. c. d. e.
Date and time of collection Identification of last name only Room number Medical record number Insurance information
ANS: A, C, D
When labeling a specimen date and time of collection, room number and medical record number should be included. Patient should be identified by full name. Insurance information is not necessarily included. DIF: Cognitive Level: Application REF: 673 OBJ: 7 TOP: Labeling specimens KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment COMPLETION 1. After a bone scan, the nurse assesses a hematoma at the injection site of the dye. The nurse
should apply
soaks or compresses.
ANS:
warm Heat will speed absorption of collected blood. DIF: Cognitive Level: Application TOP: Hematoma at injection site MSC: NCLEX: Physiological Integrity
REF: 653 OBJ: 1 KEY: Nursing Process Step: Implementation
2. When initiating a 24-hour urine collection, the nurse asks the patient to void. The nurse
then
the specimen.
ANS:
discards The first voided specimen of a 24-hour collection is discarded. DIF: Cognitive Level: Application REF: 670 | 692 OBJ: 4 | 8 TOP: 24-hour urine specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 3. Following an intravenous pyelogram, the nurse should watch the patient closely for a
delayed reaction to the dye, usually occurring within procedure. ANS:
2, 6 26 two, six two six
to
hours following the
Delayed reactions to iodine may not be obvious until 2 to 6 hours postprocedure. DIF: Cognitive Level: Application REF: 690 OBJ: 1 TOP: Iodine allergy KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 4. When collecting a stool specimen for a guaiac (occult blood in stool), the nurse should
take a specimen from
different parts of the stool.
ANS:
two 2 The selection of different parts of the stool gives a broader testing range of the specimen. DIF: Cognitive Level: Application REF: 690 OBJ: 10 TOP: Occult blood specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 5. When performing a venipuncture, the tourniquet should be left on no more than
to
minutes. ANS:
1, 2 12 one, two one two Occluding the vein for longer than 1 or 2 minutes may cause damage to the vein or cause it to rupture. DIF: Cognitive Level: Application REF: 682 OBJ: 12 TOP: Venipuncture KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment
Chapter 24: Lifespan Development Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse tells a mother that the blueprint for all inherited traits, such as height, is found in
which of the following? a. Sperm b. Ovary c. Chromosomes d. Nucleus of the cell ANS: C
The blueprint for all inherited traits is found in the chromosomes. DIF: Cognitive Level: Knowledge REF: 697 OBJ: 4 TOP: Growth KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. The nurse discovers during the intake assessment of a 5-year-old child that the child lives
with his biological parents and siblings. How would the nurse categorize this family type? a. Extended family b. Blended family c. Social family d. Nuclear family ANS: D
The nuclear family is considered the traditional family pattern. DIF: Cognitive Level: Knowledge REF: 698 TOP: Family KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 4
3. A newborn baby weighs 7 lb at birth. What does the nurse anticipate the baby’s weight
will be at 1 year of age? a. 14 lb b. 17 lb c. 21 lb d. 25 lb ANS: C
By 1 year, birth weight is expected to triple. Thus, the weight at 1 year would be 7 lb times three, which would equal 21 lb. DIF: Cognitive Level: Application REF: 704 OBJ: 4 TOP: Growth KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 4. The mother of a 5-month-old child is concerned because the child cannot sit by himself.
The nurse explains that sitting alone is not expected until the baby reaches what age? a. 6 months
b. 7 months c. 8 months d. 9 months ANS: B
By the end of the seventh month, most babies can sit up without support. DIF: Cognitive Level: Application REF: 705 OBJ: 4 TOP: Development KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. A young mother asks the nurse how long she should wait before introducing solid food to
her infant. The nurse explains that breast milk will provide all the nutrition her infant needs for how many months? a. 2 to 3 months b. 4 to 6 months c. 7 to 9 months d. 10 to 12 months ANS: B
Breast milk or formula is the only nutrition needed for the first 4 to 6 months of an infant’s life. DIF: Cognitive Level: Application REF: 707 OBJ: 4 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. When a mother asks the nurse about introducing solid foods into the child’s diet, which of
the following would be the best answer? a. “Introduce meat first.” b. “Introduce one solid food at a time several days apart.” c. “Introduce solid foods by mixing two or three foods together.” d. “Introduce solid foods by adding strained food to the infant’s bottle.” ANS: B
The best advice is to introduce one solid at a time, allowing several days between. Cereals should be introduced first, followed by fruits and vegetables. Meats should be introduced last. Avoid mixing foods to allow the infant to develop an interest in different tastes. Strained foods should not be added to a bottle. DIF: Cognitive Level: Application REF: 707 OBJ: 4 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. A baby’s muscular development progresses in what type of pattern? a. Regressive b. Erratic c. Cephalocaudal d. Unpredictable ANS: C
Muscular development proceeds from head to foot (cephalocaudal).
DIF: Cognitive Level: Comprehension REF: 697 OBJ: 4 TOP: Growth KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8. At what age does a child typically possess the physiologic, neuromuscular, and
psychological maturity necessary to master toilet training? a. 6 to 10 months b. 10 to 14 months c. 14 to 18 months d. 18 to 24 months ANS: D
Children reach psychological and physiologic maturity for toilet training by 18 to 24 months. DIF: Cognitive Level: Application REF: 709 OBJ: 5 TOP: Toilet training KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. How can a family best assist a toddler who is attempting to feed himself? a. Encourage the child to use a fork. b. Feed the child themselves using a fork. c. Encourage large portions for easier handling. d. Offer the child finger foods. ANS: D
Toddlers need to develop autonomy and do things for themselves in a trial-and-error method. Finger foods allow the child a feeling of independence. DIF: Cognitive Level: Application REF: 710 OBJ: 5 TOP: Development KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 10. A 5-year-old who has an imaginary friend with whom he converses frequently is
displaying characteristics consistent with which of Piaget’s stages of cognitive development? a. Operational stage b. Preoperational stage c. Formal operations stage d. Concrete operations stage ANS: B
Piaget’s preoperational stage describes the preschooler as imaginative and egocentric, believing in magical thinking. DIF: Cognitive Level: Application REF: 713 OBJ: 3 TOP: Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 11. A 14-year-old male patient has undergone a leg amputation. What should be the primary
focus of the patient’s care plan?
a. b. c. d.
Nutritional status Academic progress Body image Socialization needs
ANS: C
Body image is a major developmental task of the adolescent. Nutritional status, academic progress, and socialization should be addressed, but they would not be the primary focus. DIF: Cognitive Level: Analysis REF: 718 TOP: Adolescent KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
OBJ: 10
12. According to Piaget, what is the cognitive developmental level of the adolescent? a. Concrete operational stage b. Sensorimotor stage c. Preoperational stage d. Formal operational stage ANS: D
The formal operational stage is the cognitive developmental level of adolescence. DIF: Cognitive Level: Knowledge REF: 718 OBJ: 3 TOP: Cognitive development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 13. The nurse performing a routine physical assessment on a 25-year-old understands that the
patient is most likely experiencing which of the following? a. A gradual decline in physical capabilities b. Optimal level of functioning c. Slight diminishing of visual acuity d. Minimal hearing loss ANS: B
During early adult years, the body is at an optimal level of functioning. The gradual decline in physical capabilities, diminishing of visual acuity, and hearing loss will not occur until later in adulthood. DIF: Cognitive Level: Application REF: 721 OBJ: 6 TOP: Early adulthood KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 14. Erikson identifies intimacy as a developmental task of adulthood. What will occur if
intimacy is not established? a. Inferiority b. Isolation c. Mistrust d. Guilt ANS: B
Intimacy versus isolation is a developmental task of adulthood.
DIF: Cognitive Level: Knowledge REF: 721 TOP: Erikson KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance
OBJ: 8
15. What is the leading cause of death in young adults? a. Diabetes b. Accidents c. Hypertension d. Testicular cancer ANS: B
The leading cause of death in young adults is accidents. DIF: Cognitive Level: Knowledge REF: 722 OBJ: 11 TOP: Accidents KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 16. A 53-year-old woman complains of night sweats and mood swings. The nurse recognizes
that these symptoms most likely relate to which condition? a. Menopause b. Weight problems c. Dietary problems d. Thyroid problems ANS: A
Signs and symptoms of menopause may include sweats and mood swings. DIF: Cognitive Level: Application REF: 723 TOP: Menopause KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
17. A 58-year-old male is concerned about some hearing loss he is experiencing. The nurse
recognizes that this might be due to a sensory change of this age group known as which of the following? a. Presbycusis b. Otitis externa c. Presbyopia d. Otitis media ANS: A
Presbycusis is a normal age-related loss of hearing. Otitis externa and otitis media are infections of the ear. Presbyopia is a condition in which it becomes difficult to focus on objects nearby. DIF: Cognitive Level: Application REF: 722 TOP: Middle age KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18. What is the correct term for prejudice against older adults? a. Socialism b. Sexism c. Racism
OBJ: 6
d. Ageism ANS: D
Ageism is a form of discrimination and prejudice against the older adult. DIF: Cognitive Level: Knowledge TOP: Late adulthood MSC: NCLEX: N/A
REF: 725 OBJ: 13 KEY: Nursing Process Step: N/A
19. What theory claims that there is a hereditary basis for aging? a. Activity theory b. Physiologic theory c. Disengagement theory d. Biological programming theory ANS: D
Biological programming theory suggests a hereditary basis for aging. DIF: Cognitive Level: Application REF: 726 TOP: Aging KEY: Nursing Process Step: N/A
OBJ: 14 MSC: NCLEX: N/A
20. The nurse reminds an older adult patient that the task for the older adult is to achieve ego
integrity. Failure to achieve this task results in which of the following? a. Failure b. Despair c. Reminiscing d. Accomplishment ANS: B
The challenge of late adulthood is integrity versus despair. DIF: Cognitive Level: Knowledge REF: 727 OBJ: 8 TOP: Older adult KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 21. When assessing the home for fall risks and increased safety for an 85-year-old, what
should be a suggestion of the home health nurse? a. Bright lights be kept on at all times. b. Sponge baths be taken rather than showers. c. Excess furniture be removed. d. Loose, comfortable shoes be worn. ANS: C
Clearing the home of excess furniture and scatter rugs, the use of night-lights, and wearing supportive shoes reduce the risk of falls in older adults. It is not necessary to keep bright lights on at all times. It is not necessary to avoid showers. DIF: Cognitive Level: Application REF: 730 OBJ: 7 TOP: Older adult KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 22. The home health nurse assesses an older adult’s respiratory function carefully because
age-related changes in the respiratory system could result in which of the following?
a. b. c. d.
Vital capacity Susceptibility to respiratory infections Expiratory capacity due to increased chest size Oxygen and carbon dioxide exchange
ANS: B
Older adults are more susceptible to respiratory infections. DIF: Cognitive Level: Application REF: 728 TOP: Older adult KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 6
23. What is the family pattern in which the relationships are unequal and the parents attempt to
control the children with strict, rigid rules and expectations? a. Autocratic family pattern b. Patriarchal family pattern c. Matriarchal family pattern d. Democratic family pattern ANS: A
In the autocratic family pattern the relationships are unequal. The parents attempt to control the children with strict, rigid rules and expectations. This family pattern is least open to outside influence. DIF: Cognitive Level: Knowledge TOP: Family patterns MSC: NCLEX: N/A
REF: 700 OBJ: 1 KEY: Nursing Process Step: N/A
24. Which family pattern is least open to outside influence? a. Autocratic family pattern b. Patriarchal family pattern c. Matriarchal family pattern d. Democratic family pattern ANS: A
In the autocratic family pattern the relationships are unequal. The parents attempt to control the children with strict, rigid rules and expectations. This family pattern is least open to outside influence. DIF: Cognitive Level: Knowledge TOP: Family patterns MSC: NCLEX: N/A
REF: 700 OBJ: 1 KEY: Nursing Process Step: N/A
25. What is the family pattern in which the male usually assumes the dominant role and
functions in the work role, controls the finances, and makes most of the decisions? a. Autocratic family pattern b. Patriarchal family pattern c. Matriarchal family pattern d. Democratic family pattern ANS: B
In the patriarchal family pattern, the male usually assumes the dominant role. The male member functions in the work role, is responsible for control of finances, and makes most decisions. DIF: Cognitive Level: Knowledge TOP: Family patterns MSC: NCLEX: N/A
REF: 700 OBJ: 1 KEY: Nursing Process Step: N/A
26. What is the family pattern in which the female assumes primary dominance in the areas of
childcare and homemaking, as well as financial decision making? a. Autocratic family pattern b. Patriarchal family pattern c. Matriarchal family pattern d. Democratic family pattern ANS: C
In the matriarchal family pattern, the female assumes primary dominance in areas of childcare and homemaking, as well as financial decision making. DIF: Cognitive Level: Knowledge TOP: Family patterns MSC: NCLEX: N/A
REF: 700 OBJ: 1 KEY: Nursing Process Step: N/A
27. What is the family pattern in which the adult members function as equals? a. Autocratic family pattern b. Patriarchal family pattern c. Matriarchal family pattern d. Democratic family pattern ANS: D
In the democratic family pattern, the adult members function as equals. Children are treated with respect and recognized as individuals. This style encourages joint decision making, and it recognizes and supports the uniqueness of each individual member. This family pattern favors negotiation, compromise, and growth. DIF: Cognitive Level: Knowledge TOP: Family patterns MSC: NCLEX: N/A
REF: 700 OBJ: 1 KEY: Nursing Process Step: N/A
28. What is the stage of family development that begins when the couple acknowledges that
they are considering marriage? a. Expectant stage b. Parenthood stage c. Establishment stage d. Engagement/commitment stage ANS: D
The engagement/commitment stage begins when the couple acknowledges to themselves and others that they are considering marriage. At this time, opposition or support will be evident from friends and parents. Wedding plans must be arranged. Housing, work, and furnishings are some of the items discussed and explored.
DIF: Cognitive Level: Knowledge TOP: Family development MSC: NCLEX: N/A
REF: 700 OBJ: 1 KEY: Nursing Process Step: N/A
29. What is the stage of family development that extends from the wedding until the birth of
the first child? a. Expectant stage b. Parenthood stage c. Establishment stage d. Engagement/commitment stage ANS: C
The establishment stage extends from the wedding until the birth of the first child. During this phase, one of the important tasks is the adjustment from the single independent to the married, interdependent state. The challenges facing the newly married couple include learning to live with another person, decision making, conflict resolution, and communication. DIF: Cognitive Level: Knowledge TOP: Family development MSC: NCLEX: N/A
REF: 700-701 OBJ: 1 KEY: Nursing Process Step: N/A
30. What is the stage of family development that begins when conception begins and
continues through the pregnancy? a. Expectant stage b. Parenthood stage c. Establishment stage d. Engagement/commitment stage ANS: A
The expectant stage begins when conception occurs and continues through the pregnancy. DIF: Cognitive Level: Knowledge TOP: Family development MSC: NCLEX: N/A
REF: 701 OBJ: 1 KEY: Nursing Process Step: N/A
31. What is the stage of family development that begins at the birth or adoption of the first
child? a. Expectant stage b. Parenthood stage c. Establishment stage d. Engagement/commitment stage ANS: B
The parenthood stage begins at the birth or adoption of the first child. DIF: Cognitive Level: Knowledge TOP: Family development MSC: NCLEX: N/A
REF: 701-702 OBJ: 1 KEY: Nursing Process Step: N/A
32. What stage of family development involves the grown children departing from home? a. Expectant stage
b. Senescence stage c. Establishment stage d. Disengagement stage ANS: D
The disengagement stage of parenthood is the period of family life when the grown children depart from the home. DIF: Cognitive Level: Knowledge TOP: Family development MSC: NCLEX: N/A
REF: 702 OBJ: 1 KEY: Nursing Process Step: N/A
33. What is known as the last stage in the life cycle? a. Expectant stage b. Senescence stage c. Establishment stage d. Disengagement stage ANS: B
The senescence stage is the last stage of the life cycle, which requires the individual to cope with a large range of changes. For the older adult the family unit continues to be a major source of satisfaction and pleasure. Most older adults prefer to live independently. DIF: Cognitive Level: Knowledge TOP: Family development MSC: NCLEX: N/A
REF: 702 OBJ: 1 KEY: Nursing Process Step: N/A
34. The nurse recognizes that during the first 5 months of life, an infant is expected to gain
approximately how many pounds per month? a. 0.5 b. 1 c. 1.5 d. 2 ANS: C
The infant is expected to gain about 1.5 lb per month until 5 months. DIF: Cognitive Level: Application TOP: Growth and development MSC: NCLEX: N/A
REF: 704 OBJ: 4 KEY: Nursing Process Step: N/A
35. A nurse is caring for a neonate who weighs 7 lb 3 oz at birth. What should the infant’s
weight be at 1 year? a. 10 lb 3 oz b. 14 lb 6 oz c. 21 lb 9 oz d. 28 lb 12 oz ANS: C
By the time the baby is 1 year of age, the birth weight should have tripled. DIF: Cognitive Level: Analysis TOP: Growth and development
REF: 704 OBJ: 4 KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A 36. A nurse is caring for a neonate who is 22 in in height. What will the child’s expected
height be at 1 year? a. 29 in b. 33 in c. 44 in d. 56 in ANS: B
Height increases by about 1 in per month for the first 6 months. By 12 months of age, the infant’s birth length has increased about 50%. DIF: Cognitive Level: Analysis TOP: Growth and development MSC: NCLEX: N/A
REF: 704 OBJ: 4 KEY: Nursing Process Step: N/A
37. What is the average apical heart rate for a 2-month-old infant? a. 80 beats/min b. 100 beats/min c. 120 beats/min d. 150 beats/min ANS: C
At 2 months of age, the average apical rate is about 120 beats/min. DIF: Cognitive Level: Knowledge TOP: Growth and development MSC: NCLEX: N/A
REF: 704 OBJ: 4 KEY: Nursing Process Step: N/A
38. What is the average resting respiratory rate for a 12-month-old child? a. 15 breaths/min b. 20 breaths/min c. 30 breaths/min d. 50 breaths/min ANS: C
Average resting respiratory rate for the 12-month-old is about 30 breaths/min. DIF: Cognitive Level: Knowledge TOP: Growth and development MSC: NCLEX: N/A
REF: 704 OBJ: 4 KEY: Nursing Process Step: N/A
39. A nurse assessing a 2-month-old infant would expect the infant to do which of the
following? a. Crawl on the floor. b. Creep on the floor. c. Sit up steadily without support. d. Hold its head up while in the prone position. ANS: D
At 2 months the infant is able to hold the head up while in the prone position. Infants may crawl at 7 months and creep at about 9 months. By the end of the seventh month, infants can sit up steadily without support. DIF: Cognitive Level: Knowledge TOP: Growth and development MSC: NCLEX: N/A
REF: 705 OBJ: 4 KEY: Nursing Process Step: Assessment
40. A nurse assessing a 4-month-old infant would expect the infant to do which of the
following? a. Crawl up the stairs. b. Creep on the floor at least 30 ft. c. Walk upright with a waddling gait. d. Hold head at a 90-degree angle while prone. ANS: D
At 4 months the infant is able to hold the head up steadily to a 90-degree angle while in the prone position. Infants may crawl at 7 months and creep at about 9 months. Standing with support and walking occur at about 8 to 15 months. DIF: Cognitive Level: Knowledge TOP: Growth and development MSC: NCLEX: N/A
REF: 705 OBJ: 4 KEY: Nursing Process Step: Assessment
41. A nurse teaching the mother about infant oral hygiene instructs the mother to offer the
infant sips of: a. cola. b. milk. c. juice. d. water. ANS: D
Oral hygiene for the young infant consists of offering sips of clear water and wiping and massaging the infant’s gums. Cola, milk, and juice should not be introduced at this young age. DIF: Cognitive Level: Application REF: 705 OBJ: 4 TOP: Dentition KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 42. A mother asks the nurse when she should introduce solid foods into her infant’s diet. What
would be the most correct response? a. Introduce fruits and vegetables first. b. Mix foods to allow the infant variety. c. Introduce only one new food at a time. d. Introduce new foods at 24-hour intervals. ANS: C
Only one new food should be introduced at a time, followed by several days between new foods. Cereals should be introduced first, followed by fruits and vegetables, and last meats. Food should not be mixed to allow the infant to develop interest in different foods and tastes.
DIF: Cognitive Level: Application REF: 707 OBJ: 4 TOP: Diet KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 43. What is the leading cause of injury and death among infants and young children? a. Accidents b. Child abuse c. Drug abuse d. Adolescent parents ANS: A
Accidents are the leading cause of injury and death of infants and young children. DIF: Cognitive Level: Knowledge REF: 708 OBJ: 11 TOP: Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 44. A nurse assessing a toddler should consider which finding abnormal? a. Lumbar lordosis b. Cyanotic nail beds c. A protruding abdomen d. A convex lumbar curve ANS: B
Normal assessment findings in a toddler include lumbar lordosis (convex lumbar curve) and a protruding abdomen. Cyanotic nail beds are an abnormal finding. DIF: Cognitive Level: Application TOP: Abnormal findings MSC: NCLEX: N/A
REF: 708 OBJ: 4 KEY: Nursing Process Step: N/A
45. Which theory of aging suggests that the body becomes less able to tolerate the “self”? a. Free radical theory b. Autoimmunity theory c. Wear-and-tear theory d. Biological programming theory ANS: B
The autoimmunity theory holds that with aging, the body becomes less able to recognize or tolerate the “self.” As a result the immune system produces antibodies that act against the self. DIF: Cognitive Level: Knowledge TOP: Theories of aging MSC: NCLEX: N/A
REF: 726 OBJ: 14 KEY: Nursing Process Step: N/A
46. Which theory of aging suggests that there should be a natural withdrawal between the
individual and society? a. Free radical theory b. Autoimmunity theory c. Wear-and-tear theory
d. Disengagement theory ANS: D
According to supporters of the disengagement theory of aging, there should be a natural withdrawal, or disengagement, between the individual and society. DIF: Cognitive Level: Knowledge TOP: Theories of aging MSC: NCLEX: N/A
REF: 726 OBJ: 14 KEY: Nursing Process Step: N/A
47. Which theory of aging suggests that the older person who is more socially active is more
likely to adjust well to aging? a. Activity theory b. Autoimmunity theory c. Wear-and-tear theory d. Disengagement theory ANS: A
According to the activity theory, the older person who is more active socially is more likely to adjust well to aging. DIF: Cognitive Level: Knowledge TOP: Theories of aging MSC: NCLEX: N/A
REF: 726 OBJ: 14 KEY: Nursing Process Step: N/A
48. Which theory of aging suggests that previously developed coping abilities and the ability
to maintain previous roles and activities are critical to adjustment to old age? a. Continuity theory b. Autoimmunity theory c. Wear-and-tear theory d. Disengagement theory ANS: A
Supporters of the continuity theory suggest that the critical factors in adjustment to old age are previously developed coping abilities and the ability to maintain previous roles and activities. DIF: Cognitive Level: Knowledge TOP: Theories of aging MSC: NCLEX: N/A
REF: 726-727 OBJ: 14 KEY: Nursing Process Step: N/A
49. Which of the following measures would be included in a teaching plan to instruct new
parents on reducing the incidence of sudden infant death syndrome? a. Bottle-feed an infant at night. b. Place infants on their stomach to sleep. c. Keep an infant’s room well ventilated. d. Place soft bedding and pillows in an infant’s crib. ANS: C
Steps to reduce the incidence of sudden infant death syndrome include placing infants on their back to sleep, avoiding exposure to cigarette smoke, avoiding using soft bedding or pillows, keeping rooms well ventilated, breastfeeding if possible, and maintaining regular medical checkups for infants. DIF: Cognitive Level: Application REF: 707 OBJ: 4 TOP: Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 50. A nurse instructing a group of parents about safety rules for infants and young children
should include which of the following measures in the teaching plan? a. Remove plants from the child’s reach. b. Provide the infant with a pillow at night. c. Use a plastic covering on the infant’s mattress. d. Keep the crib sides up and set the mattress at the highest setting. ANS: A
Safety rules for infants and young children include keeping the crib sides up and the mattress set at the lowest setting, never using plastic bags or coverings on mattresses or near the infant’s playthings, avoiding the use of pillows with small infants, and removing plants from the child’s reach. DIF: Cognitive Level: Application REF: 709 OBJ: 4 TOP: Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 51. A child who uses senses and motor abilities to understand the world is displaying
characteristics consistent with which stage of Piaget’s cognitive development? a. Sensorimotor stage of cognitive development b. Preoperational stage of cognitive development c. Formal operational stage of cognitive development d. Concrete operational stage of cognitive development ANS: A
The Piaget’s sensorimotor stage of cognitive development uses senses and motor abilities to understand the world; this period begins with reflexes and coordinates sensorimotor skills. DIF: Cognitive Level: Application REF: 704 TOP: Piaget KEY: Nursing Process Step: Assessment
OBJ: 3 MSC: NCLEX: N/A
52. A child who has just begun to demonstrate object permanence is in which of the Piaget’s
stages of cognitive development? a. Sensorimotor b. Preoperational thought c. Formal operational thought d. Concrete operational thought ANS: A
The Piaget’s sensorimotor stage of cognitive development uses senses and motor abilities to understand the world; this period begins with reflexes and coordinates sensorimotor skills. While in this stage, a child learns that an object still exists when it is out of sight (object permanence). DIF: Cognitive Level: Application REF: 704 TOP: Piaget KEY: Nursing Process Step: Assessment
OBJ: 3 MSC: NCLEX: N/A
53. A child who has just begun to demonstrate egocentric thinking is in which of the Piaget’s
stages of cognitive development? a. Sensorimotor b. Preoperational thought c. Formal operational thought d. Concrete operational thought ANS: B
The Piaget’s preoperational stage of cognitive development includes the development of egocentric thinking (understanding the world from only one perspective, that of the self). DIF: Cognitive Level: Application REF: 704 TOP: Piaget KEY: Nursing Process Step: Assessment
OBJ: 3 MSC: NCLEX: N/A
54. A child who has just begun to demonstrate the ability to understand and apply logical
operations to help interpret specific experiences or perceptions is in which of the Piaget’s stages of cognitive development? a. Sensorimotor b. Preoperational thought c. Formal operational thought d. Concrete operational thought ANS: D
The Piaget’s concrete operational stage of cognitive development includes the ability to understand and apply logical operations or principles to help interpret specific experiences or perceptions. DIF: Cognitive Level: Application REF: 704 TOP: Piaget KEY: Nursing Process Step: Assessment
OBJ: 3 MSC: NCLEX: N/A
55. A child who is able to use a systematic, scientific problem-solving approach is in which of
the Piaget’s stages of cognitive development? a. Sensorimotor b. Preoperational thought c. Formal operational thought d. Concrete operational thought ANS: C
The Piaget’s formal operational stage of cognitive development includes the ability to use a systematic, scientific problem-solving approach. DIF: Cognitive Level: Application REF: 704 TOP: Piaget KEY: Nursing Process Step: Assessment
OBJ: 3 MSC: NCLEX: N/A
56. According to Erikson, an infant who was abandoned by his or her primary caregiver is at
risk for developing which of the following? a. Guilt b. Mistrust c. Isolation d. Confusion ANS: B
During infancy a child’s developmental task is basic trust versus mistrust. DIF: Cognitive Level: Application REF: 706 TOP: Erikson KEY: Nursing Process Step: N/A
OBJ: 8 MSC: NCLEX: N/A
MULTIPLE RESPONSE 1. Separation anxiety includes which stages? (Select all that apply.) a. Detachment b. Protest c. Anger d. Despair e. Withdrawal ANS: A, B, D
The phases of separation anxiety are protest, despair, and detachment. DIF: Cognitive Level: Knowledge REF: 707 OBJ: 9 TOP: Separation anxiety KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. The nurse informs a group of college students that young adults will face which challenges
in this particular time of life? (Select all that apply.) a. Starting a family b. Selecting housing c. Job security d. Relations with extended family e. Establishing intimacy ANS: A, B, C, D, E
All options are developmental tasks of the young adult of today. DIF: Cognitive Level: Application REF: 721 OBJ: 11 TOP: Young adult KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1. The process that refers to gradual change and differentiation is ANS:
development
.
Development is the process of gradual change and differentiation. DIF: Cognitive Level: Knowledge TOP: Development MSC: NCLEX: N/A
REF: 697 OBJ: 4 KEY: Nursing Process Step: N/A
2. Any substance such as a drug, alcohol, or virus that interferes with fetal development is
called a(n)
.
ANS:
teratogen A teratogen is any substance that interferes with fetal development, such as a drug, alcohol, or a virus. DIF: Cognitive Level: Knowledge REF: 697-698 TOP: Teratogen KEY: Nursing Process Step: N/A
OBJ: 4 MSC: NCLEX: N/A
3. Growth and development that proceeds from the head toward the feet is known as
. ANS:
cephalocaudal Cephalocaudal is defined as growth and development that proceeds from the head toward the feet. DIF: Cognitive Level: Knowledge TOP: Development MSC: NCLEX: N/A
REF: 697 OBJ: 4 KEY: Nursing Process Step: N/A
4. Growth and development that moves from the center toward the outside is known as
. ANS:
proximodistal Proximodistal refers to growth and development that moves from the center toward the outside. DIF: Cognitive Level: Knowledge TOP: Development MSC: NCLEX: N/A
REF: 697 OBJ: 4 KEY: Nursing Process Step: N/A
Chapter 25: Loss, Grief, Dying, and Death Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. What is the final stage of human growth and development? a. Integrity b. Death c. Despair d. Resolution ANS: B
Death is the final stage of growth and development. DIF: Cognitive Level: Knowledge REF: 734 TOP: Death KEY: Nursing Process Step: N/A
OBJ: 3 MSC: NCLEX: N/A
2. A young nurse caring for a dying patient hastens through the care and leaves the room as
quickly as possible. What common reaction to the care of the dying is the nurse exhibiting? a. Efficiency b. Anger c. Withdrawal d. Anxiety ANS: C
Withdrawal is a common reaction to the care of the dying. DIF: Cognitive Level: Comprehension REF: 736 TOP: Withdrawal KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 5
3. Changes in health care reimbursement measures have resulted in which of the following
changes regarding care of the terminally ill? a. Patients spend more time in hospitals. b. Nurses provide more care in hospitals. c. More patients die at home. d. Patients spend more time in rehab facilities. ANS: C
Due to changes in reimbursement measures, more patients are dying at home. DIF: Cognitive Level: Application REF: 755 OBJ: 2 TOP: Death KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 4. How does a perceived loss differ from an actual loss? a. A perceived loss is more quickly resolved. b. A perceived loss is situational. c. A perceived loss is easily overlooked. d. A perceived loss has a superficial response.
ANS: C
Perceived losses are easily overlooked. DIF: Cognitive Level: Comprehension REF: 736 TOP: Loss KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 1
5. Upon being told of her father’s death, the daughter cries out, “No! Oh, God, no!” What
stage of grief is the daughter in? a. Anger b. Bargaining c. Denial d. Prayer ANS: C
The daughter is exhibiting signs of denial, which is commonly one of the first stages of grief. DIF: Cognitive Level: Comprehension REF: 737 TOP: Grief KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 4
6. What should the nurse do before approaching a grieving family member? a. Offer sympathy b. Assess level of resolution c. Give assurance that the pain will pass d. Encourage the family member to return to normal activities ANS: B
The nurse should assess each aspect of grieving to fully understand where family members are in their grief in order to offer the most effective assistance. DIF: Cognitive Level: Application REF: 757 TOP: Grief KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 6
7. A dying patient uses the call light frequently to ask the nurse to do simple tasks. The nurse
recognizes this as a fear of: a. increased pain. b. failure. c. abandonment. d. isolation. ANS: C
A major fear of the dying patient is fear of abandonment. DIF: Cognitive Level: Application REF: 753 TOP: Death KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 10
8. What is the first thing the nurse should do before involving the family in the care of a
dying patient?
a. b. c. d.
Ask the patient if he or she wants family care. Ask family members if they want to assist with care. Check the hospital policy on the family giving care. Set a caring example.
ANS: B
Ascertaining whether the family wants to assist in the patient’s daily care will clarify what the family members are comfortable doing. DIF: Cognitive Level: Application REF: 747 OBJ: 13 TOP: Death KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 9. Which of the following would lead the home health nurse to make a patient problem of
unresolved grief for a patient who was widowed 5 months ago? a. Seeing that the patient keeps a picture of the husband by her bed. b. The patient said tearfully, “I can’t believe he is gone.” c. Assessing that the patient eats out frequently rather than cooking at home. d. The patient says that she attends church three times a week. ANS: B
Unresolved grief results when a grieving person does not move past some stage of the grief process. The widow is still in denial. It would be expected for the widow to keep pictures of her husband in the home. Eating out frequently and attending church would not lead to a diagnosis of unresolved grief, but instead would be encouraged. DIF: Cognitive Level: Analysis TOP: Unresolved grief MSC: NCLEX: Psychosocial Integrity
REF: 739 OBJ: 4 KEY: Nursing Process Step: Assessment
10. When the nurse is developing a care plan for a terminally ill patient, what might be a
realistic goal? a. The patient will remain pain-free. b. The patient will function optimally. c. The patient will spend time out of bed. d. The patient will demonstrate improved nutritional status. ANS: B
The goal of the care plan for a terminally ill patient is to assist the patient to function optimally. The other options are not realistic. DIF: Cognitive Level: Application REF: 735 TOP: Care plan KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
OBJ: 10
11. Following the death of a day-old infant, the nurse brings the baby to the parents. What is
the rationale for the parents’ visit with the deceased baby? a. Bond with the family. b. Reinforce the individuality of the baby. c. Generate preparation for another child. d. Make the death a reality.
ANS: D
When possible, the parents should see, touch, and hold the infant to cope better with the reality of the death. DIF: Cognitive Level: Application REF: 747 OBJ: 6 TOP: Death KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 12. The nurse spends a great deal of time in the room of a dying 12-year-old because the nurse
knows that most children are aware of their condition and want the nurse to do which of the following? a. Keep them clean. b. Help them eat. c. Care about them. d. Keep them comfortable. ANS: C
Children, like adults, fear abandonment as death approaches and gain comfort from the presence of the nurse. DIF: Cognitive Level: Analysis TOP: Childhood death MSC: NCLEX: Psychosocial Integrity
REF: 740 OBJ: 6 KEY: Nursing Process Step: Implementation
13. After a health care provider in the emergency department has pronounced a 2-year-old
dead following a swimming pool accident, the mother tearfully says to the father, “I am so sorry. I am so sorry.” What is the mother expressing? a. Fear b. Guilt c. Hostility d. Grief ANS: B
Parents often harbor extreme guilt in an “out of sequence death.” DIF: Cognitive Level: Analysis TOP: Out of sequence death MSC: NCLEX: Psychosocial Integrity
REF: 749 OBJ: 4 KEY: Nursing Process Step: Assessment
14. What is the termination of tube feedings to a dying patient considered? a. Active euthanasia b. Holistic care c. Passive euthanasia d. Terminal care ANS: C
Permitting the death of a patient by withholding treatments is referred to as passive euthanasia. DIF: Cognitive Level: Comprehension TOP: Passive euthanasia MSC: NCLEX: Psychosocial Integrity
REF: 749 OBJ: 7 KEY: Nursing Process Step: Implementation
15. How is a durable power of attorney helpful to an incapacitated patient? a. It directs treatment in accordance with the patient’s wishes. b. It directs an agent to make health care decisions. c. It gives power to an agent to make decisions regarding health, property, and other
assets. d. It can only be executed by an attorney. ANS: B
The durable power of attorney gives an agent the power to make health care decisions. It can be executed by anyone and does not extend beyond health care issues. A living will directs treatment according to the patient’s wishes. DIF: Cognitive Level: Application TOP: Durable power of attorney MSC: NCLEX: Psychosocial Integrity
REF: 750 OBJ: 7 KEY: Nursing Process Step: Implementation
16. When a nurse informs a patient’s spouse that the patient has died, the spouse states, “You
must be mistaken.” Which of Kübler-Ross’s stages of dying is the spouse demonstrating? a. Anger b. Denial c. Depression d. Bargaining ANS: B
When experiencing denial, the individual acts as though nothing has happened and may refuse to believe or understand that loss has occurred. DIF: Cognitive Level: Comprehension TOP: Stages of dying MSC: NCLEX: Psychosocial Integrity
REF: 739 OBJ: 3 KEY: Nursing Process Step: Assessment
17. A patient whose spouse died 1 year earlier complains of feeling overwhelmingly lonely
and has withdrawn from interpersonal interactions. The patient is demonstrating what stage of dying according to Kübler-Ross’s stages of dying theory? a. Anger b. Denial c. Depression d. Bargaining ANS: C
When experiencing depression, the individual feels overwhelmingly lonely and withdraws from interpersonal interaction. DIF: Cognitive Level: Comprehension TOP: Stages of dying MSC: NCLEX: Psychosocial Integrity
REF: 739 OBJ: 3 KEY: Nursing Process Step: Assessment
18. A nurse is caring for the dying mother of a 7-year-old child. What is important for the
nurse to understand regarding the child? a. The child associates death with aggression. b. The child believes his or her own death cannot be avoided.
c. The child lacks understanding of the concept of death. d. The child understands death as the inevitable end of life. ANS: A
A child from 5 to 9 years old understands that death is final, believes one’s own death can be avoided, associates death with aggression or violence, and believes wishes or unrelated actions can be responsible for death. A child between the ages of 9 to 12 years understands that death is the inevitable end of life. DIF: Cognitive Level: Application TOP: Understanding of death MSC: NCLEX: Psychosocial Integrity
REF: 740 OBJ: 4 KEY: Nursing Process Step: Assessment
19. The nurse explains to a grieving husband that the process of the resolution of the hurt and
the reestablishment of his life is called the a. grief b. renewal c. denial d. acceptance
process.
ANS: A
The grief process includes the resolution of the hurt and the reestablishment of life activities following bereavement. DIF: Cognitive Level: Comprehension TOP: Grief process MSC: NCLEX: Psychosocial Integrity
REF: 736 OBJ: 13 KEY: Nursing Process Step: Implementation
MULTIPLE RESPONSE 1. The home health nurse assesses that the goal of grief resolution has been accomplished
when the nurse observes that a widow has performed which activities? (Select all that apply.) a. Adjusted to an environment without the spouse. b. Put financial affairs in order. c. Made plans for a lengthy trip. d. Sought new relationships. e. Acquired a job. ANS: A, D
Environmental adjustment and seeking new relationships are clear evidence of grief resolution. A trip, arranging financial affairs, or finding employment may be a form of denial or activities that may be dictated by the situation and is not necessarily resolution of grief. DIF: Cognitive Level: Analysis TOP: Grief resolution MSC: NCLEX: Psychosocial Integrity
REF: 737 | 739 OBJ: 13 KEY: Nursing Process Step: Evaluation
2. Which of the five aspects of human functioning must a nurse address when dealing with a
grieving person? (Select all that apply.)
a. b. c. d. e.
Physical Emotional Intellectual Financial Spiritual
ANS: A, B, C, E
The five areas of human function are physical, emotional, intellectual, sociocultural, and spiritual. DIF: Cognitive Level: Comprehension TOP: Aspects of human function MSC: NCLEX: N/A
REF: 739-740 OBJ: 5 KEY: Nursing Process Step: N/A
Chapter 26: Health Promotion and Pregnancy Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. Where does implantation of the fertilized ovum usually occur? a. Lower uterine wall b. Side of the uterus c. Fundus of the uterus d. Body of the uterus ANS: C Implantation usually occurs in the fundus of the uterus. DIF: Cognitive Level: Knowledge REF: 762 OBJ: 1 TOP: Implantation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. A patient has been diagnosed with a tubal pregnancy. What is the typical outcome of a tubal pregnancy? a. The patient will carry the pregnancy to term and have a cesarean delivery. b. The patient will have to remain in bed for the remainder of the pregnancy. c. The patient will spontaneously abort this ectopic pregnancy. d. The patient will require surgery to remove the zygote. ANS: D Any pregnancy where implantation occurs outside the uterine cavity is called ectopic. Tubal pregnancies usually must be resolved by surgical removal of the zygote. DIF: Cognitive Level: Analysis REF: 762 TOP: Pregnancy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
3. How long does the embryonic stage of pregnancy typically last? a. 3 weeks b. 4 weeks c. 6 weeks d. 8 weeks ANS: D The embryonic stage encompasses the first 8 weeks. DIF: Cognitive Level: Knowledge REF: 763 OBJ: 1 TOP: Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 4. Why is the nurse concerned about a patient in her first trimester of pregnancy being exposed to German measles? a. The disease is capable of causing a spontaneous abortion.
b. The disease is capable of causing birth defects. c. The disease is capable of causing high fever and convulsions. d. The disease is capable of interfering with placental implantation. ANS: B Rubella is a known teratogen, which can cause birth defects. DIF: Cognitive Level: Application REF: 763 TOP: Teratogen KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 1
5. Which hormone is secreted by the placenta? a. Follicle-stimulating hormone (FSH) b. Alpha-fetoprotein (AFP) c. Human chorionic gonadotropin (HCG) d. Luteinizing hormone (LH) ANS: C The placenta functions as an endocrine gland, secreting estrogen, progesterone, and HCG. DIF: Cognitive Level: Comprehension REF: 763 OBJ: 2 TOP: Placenta function KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. What protects the fetus from most bacterial infections? a. The yolk sac b. The placental barrier c. The cotyledons d. The chorionic villa ANS: B The placental barrier protects the embryo/fetus from most bacteria, but not from viruses or drugs. The cotyledons are sections that make up the placenta. The chorionic villa are tiny vascular projections on the chorionic surface that help form the placenta. DIF: Cognitive Level: Comprehension REF: 763 OBJ: 2 TOP: Placental barrier KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. What period of the maternity cycle does the intrapartal period cover? a. Beginning of pregnancy to midterm b. Conception to third trimester c. Onset of labor to delivery of the baby d. Onset of labor to delivery of the placenta ANS: D
The intrapartal period of the maternity cycle covers the onset of labor to delivery of the placenta. The antepartal period begins at conception and continues until the onset of labor. The postpartal period begins after the delivery of the placenta and continues for approximately 6 weeks, until the reproductive organs return to their prepregnancy state. DIF: Cognitive Level: Knowledge REF: 777 OBJ: 3 TOP: Intrapartal period KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8. A woman who has just discovered she is pregnant states that the first day of her last menstrual period was July 10. What will be her expected date of birth (EDB)? a. April 10 b. April 17 c. May 10 d. October 17 ANS: B To determine the EDB (estimated date of birth), the woman should count from the first day of her last menstrual period. Count back 3 months and forward 7 days. DIF: Cognitive Level: Application REF: 780 OBJ: 4 TOP: Estimated date of birth (EDB) KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 9. Which is a positive sign of pregnancy? a. Positive pregnancy test b. Positive Chadwick sign c. Ultrasonic tracing of the fetus d. Positive Goodell sign ANS: C A positive sign of pregnancy is an ultrasonic tracing of the fetus. A positive pregnancy test, positive Chadwick sign, and positive Goodell sign are all probable signs of pregnancy. DIF: Cognitive Level: Comprehension TOP: Positive signs of pregnancy MSC: NCLEX: Physiological Integrity
REF: 780 OBJ: 4 KEY: Nursing Process Step: Assessment
10. What is the cause of frequent urination in early pregnancy? a. Increased fluid intake b. The fetus’s kidneys functioning c. Retention of fluid d. Increased circulating volume ANS: D Early in pregnancy, the increase in circulating volume and the enlarging uterus placing pressure on the bladder cause urinary frequency.
DIF: Cognitive Level: Application TOP: Frequency of urination Implementation MSC: NCLEX: Physiological Integrity
REF: 786 OBJ: 7 KEY: Nursing Process Step:
11. A woman asks the nurse about the safety of sexual intercourse during her pregnancy. Which response by the nurse is the most correct? a. “Sexual activity should be avoided after the first trimester.” b. “Sexual activity should be ceased in the case of vaginal bleeding.” c. “Sexual activity should be avoided in the second trimester.” d. “Sexual activity should be limited to activity that does not include intercourse.” ANS: B Sexual intercourse can be enjoyed throughout pregnancy unless it is contraindicated by other conditions. In the case of vaginal bleeding, sexual activity should cease until the cause of the bleeding is determined by the health care provider. DIF: Cognitive Level: Analysis TOP: Sexual activity during pregnancy Implementation MSC: NCLEX: Psychosocial Integrity
REF: 788 OBJ: 5 KEY: Nursing Process Step:
12. A woman tells the nurse that this is her third pregnancy. She has had twin girls at full term and one miscarriage. How does the nurse record the information? a. G2, T2, L3 b. G4, T3, A1, L1 c. G3, T3, A2, L1 d. G3, T1, A1, L2 ANS: D Standard obstetrical terminology is: G = gravida, T = term birth, P = preterm birth, A = abortion, L = living children. DIF: Cognitive Level: Comprehension REF: 780 OBJ: 3 TOP: Terminology KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 13. During which gestational week can a primigravida expect to first feel fetal movement? a. 8 b. 10 c. 16 d. 20 ANS: C At about 16 to 18 weeks, the sensation of the first movement is felt. DIF: Cognitive Level: Knowledge REF: 778 OBJ: 4 TOP: Quickening KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
14. At what week of fetal development can the nurse expect to first hear fetal heart tones with an amplified stethoscope? a. 10 b. 12 c. 14 d. 16 ANS: D During week 16, the fetal heart can be heard with an amplified stethoscope. DIF: Cognitive Level: Knowledge REF: 767 OBJ: 4 TOP: Fetal age KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 15. The nurse assures an anxious primigravida that during fetal development from week 34 and beyond, maternal antibodies are transferred to the baby. How long will these antibodies provide the baby with immunity? a. 1 month b. 3 months c. 4 months d. 6 months ANS: D The maternal antibodies that are transferred to the baby provide immunity for 6 months. DIF: Cognitive Level: Application REF: 770 OBJ: 2 TOP: Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 16. Early in the first trimester, a woman complains of morning sickness. What does the nurse suggest to aid with the discomfort? a. Eating something with a high-fat content b. Eating dry crackers before getting up c. Eating three well-balanced meals d. Getting rest and taking antiemetics ANS: B A remedy for morning sickness is to eat a few dry crackers before getting up. DIF: Cognitive Level: Application TOP: Morning sickness Implementation MSC: NCLEX: Physiological Integrity
REF: 765 OBJ: 7 KEY: Nursing Process Step:
17. What does the increase in circulating blood volume during pregnancy cause in the mother? a. Shortness of breath b. Frontal headaches c. Decreased white blood cell count d. Decreased hemoglobin
ANS: D Maternal circulating volume increases 30% to 40%, causing a virtual decrease in hemoglobin. DIF: Cognitive Level: Analysis TOP: Decreased Hgb Implementation MSC: NCLEX: Physiological Integrity
REF: 785 OBJ: 2 KEY: Nursing Process Step:
18. A woman entering the 22nd week of pregnancy complains that she has become unsightly because of chloasma. What should the nurse recommend to reduce the appearance of the chloasma? a. Use heavy makeup. b. Take extra doses of vitamin A. c. Avoid exposure to the sun. d. Reduce caffeine intake. ANS: C At week 22, skin pigment changes called chloasma are found. Avoiding exposure to the sun will reduce the pigmentation. DIF: Cognitive Level: Analysis REF: 783 OBJ: 7 TOP: Chloasma KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 19. During the final weeks of pregnancy, urinary frequency may return due to the enlarged uterus, compressing the bladder against the pelvic bones. What does the nurse suggest to aid in relieving the urinary frequency? a. Decrease fluid intake. b. Use the knee-chest position. c. Sleep on her side. d. Avoid fluid intake in evening. ANS: C The patient should decrease pressure on the bladder at night by sleeping on her side. Fluids should not be decreased unless directed by a health care provider. DIF: Cognitive Level: Application REF: 765 OBJ: 7 TOP: Frequency KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. A pregnant teenager presents with the following complaints. Which complaint could be an indicator of a serious complication? a. Painful hemorrhoids b. Linea nigra c. Visual disturbances d. Low back pain ANS: C
Visual disturbances may be an indicator of increased blood pressure and retained fluids. These are indicators of eclampsia. Hemorrhoids, linea nigra, and back pain are common discomforts of pregnancy. DIF: Cognitive Level: Analysis TOP: Danger signs MSC: NCLEX: Physiological Integrity
REF: 782 OBJ: 5 KEY: Nursing Process Step: Assessment
21. During the last trimester of pregnancy, the nurse recommends that the woman wear low-heeled shoes. What is the nurse trying to prevent with this recommendation? a. Lower back pain b. Leg cramps c. Leg swelling d. Joint pain ANS: A A remedy for backache is to wear low-heeled shoes. DIF: Cognitive Level: Application TOP: Low back pain Implementation MSC: NCLEX: Physiological Integrity
REF: 786 OBJ: 7 KEY: Nursing Process Step:
22. The newly diagnosed primigravida who is 6 weeks pregnant states, “I don’t feel like I have a real baby inside me.” To reassure the mother, the nurse provides reassurance that which of the following is functioning in the 6-week-old embryo? a. Brain b. Lungs c. Hands d. Heart ANS: D At 6 weeks, the fetus has a pumping heart. DIF: Cognitive Level: Comprehension REF: 763 OBJ: 1 TOP: Fetal development KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 23. Smoking by the mother can have what effect in the fetus? a. Hearing deficits b. Neuromuscular deformities c. Cerebral palsy d. Low birth weight ANS: D Smoking has been proven to cause slow intrauterine growth and low birth weight. DIF: Cognitive Level: Application REF: 781 OBJ: 5 TOP: Smoking KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance 24. When can the sex of the fetus be confirmed? a. Conception b. 2 weeks c. 6 weeks d. 9 weeks ANS: D At 9 weeks the genitalia are well defined. DIF: Cognitive Level: Knowledge REF: 765 OBJ: 1 TOP: Fetal sex determination KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 25. The health care provider decides to send the mother for a test to determine the fetal lung maturity. What is the name of this fetal well-being test? a. Biophysical profile b. Alpha-fetoprotein c. Amniocentesis d. Ultrasound ANS: C Amniocentesis helps determine the maturity of the fetal lungs. DIF: Cognitive Level: Knowledge TOP: Amniocentesis MSC: NCLEX: N/A
REF: 775 OBJ: 3 KEY: Nursing Process Step: N/A
26. When the young primigravida asks about how to adjust her diet for her pregnancy, what should the nurse suggest the mother add to her diet? a. Leafy green vegetables and fruit b. Beef and poultry c. Foods high in sodium and potassium d. Bread and grains ANS: A A pregnant woman should eat foods containing roughage, such as raw fruits, vegetables, and cereals with bran. DIF: Cognitive Level: Comprehension REF: 786 OBJ: 6 TOP: Diet KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 27. Which of the following discomforts of a pregnant woman should be reported to the health care provider at the first occurrence? a. Leg cramps b. Pelvic discomfort c. Vaginal bleeding
d. Urinary frequency ANS: C Vaginal bleeding at any time during pregnancy should be reported to the health care provider. Leg cramps, pelvic discomfort, and urinary frequency are common discomforts of pregnancy and not a cause for immediate concern. DIF: Cognitive Level: Application TOP: Danger indicators Implementation MSC: NCLEX: Physiological Integrity
REF: 788 OBJ: 5 KEY: Nursing Process Step:
28. What do the arteries in the umbilical cord carry? a. Nutrients to the fetus from the placenta b. Oxygenated blood to perfuse the placenta c. Antibodies from the fetus to the mother d. Deoxygenated blood back to the placenta ANS: D The arteries of the umbilical cord are unique in that they carry deoxygenated blood back to the placenta. DIF: Cognitive Level: Comprehension REF: 771 OBJ: 2 TOP: Umbilical arteries KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 29. What should a nurse instruct the patient to do before assessing fundal height? a. Press her lower back against the examination table. b. Empty her bladder. c. Take a deep breath and hold it. d. Bear down. ANS: B The bladder should be emptied before the measurement of the fundal height. DIF: Cognitive Level: Application REF: 771 OBJ: 3 TOP: Fundal height KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The nurse concludes that the prenatal patient has no need for further instruction when she correctly states that amniocentesis can determine which of the baby’s characteristics? (Select all that apply.) a. Sex b. Maturity c. Approximate weight d. Health e. Genetic defects
ANS: A, B, D, E The amniocentesis can reveal the sex, maturity, health, and some genetic defects. DIF: Cognitive Level: Analysis REF: 771 OBJ: 3 TOP: Amniocentesis KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance 2. Which of the following demonstrate culturally competent care of the pregnant patient? (Select all that apply.) a. Discuss beliefs with the patient and incorporate them in the plan of care. b. Prohibit visits from anyone other than immediate family members. c. Require the patient’s participation in every aspect of the health care system. d. Maintain the patient’s modesty at all times. e. Strive to maintain a harmonious environment for the patient. ANS: A, D, E The nurse should discuss the patient’s cultural beliefs and incorporate as many as possible into the plan of care. Modesty is important in almost all cultures, and the nurse should take measures to ensure the patient’s modesty. Absence of a stressful environment is important for a positive outcome for both mother and baby, and the nurse should strive to alleviate stress and maintain a harmonious environment. Many cultures will foster relationships, and visits from extended family members may be important. The patient may not participate in all aspects of the health care system due to cultural issues. DIF: Cognitive Level: Application REF: 790-791 OBJ: 8 TOP: Cultural considerations KEY: Nursing Process Step: Intervention MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1. The nurse instructor reminds the nursing student that the “Shiny Schultz” is a name given to the side of the placenta. ANS: fetal The fetal side of the placenta is called the Shiny Schultz and the maternal side is called the Dirty Duncan. DIF: Cognitive Level: Knowledge REF: 763 OBJ: 1 TOP: Placental sides KEY: Nursing Process Step: Intervention MSC: NCLEX: Health Promotion and Maintenance 2. The chorion and the amnion are the two components of the ANS: fetal
membrane.
The fetal membrane is composed of the chorion and the amnion. DIF: Cognitive Level: Knowledge TOP: Fetal membrane MSC: NCLEX: N/A
REF: 763 OBJ: 1 KEY: Nursing Process Step: N/A
3. During the 30th week of gestation, the nurse would anticipate that the fundal height would be cm above the symphysis. ANS: 30 thirty The fundal height is equal to the weeks of gestation. DIF: Cognitive Level: Application REF: 771 OBJ: 3 TOP: Fundal height KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. The nurse assesses a reactive result to a nonstress test when the fetal heart rate increases beats/min. ANS: 15 fifteen The reactive criterion is that the fetal heart rate will increase 15 beats/min when stimulated in the nonstress test. DIF: Cognitive Level: Application REF: 775 OBJ: 3 TOP: Nonstress test KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
Chapter 27: Labor and Delivery Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. A woman who is 38 weeks’ pregnant tells the nurse that the baby has dropped and she is having urinary frequency again. What do these symptoms describe? a. Lightening b. Braxton-Hicks contractions c. Initiation of labor d. Engagement ANS: A The symptoms of lightening are a return of urinary frequency, and the patient is able to breathe more normally. DIF: Cognitive Level: Comprehension REF: 798 TOP: Lightening KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 3
2. How do Braxton-Hicks contractions, which may begin in the first trimester and become increasingly stronger during the pregnancy, differ from labor contractions? a. Last several minutes. b. Are always regular. c. Do not dilate the cervix. d. Are only mild. ANS: C Braxton-Hicks contractions do not dilate the cervix. Braxton-Hicks contractions remain irregular, can range from mild to moderate in severity, and increase in duration as the pregnancy progresses. DIF: Cognitive Level: Comprehension TOP: Braxton-Hicks contractions MSC: NCLEX: N/A
REF: 799 OBJ: 4 KEY: Nursing Process Step: N/A
3. When trying to differentiate false labor from true labor, the nurse realizes which of the following statements regarding true labor is correct? a. Discomfort of the contraction is in the fundus. b. Contractions do not follow a pattern. c. Contractions get stronger with ambulation. d. Contractions may stop with ambulation. ANS: C Contractions get stronger with ambulation in true labor. True labor is also marked by the onset of regular, rhythmic contractions. DIF: Cognitive Level: Comprehension REF: 799 OBJ: 4 TOP: True labor KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance 4. Why is the size and shape of the true pelvis more important than that of the false pelvis? a. The fetal head must be able to pass through the true pelvis. b. The true pelvis are the mother’s measurements. c. The size of the false pelvis can change. d. The size of the true pelvis needs to be larger. ANS: A The size and shape of the true pelvis is more important than the false pelvis because the fetal head must be able to pass through for vaginal delivery to occur. DIF: Cognitive Level: Comprehension REF: 800 OBJ: 5 TOP: True pelvis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. What method is used to visualize soft tissue and to determine adequacy of the pelvis with no detrimental effects to the fetus? a. Pelvimetry b. Palpation c. Ultrasonography d. X-ray ANS: C In more than 20 years of use, ultrasonography has had no detrimental effects on the fetus. Pelvimetry and x-ray uses radiation to visualize bony prominences. Pelvimetry is not used in the pregnant patient due to detrimental effects to the fetus. Palpation does not allow for visualization of soft tissue. DIF: Cognitive Level: Comprehension REF: 801 OBJ: 5 TOP: Ultrasound KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. What area of the uterus provides the force during a contraction? a. Lower portion b. Middle portion c. Upper portion d. Cervical portion ANS: C The upper portion of the uterus provides the force during contractions. DIF: Cognitive Level: Knowledge REF: 801 TOP: Passageway KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 7. What is the largest diameter of the fetal skull? a. Temporal b. Biparietal c. Lateral
OBJ: 7
d. Frontal-occipital ANS: B The largest transverse diameter of the fetal skull is the biparietal measurement. If this is too large, the skull may not be able to enter the mother’s pelvis. DIF: Cognitive Level: Knowledge REF: 802 OBJ: 6 TOP: Passageway KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8. A nurse is teaching a group of primigravidas that during delivery, pressure on the fetal skull may produce changes in the shape of the skull. What is the reshaping of the skull called? a. Pressure response b. Overlapping c. Molding d. Spacing ANS: C The reshaping of the skull bones in response to pressure is called molding. DIF: Cognitive Level: Knowledge REF: 801 OBJ: 5 TOP: Molding KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. What is the ideal attitude for the fetal body during labor? a. Extension b. Lateral c. Flexion d. Transverse ANS: C The ideal attitude for the fetal body is flexion. DIF: Cognitive Level: Knowledge REF: 802 OBJ: 5 TOP: Attitude KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 10. Using Leopold maneuvers to assess fetal position, the nurse finds a soft rounded prominence at the level of the fundus, a hard round prominence just above the symphysis pubis, and nodulations on the left side of the uterus. How should the nurse document the fetal position? a. Right occiput anterior (ROA), vertex b. Left occiput anterior (LOA), vertex c. Right occiput transverse (ROT), breech d. Left occiput anterior (LOA), breech ANS: A
Fetal position can be determined by the Leopold maneuver, which defines the relationship of the presenting part to the maternal pelvis quadrant. A soft rounded prominence at the level of the fundus, a hard round prominence just above the symphysis pubis, and nodulations on the left side of the uterus indicate a right occiput anterior (ROA), vertex positioning. DIF: Cognitive Level: Analysis REF: 803 OBJ: 5 TOP: Fetal position KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 11. During the second stage of labor, how often should the nurse should monitor the fetal heart rate? a. Every 5 minutes b. Every 15 minutes c. Every 30 minutes d. Every hour ANS: A Fetal heart rate should be assessed every 5 minutes during the second stage of labor. DIF: Cognitive Level: Application REF: 816 OBJ: 10 TOP: Fetal heart rate (FHR) KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. Which type of monitor will assesses the intensity of contractions? a. External monitor b. Fetal monitor c. Maternal monitor d. Internal monitor ANS: D Internal monitoring is used to monitor the intensity of contractions, the frequency and duration of contractions, and the resting tone of uterine contractions. An external monitor is used to monitor the fetal heart rate and uterine activity. DIF: Cognitive Level: Application REF: 816 OBJ: 13 TOP: Fetal monitoring KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 13. When observing the fetal heart monitor, the nurse recognizes the fetal heart rate (FHR) decreases to 120 beats/min at the beginning of a contraction and returns to a baseline of 155 beats/min at the end of the contraction. What should this indicate to the nurse? a. Early deceleration due to head compression b. That the fetus is in acute distress c. Variable decelerations due to cord compression d. That these are late decelerations ANS: A
This indicates early decelerations because of head compression. DIF: Cognitive Level: Analysis REF: 815 OBJ: 10 TOP: Fetal monitoring KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 14. The first-time mother has been told by the nurse that the first stage of labor is the longest. What would be an appropriate nursing intervention for comfort during this time? a. Cool fluids to drink b. A backrub in the sacral area c. Assisting to lie in a supine position d. Decreasing illumination in the room ANS: B Backache in the sacral area is a common complaint during the first stage of labor. The keyword is “comfort” in the question. Providing a backrub is providing comfort to the laboring patient. DIF: Cognitive Level: Analysis REF: 809 OBJ: 12 TOP: First stage of labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 15. A woman is admitted in active labor, and the nurse assesses the fetal heart rate (FHR) at 124 beats/min. What action should the nurse take based on the assessment? a. Position patient on her left side. b. Start oxygen per nasal cannula. c. Reassure the mother the rate is normal. d. Notify the health care provider at once. ANS: C The normal FHR is 120 to 160 beats/min. No interventions are required. DIF: Cognitive Level: Application REF: 812 OBJ: 10 TOP: Fetal heart rate (FHR) KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 16. The patient’s membranes have just ruptured. What is the first priority of the nurse? a. Turn the patient on the left side. b. Perform a Nitrazine test. c. Check the fetal heart rate (FHR). d. Perform a vaginal examination. ANS: C The FHR should be assessed immediately after rupture of the membranes to determine the well-being of the baby. DIF: Cognitive Level: Application TOP: Ruptured membranes
REF: 816 OBJ: 10 KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and Maintenance 17. A patient arrives at the hospital having contractions. How should the nurse determine that the patient is in true labor? a. There is no dilation. b. The contractions are in the fundus. c. The cervix has softened and effaced. d. The contractions are irregular. ANS: C One sign of true labor is when the cervix has softened and effaced. True labor contractions are regular and rhythmic. DIF: Cognitive Level: Analysis REF: 799 TOP: Effacement KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 4
18. The nurse is alarmed as she assesses a protruding umbilical cord from the vagina. What immediate action should the nurse take? a. Monitor intensity of contractions. b. Place the patient in the knee-chest position. c. Notify the charge nurse. d. Ask the patient to perform a Valsalva’s maneuver. ANS: B The knee-chest position reduces the pressure on the prolapsed cord. The charge nurse will need to be notified, and the contractions will need to be monitored. However, the priority is reducing the pressure on the prolapsed cord. DIF: Cognitive Level: Analysis REF: 804 OBJ: 12 TOP: Cord prolapse KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 19. A nurse is assessing the printout from the fetal monitor. What is the legal responsibility of the nurse? a. Correctly identifying abnormal FHR patterns and prescribing medication b. Correctly identifying abnormal FHR patterns and notifying the health care provider c. The nurse is not legally responsible for fetal monitoring d. Providing technical assessment to the monitor technicians ANS: B Nurses are responsible for the timely notification of the primary caregiver in the event of an abnormal fetal heart rate (FHR) pattern. The nurse cannot write a medication order. DIF: Cognitive Level: Application REF: 817 OBJ: 10 TOP: Fetal monitoring KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
20. A mother is in early labor and asks the nurse how long the labor will last. The nurse explains that the first stage of labor lasts from the beginning of regular contractions until when? a. The cervix is completely effaced. b. The baby is in position. c. The cervix is fully dilated. d. The woman begins pushing. ANS: C The first stage of labor begins with regular contractions and ends with complete dilation of the cervix. DIF: Cognitive Level: Comprehension REF: 809 OBJ: 9 TOP: Labor and delivery KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 21. The nurse is admitting a patient to the labor and delivery unit. While performing the initial assessment, which assessment is the priority? a. The number of previous pregnancies b. When the baby is due c. When the patient last ate d. The timing of contractions ANS: D Assessment begins with timing the contractions on admission to form a database. DIF: Cognitive Level: Analysis REF: 824 OBJ: 10 TOP: Admission of labor patient KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 22. During labor, the patient screams at her husband to get out of her sight. What would be the most appropriate action for the nurse? a. Ask the husband to leave the room. b. Assure the husband that such behavior is normal. c. Remind the patient that the husband wants to help. d. Change the patient’s position. ANS: B During labor the patient frequently becomes angry and outspoken. It is a normal occurrence, but the husband needs to be reassured that such behavior is normal. DIF: Cognitive Level: Application TOP: Care during labor Implementation MSC: NCLEX: Psychosocial Integrity
REF: 823 OBJ: 12 KEY: Nursing Process Step:
23. A primigravida patient is admitted to the labor and delivery unit. During initial assessment, the baby is found to be engaged. Which statement is true?
a. b. c. d.
The narrowest diameter of the presenting part has reached the pelvic outlet. The descending part is being initiated through the midpelvis. The widest diameter of the presenting part crosses the pelvic inlet. The narrowest diameter of the presenting part is at the ischial spines.
ANS: C Engagement occurs when the biparietal diameter, which is the widest part of the fetal head, crosses the pelvic inlet. DIF: Cognitive Level: Application | Cognitive Level: Analysis REF: 807 OBJ: 8 TOP: Engagement KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 24. The health care provider has decided to induce labor with prostaglandin gel and an amniotomy. When should the nurse expect that labor will start? a. 1 hour b. 4 hours c. 8 hours d. 12 hours ANS: A Medically approved methods of inducing labor include prostaglandin gel application that usually induces labor in 1 hour or less. DIF: Cognitive Level: Comprehension REF: 828 OBJ: 13 TOP: Induction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 25. A mother has entered the second stage of labor. When does the second stage of labor end? a. When the mother begins to push b. When the baby’s head crowns c. With delivery of the baby d. With delivery of the placenta ANS: C The second stage of labor begins with complete dilation and ends with the birth of the baby. DIF: Cognitive Level: Knowledge REF: 811 OBJ: 9 TOP: Second stage of labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 26. Why is oxytocin administered in the third stage of labor? a. To stimulate lactation b. To relieve postpartum pain c. To stimulate uterine contractions d. To sedate the mother so she can rest ANS: C
Oxytocin makes the uterus contract and reduces postpartum hemorrhage. DIF: Cognitive Level: Application REF: 812 OBJ: 13 TOP: Third stage of labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 27. After the delivery of a newborn, what is the priority action of the nurse? a. Place the newborn on the right side. b. Cover the cord stump. c. Dry the infant immediately. d. Suction nose and mouth. ANS: D To prevent aspiration of amniotic fluid, the baby should be suctioned, then quickly dried to prevent hypothermia. DIF: Cognitive Level: Application REF: 800 | 821 OBJ: 12 TOP: Newborn care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 28. An infant presents 5 minutes after delivery with a heart rate of 105, is crying, has some flexion in the arms, sneezes, and has a pink body and blue limbs. What Apgar score should be assigned to this infant? a. 5 b. 7 c. 8 d. 10 ANS: C The Apgar scoring is: fetal heart rate (FHR) over 100 = 2; crying = 2; flexed arms = 1; sneeze = 2; pink body, blue limbs = 1. DIF: Cognitive Level: Application |Cognitive Level: Analysis OBJ: 10 TOP: Apgar scoring KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
REF: 820
29. For the first hour following delivery, how often should the nurse assess the mother? a. Every 5 minutes b. Every 10 minutes c. Every 15 minutes d. Every 30 minutes ANS: C During the first hour, assessments are done every 15 minutes. DIF: Cognitive Level: Comprehension TOP: Postdelivery assessment
REF: 812 OBJ: 10 KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance 30. When the nurse performs the Nitrazine test on vaginal secretions of a patient who thinks her membranes have ruptured, the paper turns yellow. What does this finding indicate? a. Acidic discharge, membranes intact b. Acidic discharge, membranes have ruptured c. Neutral, not enough discharge to measure d. Alkaline, membranes have ruptured ANS: A When the Nitrazine paper turns yellow it is indicative of acidic discharge, meaning the membranes are intact. Amniotic fluid is alkaline and turns the paper blue. DIF: Cognitive Level: Analysis REF: 799 OBJ: 4 TOP: Nitrazine test KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Which assessment findings suggest probable fetal distress? (Select all that apply.) a. Fetal heart rate (FHR) of 120 b. Meconium-stained amniotic fluid c. Decreased FHR during contractions d. Strong contractions 10 seconds apart e. Slow return of FHR to baseline ANS: B, E Meconium-stained amniotic fluid and the slow return of the FHR to the baseline are indicative of fetal distress. All other options are normal. DIF: Cognitive Level: Analysis REF: 817 OBJ: 10 TOP: Fetal distress KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. A pregnant woman is discussing her desire to have her baby in a birthing center. Which factors could exclude the patient from delivering in a birthing center? (Select all that apply.) a. The patient is a primigravida. b. The patient will be having a planned cesarean delivery. c. The mother has preeclampsia. d. The baby is a boy. e. The mother has no support system. ANS: B, C Birthing centers are ideal only for women who are considered low risk. Cesarean deliveries would not be done in a birthing center. The mother with preeclampsia would be considered high risk and would probably be excluded from delivering in the birthing center. The number of previous pregnancies, sex of the baby, and mother’s support system would not be factors considered when determining risk for delivering in a birthing center.
DIF: Cognitive Level: Application REF: 798 OBJ: 2 TOP: Birth settings KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1. The nurse explains to the patient whose membranes ruptured an hour ago that delivery is usually accomplished in to 24 hours postrupture. ANS: 18 After the rupture of membranes, labor is usually accomplished in 18 to 24 hours. DIF: Cognitive Level: Application REF: 799 OBJ: 9 TOP: Ruptured membranes KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. A primigravida has a pelvis of the android type, which usually means the delivery will be a . ANS: cesarean The narrow outlet of the android-type pelvis usually requires a cesarean delivery. DIF: Cognitive Level: Application REF: 800 OBJ: 6 TOP: Android pelvis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. A nurse shows the patient an x-ray of the fetal spine in parallel alignment with the mother’s to demonstrate a lie. ANS: longitudinal A longitudinal lie is when the fetal spine and the maternal spine are parallel to each other. DIF: Cognitive Level: Application REF: 804 OBJ: 7 TOP: Fetal lie KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
Chapter 28: Care of the Mother and Newborn Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. When assessing a mother 12 hours following the delivery of a baby, where should the nurse expect to palpate the fundus? a. 2 cm below the umbilicus b. At the umbilicus c. 1 cm below the umbilicus d. Halfway between the umbilicus and the symphysis pubis ANS: B Within 12 hours, the fundus rises to the level of the umbilicus. The fundus should be firm. Immediately following delivery, the fundus will be felt halfway between the umbilicus and the symphysis. DIF: Cognitive Level: Application REF: 849 TOP: Postpartum KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
2. What is the name of the vaginal discharge that occurs immediately following delivery? a. Lochia serosa b. Lochia rubra c. Lochia palatine d. Lochia alba ANS: B The vaginal discharge that occurs immediately following discharge is known as lochia rubra and is made up mostly of blood. As the placenta heals, the draining turns pink to dark brown in color and is known as lochia serosa. After about 7 days, the discharge turns slight yellow to white and is called lochia alba. DIF: Cognitive Level: Comprehension REF: 835 TOP: Lochia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
3. What is the first secretion produced by the breast? a. Prolactin b. Colostrum c. False milk d. Whey ANS: B The first secretion to be produced by the breast is colostrum. DIF: Cognitive Level: Knowledge REF: 837 OBJ: 2 TOP: Lactation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
4. What should be included in a teaching plan regarding breast engorgement? a. It typically occurs on the first postpartum day. b. It is usually first observed in the axillary region. c. It occurs only in women who are not breastfeeding. d. It occurs near the nipple on the third postpartum day. ANS: B Filling of the breast with milk (engorgement) usually begins in the axillary region on the third postpartum day when the milk comes in. It occurs regardless of whether the mother is breastfeeding or bottle-feeding. DIF: Cognitive Level: Application TOP: Engorgement Implementation MSC: NCLEX: Physiological Integrity
REF: 843 OBJ: 2 KEY: Nursing Process Step:
5. When is breast engorgement most likely to occur? a. When the infant’s mouth surrounds the areola when feeding b. When the breast tissue becomes congested c. When the breast is emptied completely at each feeding d. When the infant’s mouth grasps the nipple firmly ANS: B Engorgement is the result of venous and lymphatic stasis (congestion). Emptying the breast at each feeding, the infant grasping the nipple firmly, and the infant’s mouth surrounding the areola when feeding are all measures that will aid in decreasing engorgement. DIF: Cognitive Level: Application TOP: Engorgement Implementation MSC: NCLEX: Physiological Integrity
REF: 852 OBJ: 2 KEY: Nursing Process Step:
6. Which statement would be a correct description of colostrum? a. Slightly yellow and low in protein b. Slightly yellow and provides antibodies c. Creamy and high in fat and protein d. Colorless and high in fat and carbohydrates ANS: B Colostrum is slightly yellow in color and is rich in antibodies. DIF: Cognitive Level: Comprehension REF: 867 OBJ: 13 TOP: Colostrum KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The new mother has decided not to breastfeed the baby. How should the nurse correctly instruct the mother to suppress her milk supply? a. Pump the breasts to remove milk
b. Apply warm, moist compresses c. Restrict oral fluids d. Apply a firm bra and ice packs ANS: D If a patient is not breastfeeding, compress the breasts with a firm bra and wrapped ice packs to suppress the milk supply. Pumping the breasts and applying warm, moist compresses are instructions for the breast-feeding mother to deal with the painful symptoms of engorgement. DIF: Cognitive Level: Application TOP: Engorgement Implementation MSC: NCLEX: Physiological Integrity
REF: 852 OBJ: 3 KEY: Nursing Process Step:
8. During the immediate postpartum period, the mother has a temperature of 100.2°F (37.8°C), pulse 52, respirations 18, BP 138/84. What should the nurse do? a. Report the temperature as abnormal. b. Continue to monitor every 15 minutes. c. Report the pulse as abnormal. d. Nothing as the vital signs are normal. ANS: D The vital signs are normal for a new postpartum patient. DIF: Cognitive Level: Application REF: 847 OBJ: 1 TOP: Postpartum KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. Within the first hour following a vaginal delivery, the nurse assesses the mother and finds the fundus is firm and there is a trickle of bright red blood. What should be the nurse’s reaction to the assessment? a. This is a normal occurrence. b. This is abnormal and should be reported. c. The patient should be administered a blood thinner. d. The patient should be restricted to bed rest. ANS: A A bright red drainage is normal immediately after delivery. The patient should be monitored at regular intervals. Bed rest is not indicated. A blood thinner would not be given. DIF: Cognitive Level: Application REF: 835 TOP: Postpartum KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
10. What is the appropriate way to assess the fundus of the postpartum patient? a. Using the side of one hand moving down from the umbilicus b. Using one hand over the lower segment of the uterus c. Using one hand pushing upward from the lower uterus
d. Using one hand on the lower uterine segment while the other hand locates the fundus of the uterus ANS: D The proper way to assess the fundus of a mother who has just given birth is by placing one hand on the lower uterine segment while the other hand locates the fundus of the uterus. DIF: Cognitive Level: Application TOP: Fundal assessment MSC: NCLEX: Physiological Integrity
REF: 849 OBJ: 1 KEY: Nursing Process Step: Assessment
11. The postpartum mother with a third degree laceration tells the nurse she is afraid to have a bowel movement because of her painful episiotomy. What should the nurse do? a. Offer a suppository or enema. b. Encourage ambulation. c. Offer stool softeners as prescribed. d. Offer pain medication before defecating. ANS: C Stool softeners are available to ease the pain of defecation caused by hemorrhoids and birth trauma. Suppositories or enemas are contraindicated in mothers with third or fourth degree lacerations. Pain medications can often cause constipation. Ambulation may aid in defecation, but will not soften the stool. DIF: Cognitive Level: Application TOP: Postpartum elimination Implementation MSC: NCLEX: Physiological Integrity
REF: 847 OBJ: 3 KEY: Nursing Process Step:
12. A new mother had spinal anesthesia during a cesarean delivery. She now has a desire to void and can wiggle her toes. What should be the nurse’s response when the mother asks to go the bathroom? a. Assess her blood pressure. b. Obtain a wheelchair. c. Palpate her bladder. d. Put slippers on her feet. ANS: D The nurse should check that the mother is wearing slippers to ensure better footing. If the mother has a desire to void and can move her toes, there is no need for her to remain bedridden. DIF: Cognitive Level: Application REF: 848 OBJ: 3 TOP: Postspinal anesthesia KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 13. A mother delivered her baby at midnight and it is now 9 a.m. She wants to sleep and asks the nurse to take care of the baby. What is this considered?
a. b. c. d.
Fatigue from labor Normal “taking in” response Abnormal “taking in” response Risk for altered maternal-infant bonding
ANS: B Her primary focus will be on her own needs such as sleep (“taking in” stage). DIF: Cognitive Level: Analysis TOP: “Taking in” response MSC: NCLEX: Psychosocial Integrity
REF: 852 OBJ: 5 KEY: Nursing Process Step: Assessment
14. Which of the following would be considered a normal assessment finding in a 1-day postpartum patient? a. Pinkish to brown lochia b. Voiding frequently 50 to 75 mL of urine c. Complaining of “after pains” d. Fundus 1 cm above the umbilicus ANS: C The common discomfort of after pains is a normal assessment finding at 1-day postpartum. The normal discharge 1-day postpartum would be lochia rubra, which is made up of mostly blood. The fundus would be palpated at the level of the umbilicus. Frequent voiding would be considered abnormal. DIF: Cognitive Level: Analysis REF: 855 TOP: Postpartum KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 2
15. A new Native American mother tells the nurse that when she goes home, her mother-in-law will be caring for the baby while she rests. The nurse has concerns. What should the nurse do? a. Explain the importance of ambulating to recover. b. Explain the importance of maternal-infant bonding. c. Explore ways to blend this with safe health teaching. d. Encourage this cultural behavior. ANS: C Follow principles that facilitate nursing practice within transcultural situations. DIF: Cognitive Level: Analysis TOP: Ethnic considerations MSC: NCLEX: Psychosocial Integrity
REF: 858 OBJ: 5 KEY: Nursing Process Step: Planning
16. Before initially feeding an infant, what reflex should the nurse assess? a. Moro reflex b. Rooting reflex c. Babinski reflex d. Swallow reflex ANS: D
The nurse should verify that the infant is able to swallow normally before feeding. DIF: Cognitive Level: Application REF: 867 TOP: Postpartum KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment
OBJ: 9
17. Following delivery of the newborn, which nursing intervention should be carried out immediately? a. Weigh the infant. b. Warm the infant. c. Bathe the infant. d. Inoculate the infant. ANS: B Maintenance of body temperature is the primary concern when caring for the newborn. The infant will also be weighed, bathed, and inoculated, but those measures are not the primary concern. DIF: Cognitive Level: Application REF: 868 OBJ: 8 TOP: Newborn care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 18. Where would acrocyanosis be assessed on a newborn? a. Circumoral area b. Brow c. Feet d. Mucous membrane ANS: C Acrocyanosis is the slightly blue appearance of the hands and feet that is caused by poor circulation. It can last for 7 to 10 days in the newborn. DIF: Cognitive Level: Comprehension TOP: Newborn assessment MSC: NCLEX: Physiological Integrity
REF: 860 OBJ: 7 KEY: Nursing Process Step: Assessment
19. The nurse identifies that the newborn is jaundiced within the first 24 hours of birth, with jaundice occurring over bony prominences of the face and the mucous membrane. What type of jaundice does this represent? a. Physiologic b. Normal c. Pathologic d. Transitory ANS: C Jaundice that appears within the first 48 hours of life is termed pathologic jaundice and is abnormal. Pathologic jaundice indicates excessive red blood cell destruction and it should be reported. Jaundice that appears after the first 48 hours of life is known as physiologic jaundice and is considered normal.
DIF: Cognitive Level: Application TOP: Newborn assessment MSC: NCLEX: Physiological Integrity
REF: 861 OBJ: 9 KEY: Nursing Process Step: Assessment
20. What is the term for the cream cheese–like substance that protects the infant’s skin from amniotic fluid? a. Lanugo b. Meconium c. Desquamation d. Vernix caseosa ANS: D At birth, the skin is covered with a yellowish-white cream cheese–like substance called vernix caseosa. DIF: Cognitive Level: Knowledge TOP: Newborn assessment MSC: NCLEX: Physiological Integrity
REF: 861 OBJ: 8 KEY: Nursing Process Step: Assessment
21. Which tests are performed to detect inborn errors of metabolism in the newborn? a. Blood glucose b. Phenylketonuria (PKU) c. Blood urea nitrogen (BUN) d. Prothrombin time (PT) ANS: B State law requires certain diagnostic tests be performed on the newborn, including PKU, which detects an inborn error of metabolism. DIF: Cognitive Level: Knowledge REF: 867 OBJ: 7 TOP: Newborn care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 22. Which newborn assessment finding can suggest a chromosomal disorder? a. Epstein pearls b. Gynecomastia c. Babinski reflex d. Simian crease ANS: D A simian crease may indicate a chromosomal disorder. DIF: Cognitive Level: Comprehension REF: 863 OBJ: 9 TOP: Newborn assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 23. Why is vitamin K given by injection to the newborn? a. Most mothers have a vitamin K deficiency that develops during pregnancy.
b. Bacteria that synthesize vitamin K are not present in newborns. c. Vitamin K prevents the synthesis of prothrombin. d. The newborn does not store vitamin K. ANS: B Newborns are not able to synthesize vitamin K in the colon until they have adequate intestinal flora, therefore, the vitamin K injection is given as a prevention measure against hemorrhage. DIF: Cognitive Level: Application REF: 867 OBJ: 8 TOP: Care of newborn KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 24. What should be included when discussing the care of a circumcised infant after discharge from the hospital? a. Gently remove the yellow exudate from the foreskin. b. Apply sterile petroleum gauze after each diaper change. c. Wipe the circumcision with alcohol each day. d. Avoid the use of cloth diapers until the foreskin has healed. ANS: B Wash the penis at diaper change and apply sterile petroleum gauze. The yellow exudate should not be removed as it is part of the normal healing process. The circumcised area should be cleansed gently, not with alcohol. Cloth diapers are sometimes recommended to promote healing. DIF: Cognitive Level: Application TOP: Circumcision Implementation MSC: NCLEX: Physiological Integrity
REF: 869 OBJ: 11 KEY: Nursing Process Step:
25. The nurse is caring for a newborn who was circumcised earlier in the day. What should be included in the plan of care? a. Administration of a topical anesthetic to the site b. Application of ice to stop bleeding c. Retraction of any remaining foreskin d. Observation for bleeding for the first 12 hours ANS: D The nurse should assess for bleeding for the first 12 hours following the circumcision. Gentle pressure should be applied to control bleeding. The administration of topical anesthetic and the retraction of the remaining foreskin are not included in the plan of care. DIF: Cognitive Level: Application TOP: Circumcision Implementation MSC: NCLEX: Physiological Integrity
REF: 869 OBJ: 11 KEY: Nursing Process Step:
26. Which finding should the nurse suspect as abnormal in the newborn during the initial assessment? a. Eyes crossed at times b. Persistent high-pitched cry c. Arms and legs flexed d. Slight bluish tinge of the extremities ANS: B A high-pitched cry may indicate neurologic problems. Occasional crossing of the eyes, flexing of the arms and legs, and a bluish tinge of the extremities are all considered normal assessment findings in the newborn. DIF: Cognitive Level: Analysis REF: 871 OBJ: 9 TOP: Newborn assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 27. What is a characteristic of a normal breast-fed infant’s stool? a. Green and loose b. Dark green and sticky c. Pale yellow and frequent d. Light brown and pasty ANS: C Breast-fed infants tend to pass stools frequently and they are pale yellow to golden in color and pasty in consistency. DIF: Cognitive Level: Comprehension TOP: Breast-fed stool Implementation MSC: NCLEX: Physiological Integrity
REF: 869 OBJ: 8 KEY: Nursing Process Step:
28. The new mother calls the nurse to her room to show how her baby is “jerking around” when she changes his position. The nurse understands that the baby is exhibiting which normal reflex? a. Traction reflex b. Babinski reflex c. Tonic neck reflex d. Moro reflex ANS: D The Moro reflex (startle reflex) causes the baby to abduct the extremities and fan the fingers with the thumb and index fingers making a “C” shape followed by flexion and adduction of the extremities. DIF: Cognitive Level: Application REF: 863 | 864 OBJ: 10 TOP: Reflexes KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 29. The nurse is giving a bath demonstration for a group of new mothers. What should be included in the demonstration?
a. b. c. d.
Apply baby powder generously to keep baby dry. Cleanse perineum from front to back. Use scented soap to make baby smell good. Partially submerge head in water when shampooing.
ANS: B The perineum should be cleansed by wiping from the anterior to the posterior. Excessive use of powders and scented soaps can irritate the skin. The head should not be submerged in water. DIF: Cognitive Level: Application REF: 870 OBJ: 4 TOP: Newborn bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Which of the following measures could help prevent infant abduction? (Select all that apply.) a. Only transport infants by carrying them. b. Require staff members to wear appropriate identification badges. c. Respond immediately when an alarm sounds. d. Never leave infants unattended at any time. e. Take all the infants to their mothers at the same time. ANS: B, C, D Staff members should always wear appropriate ID badges and should respond immediately when an alarm sounds. Infants should never be left unattended. Infants should always be transported in their cribs, never by carrying them. The nurse should transport only one infant at a time. DIF: Cognitive Level: Application REF: 859 OBJ: 6 TOP: Infant abduction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. The nurse is observing a new mother interact with her infant. Which observation would indicate that bonding is occurring? (Select all that apply.) a. The mother is making eye contact with the infant. b. The mother is sending the infant to the nursery for feedings. c. The mother is cuddling with the infant and napping. d. The mother is requesting that the mother-in-law change all diapers. e. The mother states that her favorite thing to do with her baby is to breastfeed. ANS: A, C, E Eye contact, cuddling, and enjoying infant feeding are all signs of positive parent-infant attachment (bonding). Sending the infant to the nursery for feedings and having someone else change all diapers could indicate difficulty with bonding. DIF:
Cognitive Level: Application
REF: 841
OBJ: 12
TOP: Bonding KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. A new mother asks for advice on how to quiet her fussy newborn. Which responses would be appropriate to suggest to the mother? (Select all that apply.) a. Prewarm the crib sheets with a hot water bottle b. Swaddle the newborn tightly in a receiving blanket c. Place the baby in a larger crib or infant bed d. Offer a pacifier or allow the infant to suckle at the breast e. Take the infant for a ride in the car ANS: A, B, D, E Oftentimes, infants are comforted by warm sheets. Infants tend to like to be swaddled snugly. Many infants find comfort sucking a pacifier; breast-fed infants can suckle at the breast. Car rides are often soothing for infants. A large sleeping space is not soothing for infants. The opposite is true. A small sleeping space, such as a bassinette, tends to comfort a fussy baby. DIF: Cognitive Level: Application REF: 871 OBJ: 14 TOP: Infant quieting techniques KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1. After delivery of a 9-lb baby, the nurse assesses a perineal laceration extending through the muscles of the perineum. The nurse records this as a -degree laceration. ANS: second A second-degree laceration extends through the superficial tissues into the muscles of the perineum. DIF: Cognitive Level: Analysis TOP: Second-degree lacerations MSC: NCLEX: Physiological Integrity
REF: 837 OBJ: 3 KEY: Nursing Process Step: Assessment
2. The nurse describes the return of the postpartum patient’s uterus to a pregravid state as . ANS: involution Involution is the decrease in size of the uterus to a prepregnant state. DIF: Cognitive Level: Knowledge REF: 835 OBJ: 2 TOP: Involution KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
3. The new mother tells the home health nurse that she is concerned about her 5-day-old infant’s hard, dried umbilical stump. What time frame should the nurse give the mother for the umbilical stump to fall off? 10 to 14 . ANS: days The umbilical stump will turn brownish black and fall off within 10 to 14 days after birth. DIF: Cognitive Level: Knowledge REF: 863 OBJ: 4 TOP: Mummification KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
Chapter 29: Care of the High-Risk Mother, Newborn, and Family With Special Needs Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. A patient is admitted to the hospital with hyperemesis gravidarum. The patient is malnourished and severely dehydrated. The care plan should be altered to include which interventions? a. Hyperalimentation b. IV fluids and electrolyte replacement c. Hormone replacement therapy d. Vitamin supplements ANS: B Medical treatment is aimed at meeting fluid and electrolyte replacement. DIF: Cognitive Level: Application TOP: Hyperemesis gravidarum MSC: NCLEX: Physiological Integrity
REF: 910 OBJ: 1 KEY: Nursing Process Step: Planning
2. A patient with hyperemesis gravidarum asks the nurse what would have happened if she had not come to the hospital. What result is the best response by the nurse? a. A large for gestational age infant b. Anorexia nervosa c. Preterm delivery d. Maternal or fetal death ANS: D If untreated, hyperemesis gravidarum can result in maternal or fetal death. DIF: Cognitive Level: Application TOP: Hyperemesis gravidarum Implementation MSC: NCLEX: Physiological Integrity
REF: 879 OBJ: 1 KEY: Nursing Process Step:
3. How should twins who share a placenta and come from one fertilized ovum be identified? a. Dizygotic b. Trizygotic c. Genetically different d. Monozygotic ANS: D Monozygotic twins, also known as identical twins, originate from one fertilized ovum and share a placenta. Monozygotic twins carry the same genetic code. Dizygotic twins are the result of two separate ova being fertilized at the same time. DIF: Cognitive Level: Comprehension TOP: Multifetal pregnancy
REF: 879 OBJ: 1 KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance 4. What complication of delivery should the nurse expect with the birth of multiple fetuses? a. An ectopic tendency b. Difficulty with breast-feeding c. A vaginal delivery d. Loss of uterine tone ANS: D Delivery of multiple fetuses is often complicated by loss of uterine tone. Oftentimes multiple fetuses are delivered by cesarean. An ectopic tendency would present before delivery. While it can be difficult to breastfeed multiple infants, this does not relate to the delivery. DIF: Cognitive Level: Application TOP: High-risk pregnancy MSC: NCLEX: Physiological Integrity
REF: 879 OBJ: 1 KEY: Nursing Process Step: Assessment
5. A patient is admitted to the hospital with signs of an ectopic pregnancy. What should the plan of care include for the patient? a. Long-term bed rest b. Episodes of extreme hypertension c. Surgery to remove the embryo/fetus d. Treatment for dehydration ANS: C An ectopic implantation occurs somewhere outside the uterus and either resolves itself in a spontaneous abortion or requires surgical intervention. DIF: Cognitive Level: Application TOP: Ectopic pregnancy MSC: NCLEX: Physiological Integrity
REF: 880 OBJ: 1 KEY: Nursing Process Step: Planning
6. What percent of first-trimester pregnancies spontaneously abort? a. 5% to 10% b. 10% to15% c. 20% to 25% d. 40% to 50% ANS: B It is estimated that 10% to 15% of first-trimester pregnancies end in spontaneous abortion. DIF: Cognitive Level: Knowledge REF: 882 OBJ: 1 TOP: Abortions KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 7. What symptom, no matter what stage of pregnancy, should be reported immediately? a. Backache b. Urinary frequency
c. Vaginal bleeding d. Uterine tightening ANS: C Women should be instructed to contact their health care provider if any bleeding occurs during pregnancy. DIF: Cognitive Level: Comprehension REF: 883 OBJ: 2 TOP: Vaginal bleeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8. A patient in her second trimester of pregnancy arrives at the hospital complaining of bright red, painless vaginal bleeding. What condition should the nurse immediately suspect? a. Abruptio placentae b. Hemorrhage c. Placenta previa d. Placentitis ANS: C Placenta previa is a serious condition that consists of bright red painless vaginal bleeding occurring after 20 weeks of pregnancy. The major symptoms of abruptio placentae are severe abdominal pain and uterine rigidity. DIF: Cognitive Level: Application TOP: Placenta previa MSC: NCLEX: Physiological Integrity
REF: 885 OBJ: 2 KEY: Nursing Process Step: Assessment
9. A pregnant woman comes to the hospital 3 weeks before her estimated date of birth (EDB) complaining of severe pain and a rigid abdomen. What should the nurse immediately suspect as the cause of the pain? a. Placenta previa b. Appendicitis c. Ectopic pregnancy d. Abruptio placentae ANS: D The major symptoms of abruptio placentae are severe pain and a rigid abdomen. Placenta previa consists of painless bleeding. Appendicitis is not usually accompanied by a rigid abdomen. Symptoms of an ectopic pregnancy would usually occur in the first trimester. DIF: Cognitive Level: Application TOP: Abruptio placentae MSC: NCLEX: Physiological Integrity
REF: 887 OBJ: 2 KEY: Nursing Process Step: Assessment
10. A patient presents with symptoms of abruptio placentae. To facilitate uterine-placental perfusion, in what position would the nurse place the patient? a. Prone position
b. Trendelenburg’s position c. Supine position d. Modified side-lying position ANS: D A modified side-lying position facilitates uterine-placental perfusion. DIF: Cognitive Level: Application TOP: Abruptio placentae Implementation MSC: NCLEX: Physiological Integrity
REF: 888 OBJ: 2 KEY: Nursing Process Step:
11. A pregnant woman visits a clinic visit during her 21st week of pregnancy. The nurse identifies edema, hypertension, and proteinuria. What condition does the nurse suspect? a. Allergy b. Protein deficiency c. Circulatory problem d. Gestational hypertension ANS: D Gestational hypertension (GH), formerly referred to as pregnancy-induced hypertension (PIH), is a disease encountered during pregnancy or early in the puerperium, characterized by increasing hypertension, proteinuria, and generalized edema. These signs generally appear after the 20th week of pregnancy. DIF: Cognitive Level: Analysis REF: 890 OBJ: 4 TOP: Pregnancy-induced hypertension (PIH) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. What condition is a possible cause of gestational hypertension? a. Too much salt b. A toxin c. Renal disease d. Diabetes ANS: C Gestational hypertension may be caused by other existing conditions, such as renal disease. DIF: Cognitive Level: Knowledge REF: 890 OBJ: 4 TOP: Pregnancy-induced hypertension (PIH) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. What should the nurse hope to identify by keeping a record of a patient’s blood pressure during prenatal visits? a. Ketoacidosis b. Placenta previa c. Gestational diabetes d. Gestational hypertension ANS: D
Blood pressure should be assessed routinely during pregnancy, because symptoms of gestational hypertension include hypertension. DIF: Cognitive Level: Comprehension REF: 890 TOP: Pregnancy-induced hypertension (PIH) KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 4
14. The nurse is assessing a “kick count” for a patient with gestational hypertension. What result should be a cause for concern? a. Less than three kicks per hour b. Less than five kicks per hour c. Less than seven kicks per hour d. Less than nine kicks per hour ANS: A A kick count of fewer than three per hour is considered serious and a cause for concern. DIF: Cognitive Level: Application REF: 892 OBJ: 3 TOP: Pregnancy-induced hypertension (PIH) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. When discussing toxoplasmosis infection during pregnancy, what should the nurse caution the patient to avoid? a. Contacting with an infected person b. Emptying cat litter boxes bare-handed c. Having unprotected sex d. Eating excessive amounts of shellfish ANS: B A pregnant woman should wear gloves whenever having contact with cat feces as this is a possible source of toxoplasmosis infection. DIF: Cognitive Level: Application REF: 897 OBJ: 6 TOP: Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 16. What is a major complication of gestational diabetes that affects the infant? a. Lack of nutrition b. Dehydration c. Hypoglycemia d. Hyperglycemia ANS: C A result of gestational diabetes is neonatal hypoglycemia. DIF: Cognitive Level: Comprehension REF: 897 OBJ: 1 TOP: Diabetes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
17. A pregnant patient who has type 2 diabetes (NIDDM) may require insulin. Why is the insulin necessary? a. The growing baby will require more glucose. b. Oral hypoglycemic agents may be teratogenic. c. Increased hormone levels raise blood glucose. d. Oral hypoglycemics do not reach the fetus. ANS: B Oral hypoglycemics are discontinued because of teratogenic effects. DIF: Cognitive Level: Comprehension REF: 898 OBJ: 5 TOP: Diabetes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. Why is the fetus dependent on the mother for glucose control? a. The insulin requirements are higher. b. Insulin is destroyed by the placenta. c. Insulin does not cross the placenta. d. Insulin is absorbed by the fetus. ANS: C Insulin will not cross the placenta, but high glucose levels do. Therefore, it is imperative that the mother control glucose levels. DIF: Cognitive Level: Analysis REF: 901 TOP: Diabetes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
19. A patient with a history of rheumatic heart disease is being admitted to the labor and delivery unit. To prevent further stress on the heart, what should the nurse anticipate to be ordered? a. Oxygen administration b. Administering large amount of IV fluids c. Positioning the patient on her back d. Encouraging activity between contractions ANS: A Oxygen is administered to increase blood oxygen saturation and decrease the stress on the heart. IV fluid administration is kept to a minimum to prevent fluid overload. The patient would be positioned in a semi-Fowler’s position to improve circulation. The patient should be encouraged to rest between contractions to conserve energy. DIF: Cognitive Level: Application REF: 901 OBJ: 12 TOP: Cardiovascular defects KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 20. A 14-year-old pregnant adolescent arrives at the hospital in early labor. The nurse should recognize that the adolescent is at a greater risk for which problem? a. Calcium deficit b. Cephalopelvic disproportion
c. Bleeding tendency d. Low hemoglobin levels ANS: B There are several physiologic concerns for pregnant adolescents, including cephalopelvic disproportion. DIF: Cognitive Level: Analysis TOP: Adolescent pregnancy Assessment MSC: NCLEX: Physiological Integrity
REF: 903 KEY:
OBJ: 7 Nursing Process Step:
21. When should the gestational age of the infant be determined? a. Within 5 to 10 minutes of delivery b. Within 1 to 2 hours of delivery c. Within 2 to 8 hours of delivery d. Within 12 to 24 hours of delivery ANS: C The gestational age tests are done within 2 to 8 hours of delivery. DIF: Cognitive Level: Comprehension REF: 908 OBJ: 9 TOP: Gestational age KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 22. The newborn infant has oxygenation problems and a lack of subcutaneous fat. What should the nurse determine as the gestational age of this infant? a. 20 to 37 completed weeks of pregnancy b. 38 to 41 completed weeks of pregnancy c. 14 to 36 completed weeks of pregnancy d. 42 or more completed weeks of pregnancy ANS: A The lungs of preterm infants have not fully developed; therefore, they have problems with oxygenation. Preterm infants also lack subcutaneous fat. The gestational age of the preterm is classified as 20 to 37 complete weeks of pregnancy. DIF: Cognitive Level: Analysis REF: 909 TOP: Preterm KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 9
23. Compared to older infants of comparable weight, how much higher is the morbidity and mortality rate for preterm infants? a. One to two times b. Two to three times c. Three to four times d. Four to five times ANS: C The morbidity and mortality rate for preterm infants is higher by three to four times that of an older infant of similar weight.
DIF: Cognitive Level: Comprehension REF: 907-908 OBJ: 9 TOP: Preterm KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 24. A neonate is born with weak muscle tone, froglike extremities, and ears that fold easily. From these observations, what gestational age should the nurse give this infant? a. Full term b. Small for gestational age c. Preterm d. Postterm ANS: C Preterm infant posture is froglike, the muscle tone is weak, and the ears are easily folded. DIF: Cognitive Level: Analysis REF: 910 TOP: Preterm KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 9
25. A primigravida is Rh negative and her husband is Rh positive. She is concerned about the health of the fetus. The nurse explains that there is little danger to the fetus if it is Rh positive; however, the mother would become sensitized during delivery. If this were the case, the mother would produce what in subsequent pregnancies? a. Rh-negative blood cells b. Rh-positive blood cells c. Rh-negative antibodies d. Rh-positive antibodies ANS: D If the mother is exposed to the Rh antigen, Rh-positive antibodies will be produced after delivery of an Rh-positive baby. If the baby is Rh negative, no antibodies will be produced. DIF: Cognitive Level: Analysis TOP: Hemolytic disease Implementation MSC: NCLEX: Physiological Integrity
REF: 912 OBJ: 10 KEY: Nursing Process Step:
26. The nurse assures a patient who has become sensitized to the Rh antigen that she can be protected for future pregnancies by receiving what injection? a. Iron b. Vitamin B12 c. RhoGAM d. Type O blood ANS: C RhoGAM prevents the development of naturally occurring maternal antibodies. DIF: Cognitive Level: Comprehension TOP: Hemolytic disease
REF: 912 OBJ: 10 KEY: Nursing Process Step:
Implementation MSC: NCLEX: Health Promotion and Maintenance 27. The nurse is assessing the newborn and discovers a yellowing of the skin. What is true for jaundice that appears at birth? a. Within normal limits b. Pathologic c. A result of iron deficiency d. Indicating possible hepatitis ANS: B Jaundice observed at birth is considered an indicator of a pathologic condition, erythroblastosis fetalis. It is considered abnormal. DIF: Cognitive Level: Comprehension TOP: Hemolytic disease MSC: NCLEX: Physiological Integrity
REF: 911-912 OBJ: 10 KEY: Nursing Process Step: Assessment
28. What test is used to identify the maternal level of Rh antibodies in the mother’s blood? a. Indirect Coombs’ test b. Hemolytic test c. Rh antibody test d. Direct Coombs’ test ANS: A The indirect Coombs’ test measures the maternal level of antibodies. DIF: Cognitive Level: Knowledge REF: 912 OBJ: 3 TOP: Hemolytic disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 29. A nursery nurse is implementing phototherapy for a jaundiced infant. What is the purpose of the phototherapy? a. It is initiated when the bilirubin level reaches 5 mg/dL. b. It converts bilirubin to a water-soluble form to be excreted in the urine. c. It changes bilirubin to a bile salt to be excreted through the bowel. d. It requires eye patches to remain in place 24 hours a day. ANS: B Phototherapy converts the bilirubin into a water-soluble form to be excreted by the kidneys. It is initiated when the bilirubin level reaches 12 to 15 mg/dL. The eye patches are worn during therapy, but removed for feeding, bathing, and socialization. DIF: Cognitive Level: Analysis TOP: Hemolytic disease Implementation MSC: NCLEX: Physiological Integrity
REF: 912 OBJ: 10 KEY: Nursing Process Step:
30. Why do alcohol and illegal drugs endanger the fetus?
a. b. c. d.
Both are absorbed into the bloodstream. Both affect the mother. Both cross the placental barrier. Both increase the heart rate of the fetus.
ANS: C Alcohol and illicit drugs cross the placental barrier and affect the fetus. DIF: Cognitive Level: Application REF: 876 | 913 OBJ: 8 TOP: Fetal risk from drugs KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 31. Cognitive impairment, facial abnormalities, and growth retardation are characteristics of which abnormality in a fetus? a. Fetal dependency b. Fetal immaturity c. Malnutrition dependency d. Fetal alcohol syndrome ANS: D Use of alcohol may result in multiple anomalies called fetal alcohol syndrome. The fetus may also be born with alcohol dependency and immaturity, but the characteristics noted are specific for fetal alcohol syndrome. DIF: Cognitive Level: Application REF: 876 OBJ: 8 TOP: Fetal risk KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 32. What should be specifically monitored in a patient who is hospitalized with gestational hypertension? a. Blood sugar b. Temperature c. Level of consciousness d. Deep tendon reflexes ANS: D If the patient is hospitalized for gestational hypertension, deep tendon reflexes are monitored. The blood sugar, temperature, and LOC will also be monitored, but they are not the priority in the hypertensive patient. DIF: Cognitive Level: Application REF: 891 OBJ: 4 TOP: Eclampsia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. What is the antidote for magnesium sulfate toxicity? a. Vitamin K b. Calcium gluconate c. Potassium sulfate d. Calcium carbonate
ANS: B The antidote for magnesium sulfate toxicity is calcium gluconate. DIF: Cognitive Level: Knowledge REF: 892 OBJ: 11 TOP: Maternal risk KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 34. What is a prominent feature of postpartum depression? a. Failure to thrive b. Rejection of the infant c. Inability to care for the baby d. Problems with the baby’s father ANS: B A prominent feature of PPD is rejection of the infant. DIF: Cognitive Level: Comprehension TOP: Postpartum depression (PPD) MSC: NCLEX: Psychosocial Integrity
REF: 916 OBJ: 1 KEY: Nursing Process Step: Assessment
35. What is the usual treatment for severe postpartum depression? a. Improved nutrition b. Vitamin therapy c. Pharmacologic interventions d. Support group therapy ANS: C Support therapy is not enough for major PPD. Pharmacologic interventions are needed in most instances. DIF: Cognitive Level: Comprehension TOP: Postpartum depression (PPD) Implementation MSC: NCLEX: Psychosocial Integrity
REF: 878 OBJ: 1 KEY: Nursing Process Step:
MULTIPLE RESPONSE 1. A pregnant patient with tuberculosis asks the nurse how the disease will affect her pregnancy and her newborn. What statements by the nurse are most appropriate? (Select all that apply.) a. “You have nothing to worry about. You will be disease free before you deliver.” b. “The tuberculosis can be transmitted to the fetus in rare occurrences.” c. “Your newborn will be tested for tuberculosis after delivery.” d. “There is no approved treatment for the infant if she tests positive for the disease.” e. “You will not be able to hold your newborn until you have been cleared according to the health department guidelines.” ANS: B, C, E
TB can be transmitted to a fetus in the womb. Newborns of infected mothers are skin tested for TB after birth and treated if the skin test is positive. Mothers who have TB are not allowed to have exposure to their newborn until they have been cleared according to the health department standards. DIF: Cognitive Level: Application REF: 894 OBJ: 13 TOP: Pulmonary tuberculosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1. Following an abruptio placentae, the patient suddenly becomes dyspneic, complains of chest pain, and begins to ooze blood from her IV insertion site. The nurse assesses these as indicators of disseminated coagulation. ANS: intravascular DIC is characterized by dyspnea, chest pain, and uncontrolled bleeding. DIF: Cognitive Level: Application REF: 887 OBJ: 2 TOP: Disseminated intravascular coagulation (DIC) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse reports to the charge nurse that the 3-hour postpartum patient is bleeding excessively as she has saturated one peripad in less than minutes. ANS: 15 fifteen The saturation of one peripad within 15 minutes is considered to be excessive bleeding. DIF: Cognitive Level: Comprehension TOP: Postpartum hemorrhage MSC: NCLEX: Physiological Integrity
REF: 889 OBJ: 3 KEY: Nursing Process Step: Assessment
3. The nurse explains that severe needs to be controlled because it can develop into another syndrome called HELLP (Hypertension, Elevated Liver enzymes, and Low Platelets). ANS: preeclampsia Progressive preeclampsia can develop into HELLP syndrome. DIF: Cognitive Level: Comprehension REF: 890 OBJ: 4 TOP: Hypertension | Elevated Liver enzymes, and Low Platelets (HELLP)
KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 4. The patient who has taken the ovulation stimulant clomiphene (Clomid), and who has been determined to be pregnant, calls the clinic nurse to report that she is bleeding and has passed a small grapelike object. From this information the nurse suspects a hydatidiform . ANS: mole Hydatidiform moles occur frequently in people who have taken Clomid. The physical changes are similar to a real pregnancy until bleeding occurs and some grapelike clusters are passed. DIF: Cognitive Level: Application TOP: Hydatidiform mole MSC: NCLEX: Physiological Integrity
REF: 880 OBJ: 3 KEY: Nursing Process Step: Assessment
5. A woman who is 14 weeks’ pregnant calls the clinic nurse to report that after a brief bleeding episode a week ago, her uterus seems to have gotten smaller, but her periods have not begun. The nurse assesses the indicators for a abortion. ANS: missed A missed abortion is initiated by a bleeding episode in which the fetus is not expelled. The uterus begins to shrink, but periods do not resume. DIF: Cognitive Level: Application TOP: Missed abortion MSC: NCLEX: Physiological Integrity
REF: 880 OBJ: 3 KEY: Nursing Process Step: Assessment
Chapter 30: Health Promotion for the Infant, Child, and Adolescent Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse stresses that regular physical activity has been identified as a leading health indicator. Regular physical activity has which positive effect on children? a. Improves social skills. b. Reduces fluid retention. c. Increases bone and muscle strength. d. Increases attention span. ANS: C In children, regular physical activity increases bone and muscle strength. DIF: Cognitive Level: Application REF: 919 OBJ: 2 TOP: Physical activity KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. What is the single most preventable cause of death and disease in the United States today? a. Drug use b. Alcohol addiction c. Cigarette smoking d. Malnutrition ANS: C Cigarette smoking continues to be the single most preventable cause of death. DIF: Cognitive Level: Knowledge REF: 921 TOP: Tobacco use KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 1
3. Smoking contributes to an increased risk of heart and lung disease in children by which methods? a. Air pollution b. Allergens in the environment c. Environmental smoke d. Lack of oxygen in the air ANS: C Environmental smoke may result in an increased risk of heart and lung disease, particularly asthma and bronchitis in children. DIF: Cognitive Level: Comprehension REF: 922 TOP: Tobacco use KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 1
4. Which factor is mostly associated with problems such as domestic violence, sexually transmitted infections (STIs), school failure, and motor vehicle accidents (MVAs)? a. Lack of supervision b. Psychological problems c. Substance abuse d. Physiological problems ANS: C Substance abuse is associated with many social problems such as domestic violence, STIs, school failure, and MVAs. DIF: Cognitive Level: Knowledge REF: 923 OBJ: 1 TOP: Substance abuse KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 5. Approximately half of all new HIV cases are among people under what age? a. 50 years b. 40 years c. 30 years d. 25 years ANS: D Approximately half of all new HIV cases are among people younger than 25. DIF: Cognitive Level: Knowledge REF: 924 OBJ: 1 TOP: Sexual behavior KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. Which children must be secured in the back seat in a rear-facing safety seat? a. Children weighing up to 20 lb b. Children weighing between 20 and 30 lb c. Children weighing between 30 and 40 lb d. Children weighing more than 40 lb ANS: A The law states that a child from birth to 20 lb must be situated in a rear-facing safety seat that is secured in the back seat when riding in an automobile. DIF: Cognitive Level: Application REF: 925 OBJ: 7 TOP: Injury KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. The pediatric nurse reminds the parents of a 2-year-old that by this age the child should be protected against how many vaccine-preventable childhood diseases? a. 4 b. 6 c. 8 d. 10 ANS: D
Children who follow the immunization schedule are protected against 10 vaccine-preventable childhood diseases by age 2. DIF: Cognitive Level: Application REF: 926 OBJ: 3 TOP: Immunizations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8. A major dental problem among very young children is bottle mouth caries. What is a preventive measure the nurse should suggest? a. Juice at bedtime b. Milk at bedtime c. A sugar-coated pacifier d. Water at bedtime ANS: D Specific interventions can prevent bottle mouth caries, such as offering water in the bedtime bottle. DIF: Cognitive Level: Application REF: 926 OBJ: 4 TOP: Dental health KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. What practice should be used by a pediatric nurse to remind parents of their responsibility in reducing the number of accidents involving children? a. Child awareness b. Good manners c. Anticipatory guidance d. Strict discipline ANS: C Anticipatory guidance has been the most widely used approach to educating parents in accident prevention. DIF: Cognitive Level: Application REF: 927 OBJ: 9 TOP: Injury prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 10. To prevent accidental poisoning of a child, where should medications be placed in the home? a. In a dresser drawer b. In the medicine cabinet c. In a locked cupboard d. On a high shelf ANS: C Medications should be kept in a locked cupboard.
DIF: Cognitive Level: Application REF: 928 OBJ: 5 TOP: Poisoning KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 11. What is the leading cause of fatal injury in children younger than 1 year old? a. Burns b. Poisons c. Asphyxiation d. Motor vehicle accidents ANS: C In children younger than 1 year, the leading cause of fatal injury is asphyxiation by aspiration of foreign material into the respiratory tract. DIF: Cognitive Level: Comprehension REF: 928 OBJ: 6 TOP: Asphyxiation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. What is the third leading cause of accidental death in children 1 to 4 years of age? a. Falls b. Asphyxiation c. Poisons d. Burns ANS: D Burns are the third leading cause of accidental death in children 1 to 4 years of age. DIF: Cognitive Level: Knowledge REF: 930 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 9
13. The school nurse recognizes that lack of physical activity and increased consumption of fast food by children are causative factors contributing to which of the following problems? a. Nutritional disorders b. Weight gain c. Type I diabetes d. Dental caries ANS: B Many factors have contributed to the excess weight carried by children, including lack of physical activity and increased consumption of fast food. DIF: Cognitive Level: Analysis REF: 920 TOP: Obesity KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 1
14. The nurse sets up a sample physical activities schedule to fit the FDA’s Dietary Guidelines for Americans that recommends that children get at least how many minutes of physical activity per day? a. 15 b. 30 c. 45 d. 60 ANS: D The Dietary Guidelines for Americans recommend that children get at least 60 minutes of physical activity per day. DIF: Cognitive Level: Comprehension REF: 921 OBJ: 2 TOP: Physical activity KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 15. What age group is experiencing the largest increase in drug use? a. 7- to 9-year-olds b. 10- to 12-year-olds c. 12- to 13-year-olds d. 15- to 17-year-olds ANS: C Research shows an increase in children aged 12 to 13 years who are experimenting with drugs. DIF: Cognitive Level: Knowledge REF: 923 OBJ: 1 TOP: Substance abuse KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 16. Because the water in the infant’s residential area is not fluoridated, when should the nurse suggest that the infant receive supplemental fluoride? a. 2 months old b. 4 months old c. 5 months old d. 6 months old ANS: D Fluoride supplementation should be initiated at 6 months of age if the water in the infant’s residential area is not fluoridated. DIF: Cognitive Level: Application REF: 927 OBJ: 4 TOP: Dental care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE
1. What are reasons that a pediatric nurse should stress that health promotion activities must be ongoing? (Select all that apply.) a. To identify health risks b. To encourage healthy behavior c. To strengthen family bonds d. To improve nutrition e. To prevent accidents ANS: A, B, D, E Health promotion activities must be ongoing to identify health risks, to encourage healthy behavior, to improve nutrition, and to prevent accidents. There is no link between health promotion activities and strengthening family bonds. DIF: Cognitive Level: Comprehension REF: 918 OBJ: 1 TOP: Health promotion KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. The school nurse collaborates with the physical education instructor to increase the amount of physical activity during the school day. What are major benefits of physical activity? (Select all that apply.) a. Reduced death rates as adults b. Reduced risk of cardiovascular disease c. Reduced risk of hypertension d. Reduced risk of diabetes e. Reduced self-esteem ANS: A, B, C, D Physical activity reduces death rates as adults, reduces the risk of cardiovascular disease, and reduces the risk of diabetes and hypertension. Physical activity increases self-esteem. DIF: Cognitive Level: Comprehension REF: 919 OBJ: 2 TOP: Benefits of physical exercise KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. Which are physical risks associated with excess weight? (Select all that apply.) a. Poor eyesight b. Heart disease c. Arthritis d. Stroke e. Appendicitis ANS: B, C, D Heart disease, arthritis, and stroke are physical risks that are associated with excess weight. Poor eyesight and appendicitis are not associated with weight gain. DIF: Cognitive Level: Comprehension REF: 920 OBJ: 10 TOP: Obesity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance 4. Which of the following interventions should be included when teaching a healthy behaviors class for parents of adolescents? (Select all that apply.) a. Always monitor the child’s telephone conversations. b. Insist on seatbelt use at all times. c. Encourage tanning bed use versus exposure to the sun. d. Maintain recommended immunization schedule. e. Encourage good dental care. ANS: B, D, E Adolescents should always wear seatbelts. Immunizations should be obtained according to the recommended schedule. Good dental care is important. Parents should give the child privacy in their telephone conversations. Tanning bed exposure is as detrimental to skin as exposure to the sun and both should be avoided. DIF: Cognitive Level: Application REF: 929 OBJ: 10 TOP: Healthy behaviors KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1. A nurse emphasizes a study that focused on the amount of time children spend using various media, such as TV, video games, and computers, and stated that by cutting this time by %, it would have a significant impact on increasing physical activity. ANS: 50 If sedentary time were cut in half, this would have a significant effect on the increase in physical activity. DIF: Cognitive Level: Comprehension REF: 923 OBJ: 2 TOP: Sedentary lifestyle KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. The nurse recognizes that preventive programs in schools must be stepped up in order to prevent violence, especially . ANS: shootings Premeditated intentional shootings are occurring more frequently among adolescents. DIF: Cognitive Level: Application REF: 925 OBJ: 10 TOP: Shootings KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
Chapter 31: Basic Pediatric Nursing Care Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. What was one of the major strides in pediatric care made by Dr. Abraham Jacobi? a. Pediatric wards in hospitals b. Free inoculations against smallpox c. Milk stations in the city of New York d. Serving nutritious foods in orphanages ANS: C
Dr. Abraham Jacobi, referred to as the father of pediatrics, initiated the establishment of milk stations in New York demonstrating how to sanitize milk for children. DIF: Cognitive Level: Knowledge TOP: Abraham Jacobi MSC: NCLEX: N/A
REF: 934 OBJ: 2 KEY: Nursing Process Step: N/A
2. What was founded by Lillian Wald? a. National Commission on Children b. Henry Street Settlement c. White House Conference d. US Children’s Bureau ANS: B
Lillian Wald, regarded as the founder of public health, founded Henry Street Settlement, which provided nursing services and social assistance. DIF: Cognitive Level: Knowledge REF: 934 TOP: Lillian Wald KEY: Nursing Process Step: N/A
OBJ: 2 MSC: NCLEX: N/A
3. When the pediatric nurse is attempting to establish a trusting relationship with a child,
what is the most important and lasting thing to do? a. Convey respect. b. Talk with the child. c. Be honest. d. Talk with family. ANS: C
To establish a trusting relationship, the most important thing is to be honest. DIF: Cognitive Level: Application TOP: Pediatric nurse KEY: MSC: NCLEX: Psychosocial Integrity
REF: 935 OBJ: 4 Nursing Process Step: Implementation
4. What is the special category that encompasses children who have congenital
abnormalities, malignancies, gastrointestinal (GI) diseases, or central nervous system (CNS) anomalies? a. Very dependent children b. Children requiring special education
c. Children with special needs d. Children requiring long-term care ANS: C
The definition of children with special needs includes congenital abnormalities, malignancies, GI diseases, and CNS anomalies. DIF: Cognitive Level: Comprehension REF: 936 OBJ: 6 TOP: Children KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. The mother of a child with diabetes asks the nurse in charge of the family-centered
pediatric unit if she might see her child’s laboratory reports. What response by the nurse is the most appropriate? a. “Although the actual reports are not shared, I can tell you the blood sugar is 200 mg.” b. “I’ll write them down for you and bring them to your room.” c. “Come to the conference room where we can have privacy while you look at them.” d. “I’ll notify the health care provider that you wish to see the reports.” ANS: C
With a family-centered care approach, hospitals welcome parents, and parents have access to information 24 hours a day. DIF: Cognitive Level: Analysis REF: 936 OBJ: 5 TOP: Family-centered care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. What should be the focus of a practice where the pediatric nurse uses a developmental
approach? a. Stimulation of the child to reach expected norms b. Age-centered care plans c. Strengths and abilities of the child d. Characteristics for the particular age ANS: C
A developmental approach emphasizes the child’s strengths and abilities and considers individuality. It builds on what the child can do instead of focusing on what the child cannot do. DIF: Cognitive Level: Application REF: 938 OBJ: 6 TOP: Developmental approach KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. When using anticipatory guidance to prepare a 5-year-old for an IM injection, what
statement by the nurse would be most appropriate? a. “Ethan, I’m going to give you a shot.” b. “Ethan, the health care provider wants you to have some medicine, and it will hurt.” c. “Ethan, some medicine can only be given with a needle.” d. “Ethan, I am going to give you some medicine that will sting, but only for a little
while.” ANS: D
Anticipatory guidance is the psychological preparation of a patient for a stressful event by explaining what will happen and the probable outcome. DIF: Cognitive Level: Analysis TOP: Anticipatory guidance MSC: NCLEX: Psychosocial Integrity
REF: 938 OBJ: 14 KEY: Nursing Process Step: Implementation
8. When measuring the head circumference of an infant, where should the nurse place the
tape measure? a. Across the eyebrows and around the occipital lobe b. Over the zygomatic arches and around the parietal areas c. Around forehead and around the crown of the head d. Above the eyebrows and pinnas, and around the occipital lobe ANS: D
Head circumference is measured in children up to 36 months above the eyebrows and pinnas, and around the occipital lobe. DIF: Cognitive Level: Application REF: 940 OBJ: 14 TOP: Head circumference KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. What activity by an infant would cause a false elevation of the tympanic temperature? a. Having a bowel movement b. Crying vigorously c. Having just eaten d. Having been in a cold room ANS: B
Crying increases the temperature; eating and bowel movements do not. A cold room would lower the temperature. DIF: Cognitive Level: Application REF: 941 OBJ: 7 TOP: Vital signs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. What is the correct order for assessing vital signs in an infant to ensure the accuracy of
measurements? a. Respiration, temperature, pulse b. Pulse, respiration, temperature c. Temperature, pulse, respiration d. Respiration, pulse, temperature ANS: D
The respiration is taken first on an infant before the child is disturbed, pulses are assessed next, and last the temperature is obtained. DIF: Cognitive Level: Application REF: 941 OBJ: 7 TOP: Vital signs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
11. Why does obtaining the respirations of an infant require a modified approach from that of
an adult? a. Infants breathe through their noses. b. Infants have very rapid respirations. c. Infants’ respirations are thoracic in nature. d. Infants’ respiratory movements are abdominal. ANS: D
In children under 6 or 7 years of age, respiratory movements are abdominal or diaphragmatic. Abdominal movements must be observed when counting respirations. DIF: Cognitive Level: Application REF: 942 TOP: Vital signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 7
12. An 8-year-old child asks how a blood pressure is taken. What would be the most
appropriate response? a. “This small machine will measure your systolic and diastolic pressure.” b. “The armband will hug your arm and tell me how well your blood is going through your arm.” c. “The armband will cut off your circulation for a while and then we can hear when it comes back.” d. “When you are ill we need to know if your blood is still moving in your body.” ANS: B
Because children are upset by unfamiliar procedures, it is best to explain each step in simple terms. It is best not to mention anything that may increase anxiety. DIF: Cognitive Level: Application REF: 942-943 OBJ: 9 TOP: Vital signs KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 13. What is the correct way to assess for the presence of jaundice in an African-American
child? a. Examine the sclera. b. Press the edge of the pinna. c. Apply pressure to the gum. d. Compare the color on the soles of the feet. ANS: C
The gums in individuals with dark complexions can be used to assess jaundice by pressing the gums about the teeth. DIF: Cognitive Level: Application REF: 944 TOP: Jaundice KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 7
14. When discussing growth and development with the parents of a child, the nurse explains
that nutrition is the single most important influence on: a. cognitive development. b. secondary sexual characteristics.
c. the production of blood cells. d. the growth of bones and muscle. ANS: D
Nutrition is probably the single most important influence on growth. DIF: Cognitive Level: Application REF: 947 TOP: Nutrition KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
OBJ: 8
15. The mother of a 3-year-old expresses concern about her daughter’s slowed growth rate.
What would be the most informative response by the nurse? a. “Three-year-olds have typically finished a growth spurt, and you may notice a decreased rate in your daughter’s growth.” b. “Children’s growth is hereditary. She may be of small stature like you.” c. “The growth of a 3-year-old is associated with their nutrition. How is she eating?” d. “Your daughter is healthy and happy. Don’t worry about her growth right now.” ANS: A
Three-year-olds slow down in their growth in a natural cycle. DIF: Cognitive Level: Application REF: 937-938 OBJ: 7 TOP: Growth KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 16. What should be included in the teaching plan for the parents of a 3-year-old child who has
been prescribed an opioid analgesic? a. The opioid is likely to cause significant respiratory depression. b. The medicine is prescribed with the knowledge that addiction may occur. c. The opioid is very effective as a pain control method. d. The opioid is only to be given in cases of severe pain. ANS: C
It is an effective type of analgesia. When administered to children, opioid analgesics do not have any greater respiratory depression than when given to an adult, and the risk of addiction is virtually nonexistent in children. DIF: Cognitive Level: Application TOP: Opioid analgesia MSC: NCLEX: Physiological Integrity
REF: 956 OBJ: 12 KEY: Nursing Process Step: Implementation
17. The parents ask about preparation of their toddler for hospital admission. When does the
nurse suggest that the parents tell their toddler of the admission? a. A week prior b. 2 weeks prior c. The day of admission d. Only 2 or 3 days before ANS: D
The nurse should suggest the toddler be told only days before. School-age children can be given more time to prepare. Adolescents should be told as far in advance as possible.
DIF: Cognitive Level: Application TOP: Hospitalization MSC: NCLEX: Psychosocial Integrity
REF: 953 OBJ: 11 KEY: Nursing Process Step: Implementation
18. When the newly admitted 2-year-old who was potty-trained before admission begins to
wet the bed, the mother is frightened. What statement by the nurse will be most helpful to the mother? a. “Don’t be concerned. Accidents happen.” b. “Let’s put a diaper on your child until this gets better.” c. “The stress of hospitalization makes children regress a little.” d. “Your child will relearn ‘potty-training’ if you are patient.” ANS: C
It is not unusual for children to regress when hospitalized. Explaining that regression is normal during hospitalization will help allay the mother’s anxiety. DIF: Cognitive Level: Application REF: 955 OBJ: 13 TOP: Hospitalization regression KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 19. When attempting to provide information to the parents of a child undergoing surgery, the
nurse notes that the parents appear confused and do not seem to remember what they are being told. What is the most probable cause of the parents’ forgetfulness? a. Noisy environment b. Serious nature of surgery c. Increased level of parents’ anxiety d. Developmental age of the child ANS: C
Anxiety of the parents may result in confusion and forgetfulness. It is not known if the environment is noisy, if the surgery is serious in nature, or what is the developmental age of the child. DIF: Cognitive Level: Application TOP: Hospitalization MSC: NCLEX: Psychosocial Integrity
REF: 958 OBJ: 13 KEY: Nursing Process Step: Implementation
20. What is the best time to bathe an infant? a. At bedtime b. Early in the morning c. After a feeding d. Before a feeding ANS: D
Bathing is usually done before a feeding to reduce the possibility of vomiting, regurgitation, or stimulation. DIF: Cognitive Level: Comprehension REF: 959 TOP: Feeding KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 21. How should an infant be positioned after a feeding?
OBJ: 11
a. b. c. d.
On the stomach On the right side On the left side On the back
ANS: B
After feeding, the infant is positioned on the right side to direct the food into the stomach. DIF: Cognitive Level: Comprehension REF: 960 OBJ: 11 TOP: Feeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. When a safety reminder device (SRD) is used to protect a child, what is a responsibility of
the nurse? a. Apply it loosely. b. Remove it every 2 hours. c. Place it over clothing. d. Apply only one type. ANS: B
Any SRD should be removed every 2 hours. DIF: Cognitive Level: Comprehension REF: 961 OBJ: 11 TOP: Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 23. What should be done before initiating a gavage feeding? a. Hold the feeding tube under water to check for bubbling. b. Check for gastric distention. c. Aspirate stomach contents. d. Ensure the sterility of feeding equipment. ANS: C
Aspirating stomach contents and aspirating a small amount of air while listening for stomach gurgling are the best ways to ensure correct tube placement. Holding the feeding tube under water to check for bubbling is not an effective method to check tube placement. Gastric distention would be important following the feeding. A gavage feeding is not a sterile procedure. DIF: Cognitive Level: Application REF: 960 OBJ: 14 TOP: Tube feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 24. What is the purpose of a mist tent? a. To provide a constant oxygen supply b. To liquefy respiratory secretions c. To aid in lowering temperature d. To improve the infant’s hydration ANS: B
The purpose of the mist tent is to liquefy respiratory secretions. A constant oxygen supply can be given by methods other than a mist tent. A mist tent does not lower temperature or improve hydration. DIF: Cognitive Level: Comprehension REF: 962 OBJ: 14 TOP: Mist tent KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. What is the maximum amount of time that a nurse should suction an artificial airway? a. 1 second b. 5 seconds c. 30 seconds d. 1 minute ANS: B
The nurse should limit suctioning to no more than 5 seconds. DIF: Cognitive Level: Comprehension TOP: Tracheal suction MSC: NCLEX: Physiological Integrity
REF: 963 OBJ: 14 KEY: Nursing Process Step: Implementation
26. What is a disadvantage of using a mist tent with a toddler? a. The nurse must remove the restless child. b. The wet bedding and clothing must be changed frequently. c. The mist tent must be opened at least once every hour. d. All objects must be kept outside of the tent. ANS: B
Frequent linen and clothing changes will be necessary because of the heavy humidity in the tent. The nurse can open the tent to soothe the restless child instead of removing the child. The tent does not have to be opened every hour. Toys can be placed inside the tent. DIF: Cognitive Level: Application REF: 962 OBJ: 14 TOP: Mist tent KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. What is one way to enhance the nutrition of the hospitalized toddler? a. Reward with sweets for eating meals. b. Discourage participation in noneating activities. c. Offer nutritious fluids frequently. d. Leave nutritious finger foods out for the child to eat. ANS: C
Using nutritious liquids may satisfy the nutritional needs when a toddler is “too busy” to eat. Toddlers should not be left to eat unsupervised because of the danger of aspiration. Junk food should not be used as rewards. Activities are important and should not be discouraged. DIF: Cognitive Level: Application REF: 960 OBJ: 11 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
28. Why must the pediatric nurse be cautious about medicating infants and young children? a. They are less susceptible to medication effects than adults. b. They are more susceptible to medication effects than adults. c. They are equally susceptible to medication effects as adults. d. They are more susceptible to drug interactions than adults. ANS: B
Newborns and young children are more susceptible to the toxic effects of certain medications than adults. DIF: Cognitive Level: Application REF: 966 OBJ: 15 TOP: Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. What is the preferred IM injection site for a 2-year-old? a. Deltoid muscle b. Upper thigh c. Vastus lateralis d. Gluteus ANS: C
The preferred site for an IM injection for a 2-year-old is the vastus lateralis. DIF: Cognitive Level: Knowledge REF: 967 OBJ: 15 TOP: IM medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 30. Where is the typical IV insertion site in an infant younger than 9 months of age? a. Radial vein b. Scalp vein c. Femoral vein d. Brachial vein ANS: B
A superficial scalp vein is the injection site for administering IV medication to infants younger than 9 months of age. DIF: Cognitive Level: Knowledge REF: 969 OBJ: 15 TOP: IV medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 31. Following a lumbar puncture of a 2-year-old, what should the nurse do? a. Keep the child flat for several hours. b. Allow the child to play quietly at will. c. Hold the child in a flexed position for 5 minutes. d. Stand the child upright immediately. ANS: B
Children younger than 3 years of age are usually not affected by postlumbar headache. These children are allowed to play at will following a lumbar puncture. DIF: Cognitive Level: Comprehension TOP: Lumbar puncture
REF: 966 OBJ: 14 KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 32. What should the nurse do to minimize an unpleasant-tasting drug? a. Pour the drug over ice. b. Squirt the drug in the mouth with a syringe. c. Administer the drug through a straw. d. Enlist the parent’s assistance. ANS: C
Administering the drug through a straw will diminish an unpleasant taste. Having the child hold the nose is helpful, as bad taste is associated with the smell of the drug. Pouring the drug over ice may result in the child not getting the entire amount of the drug. Squirting the drug into the mouth with a syringe will still allow the child to taste the medication. The parent’s assistance should be enlisted, but will not minimize the taste of the drug. DIF: Cognitive Level: Application REF: 967 OBJ: 15 TOP: Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. A disfiguring facial wound would have the most significant developmental impact on
which child? a. 4-year-old b. 6-year-old c. 10-year-old d. 14-year-old ANS: D
The adolescent fears a change in body image associated with surgery. DIF: Cognitive Level: Application REF: 938 | 957 TOP: Surgery KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 6
34. When the nurse is inserting a feeding tube in an 8-month-old, what safety reminder device
(SRD) should the nurse most likely use? a. Mummy b. Clove hitch c. Jacket device d. Elbow device ANS: A
The mummy restraint controls the arms and the body of the infant. DIF: Cognitive Level: Application REF: 961 OBJ: 14 TOP: Safety reminder devices (SRDs) KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 35. The nurse clarifies that child abuse and neglect are complicated and preventable problems
falling under which broader term? a. Child abandonment b. Child mismanagement c. Child maltreatment
d. Child torment ANS: C
Child maltreatment is a broad term used to describe neglect and abuse of children. DIF: Cognitive Level: Knowledge REF: 950 OBJ: 10 TOP: Child abuse KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 36. What observation in an emergency department should lead a nurse to suspect child abuse
in a child with a fractured arm? a. Lack of parental concern for the severity of the injury b. The child not answering questions concerning the injury c. Parents not asking about the child’s condition d. Inconsistency between the injury and the parents’ explanation of it ANS: D
Special attention must be paid to injuries that are inconsistent with the parents’ explanation. DIF: Cognitive Level: Application REF: 951 TOP: Child abuse KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 10
37. When communicating with parents suspected of child abuse, what should the nurse be sure
to do? a. Tell them the law requires reporting of the incident. b. Be sympathetic to their needs. c. Interact with them in a nonjudgmental manner. d. Suggest psychiatric counseling. ANS: C
The nurse should maintain a nonjudgmental attitude toward the parents. The nurse does not have to tell the parents that she is reporting them. The nurse does not have to be sympathetic, she only has to be professional at all times. It is not the place of the nurse to suggest counseling. DIF: Cognitive Level: Application REF: 952 OBJ: 10 TOP: Child abuse KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 38. After observing parental behavior that leads the nurse to suspect child abuse, when should
the nurse report the abuse? a. If the parent confesses to child abuse b. If the child admits to being abused c. Whenever maltreatment of a child is suspected d. When the type of abuse can be determined ANS: C
Mandatory reporting of child abuse is required when the health care provider has reason to suspect the child has been abused.
DIF: Cognitive Level: Application REF: 952 TOP: Child abuse KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 10
MULTIPLE RESPONSE 1. The nurse welcomes the presence of the family in a pediatric unit because it reduces the
stressors of hospitalization. Which are common stressors for the hospitalized child? (Select all that apply.) a. Separation b. Lack of love c. Fear of pain d. Unfamiliar food e. Loss of control ANS: A, C, E
Parents lend stability and comfort for the child and restore his or her sense of control. DIF: Cognitive Level: Application REF: 954 OBJ: 5 TOP: Parents on the pediatric unit KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. The nurse clarifies that the family-centered care approach terminates which policies?
(Select all that apply.) a. Rigid visiting hours b. Freedom to choose which medications to take c. Exclusion of family during procedures d. Discouraging family to stay overnight e. Restricting parents from reading the chart ANS: A, C, D, E
Family-centered care terminates all the restrictive policies of traditional hospitals. Medication orders should still be followed. DIF: Cognitive Level: Application REF: 937 OBJ: 5 TOP: Family-centered care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1. The pediatric nurse, along with the primary caregiver(s), has a special duty to
the child and the family. ANS:
teach The pediatric nurse is in a position to assess, instruct, and support children and their families about developmental progress, nutrition, and possible undiagnosed anomalies. DIF: Cognitive Level: Comprehension REF: 935 OBJ: 4 TOP: Teaching KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance 2. The nurse is aware that visual acuity evaluation in a child is best assessed after the age of
years. ANS:
6 six A child’s refraction does not reach 20/20 until about the age of 6. DIF: Cognitive Level: Comprehension REF: 944 OBJ: 7 TOP: Visual acuity KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
Chapter 32: Care of the Child With a Physical and Mental or Cognitive Disorder Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse uses a diagram to show that the tetralogy of Fallot involves a combination of
four congenital defects. What are the defects? a. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy b. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, atrial septal defect, overriding aorta, right ventricular hypertrophy d. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy ANS: B
Tetralogy of Fallot involves a combination of four congenital defects: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. DIF: Cognitive Level: Knowledge REF: 982 OBJ: 1 TOP: Heart defect KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. What is the most common clinical manifestation of coarctation of the aorta? a. Clubbing of the digits b. Upper extremity hypertension c. Pedal edema and portal congestion d. Loud systolic ejection murmur ANS: B
Coarctation of the aorta results in hypertension in the upper extremities. The pressure in the arms is typically 20 mm Hg higher than in the legs. DIF: Cognitive Level: Knowledge REF: 983 TOP: Heart defect KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
3. Parents of a 6-month-old child, who has just been diagnosed with iron deficiency anemia,
ask why it was not diagnosed earlier. What would be the best response by the nurse? a. “Are you sure your child has iron deficiency anemia?” b. “This happens when the maternal stores of iron are depleted at about 6 months.” c. “This anemia is caused by blood loss.” d. “The child may not have had it for a long time.” ANS: B
Iron deficiency anemia becomes apparent at about 6 months of age in a full-term infant, when maternal stores of iron are depleted. DIF: Cognitive Level: Application REF: 984 OBJ: 2 TOP: Anemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
4. What should the therapeutic management of iron deficiency anemia include? a. Multivitamins b. Calcium c. Ferrous sulfate d. Iodine ANS: C
Therapeutic management of iron deficiency anemia is iron (ferrous sulfate) supplementation, nutritional counseling, and treatment of any underlying condition. DIF: Cognitive Level: Knowledge REF: 984 OBJ: 2 TOP: Anemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The parents of a child who has been diagnosed with sickle cell anemia ask why their child
experiences pain. What is the most likely cause of the pain? a. Inflammation of the vessels b. Obstructed blood flow c. Overhydration d. Stress-related headaches ANS: B
The signs and symptoms of sickle cell anemia include the sickle-shaped cells clumping and obstructing blood flow, which causes severe tissue hypoxia and necrosis leading to pain. DIF: Cognitive Level: Application TOP: Blood disorders MSC: NCLEX: Physiological Integrity
REF: 984-985 OBJ: 2 KEY: Nursing Process Step: Implementation
6. The parents of a child recently diagnosed with sickle cell anemia ask what can be done to
avoid a sickle cell crisis. What should be included in the medical management of sickle cell crisis? a. Information for the parents including home care b. Provisions for adequate hydration and pain management c. Pain management and administration of iron supplements d. Adequate oxygenation and factor VIII ANS: B
Medical management of sickle cell crisis includes palliative analgesics, hydration, and oxygen. DIF: Cognitive Level: Application TOP: Blood disorders MSC: NCLEX: Physiological Integrity
REF: 985-986 OBJ: 2 KEY: Nursing Process Step: Implementation
7. Which laboratory results should the nurse anticipate to be abnormal in a child with
hemophilia? a. Prothrombin time b. Bleeding time c. Platelet count d. Partial thromboplastin time
ANS: D
Expected laboratory findings for a child with hemophilia include a prolonged partial thromboplastin time. The prothrombin time, bleeding time, and platelet count are typically normal. DIF: Cognitive Level: Comprehension TOP: Blood disorders MSC: NCLEX: Physiological Integrity
REF: 986 OBJ: 3 KEY: Nursing Process Step: Assessment
8. The parents of a child with acute lymphoblastic leukemia ask about the best approach for
maintaining remission of the disease. What would be the most effective therapy? a. Surgery to remove enlarged lymph nodes b. Long-term chemotherapy c. Nutritional supplements to enhance blood cell production d. Blood transfusions to replace ineffective red cells ANS: B
The treatment of choice is methotrexate, a chemotherapeutic agent, to produce remission. DIF: Cognitive Level: Application TOP: Blood disorders MSC: NCLEX: Physiological Integrity
REF: 989 OBJ: 4 KEY: Nursing Process Step: Implementation
9. What most influences the severity of respiratory distress syndrome (RDS)? a. Poor cough and gag reflex b. The gestational age at birth c. Administering high concentrations of oxygen d. The sex of the infant ANS: B
RDS is caused by a deficiency of surfactant and it occurs almost exclusively in preterm, low–birth weight infants. DIF: Cognitive Level: Comprehension REF: 993 TOP: Respiratory distress syndrome (RDS) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 7
10. A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the oxygen
tent. The oxygen level in the tent is 25%, and blood gases are normal. What would be the correct action by the nurse? a. Restrain the child in the tent and notify the health care provider. b. Increase the oxygen concentration in the tent. c. Take the child out of the tent and into the playroom. d. Ask the mother for help in comforting the child. ANS: B
The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is caused by poor oxygenation. The child should not be taken out of the oxygenated tent. While the mother could be asked to help comfort the child, and the health care provider may be notified, the priority is to set the oxygen at the correct level.
DIF: Cognitive Level: Analysis TOP: Laryngotracheobronchitis (LTB) MSC: NCLEX: Physiological Integrity
REF: 997 OBJ: 7 KEY: Nursing Process Step: Implementation
11. The mother of a child with acute laryngotracheobronchitis (LTB) asks why her child must
be kept NPO. Which responses would be the most correct? a. The epinephrine given causes nausea and vomiting. b. The child is being hydrated with IV fluids. c. The child is not hungry. d. The child’s rapid respirations pose a risk for aspiration. ANS: D
Rapid respirations predispose to aspiration. The child is kept hydrated with IV fluids, but this is not the reason that the child must be kept NPO. DIF: Cognitive Level: Application TOP: Laryngotracheobronchitis (LTB) MSC: NCLEX: Physiological Integrity
REF: 998 OBJ: 7 KEY: Nursing Process Step: Implementation
12. What could suddenly occur in a child with acute epiglottitis? a. Increased carbon dioxide levels b. Airway obstruction c. Inability to swallow d. Bronchial collapse ANS: B
In acute epiglottitis, the infected epiglottis becomes inflamed and causes total airway obstruction. Immediate treatment of acute epiglottitis includes an artificial airway. DIF: Cognitive Level: Comprehension REF: 997-998 TOP: Epiglottitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 7
13. When conducting a class for parents about sudden infant death syndrome (SIDS), the
nurse instructs the class that the infant should be placed in which position to sleep? a. Right side-lying b. Left side-lying c. Prone d. Supine ANS: D
The American Academy of Pediatrics recommends placing the infant on its back, or supine, to sleep. DIF: Cognitive Level: Comprehension REF: 996 TOP: Sudden infant death syndrome (SIDS) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 7
14. When interacting with the parents of a SIDS infant, the nurse should attempt to assist the
parents with: a. encouraging the parents to have another baby.
b. encouraging the parents to remain stoic. c. allaying feelings of guilt and blame. d. learning how the event could have been prevented. ANS: C
As parents try to cope, they have feelings of guilt and blame. DIF: Cognitive Level: Application REF: 996 TOP: Sudden infant death syndrome (SIDS) KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
OBJ: 7
15. The nurse educates the family of a newly admitted child with cystic fibrosis that the
treatment will be centered on what therapy? a. Chest physiotherapy b. Mucus-drying agents c. Prevention of diarrhea d. Insulin therapy ANS: A
Chest physiotherapy and aerosol medications are the center of treatment for cystic fibrosis. DIF: Cognitive Level: Application TOP: Cystic fibrosis MSC: NCLEX: Physiological Integrity
REF: 1000 OBJ: 7 KEY: Nursing Process Step: Implementation
16. What is the main characteristic of cystic fibrosis? a. Multiple upper respiratory infections b. An underproduction of exocrine glands c. Excessive, thick mucus d. An overproduction of thin mucus ANS: C
The pathophysiology of cystic fibrosis includes excessive, thick mucus. DIF: Cognitive Level: Comprehension TOP: Cystic fibrosis MSC: NCLEX: Physiological Integrity
REF: 999 OBJ: 7 KEY: Nursing Process Step: Assessment
17. What is the best time to administer pancreatic enzyme replacement? a. Before meals and snacks b. Before bedtime c. Early in the morning d. After meals and snacks ANS: A
Pancreatic enzymes are administered before meals and snacks to digest carbohydrates, fats, and proteins. DIF: Cognitive Level: Application TOP: Cystic fibrosis MSC: NCLEX: Physiological Integrity
REF: 1000 OBJ: 7 KEY: Nursing Process Step: Implementation
18. Following surgical repair of a cleft palate, what should be used to prevent injury to the
suture line? a. Straw b. Spoon c. Syringe d. Cup ANS: D
When feeding a child with a repaired cleft palate, the nurse should avoid utensils, straws, droppers, and syringes. DIF: Cognitive Level: Application REF: 1005 OBJ: 8 TOP: Cleft lip and palate KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 19. What is the priority patient problem for the parents of a newborn born with cleft lip and
palate? a. Parental role conflict b. Risk for delayed growth and development c. Risk for impaired attachment d. Anticipatory grieving ANS: C
Parents of a child with cleft lip and palate may have difficulty bonding with their child due to the appearance of the child. The priority patient problem is risk for impaired attachment. A goal is to promote bonding between parents and infant. DIF: Cognitive Level: Analysis TOP: Cleft lip and palate MSC: NCLEX: Psychosocial Integrity
REF: 1004 OBJ: 8 KEY: Nursing Process Step: Assessment
20. Which is a long-term complication of cleft lip and palate? a. Cognitive impairment b. Altered growth and development c. Faulty dentition d. Physical abilities ANS: C
The older child with cleft lip and palate may experience psychological difficulties because of the cosmetic appearance of the defect, problems with impaired speech, and faulty dentition. DIF: Cognitive Level: Comprehension TOP: Cleft lip and palate MSC: NCLEX: Physiological Integrity
REF: 1005 OBJ: 8 KEY: Nursing Process Step: Implementation
21. How should the nurse measure urinary output for an infant with dehydration? a. Attaching a urine collecting bag b. Wringing out the diaper c. Weighing the diaper d. Inserting a catheter
ANS: C
Wet diapers are weighed to assess the amount of output. DIF: Cognitive Level: Application REF: 1005 OBJ: 8 TOP: Dehydration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. Following a bout of diarrhea, which foods should be offered to the school-age child? a. Apricots and peaches b. Chocolate milk c. Applesauce and milk d. Bananas and rice ANS: D
When rehydration has been completed, foods that are nonirritating to the bowel should be offered to the child. Bananas and rice would be the least irritating to the bowel, as fruits and milk could cause GI irritation. DIF: Cognitive Level: Application REF: 1006 OBJ: 8 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. How is the infant with gastroesophageal reflux (GER) typically treated? a. By making the infant NPO b. By thickening the formula or breast milk with cereal c. By placing the infant to sleep on the side d. By switching the infant to cow’s milk ANS: B
GER is treated with small feedings thickened with cereal. The infant should not be made NPO or switched to cow’s milk. Infants should only be placed on the back to sleep due to the risk of SIDS. DIF: Cognitive Level: Application REF: 1008 OBJ: 8 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. What should the nurse assess in an infant who has been diagnosed with hypertrophic
pyloric stenosis? a. A history of diarrhea following each feeding b. Gastric pain evidenced by vigorous crying c. Poor appetite due to a poor sucking reflex d. An olive-shaped mass right of the midline ANS: D
Examination of the abdomen may assist in the diagnosis and reveal key signs of hypertrophic pyloric stenosis. Visible peristaltic waves that move from left to right across the epigastric region may be evident, and palpation may reveal an olive-shaped mass in this area to the right of the midline. DIF: Cognitive Level: Application TOP: Pyloric stenosis
REF: 1009 OBJ: 8 KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 25. What is the hallmark sign of intussusception? a. Mucus-like stools b. Currant jelly–like stools c. Tarry, black stools d. Green, soft stools ANS: B
The hallmark sign of intussusception is currant jelly stools. DIF: Cognitive Level: Knowledge TOP: Gastrointestinal disorders MSC: NCLEX: Physiological Integrity
REF: 1010 OBJ: 8 KEY: Nursing Process Step: Assessment
26. Which is a causative factor of Hirschsprung disease? a. Frequent evacuation of solids, liquid, and gases b. Excessive peristaltic movement c. The absence of parasympathetic ganglion cells in a portion of the colon d. One portion of the bowel telescoping into another ANS: C
The causative factor in Hirschsprung disease is the absence of parasympathetic ganglion cells in a portion of the colon. DIF: Cognitive Level: Comprehension TOP: Gastrointestinal disorders MSC: NCLEX: Physiological Integrity
REF: 1010 OBJ: 8 KEY: Nursing Process Step: Implementation
27. What should the nurse caring for a 6-year-old child with acute glomerulonephritis
anticipate as the most difficult part of the care to implement? a. Forced fluids b. Increased feedings c. Bed rest d. Frequent position changes ANS: C
During the acute phase of glomerulonephritis, bed rest is usually recommended. A diet of restricted fluid, sodium, potassium, and phosphate is initially required. Bed rest can be very hard to implement with an active 6-year-old child. DIF: Cognitive Level: Application TOP: Genitourinary disorders MSC: NCLEX: Physiological Integrity
REF: 1014 OBJ: 10 KEY: Nursing Process Step: Implementation
28. When selecting patient problems for the 4-year-old child with nephrosis, what should be a
priority for the nurse? a. Impaired body image b. Skin impairment c. Nutritional deficit d. Injury
ANS: B
Nephrosis is a clinical state characterized by gross edema, which makes skin care a priority. DIF: Cognitive Level: Analysis TOP: Genitourinary disorders MSC: NCLEX: Physiological Integrity
REF: 1013 OBJ: 10 KEY: Nursing Process Step: Assessment
29. When caring for a 7-week-old infant with hypothyroidism, the nurse explains that the
prevention of what complication is dependent on the administration of oral thyroid replacement therapy and is critical for the child? a. Excessive growth b. Cognitive impairment c. Damage to the nervous system d. Damage to the urinary system ANS: B
The treatment of choice for congenital and acquired hypothyroidism is oral thyroid hormone replacement therapy. Prompt treatment is especially critical in the infant with congenital hypothyroidism to avoid permanent cognitive impairment. DIF: Cognitive Level: Application TOP: Hypothyroidism MSC: NCLEX: Physiological Integrity
REF: 1016 OBJ: 11 KEY: Nursing Process Step: Implementation
30. The nurse explains to the parents of a child with developmental hip dysplasia that the
application of a Pavlik harness is necessary. In what position will the harness hold the child’s femurs? a. Abduction b. Adduction c. Flexion d. Extension ANS: A
The use of the Pavlik harness maintains the hips in abduction for 4 to 6 months. DIF: Cognitive Level: Application TOP: Pavlik harness MSC: NCLEX: Physiological Integrity
REF: 1019 OBJ: 12 KEY: Nursing Process Step: Implementation
31. A teenage girl has been placed in a brace for the treatment of scoliosis, the most common
skeletal deformity of adolescence. The family asks what they can do to be more supportive. What suggestion of the nurse is the most appropriate? a. Enrolling her in a health club b. Taking her to the mall in a wheelchair c. Purchasing clothes to disguise the cast d. Spending a majority of their time with her ANS: C
The adolescent is trying to fit in with peers and has concerns about body image. DIF: Cognitive Level: Analysis
REF: 1023
OBJ: 12
TOP: Scoliosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 32. A newborn has talipes and is wearing casts. How often should the casts be changed? a. Daily b. Weekly c. Biweekly d. Monthly ANS: B
Treatment of talipes consists of manipulation and the application of a series of short leg casts. The foot is gently manipulated into a more normal position and then placed in a cast to maintain the correction. Casts are changed weekly to allow for further manipulation and to accommodate the rapidly growing infant. DIF: Cognitive Level: Application REF: 1023 OBJ: 12 TOP: Club foot KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. A child with Duchenne muscular dystrophy rises from the floor by walking up the thighs
with the hands. How should the nurse record this observation? a. Hand assistance b. Leg crawling c. Gowers sign d. Bright sign ANS: C
Using the hands to walk up the thighs is known as the Gowers sign. DIF: Cognitive Level: Comprehension REF: 1024 OBJ: 12 TOP: Duchenne muscular dystrophy (DMD) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 34. Which signs/symptoms would be considered classical signs of meningeal irritation? a. Positive Kernig sign, diarrhea, and headache b. Negative Brudzinski sign, positive Kernig sign, and irritability c. Positive Brudzinski sign, positive Kernig sign, and photophobia d. Negative Kernig sign, vomiting, and fever ANS: C
Classical manifestations of meningitis include positive Kernig and Brudzinski signs. DIF: Cognitive Level: Comprehension REF: 1026 TOP: Meningitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
35. The health care provider is treating a child with meningitis with a course of antibiotic
therapy. When should the nurse expect the child to be out of isolation? a. When the course of antibiotics is complete b. When a negative CNS culture is obtained c. When the antibiotics have been initiated for 24 hours d. When the child has no symptoms of the disease
ANS: C
The child with bacterial meningitis is isolated for at least 24 hours until antibiotic therapy has been administered. DIF: Cognitive Level: Application REF: 1030 OBJ: 13 TOP: Meningitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 36. What are priority nursing interventions designed to do for a 4-year-old child with cerebral
palsy? a. Assist with referral to specialized education. b. Support the child with independent toileting. c. Assist the child to develop effective communication. d. Encourage the child to ambulate independently. ANS: D
A child with cerebral palsy is usually in need of support with communication, locomotion, and self-help. DIF: Cognitive Level: Application TOP: Cerebral palsy MSC: NCLEX: Physiological Integrity
REF: 1032 OBJ: 13 KEY: Nursing Process Step: Planning
37. The nurse is caring for a newborn with a myelomeningocele. Before surgery, what should
the nursing interventions include? a. Leaving the lesion uncovered and placing the infant supine b. Covering the lesion with a sterile, saline-soaked gauze c. Applying lotion to the lesion to keep it moist d. Covering the lesion with a dry, sterile gauze ANS: B
Nursing interventions for an infant with myelomeningocele include covering the lesion with a sterile, saline-soaked gauze. DIF: Cognitive Level: Application REF: 1028 OBJ: 13 TOP: Spina bifida KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 38. Which additional congenital malformation is expected in 80% of infants with a
myelomeningocele? a. Cerebral palsy b. Hydrocephalus c. Meningitis d. Neuroblastoma ANS: B
Hydrocephalus is present in 80% of infants affected by a myelomeningocele. DIF: Cognitive Level: Comprehension REF: 1033 TOP: Spina bifida KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
39. When speaking to young parents, the nurse states that lead poisoning is one of the most
common preventable health problems affecting children. What condition occurs when the level of lead ingested exceeds the amount that can be absorbed by the bone? a. Malnutrition b. Anemia c. Bone pain d. Diarrhea ANS: B
When the amount of lead ingested exceeds the amount that can be absorbed by the bone, it leads to anemia. DIF: Cognitive Level: Application TOP: Lead poisoning MSC: NCLEX: Physiological Integrity
REF: 1037 OBJ: 14 KEY: Nursing Process Step: Assessment
40. An infant has been diagnosed with cradle cap. What is the correct intervention to treat the
scalp? a. Alcohol b. Mineral oil c. Calamine d. A&D ointment ANS: B
Crusty patches can be removed with the application of mineral oil. DIF: Cognitive Level: Application TOP: Skin disorders MSC: NCLEX: Physiological Integrity
REF: 1039 OBJ: 15 KEY: Nursing Process Step: Implementation
41. An adolescent female asks the nurse about taking retinoic acid (Accutane). What guidance
should be provided by the nurse? a. The medication should be used only for 10 weeks. b. The medication requires that sexually active females use contraception. c. The medication lowers hemoglobin very quickly. d. The medication has few side effects. ANS: B
Accutane has many side effects and can produce birth defects. Effective contraception is necessary during treatment and for 1 month after the 20 weeks it is to be taken. DIF: Cognitive Level: Application REF: 1040 OBJ: 15 TOP: Acne KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 42. A new mother asks the clinic nurse if she must continue giving her baby nystatin for
thrush since the white lesions on his tongue have disappeared. What response by the nurse is most appropriate? a. “No. When the lesions have gone you may stop the nystatin.” b. “Yes. You should continue it for the full 7 days.” c. “No. Thrush is a self-limiting disorder and nystatin is given for comfort only.” d. “Yes. The medication should be refilled for a second week of therapy.”
ANS: B
Nystatin should be given for the full 7 days even if the lesions are no longer present. DIF: Cognitive Level: Analysis TOP: Skin disorders MSC: NCLEX: Physiological Integrity
REF: 1042 OBJ: 15 KEY: Nursing Process Step: Implementation
43. What are early signs of varicella disease? a. High fever over 101°F (38.3°C) b. General malaise c. Increased appetite d. Crusty sores ANS: B
Early signs of varicella will develop during the prodromal period and are mainly low-grade fever, malaise, and anorexia. Lesions do not appear until later. DIF: Cognitive Level: Comprehension TOP: Skin disorders MSC: NCLEX: Physiological Integrity
REF: 1044 OBJ: 15 KEY: Nursing Process Step: Implementation
44. The mother of a child who has been diagnosed with varicella asks the nurse when the child
can return to school. When is the child no longer contagious? a. When the fever dissipates b. After the incubation period c. When the lesions have healed d. When the lesions are crusted over ANS: D
Varicella is no longer contagious when the lesions are dry. DIF: Cognitive Level: Application TOP: Skin disorders MSC: NCLEX: Physiological Integrity
REF: 1036 OBJ: 15 KEY: Nursing Process Step: Implementation
45. A child has developed a diaper rash, and the parents are using zinc oxide to treat it. What
does the nurse suggest to aid in the removal of the zinc oxide? a. Mild soap and water b. A cotton ball c. Mineral oil d. Alcohol swabs ANS: C
To completely remove ointment, especially zinc oxide, mineral oil should be used. DIF: Cognitive Level: Application REF: 1042 OBJ: 15 TOP: Diaper rash KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 46. The nurse instructs the parents of a child who has had a myringotomy to place the child in
which position? a. Supine
b. On the affected side c. On the unaffected side d. In a Trendelenburg’s position ANS: B
Lying on the affected side facilitates ear drainage following a myringotomy. DIF: Cognitive Level: Application TOP: Myringotomy MSC: NCLEX: Physiological Integrity
REF: 1042 OBJ: 16 KEY: Nursing Process Step: Implementation
47. What are the clinical manifestations of otitis media? a. Earache, wheezing, vomiting b. Coughing, rhinorrhea, headache c. Fever, irritability, pulling on ear d. Wheezing, cough, drainage in ear canal ANS: C
Clinical manifestations of otitis media include fever, irritability, and pulling on the ear. DIF: Cognitive Level: Comprehension REF: 982 OBJ: 16 TOP: Otitis media KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 48. The nurse instructs the mother of a child with a ventricular septal defect that she can
expect the child to become cyanotic when the child does what? a. Experiences an elevation in temperature. b. Sleeps on the left side. c. Cries vigorously. d. Eats. ANS: C
Crying vigorously will increase the pressure in the right ventricle, which will allow unoxygenated blood to enter the circulating volume. DIF: Cognitive Level: Analysis TOP: Septal defects MSC: NCLEX: Physiological Integrity
REF: 1048 OBJ: 1 KEY: Nursing Process Step: Implementation
49. Parents of a 5-year-old child diagnosed as cognitively impaired have come to the nurse to
discuss different approaches to the ongoing care of their child. The nurse should suggest focusing on what activity? a. Acquiring job skills b. Making decisions c. Performing self-care activities d. Reading and doing simple math ANS: C
The cognitively impaired young child should be encouraged to learn simple skills for doing self-care. DIF: Cognitive Level: Application TOP: Cognitive impairment
REF: 1048 OBJ: 19 KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity 50. The nurse explains that cognitive impairment is categorized by four levels that depend on
the intelligence quotient (IQ). How is a child with an IQ of 45 classified? a. Within the normal low range b. Educable c. Trainable d. Severe ANS: C
The category of trainable is identified on the basis of an IQ of 35 to 55. DIF: Cognitive Level: Application TOP: Cognitive impairment MSC: NCLEX: Psychosocial Integrity
REF: 1048 OBJ: 17 KEY: Nursing Process Step: Implementation
51. What is the major criterion for diagnosing a child as cognitively impaired? a. An IQ of 75 or less b. Subaverage functioning c. An IQ of 70 or less d. Onset before 18 ANS: C
Cognitive impairment is based upon IQs from 20 to 70. DIF: Cognitive Level: Application REF: 1048 OBJ: 17 TOP: Cognitive impairment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 52. Which is a priority nursing intervention for the cognitively impaired child? a. The family will provide good nutrition. b. The family will provide loving interactions. c. Stimulation will improve. d. There will be contact with peers. ANS: B
Nursing interventions focus on promoting optimal development and loving interactions with family. DIF: Cognitive Level: Application REF: 977 OBJ: 19 TOP: Cognitive impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 53. Which statement correctly explains the etiology of Down syndrome? a. There is an extra chromosome on the 21st pair. b. There is a missing chromosome on the 21st pair. c. There are two pairs of the 21st chromosome. d. The chromosome’s 21st pair is missing. ANS: A
Down syndrome is attributed to an extra chromosome on the 21st pair. DIF: Cognitive Level: Comprehension
REF: 1050
OBJ: 18
TOP: Cognitive impairment KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance 54. What other congenital defects are common in children with Down syndrome? a. Hypospadias b. Pyloric stenosis c. Heart defects d. Hip dysplasia ANS: C
Many children with Down syndrome have congenital heart defects. DIF: Cognitive Level: Comprehension TOP: Congenital impairment MSC: NCLEX: Physiological Integrity
REF: 1050 OBJ: 18 KEY: Nursing Process Step: Implementation
55. What assessment findings should lead the nurse to suspect Down syndrome in a newborn? a. Hypertonia and dark skin b. Low-set ears and a simian crease c. Inner epicanthal folds and a high, domed forehead d. Long, thin fingers and excessive hair ANS: B
Manifestations of the Down syndrome infant include low-set ears, simian crease, protruding tongue, and hypotonic extremities. DIF: Cognitive Level: Analysis TOP: Congenital impairment MSC: NCLEX: Physiological Integrity
REF: 1052 OBJ: 18 KEY: Nursing Process Step: Assessment
56. Parents of a school-age child ask the nurse for suggestions in helping the child who is
demonstrating school avoidance. What is an appropriate suggestion by the nurse? a. Take the child to the health care provider for testing. b. Be firm and insist the child go to school. c. Allow the child to stay home and rest. d. Consult with the teacher at school. ANS: B
Parents should be firm and insist the child go to school. DIF: Cognitive Level: Application TOP: Nursing interventions MSC: NCLEX: Psychosocial Integrity
REF: 1053 OBJ: 20 KEY: Nursing Process Step: Implementation
57. The nurse is caring for a child who has been diagnosed as having an attention deficit
hyperactivity disorder (ADHD). What is the most important intervention for the nurse? a. Have the child enrolled in a special education class. b. Allay any feelings of guilt the parents may have. c. Counsel the parents that the medications are lifelong. d. Teach the parents to set limits. ANS: B
It is most important to allay any feelings of guilt the parents may have.
DIF: Cognitive Level: Application REF: 1053 TOP: Attention deficit hyperactivity disorder (ADHD) KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
OBJ: 21
58. Since children with attention deficit hyperactivity disorder (ADHD) take medication for
long periods of time, side effects must be considered. How often should children be assessed for side effects of the drug therapy? a. Every 2 months b. Every 4 months c. Every 6 months d. Every 8 months ANS: C
Children should be checked for medication side effects every 6 months. DIF: Cognitive Level: Application REF: 1053 TOP: Attention deficit hyperactivity disorder (ADHD) KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
OBJ: 21
59. The parents of a child suffering from depression ask the nurse what causes depression in
children. Which answer is an appropriate response by the nurse? a. The causes of major depression are unknown. b. Major affective disorders in parents increase depression in children. c. Boys are more likely than girls to be depressed. d. The prevalence rate is higher in prepubescent children. ANS: A
The causes of depression have not been established. However, many studies have shown that children have a three times greater rate of suffering from depression if their parents have a major affective disorder. DIF: Cognitive Level: Application REF: 1053 TOP: Depression KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 22
60. When the nurse performs the initial assessment of an adolescent with depression, what is
the most important question to ask? a. “What is making you depressed?” b. “Have you ever thought about suicide?” c. “What could we do to make you happy?” d. “Would you like your friends to visit?” ANS: B
Ask direct questions about suicidal thoughts. The discovery of whether the person has an actual plan is an indicator of the seriousness of the situation. DIF: Cognitive Level: Analysis REF: 1054 TOP: Suicide KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 23
61. What is the most common method of attempted suicide? a. Hanging b. Drug overdose c. Gunshot d. Slashing the wrists ANS: B
Drug overdose is the most common method of attempted suicide. DIF: Cognitive Level: Knowledge REF: 1054 TOP: Suicide KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 23
62. Recurrent abdominal pain (RAP) is most often seen in school-age or adolescent children.
The nurse should assess closely for what potential problems? a. Physical problems b. Relational problems c. Eating disorders d. Emotional problems ANS: D
RAP is often related to emotional factors in the child. DIF: Cognitive Level: Application TOP: Recurrent abdominal pain (RAP) MSC: NCLEX: Psychosocial Integrity
REF: 1056 OBJ: 22 KEY: Nursing Process Step: Assessment
63. When performing an assessment of a child with recurrent abdominal pain (RAP), the nurse
recognizes the child will most likely experience what symptom? a. Increased temperature b. Constipation c. Right quadrant pain d. Exercise-associated pain ANS: B
The child may be constipated with periumbilical pain unrelated to eating, defecation, or exercise. DIF: Cognitive Level: Analysis TOP: Recurrent abdominal pain (RAP) MSC: NCLEX: Physiological Integrity
REF: 1056 OBJ: 22 KEY: Nursing Process Step: Assessment
64. The nurse is recording a history for a child who has been diagnosed with recurrent
abdominal pain (RAP). What is a finding that is characteristic of this disorder? a. Morning headaches b. Pain for 3 consecutive months c. Febrile episodes in the late afternoon d. Diaphoresis when attacks occur ANS: B
Recurrent abdominal pain occurring consecutively for 3 months supports a diagnosis of RAP once other causes have been ruled out. DIF: Cognitive Level: Application TOP: Recurrent abdominal pain (RAP) MSC: NCLEX: Physiological Integrity
REF: 1056 OBJ: 22 KEY: Nursing Process Step: Assessment
MULTIPLE RESPONSE 1. When assessing the laboratory values of a child with nephrosis, the nurse anticipates
which results? (Select all that apply.) a. High levels of protein in the urine b. High serum lipid levels c. Low serum protein levels d. Low hemoglobin e. High white blood cell count ANS: A, B, C
A patient with nephrotic syndrome has high levels of serum lipids, low serum protein, and albumin in urine that is dark and frothy with a high specific gravity. The hemoglobin and WBC are usually normal. DIF: Cognitive Level: Application REF: 1014 TOP: Nephrosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 10
2. The nurse explains that which diagnostic studies are needed for the diagnosis of cognitive
impairment? (Select all that apply.) a. Denver Developmental Screening Test b. Stanford-Binet Intelligence Scale c. Wechsler Intelligence Scale d. Miller’s Analogies e. Strong Personality Assessment ANS: A, B, C
The Denver, Stanford-Binet, and Wechsler are standard intelligence tests that aid in the diagnosis of a cognitively impaired child. DIF: Cognitive Level: Analysis REF: 1048 OBJ: 17 TOP: Intelligence tests KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1. When the mother of a child with gastroesophageal reflux calls the clinic nurse to report
that her baby is vomiting small amounts of blood, the nurse explains that the esophagus has been irritated by gastric . ANS:
acid
Gastric acid that has repeatedly come in contact with the esophageal mucosa will erode the mucosa, and bleeding will result. DIF: Cognitive Level: Application TOP: Gastroesophageal reflux (GER) MSC: NCLEX: Physiological Integrity
REF: 1008 OBJ: 8 KEY: Nursing Process Step: Implementation
2. The nurse reassures the anxious mother of a child with pyloric stenosis who is to have
surgery that the surgical procedure, called a recovers almost immediately.
, is quickly done and the child
ANS:
pyloromyotomy When the muscle is cut, the obstruction is immediately relieved and the child who is hungry will begin to eat and keep food down. DIF: Cognitive Level: Comprehension TOP: Pyloromyotomy MSC: NCLEX: Physiological Integrity
REF: 1009 OBJ: 8 KEY: Nursing Process Step: Implementation
3. The nurse anticipates that the cerebrospinal fluid (CSF) taken from a child with bacterial
meningitis would have a low
level.
ANS:
glucose The glucose level in the CSF of a child with bacterial meningitis is low because the bacteria in the fluid have digested the glucose. DIF: Cognitive Level: Analysis TOP: Cerebrospinal fluid (CSF) MSC: NCLEX: Physiological Integrity 4. Autism is typically diagnosed between
REF: 1026 OBJ: 13 KEY: Nursing Process Step: Assessment
and 3 years of age.
ANS:
2 Autistic is typically diagnosed between 2 and 3 years of age. DIF: Cognitive Level: Knowledge REF: 1050 OBJ: 19 TOP: Autism KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
Chapter 33: Health Promotion and Care of the Older Adult Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. When discussing aging, to whom does the term older adulthood apply? a. Age 55 and above b. Age 65 and above c. Age 70 and above d. Age 75 and above ANS: B
Older adulthood begins at about age 65. DIF: Cognitive Level: Knowledge REF: 1060 OBJ: 1 TOP: Aging KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. When the nurse discusses prevention of cardiac disease, falls, and depression with a group
of older adults, the benefits of what are important to stress? a. Nutrition b. Medications c. Exercise d. Sleep ANS: C
Primary prevention stresses exercise for the prevention of cardiac disease, falls, and depression. DIF: Cognitive Level: Comprehension REF: 1061 OBJ: 1 TOP: Health promotion KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. When was the Social Security Act, which was the first major legislation providing
financial security for older adults, passed? a. 1930 b. 1935 c. 1940 d. 1945 ANS: B
The first major legislation to provide financial security for older adults was the Social Security Act of 1935. DIF: Cognitive Level: Knowledge REF: 1064 OBJ: 1 TOP: Legislation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 4. When assessing the skin of an older adult patient who is complaining of pruritus, what
should the nurse advise the patient to avoid to reduce further drying of her skin? a. Perfumed soap
b. Hard-milled soap c. Antibacterial soap d. Lotion soap ANS: C
Antibacterial soap is very drying. DIF: Cognitive Level: Application TOP: Integumentary alterations MSC: NCLEX: Physiological Integrity
REF: 1067 OBJ: 8 KEY: Nursing Process Step: Implementation
5. Because thin skin and lack of subcutaneous fat predisposes the older adult to pressure
injuries, the nurse alters the care plan to include turning the bedfast patient how often? a. Once every shift b. Every 4 hours c. Each evening d. Every 2 hours ANS: D
Pressure injuries can be avoided by repositioning the patient every 2 hours. DIF: Cognitive Level: Application REF: 1067 OBJ: 8 TOP: Integumentary alterations KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 6. At mealtime, the older adult seems to be eating less food than would be adequate.
Compared to the younger adult, what is a requirement for the older adult? a. More fluids b. Less calcium c. Fewer calories d. More vitamins ANS: C
The older adult requires 30 calories per kilogram of body weight, whereas the younger adult requires 40 calories. DIF: Cognitive Level: Application REF: 1069 OBJ: 5 TOP: Gastrointestinal alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 7. The older patient informs the nurse that food has no taste and therefore the patient has no
appetite. What is this most likely caused by? a. Tasteless food b. Overuse of salt c. Lack of variety d. Loss of taste buds ANS: D
Older adults may experience a loss of appetite. Change in taste as a result of decreased saliva production and a decreased number of taste buds may make food unappealing. DIF: Cognitive Level: Application TOP: Gastrointestinal alterations
REF: 1070 OBJ: 5 KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 8. An older adult is having difficulty swallowing. What position should the nurse recommend
to aid in swallowing? a. Chin parallel b. Chin upward c. Chin down d. Chin to the side ANS: C
The upright position, leaning slightly forward with the chin down, improves swallowing with the assistance of gravity. DIF: Cognitive Level: Application TOP: Gastrointestinal alterations MSC: NCLEX: Physiological Integrity
REF: 1071 OBJ: 8 KEY: Nursing Process Step: Implementation
9. The patient complains to the nurse about a newly developed intolerance to milk. What
should the nurse suggest to fulfill calcium needs? a. Rye bread b. Yogurt c. Apples d. Raisins ANS: B
Lactose, primarily found in milk, is a common source of food intolerance. Dairy products are an important source of calcium, which is needed to prevent osteoporosis. Lactose-intolerant individuals need to replace milk with cheese and yogurt, which are processed and digested more easily. DIF: Cognitive Level: Application TOP: Gastrointestinal alterations MSC: NCLEX: Physiological Integrity
REF: 1070 OBJ: 8 KEY: Nursing Process Step: Implementation
10. The older adult patient complains to the nurse about nocturia. This problem is most likely
related to: a. loss of bladder tone. b. decrease in testosterone. c. decrease in bladder capacity. d. intake of caffeine. ANS: C
At least 50% of older men and 70% of older women must get up two or more times during the night to empty their bladders, a condition known as nocturia (excessive urination at night). The most significant age-related change is the decrease in bladder capacity. DIF: Cognitive Level: Application REF: 1073 TOP: Incontinence KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
11. The older adult female patient is concerned about incontinence when she sneezes. What is
the correct terminology for this type of incontinence?
a. b. c. d.
Urge incontinence Stress incontinence Overflow incontinence Functional incontinence
ANS: B
Stress incontinence results from increased abdominal pressure, which occurs with coughing or sneezing. Urge incontinence occurs after a sudden urge to void and is associated with cystitis, tumors, stones, and CNS disorders. Overflow incontinence is associated with diabetic neuropathy and spinal cord injuries. Functional incontinence results from unwillingness or inability to get to the toilet. DIF: Cognitive Level: Comprehension REF: 1073 OBJ: 5 TOP: Incontinence KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. A change of aging related to the circulatory system includes decreased blood vessel
elasticity. For what should the nurse assess? a. Confusion b. Tachycardia c. Hypertension d. Retained secretions ANS: C
The blood vessels become less elastic because of aging and may lead to increased blood pressure. DIF: Cognitive Level: Application TOP: Circulatory alterations MSC: NCLEX: Physiological Integrity
REF: 1074 OBJ: 5 KEY: Nursing Process Step: Assessment
13. What should be suggested to a patient to aid with the pain of claudication? a. Rest b. Exercise c. Cross legs d. Stand ANS: A
A nursing intervention to relieve pain is to recommend the patient rest periodically until the pain subsides. Exercise and standing for long periods of time can exacerbate the pain. Crossing the legs can limit blood flow to the extremities and increase pain. DIF: Cognitive Level: Application TOP: Circulatory alterations MSC: NCLEX: Physiological Integrity
REF: 1075-1076 OBJ: 8 KEY: Nursing Process Step: Implementation
14. The nurse recommends a breathing technique to help a patient with chronic obstructive
pulmonary disease (COPD) to empty the lungs of used air and to promote inhalation of adequate oxygen. What is this method of breathing called? a. Pursed-lip breathing b. Increased inspiration c. Vital capacity
d. Decreased expiration ANS: A
Pursed-lip breathing can help empty the lungs of used air and promote inhalation of additional oxygen. DIF: Cognitive Level: Comprehension REF: 1077 TOP: Chronic obstructive pulmonary disease (COPD) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 8
15. The nurse reminds the 80-year-old patient that her respiratory system has decreased
resistance to respiratory infections. For what is this patient at increased risk? a. COPD b. Bronchitis c. Pneumonia d. Atelectasis ANS: C
Decreased resistance to respiratory infections places older adults at higher risk for pneumonia. DIF: Cognitive Level: Application TOP: Respiratory alterations MSC: NCLEX: Physiological Integrity
REF: 1077 OBJ: 5 KEY: Nursing Process Step: Assessment
16. The nurse recognizes that an older adult patient with COPD has a higher incidence of
developing which age-related skeletal change that will alter the ability to exchange air effectively? a. Osteoporosis b. Arthritis c. Kyphosis d. Osteomyelitis ANS: C
Kyphosis, usually caused by osteoporosis, is a curvature of the spine that alters respiration and air exchange. DIF: Cognitive Level: Application TOP: Musculoskeletal alterations MSC: NCLEX: Physiological Integrity
REF: 1076 OBJ: 5 KEY: Nursing Process Step: Assessment
17. What is a major difference between rheumatoid arthritis and osteoarthritis? a. Rheumatoid arthritis is degenerative. b. Rheumatoid arthritis only affects patients over 40 years of age. c. Rheumatoid arthritis is inflammatory. d. Rheumatoid arthritis is curable. ANS: C
Rheumatoid arthritis is an inflammatory disease; osteoarthritis is degenerative. Rheumatoid arthritis can affect patients at any age. Neither type of arthritis is curable. DIF: Cognitive Level: Application
REF: 1078-1079
OBJ: 5
TOP: Arthritis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. For what is the older adult patient at increased risk because of age-related changes in the
musculoskeletal system? a. Fractures due to poor uptake of calcium b. Heart attacks due to increased effort to ambulate c. Respiratory failure due to kyphosis d. Falls related to posture changes ANS: D
Falls are the leading cause of accidental death in individuals over 65, in part because of posture changes brought on by aging. DIF: Cognitive Level: Analysis REF: 1091 OBJ: 7 TOP: Musculoskeletal alterations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 19. The nurse is assisting an older adult patient out of bed when suddenly the patient begins to
fall. What is the likely cause of the fall? a. Fever b. Orthostatic hypotension c. Dehydration d. A decrease in venous return ANS: B
Orthostatic hypotension occurs when the patient changes position. In the older adult, the loss of elasticity in the vessels slows the vascular accommodation to sudden postural changes to a standing position. DIF: Cognitive Level: Application TOP: Musculoskeletal alterations MSC: NCLEX: Physiological Integrity
REF: 1091 OBJ: 10 KEY: Nursing Process Step: Implementation
20. To help prevent falls related to muscle weakness, what type of exercises should be selected
for the aging patient? a. Daily b. Running c. Weight-bearing d. Aerobic ANS: C
Appropriate interventions to increase muscle strength begin with weight-bearing exercises. They do not have to be done daily to be effective. Running and aerobic exercise would not be appropriate or effective for the aging patient. DIF: Cognitive Level: Application TOP: Musculoskeletal alterations MSC: NCLEX: Physiological Integrity
REF: 1080 OBJ: 8 KEY: Nursing Process Step: Implementation
21. What is the best test to identify the risk of osteoporosis in postmenopausal women? a. Skeletal x-ray
b. Bone density scan c. Calcium blood level d. CAT scan ANS: B
Bone density testing can identify women at risk for fractures. DIF: Cognitive Level: Comprehension TOP: Osteoporosis MSC: NCLEX: Physiological Integrity
REF: 1080 OBJ: 5 KEY: Nursing Process Step: Implementation
22. When an older female patient complains of painful sexual intercourse, what should the
nurse recognize as the probable cause? a. Urinary incontinence b. Arthritic joints c. Kyphosis d. Mucosal drying ANS: D
Sexual intercourse may be uncomfortable because of drying of the mucosa of the vagina. DIF: Cognitive Level: Application TOP: Reproductive alterations MSC: NCLEX: Physiological Integrity
REF: 1082 | 1083 OBJ: 5 KEY: Nursing Process Step: Implementation
23. What is age-related vision change caused by the loss of elasticity of the lens called? a. Nearsightedness b. Cataracts c. Presbyopia d. Blepharitis ANS: C
Age-related changes include presbyopia and farsightedness resulting from a loss of elasticity of the lens. Cataracts are due to opacity of the lens. DIF: Cognitive Level: Comprehension TOP: Sensory alterations MSC: NCLEX: Physiological Integrity
REF: 1084 OBJ: 5 KEY: Nursing Process Step: Assessment
24. When communicating with an older adult patient who has difficulty hearing, how should
the nurse change her speech? a. Speak very loudly b. Speak rapidly c. Lower the tone of the voice d. Raise the tone of the voice ANS: C
To communicate with a patient with a hearing loss, the nurse should lower the tone of the voice. DIF: Cognitive Level: Application TOP: Sensory alterations MSC: NCLEX: Physiological Integrity
REF: 1086 OBJ: 8 KEY: Nursing Process Step: Implementation
25. Which symptom of diabetes distorts tactile sensation? a. Proprioception b. Loss of visual acuity c. Progressive paresis d. Peripheral neuropathy ANS: D
Peripheral neuropathy is the presence of abnormal sensation and it distorts tactile sensation. DIF: Cognitive Level: Comprehension REF: 1085 TOP: Diabetes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
26. What is the result of a slowing of the impulse transmission in the nervous system? a. Hypertension b. Hearing deficit c. Decrease in tactile sensations d. Longer reaction time ANS: D
When nerve impulses in the nervous system of an older adult slow down, the result is a longer reaction time. DIF: Cognitive Level: Application TOP: Neurologic alterations MSC: NCLEX: Physiological Integrity
REF: 1086 OBJ: 5 KEY: Nursing Process Step: Assessment
27. What is the most common cause of dementia? a. Multi infarct b. Medications c. Alzheimer’s disease d. Parkinson disease ANS: C
Alzheimer’s disease is the most common cause of dementia. DIF: Cognitive Level: Knowledge REF: 1088 TOP: Dementia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 9
28. What is one positive aspect of Parkinson disease? a. The disease does not alter ability to communicate. b. Anti-Parkinson drugs have few side effects. c. Intellectual function is not impaired. d. Involuntary movements can be controlled. ANS: C
Parkinson disease does not impair the intellect. The disease does alter the ability to communicate. Anti-Parkinson drugs have many side effects. The involuntary movements associated with the disease cannot be controlled.
DIF: Cognitive Level: Application TOP: Parkinson disease MSC: NCLEX: Physiological Integrity
REF: 1090 OBJ: 4 KEY: Nursing Process Step: Assessment
29. When should family members of a stroke victim expect to see some of the neurologic
involvement disappear? a. Within 2 to 3 weeks b. Within 1 to 2 months c. Within 3 to 6 months d. Within 6 to 9 months ANS: C
Some of the initial neurologic deficits of a cerebrovascular accident may disappear in 3 to 6 months. DIF: Cognitive Level: Application REF: 1090 TOP: Stroke KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
30. When communicating with an older adult patient, the nurse becomes aware of the fact that
the patient is well satisfied with his accomplishments over a lifetime and has no regrets concerning aging. Which of Erikson’s developmental stages has the patient achieved? a. Acceptance b. Withdrawal c. Ego integrity d. Interaction ANS: C
The last stage of life is acceptance of life and it results in ego integrity. DIF: Cognitive Level: Analysis REF: 1064 TOP: Aging KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 3
31. Which areas are affected only minimally by age? a. Physical activity b. Productivity c. Cognition d. Sexuality ANS: C
Aging has little influence on cognition. Only through disease processes is cognition altered. DIF: Cognitive Level: Comprehension REF: 1086 OBJ: 5 TOP: Aging KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 32. How often does a 76-year-old need a screening for preventive health? a. Every 2 years b. Every 6 months
c. Every 3 years d. Every year ANS: D
A complete physical is recommended annually after 75. DIF: Cognitive Level: Comprehension REF: 1062 OBJ: 6 TOP: Health promotion KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 33. When assessing the older adult, the nurse considers which aspect of the patient’s routine as
a possible contributor to constipation? a. Intake of antacids several times a day b. Taking a laxative once a week c. Excessive exercise routine d. Eating two apples a day ANS: A
Intake of antacids is constipating. All other options decrease the risk of constipation. DIF: Cognitive Level: Analysis REF: 1071 TOP: Constipation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 8
MULTIPLE RESPONSE 1. What should the nurse do to help the dysphagic patient? (Select all that apply.) a. Sit the patient upright. b. Reduce distraction during mealtime. c. Offer fluid from a straw. d. Thicken liquids. e. Cue the patient to swallow. ANS: A, B, D, E
Offering fluids using a straw increases the possibility of choking or aspiration. All other options would be beneficial to the dysphagic patient. DIF: Cognitive Level: Application TOP: Gastrointestinal alterations MSC: NCLEX: Physiological Integrity
REF: 1071 OBJ: 8 KEY: Nursing Process Step: Implementation
2. Which statements are myths that have been disproved concerning aging? (Select all that
apply.) a. All older adults are senile. b. Most older adults live in their own homes. c. Older adults are poor. d. Older adults have frequent contact with family members. e. Older adults are disabled. ANS: A, C, E
All older adults are not senile; this is a myth. Mental decline is not inevitable. Older adults are not all poor; this is a myth. Older adults have a lower poverty rate than younger adults. Older adults are not all disabled; this is a myth. Most are able to manage their own care. Most older adults do live in their own homes and have frequent contact with family members. DIF: Cognitive Level: Comprehension REF: 1064 OBJ: 2 TOP: Aging myths KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. Which approaches should be included when teaching medication safety to an older,
homebound adult? (Select all that apply.) a. Always dispose of expired medications in the toilet or the sink; never throw them in the trash can. b. Never share medications with others. c. If a medication is not finished as prescribed, save it for future use. d. Keep medications in their original containers. e. Always request childproof containers, even if the patient has trouble opening the lids. ANS: A, B, D
Expired medications should always be disposed of in the toilet or sink; they should never be thrown in the trash where they could be retrieved by others. Medications should never be shared with anyone else. Medications should always be stored in their original containers. A prescription should always be taken as prescribed by the health care provider. Medications should never be saved for future use. If an older adult has trouble opening childproof medication containers, he should request non-childproof lids. DIF: Cognitive Level: Application REF: 1093 OBJ: 8 TOP: Medication practices KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1. When bathing an 80-year-old woman who lives on a farm, the nurse assesses brown
macules on the patient’s hands and forearms. The nurse recognizes these as
.
ANS:
lentigo Lentigo is a term that refers to brown-pigmented lesions on the skin of the older person who has spent a great deal of time in the sun. These macules are also called “age spots.” DIF: Cognitive Level: Comprehension TOP: Integumentary alterations MSC: NCLEX: Physiological Integrity
REF: 1066 OBJ: 5 KEY: Nursing Process Step: Assessment
2. The nurse initiates the application of a draw sheet on every bedfast patient on her unit to
facilitate lifting and to prevent ANS:
forces.
shearing Shearing forces cause skin damage by friction; for instance, when a patient is dragged across bed linens during a position change. DIF: Cognitive Level: Knowledge TOP: Integumentary alterations MSC: NCLEX: Physiological Integrity
REF: 1067 OBJ: 8 KEY: Nursing Process Step: Planning
3. The nurse recognizes that a term referring to mechanical difficulty of swallowing is
. ANS:
dysphagia Dysphagia is a term that refers to mechanical difficulties in swallowing. DIF: Cognitive Level: Knowledge TOP: Gastrointestinal alterations MSC: NCLEX: Physiological Integrity
REF: 1071 OBJ: 5 KEY: Nursing Process Step: Implementation
Chapter 34: Concepts of Mental Health Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. What is the mental health nurse referring to when using the term behavior? a. An isolated incident b. The manner in which a person performs c. A product of a coping strategy d. Failure to adapt ANS: B
Behavior may be defined as the manner in which a person performs any or all of the activities of daily living. DIF: Cognitive Level: Knowledge TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1100 OBJ: 1 KEY: Nursing Process Step: Implementation
2. What definition should the nurse use to clarify the concept of “mental health”? a. A wellness of attitude b. A person’s response to disease and dysfunction c. The ability to cope and adjust to everyday stresses d. How the person performs activities of daily living ANS: C
Mental health can be defined as a person’s ability to cope and adjust to everyday stresses. DIF: Cognitive Level: Comprehension TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1100 OBJ: 1 KEY: Nursing Process Step: Assessment
3. How should the nurse document the behavior of a patient with mental illness? a. Very disruptive to a person in society b. Differing from socially acceptable behavior c. Causing the person to be involved in problems d. Resulting from an inability to exercise control ANS: B
Mental illness can cause behavior that deviates from socially and culturally acceptable behavior. DIF: Cognitive Level: Analysis TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1101 OBJ: 2 KEY: Nursing Process Step: Assessment
4. How many people in the United States will develop a mental disorder during their
lifetime? a. One in two b. One in five c. One in eight
d. One in ten ANS: A
It is estimated that 50% of people in the United States will develop a mental disorder during their lifetime. DIF: Cognitive Level: Comprehension TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1101 OBJ: 2 KEY: Nursing Process Step: Assessment
5. During the 17th and 18th centuries, care of patients with mental illness often was cruel.
What type of care was used by Dr. Philippe Pinel to bring about change? a. Personal care b. Individual care c. Behavior care d. Humane care ANS: D
Dr. Philippe Pinel advocated humane care. DIF: Cognitive Level: Comprehension TOP: Mental health MSC: NCLEX: N/A
REF: 1102 OBJ: 1 KEY: Nursing Process Step: N/A
6. When was psychiatric training for nurses initially offered? a. 1852 b. 1882 c. 1902 d. 1922 ANS: B
In 1882, McLean Hospital in Waverly, Massachusetts, provided the first psychiatric training school for nurses. DIF: Cognitive Level: Knowledge TOP: Mental health MSC: NCLEX: N/A
REF: 1102 OBJ: 1 KEY: Nursing Process Step: N/A
7. Using the mental health continuum as a guide, the nurse observes behavior that usually
places an individual on the illness end of the continuum. What is true of this behavior? a. It causes extreme concern about health. b. It results in inability to function in society. c. It demonstrates that the person is out of touch with reality. d. It results in inability to interact with people. ANS: C
On the illness end of the mental health continuum, the person is rarely in touch with reality. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1103 OBJ: 1 KEY: Nursing Process Step: Assessment
8. The majority of people function in a relatively healthy manner. What can diminish their
functional capacity? a. Lack of a support system b. Periods of crisis c. Nutritional deficits d. A physical disease process ANS: B
Periods of crisis can decrease functional capacity, moving a person toward the illness end of the continuum. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: N/A
REF: 1103 OBJ: 1 KEY: Nursing Process Step: N/A
9. What is the basis for classifying a person as having a mental illness? a. Behavior exhibited and the context b. Response of society to the behavior c. Ability of the patient to conform d. Patient’s history and previous behavior ANS: A
A person is deemed to be mentally ill by the behavior exhibited and the context in which that behavior occurs. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: N/A
REF: 1104 OBJ: 2 KEY: Nursing Process Step: N/A
10. Using Freud’s personality theory, what action by a patient identifies the influence of the
superego? a. Eating an entire chocolate pie b. Becoming anxious about having no visitors c. Monopolizing the attention of the health care provider d. Returning a $5 bill that another patient left on the table ANS: D
The superego is the mediator between right and wrong (the conscience). DIF: Cognitive Level: Analysis TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1104 OBJ: 3 KEY: Nursing Process Step: Assessment
11. Using Freud’s personality theory, what action by a patient indicates a strong ego? a. Laughs at himself for being foolish. b. Continually boasts of his accomplishments. c. Apologizes continually. d. Insists that the TV channel stay tuned to CNN. ANS: A
Ego is the reality tester. Laughing at oneself shows that the patient can compare his own foolish behavior to the norm.
DIF: Cognitive Level: Analysis TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1104 OBJ: 3 KEY: Nursing Process Step: Assessment
12. Which theorist believed that personality development was based on task mastery? a. Sigmund Freud b. Erik Erikson c. Jean Piaget d. Friedrich Nietzsche ANS: B
Erik Erikson provided a framework for understanding personality development in terms of task mastery. Sigmund Freud described personality development as having three parts: id, ego, and superego. Jean Piaget theorized that development was based on how humans acquire and utilize knowledge. Friedrich Nietzsche’s theories had more to do with morality than personality development. DIF: Cognitive Level: Comprehension TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1104 OBJ: 2 KEY: Nursing Process Step: N/A
13. Which role is an example of an ascribed role? a. Sex b. Occupation c. Manner of dealing with stress d. Attitude toward homosexuality ANS: A
Ascribed roles are those that a person takes on, but had no personal choice in the matter. Ethnicity, sex, and nationality are examples of ascribed roles. DIF: Cognitive Level: Comprehension TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1105 OBJ: 3 KEY: Nursing Process Step: Implementation
14. The nurse is assessing a young woman who is a teacher, happily married, raising two
children, taking care of her disabled mother, and going to school to get a master’s degree. How should the behavior of the young woman be classified? a. Ego-centered b. Role integrated c. High-level wellness d. Unbounded energy ANS: B
Role integration is performing several ascribed roles at the same time. DIF: Cognitive Level: Analysis TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1105 OBJ: 3 KEY: Nursing Process Step: Assessment
15. What action consistently done by a patient should indicate to a nurse that the patient has a
poor self-concept? a. Wears bright-colored clothing. b. Demands the attention of staff. c. Apologizes to others repeatedly. d. Becomes angry when frustrated. ANS: C
Apologizing repeatedly is indicative of self-effacement. Anger, demanding attention, and wearing attention-getting clothing are not characteristics of a poor self-concept. DIF: Cognitive Level: Analysis TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1103 | 1104 OBJ: 2 KEY: Nursing Process Step: Assessment
16. What does any event that requires change stimulate? a. Anger b. Depression c. Stress d. Anxiety ANS: C
Any event that requires change leads to stress, which is the nonspecific response of the body to any demand. DIF: Cognitive Level: Comprehension TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1105 OBJ: 7 KEY: Nursing Process Step: Assessment
17. A nurse tearfully confides to the head nurse that being assigned to care for eight patients is
stressful and overwhelming. What demonstrates the use of a healthy coping mechanism? a. Writing down long lists of needed interventions before starting the day’s work b. Delegating appropriate care assignments to unlicensed assistive personnel c. Asking a coworker to take one of her patients d. Asking for the day off ANS: B
The use of delegation is an effective coping mechanism. The other options are not healthy as they either delay or avoid dealing with the stress. DIF: Cognitive Level: Analysis TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1105 | 1106 OBJ: 2 KEY: Nursing Process Step: Assessment
18. A perceived threat to self causes what emotion? a. Fear b. Anger c. Depression d. Anxiety ANS: D
Anxiety can be defined as a vague feeling of apprehension resulting from a perceived threat to self. DIF: Cognitive Level: Knowledge TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1105 OBJ: 7 KEY: Nursing Process Step: Implementation
19. What action by a student before taking a test should indicate to a nursing instructor that the
student is demonstrating signs of moderate anxiety? a. Studies for 6 hours b. Sleeps 6 hours because of fatigue c. Vomits d. Argues about the scheduling of the test ANS: C
Symptoms of anxiety include the following: vocal changes, rapid speech, increased pulse, respirations, and blood pressure, tremors, restlessness, increased perspiration, nausea, decreased appetite, diarrhea, frequent urination, and vomiting. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1105 OBJ: 7 KEY: Nursing Process Step: Assessment
20. What coping mechanism demonstrated by a patient should indicate to the nurse that the
patient is seeking ways to deal with and resolve stress? a. Projection b. Adaptation c. Reaction formation d. Compensation ANS: B
An individual who develops ways to deal with stress and resolve it has adapted. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1106 OBJ: 9 KEY: Nursing Process Step: Assessment
21. A 40-year-old patient cries and has a tantrum when the health care provider refuses to give
her a prescription for diet pills. The nurse realizes that this is the use of which defense mechanism? a. Compensation b. Denial c. Regression d. Repression ANS: C
Regression is a behavior that reflects the return to an earlier form of coping. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1107 OBJ: 6 KEY: Nursing Process Step: Assessment
22. When the patient who overeats insists that weight gain is related to retained fluids, the
nurse recognizes the patient is using which defense mechanism? a. Compensation b. Rationalization c. Sublimation d. Regression ANS: B
Defense mechanisms are unconscious reactions that offer protection to the self from stressful situations. Rationalization offers a reasonable explanation for an event rather than facing reality. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1106 OBJ: 6 KEY: Nursing Process Step: Assessment
23. After finding the patient with diabetes eating candy, the nurse reminds the patient that the
candy will elevate blood sugar levels. The patient’s response is: “It’s only a little bit, and it won’t do anything.” Which defense mechanism is the patient using? a. Conversion b. Denial c. Repression d. Regression ANS: B
The patient is using denial as a defense mechanism. Reality is denied. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1107 | 1109 OBJ: 6 KEY: Nursing Process Step: Assessment
24. The patient complains to the nurse that the health care provider does not like him and
wants him to fail at following the diet prescribed. The nurse recognizes that the patient is using which defense mechanism? a. Conversion b. Projection c. Introjection d. Repression ANS: B
Projection is attributing to other’s characteristics that the person does not want to acknowledge. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1107 OBJ: 6 KEY: Nursing Process Step: Assessment
25. The nurse is sensitive to the fact that patients lose control over their lives when admitted to
the hospital. In what does this loss of control frequently result? a. Anger b. Depression c. Fear
d. Anxiety ANS: D
Loss of control may result in feelings of apprehension and uncertainty. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1106 OBJ: 5 KEY: Nursing Process Step: Assessment
26. The patient admitted to the hospital may adjust to illness by assuming a role in which
everyday responsibilities are avoided. What is this role called? a. Patient role b. Illness role c. Sick role d. Dependent role ANS: C
The sick role allows the patient to be excused from everyday responsibilities. DIF: Cognitive Level: Comprehension TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1108 OBJ: 8 KEY: Nursing Process Step: Assessment
27. Why is it important for the nurse to be observant of patient behavior? a. Behavior is preformed. b. Behavior is important. c. Behavior is learned. d. Behavior is repeated. ANS: C
Behavior is learned and has meaning. DIF: Cognitive Level: Comprehension TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1109 OBJ: 9 KEY: Nursing Process Step: Assessment
28. What is a nursing intervention that helps to build trust, encourages the patient to have faith
in the care being received, and meets psychosocial needs? a. Developing a care plan b. Implementing nurse orders c. Patient education d. Meeting patient goals ANS: C
One of the steps to meet the psychosocial needs of the patient is patient education. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1108 OBJ: 10 KEY: Nursing Process Step: Implementation
29. A family is informed that the brain damage to their daughter is irreversible. The father is
later overheard making vacation plans and discussing what the family will do when his daughter leaves the hospital. The nurse recognizes the father is in which crisis stage?
a. b. c. d.
High anxiety Denial Reconciliation Adaptation
ANS: B
The father is exhibiting signs of denial. Once the reality of the situation becomes evident, anger and confusion follow. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1107 | 1109 OBJ: 9 KEY: Nursing Process Step: Assessment
30. When developing a care plan for a mentally ill patient, what should the nurse assess first? a. Coping strategies b. Emotional status c. Medications taken d. Nutritional status ANS: B
The nurse’s first priority would be to assess the emotional status of the mentally ill patient. DIF: Cognitive Level: Comprehension TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1110 OBJ: 9 KEY: Nursing Process Step: Assessment
31. When the patient is told that his insurance will no longer pay for his physical therapy, the
nurse is aware that this obstruction to his goal may result in which concept? a. Conflict b. Adaptation c. Frustration d. Anxiety ANS: C
Frustration refers to anything that interferes with goal-directed activity. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1106 OBJ: 9 KEY: Nursing Process Step: Assessment
32. What is the most likely result when an attempt at adaptation fails? a. Depression b. Anger c. Frustration d. Anxiety ANS: D
When adaptive behavior fails, anxiety increases. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1106 OBJ: 5 KEY: Nursing Process Step: Assessment
33. The nurse is assessing a nervous 18-year-old patient who has vital signs of P 120, R 30,
and BP 160/90. The patient states that he feels something bad is about to happen. Based on this data alone, how should the nurse identify the patient’s level of anxiety? a. Mild b. Moderate c. Severe d. Panic ANS: C
Severe anxiety may be manifested by elevated blood pressure, pulse, and respiratory rate, a feeling of impending danger, and feelings of fatigue. DIF: Cognitive Level: Analysis TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1105 OBJ: 9 KEY: Nursing Process Step: Assessment
34. When assisting the older adult who is despondent about the need to leave his home, what
technique should the nurse use? a. Ask him if he has a drinking problem. b. Explore the option of his moving in with someone. c. Reminisce with the patient and review his life. d. Assess for hopelessness and helplessness. ANS: C
Reminiscence and life review are effective techniques to help older adults deal with changing life circumstances. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1108 OBJ: 10 KEY: Nursing Process Step: Assessment
35. A patient admitted to the hospital after a motorcycle crash that has left him paralyzed from
the waist down tells the nurse he has feelings of helplessness and hopelessness. What other feelings may the patient have that should be recognized? a. Isolation b. Suicidal ideation c. Fear d. Anger ANS: B
Hopelessness and helplessness can lead to possible thoughts of suicide. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1108 OBJ: 9 KEY: Nursing Process Step: Assessment
36. Which event in the mental health care movement occurred first? a. Establishment of Pennsylvania Hospital b. Deinstitutionalization movement c. Formation of Committee for Mental Health d. Passage of Omnibus Budget Reconciliation Act (OBRA) e. Dorothea Dix awakens public awareness of plight of mentally ill
ANS: A
Pennsylvania Hospital—1731, Dorothea Dix—1882, Committee for Mental Health—1909, deinstitutionalization movement—1960, OBRA—1981. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: N/A
REF: 1102 OBJ: 1 KEY: Nursing Process Step: N/A
MULTIPLE RESPONSE 1. The nurse uses a diagram to show how the four parts of “self” fit together. What are the
four parts? (Select all that apply.) a. Body image b. Ego c. Self-esteem d. Role e. Identity ANS: A, C, D, E
The four parts of the “self” are body image, self-esteem, role, and identity. DIF: Cognitive Level: Comprehension TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1104 OBJ: 3 KEY: Nursing Process Step: Implementation
2. A variety of factors influence the level of anxiety experienced by the patient faced by a
stressful situation. Which would the nurse outline? (Select all that apply.) a. How others perceive the event b. The number of stressors present at one time c. Degree of change the stressors require d. Present role assumption e. Previous experience with a similar situation ANS: B, C, D, E
The number of stressors present at one time, the degree of change the stressors require, present role assumption, and previous experience with a similar situation are all factors that can influence the level of anxiety experienced when faced with a stressful situation. The level of anxiety experienced is also influenced by how the event is perceived by the individual, not how the event is perceived by others. DIF: Cognitive Level: Analysis TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1106 OBJ: 7 KEY: Nursing Process Step: Implementation
COMPLETION 1. The situation in which a parent must choose between attending a daughter’s ballet recital
or a son’s baseball game is an example of a ANS:
.
conflict Conflict occurs when there is a presence of simultaneous goals, only one of which can be met. DIF: Cognitive Level: Application TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1106 OBJ: 7 KEY: Nursing Process Step: Implementation
2. In the movie Gone With the Wind, Scarlett O’Hara says, “I’ll think about that tomorrow.
Tomorrow is another day.” The nurse recognizes the defense mechanism of ANS:
repression Repression is an unconscious barring of anxiety-producing thoughts. DIF: Cognitive Level: Comprehension TOP: Mental health MSC: NCLEX: Psychosocial Integrity
REF: 1107 OBJ: 6 KEY: Nursing Process Step: Assessment
.
Chapter 35: Care of the Patient With a Psychiatric Disorder Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse is discussing the differences between a patient with a neurosis and one with a
psychosis. What is true of the patient experiencing a neurosis? a. The patient experiences a flight from reality. b. The patient usually needs hospitalization. c. The patient has insight that there is an emotional problem. d. The patient has severe personality deterioration. ANS: C
An individual with a neurosis has insight that he has an emotional problem. A person with psychosis is out of touch with reality and has severe personality deterioration. Treatment for neurosis is usually completed in the outpatient setting, while treatment for psychosis often requires hospitalization. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1113 OBJ: 2 KEY: Nursing Process Step: Assessment
2. When the patient with a psychosis is thought to be a danger to self or others, by what
method should the patient be admitted to the hospital? a. Probating b. Nurse’s request c. Health care provider’s order d. Family request ANS: A
Probating can be done if the individual is thought to be a danger to self or others. DIF: Cognitive Level: Comprehension TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1113 OBJ: 4 KEY: Nursing Process Step: Implementation
3. The Diagnostic and Statistical Manual of Psychiatric Disorders, V (DSM-V), is used by
most hospitals and is the current tool used to examine mental health and illness. What approach does the DSM-V use to classify mental disorders? a. Holistic system b. Hierarchical system c. Multiaxial system d. Evaluation system ANS: C
The DSM-V is a multiaxial system. DIF: Cognitive Level: Comprehension TOP: Mental illness MSC: NCLEX: N/A
REF: 1113 OBJ: 1 KEY: Nursing Process Step: N/A
4. When all five axes of the Diagnostic and Statistical Manual of Psychiatric Disorders, V,
are used, it provides what type of assessment approach to comprehensive care? a. Personalized b. Individualized c. Holistic d. Organic ANS: C
Using all five axes of the DSM-V provides a holistic assessment. DIF: Cognitive Level: Comprehension TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: NIT OBJ: 1 KEY: Nursing Process Step: Assessment
5. A young man with malaria spikes a temperature of 105°F (40.5°C) and begins to
hallucinate. How should the nurse assess this? a. Delirium b. Psychotic break c. Possible stroke d. Anxiety disorder ANS: A
Delirium is an organic mental disorder that is frequently brought on by a severe physical illness, such as fever. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1114 OBJ: 2 KEY: Nursing Process Step: Assessment
6. A patient admitted for delirium demonstrates increased disorientation and agitation only
during the evening and nighttime. What is the term applied to this type of delirium? a. Disordered thinking b. Schizophrenia c. Dementia d. Sundowning syndrome ANS: D
A patient with sundowning syndrome displays increased disorientation and agitation only during evening and nighttime. Disordered thinking occurs when an individual is not able to interpret information being received in the brain. Disordered thinking is one characteristic of schizophrenia, which is a large group of psychotic disorders that includes nonreality-based thinking. Dementia is an altered mental state secondary to cerebral disease. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1114 OBJ: 2 KEY: Nursing Process Step: Assessment
7. Dementia is an organic mental disease secondary to what problem? a. Chemical imbalance b. Emotional problems c. Circulatory impairment
d. Cerebral disease ANS: D
Dementia describes an altered mental state secondary to cerebral disease. DIF: Cognitive Level: Knowledge TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1114 OBJ: 2 KEY: Nursing Process Step: Implementation
8. A profound, disabling mental illness is characterized by bizarre, nonreality thinking. What
is the illness? a. Manic depressive b. Schizophrenia c. Paranoia d. Bipolar ANS: B
Schizophrenia, a thought process disorder, is one of the most profoundly disabling mental illnesses. DIF: Cognitive Level: Knowledge TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1114 OBJ: 2 KEY: Nursing Process Step: Implementation
9. A patient believes himself to be the president of the United States and that terrorists are
trying to kidnap him. The nurse records these observations as which type of behavior? a. Absent behavior b. Positive behavior c. Negative behavior d. False behavior ANS: B
The behaviors of schizophrenic individuals can be categorized as positive (or excessive) or negative (or absent). Examples of positive behaviors include hallucinations, delusions, and disordered thinking. Examples of negative behaviors include apathy, social withdrawal, and flat affect. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1114 OBJ: 2 KEY: Nursing Process Step: Assessment
10. The patient talks with his dead brother and arranges furniture so that his brother will have
a place to sit. How should the nurse document this behavior? a. Disordered thinking b. Anhedonia c. Hallucination d. Alogia ANS: C
A hallucination is a sensory experience without a stimulus trigger. Disordered thinking occurs when the individual is not able to interpret information being received in the brain. Anhedonia describes lack of expressed feelings. Alogia is reduced content of speech.
DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1120 OBJ: 2 KEY: Nursing Process Step: Assessment
11. What is the prognosis for a schizophrenic patient who is exhibiting positive behaviors? a. Guarded b. Poor c. Good d. Repeatable ANS: C
Prognosis for schizophrenic patients who are exhibiting positive behavior patterns is good. DIF: Cognitive Level: Comprehension TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1114 OBJ: 2 KEY: Nursing Process Step: Assessment
12. The nurse cautions a patient to watch his step. What response indicates concrete thinking? a. The patient fixedly begins to watch his feet. b. The patient immediately examines his watch. c. The patient begins to watch the nurse’s feet. d. The patient stands rigidly in one place without moving. ANS: A
Concreteness is an indication of disordered thinking. The patient is unable to translate any words except by a very concrete definition. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1120 OBJ: 2 KEY: Nursing Process Step: Assessment
13. The nurse asks a patient with schizophrenia if he had any visitors on Sunday. Which
response indicates loose association? a. “No.” b. “Yes! I had 90 visitors who came from every state in the union.” c. “Sunday is the Sabbath. Do we have visitors on the Sabbath?” d. “We visited Yellowstone Park last summer.” ANS: D
Loose association is a type of disordered thinking that occurs when the individual cannot interpret information and the conversation does not flow. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1120 OBJ: 2 KEY: Nursing Process Step: Assessment
14. The nurse is caring for a patient with a diagnosis of catatonic schizophrenia. What
behavior is consistent with this diagnosis? a. Talks excitedly about going home. b. Suspiciously watches the staff. c. Stands on one foot for 15 minutes.
d. States he has a cat under his bed that talks to him. ANS: C
Maintaining a rigid pose for long periods of time is an example of behavior expected with catatonic schizophrenia. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1120 OBJ: 2 KEY: Nursing Process Step: Assessment
15. What is the term used for the beginning stage of schizophrenia, characterized by a lack of
energy and complaints of multiple physical problems? a. Prepsychotic b. Residual c. Acute d. Prodromal ANS: D
The prodromal phase is the beginning stage of schizophrenia. Hallucinations and delusions sometimes occur in the prepsychotic stage. In the acute phase, individuals often lose touch with reality. The residual phase follows the acute phase and the symptoms of that phase are similar to those of the prodromal stage. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1120 OBJ: 2 KEY: Nursing Process Step: Assessment
16. For the past 3 weeks, the nurse has observed a patient interacting with staff and other
patients, helping decorate the dining room for a party, and leading the singing in the activity room. Today, the patient tearfully refuses to dress or get out of bed. The nurse recognizes these behaviors as evidence of which psychiatric disorder? a. Unipolar depression b. Dysthymic disorder c. Hypomanic episode d. Bipolar disorder ANS: D
Bipolar disorder can cause the patient to experience a sudden shift in emotion from one extreme to the other. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1121 OBJ: 2 KEY: Nursing Process Step: Assessment
17. The nurse recognizes that researchers have identified that hereditary factors account for
what percentage of mood disorders? a. 10% to 15% b. 20% to 30% c. 35% to 50% d. 60% to 80% ANS: D
Research indicates that hereditary factors account for 60% to 80% of mood disorders. DIF: Cognitive Level: Comprehension TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1121 OBJ: 2 KEY: Nursing Process Step: Assessment
18. A home health nurse has a patient who is taking lithium. What should be included in the
teaching plan? a. Examine her skin closely for eruptions. b. Take her blood pressure twice a day to check for hypertension. c. Have her drug blood level checked every month. d. Avoid aged cheese and red wine. ANS: C
Lithium has a very narrow therapeutic window. The drug blood levels should be closely monitored. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Physiological Integrity
REF: 1122 OBJ: 6 KEY: Nursing Process Step: Implementation
19. The nurse alters the care plan for a patient with depression to include what type of
activity? a. Domino game with three other patients b. Ping-Pong game with one other patient c. Group outing to view wildflowers d. Magazine to read alone ANS: C
The quiet, noncompetitive trip to view wildflowers would be the best option. Depressed people should not be put in situations where they must concentrate or compete. DIF: Cognitive Level: Analysis TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1121 OBJ: 5 KEY: Nursing Process Step: Planning
20. The nurse is assessing a female patient who has become rapidly and exceedingly anxious
because her fingernail polish is chipped. What type of anxiety should the nurse conclude that the patient is exhibiting? a. Signal anxiety b. General anxiety c. Anxiety traits d. Panic disorder ANS: C
An individual with anxiety traits has anxious reactions to relatively nonstressful events. Signal anxiety is a learned response to an event such as test taking. An individual with general anxiety worries over many things. A panic attack occurs suddenly and typically peaks within 10 minutes. DIF: Cognitive Level: Application TOP: Mental illness
REF: 1122 OBJ: 2 KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity 21. The home health nurse assesses a patient who creates elaborate excuses for not leaving
home. Further questioning reveals the patient had not left home for 6 months. How should this be documented? a. Mania b. Depression c. Agoraphobia d. Anxiety ANS: C
Agoraphobia is a high level of anxiety in which an anxiety attack could occur in individuals who avoid other people, places, or events. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1125 OBJ: 2 KEY: Nursing Process Step: Assessment
22. When a patient demonstrates accelerated heart rate, trembling, choking, and chest pain
along with acute, intense, and overwhelming anxiety, the nurse should recognize that the patient is most likely experiencing what condition? a. Terror b. Fright c. Fear d. Panic ANS: D
Panic can be defined as an attack of acute, intense, and overwhelming anxiety. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1122 OBJ: 2 KEY: Nursing Process Step: Assessment
23. When a patient is experiencing a panic attack, how should the nurse best assist the patient? a. Assist with reality orientation. b. Aid in decision making. c. Assist with rational thought. d. Coach in deep breathing. ANS: D
Coaching in relaxation techniques such as deep breathing is an effective intervention for a patient who is experiencing a panic attack. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1117 OBJ: 5 KEY: Nursing Process Step: Implementation
24. A patient is frequently late for appointments because he goes back to his room numerous
times to assure himself that none of his belongings have been stolen. What does this behavior represent? a. Senseless behavior b. Controlled repetition
c. Obsessive-compulsive d. Anxiety tension ANS: C
Obsessive-compulsive disorders have two features: thoughts that are recurrent, intrusive, and senseless; and behaviors that are performed repeatedly and ritualistically. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1125 OBJ: 2 KEY: Nursing Process Step: Assessment
25. A 14-year-old survivor of a school shooting screams and dives under a table when
firecrackers go off. What does this behavior represent? a. Phobia b. Posttraumatic stress disorder c. Obsessive-compulsive disorder d. Disordered thinking ANS: B
Posttraumatic stress disorder describes a response to an intense traumatic experience that is beyond the usual range of human experience. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1126 OBJ: 2 KEY: Nursing Process Step: Assessment
26. What should the nurse preparing a patient for a scheduled appointment for
electroconvulsive therapy (ECT) remind the patient to do? a. Drink plenty of fluids before ECT to ensure adequate hydration. b. Bring a change of clothes in case of incontinence. c. Be prepared for visual disturbances after the treatment. d. Arrange for transportation to and from the appointment. ANS: D
If the patient has not arranged for adequate transportation to and from the appointment, the treatment will be canceled because driving after ECT is dangerous. The patient is typically NPO before the procedure. Incontinence and visual disturbances are not common following the procedure. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Physiological Integrity
REF: 1123 OBJ: 5 KEY: Nursing Process Step: Implementation
27. The nurse is told that a patient believes he was born into the wrong body. What is the
correct terminology for the desire to have the body of the opposite sex? a. Homosexuality b. Transsexualism c. Heterosexuality d. Bisexuality ANS: B
Transsexualism is a persistent desire to be the opposite sex and to have the body of the opposite sex. DIF: Cognitive Level: Comprehension TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1127 OBJ: 2 KEY: Nursing Process Step: Assessment
28. The patient complains of recurrent, multiple physical ailments for which there is no
organic cause. How should the nurse assess this? a. Obsessive-compulsive disorder b. Phobia anxiety disorder c. Somatic symptom disorder d. Delusional disorder ANS: C
Somatic symptom disorder is characterized by recurrent, multiple physical complaints for which there is no organic cause. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1127 OBJ: 2 KEY: Nursing Process Step: Assessment
29. What disorder is a severe form of self-starvation that can lead to death? a. Bulimia nervosa b. Anorexia nervosa c. Teenage nervosa d. Obesity nervosa ANS: B
Anorexia nervosa is a severe form of self-starvation that can lead to death. DIF: Cognitive Level: Knowledge TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1128 OBJ: 2 KEY: Nursing Process Step: Assessment
30. The patient is concerned about confidentiality and asks the nurse not to tell anyone what is
said. What is the best response by the nurse? a. “I am required to report any intent to hurt yourself or others.” b. “Conversations between patient and nurse are confidential.” c. “What we say can be secret. What I write in the chart is available to the health team.” d. “I can’t help you unless you trust me.” ANS: A
No secrets are allowed to be kept by a member of the health care team. DIF: Cognitive Level: Application TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1132 OBJ: 5 KEY: Nursing Process Step: Implementation
31. What is the term for a long-term and intense form of psychotherapy developed by
Sigmund Freud that allows a patient’s unconscious thoughts to be brought to the surface?
a. b. c. d.
Adjunctive Behavior Psychoanalysis Cognitive
ANS: C
Psychoanalysis technique was developed by Sigmund Freud and is a long-term and intense therapy. DIF: Cognitive Level: Comprehension TOP: Psychotherapy MSC: NCLEX: N/A
REF: 1132 OBJ: 5 KEY: Nursing Process Step: N/A
32. What is the typical schedule for electroconvulsive therapy (ECT)? a. 3 treatments over 2 weeks b. 6 treatments over 2 months c. 8 treatments over several weeks d. 10 treatments over several weeks ANS: D
ECT is done as a treatment for depression, mania, and schizoaffective disorders that have not responded to other treatments. The usual protocol is 10 treatments over several weeks. DIF: Cognitive Level: Comprehension TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1132 OBJ: 5 KEY: Nursing Process Step: Implementation
33. A patient who is taking a monoamine oxidase inhibitor (MAOI) asks the nurse about the
addition of St. John’s wort to help with his depression. What would be the best response of the nurse? a. “That is a great idea. Alternative therapies can be very helpful.” b. “You will feel better sooner if you include phenylalanine.” c. “Did you know that St. John’s wort can raise your blood pressure dramatically?” d. “You will need to drink lots of water.” ANS: C
St. John’s wort can raise blood pressure dramatically in people who are also taking MAOIs. DIF: Cognitive Level: Analysis TOP: Psychopharmacology MSC: NCLEX: Physiological Integrity
REF: 1136 OBJ: 6 KEY: Nursing Process Step: Implementation
MULTIPLE RESPONSE 1. Adjunctive therapies are used for which reasons? (Select all that apply.) a. To increase self-esteem b. To promote positive interaction c. To enhance reality orientation d. To stimulate communication e. To increase energy
ANS: A, B, C
The purpose of adjunctive therapies is to increase self-esteem, promote positive interaction, and enhance reality orientation. DIF: Cognitive Level: Comprehension TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1132 OBJ: 6 KEY: Nursing Process Step: Implementation
2. What are considered warning signs of suicide? (Select all that apply.) a. Talking about suicide b. Increased interactions with friends and family c. Drug or alcohol abuse d. Difficulty concentrating on work or school e. Personality changes ANS: A, C, D, E
Warning signs of suicide include talking about suicide, decreased interactions with friends and family, drug/alcohol abuse, difficulty concentrating on work or school, and personality changes. DIF: Cognitive Level: Comprehension REF: 1121 OBJ: 3 TOP: Suicide KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity COMPLETION 1. The nurse instructs a patient who has just been prescribed a protocol of fluoxetine HCl
(Prozac) that the drug takes 2 to 4
to take effect.
ANS:
weeks Antidepressants of this type take 2 to 4 weeks before any effect is felt by the patient. DIF: Cognitive Level: Comprehension TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1122 OBJ: 5 KEY: Nursing Process Step: Implementation
2. The nurse explains that an alternative therapy that uses essential oils and scented candles
to help a patient relax and focuses on the atmosphere of the moment is ANS:
aromatherapy Aromatherapy uses essential oils and scented candles to soothe the senses and make people aware of the here and now of the pleasant environment. DIF: Cognitive Level: Comprehension TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1136 OBJ: 6 KEY: Nursing Process Step: Implementation
.
3. The nurse recognizes that stress can cause an ulcer, which is classified as a
symptom illness. ANS:
Somatic Somatic symptom illness addresses the stress-related problems that can result in physical signs and symptoms. Psychophysiologic disorders are thought to have an emotional basis, manifested as a physical illness. DIF: Cognitive Level: Comprehension TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1127 OBJ: 2 KEY: Nursing Process Step: Assessment
Chapter 36: Care of the Patient With an Addictive Personality Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. A 60-year-old man was admitted for cholecystitis that resulted in a cholecystectomy. On
his third day of hospitalization, he begins to sweat profusely, tremble, and has a blood pressure of 160/100. Based on these findings, what focused assessment should the nurse complete? a. Cardiac problems b. Respiratory problems c. Withdrawal problems d. Circulatory problems ANS: C
Diaphoresis, tremors, and hypertension are all symptoms of withdrawal from alcohol consumption. The nurse, concerned about the patient’s medical condition, may not consider substance abuse until withdrawal symptoms appear. DIF: Cognitive Level: Analysis REF: 1143 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
2. What age of onset of alcohol consumption is most predictive of alcohol addiction? a. 8 or younger b. 10 or younger c. 12 or younger d. 14 or younger ANS: D
Forty-four percent of those who start drinking at the age of 14 or younger will develop alcoholism. DIF: Cognitive Level: Comprehension REF: 1141 TOP: Alcoholism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
3. Alcohol is involved in motor vehicle accidents, suicides, and homicides. Approximately
how many deaths each year are related to alcohol consumption? a. 58,000 b. 78,000 c. 88,000 d. 108,000 ANS: C
About 88,000 deaths each year are related to alcohol consumption. DIF: Cognitive Level: Knowledge REF: 1141 TOP: Alcoholism KEY: Nursing Process Step: N/A
OBJ: 4 MSC: NCLEX: N/A
4. What stage of dependence is described by a patient when he tells the nurse that he has tried
to stop his drug habit, but he does not feel “normal” without it? a. Early b. Prodromal c. Middle d. Late ANS: C
In the middle stage, the user shows signs of withdrawal with abstinence and must use the drug to feel normal. DIF: Cognitive Level: Comprehension REF: 1142 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 2
5. What must a patient in the late stages of dependence do in order to recover? a. Gain insight into the addiction. b. Receive treatment for substance abuse. c. Pledge to lead a completely different lifestyle. d. Seek a nondrug-oriented support system. ANS: B
Very few people in the late stage of dependence will recover without treatment. The other options may aid in the recovery, but it is the treatment that is essential for recovery. DIF: Cognitive Level: Application REF: 1142 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 2
6. What is the best response by a nurse when a patient inquires how alcohol acts so quickly
on his system? a. Alcohol is digested quickly. b. Alcohol is converted to glycogen immediately. c. Alcohol is metabolized into ethanol rapidly. d. Alcohol is excreted in urine slowly. ANS: C
Alcohol is not digested or converted into glycogen, but it is metabolized quickly by the liver to ethanol. DIF: Cognitive Level: Analysis REF: 1143 OBJ: 4 TOP: Alcoholism KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The nurse reminds a group of high school students that most states have laws limiting
blood alcohol levels of drivers. What is the legal blood alcohol serum level in most states? a. 0.08% b. 0.20% c. 0.40% d. 0.50% ANS: A
Most states designate blood alcohol serum levels of 0.08% as the legal limit for driving a motor vehicle. DIF: Cognitive Level: Comprehension REF: 1143 OBJ: 3 TOP: Alcoholism KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8. A pregnant adolescent tells the nurse that she “only drinks a little.” How many drinks per
day can cause an adverse effect in an infant? a. One drink a day b. Two drinks a day c. Three drinks a day d. Four drinks a day ANS: B
As few as two drinks per day may cause adverse effects in an infant. DIF: Cognitive Level: Comprehension REF: 1143 OBJ: 4 TOP: Alcoholism KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse assesses an alcoholic patient carefully for signs of withdrawal. How soon after
cessation of alcohol intake do withdrawal symptoms usually appear? a. 3 hours b. 4 hours c. 5 hours d. 6 hours ANS: D
Withdrawal signs can occur as early as 6 hours after cessation of alcohol intake and sometimes last for 3 to 5 days. DIF: Cognitive Level: Comprehension REF: 1143 TOP: Alcoholism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
10. The nurse is performing an initial assessment on an alcoholic patient. Which of the
following actions by the nurse would best ensure honest answers? a. Not asking personal questions b. Having a nonjudgmental attitude c. Including the family d. Promising the patient not to tell anyone ANS: B
Maintaining a nonjudgmental attitude may reassure the patient and allow him to be more honest in his responses to the admission assessment. DIF: Cognitive Level: Application REF: 1144 TOP: Alcoholism KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 5
11. During the detoxification period, what does the nurse aim to achieve when designing
interventions? a. Enroll the patient in Alcoholics Anonymous (AA). b. Keep the patient safe from aspiration and seizure. c. Help the patient interact in nonaddictive activities. d. Help the patient gain insight into the addiction. ANS: B
Care for the addicted patient starts with detoxification and is focused on keeping the patient safe from the symptoms of withdrawal. Enrolling the patient in AA, helping the patient interact in nonaddictive activities, and helping the patient gain insight into the addiction would be part of the rehabilitation process. DIF: Cognitive Level: Application REF: 1145 OBJ: 5 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. What should the entire health team focus on during the rehabilitation phase? a. Establishing a support system b. Seeking and maintaining employment c. Abstaining from drug use d. Addressing the problems related to addiction ANS: C
The focus of rehabilitation is for the patient to abstain from drug use. DIF: Cognitive Level: Application REF: 1145 OBJ: 5 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 13. What should the nurse do to decrease the patient’s disorientation at night during the
detoxification period? a. Place the patient in a room with another recovering patient. b. Instruct the patient to orient himself to his surroundings at bedtime. c. Wake the patient up every 4 hours to eat a small snack. d. Use nightlights and remove extra furniture from the room. ANS: D
Use of nightlights and removing extra furniture that could be misidentified will reduce disorientation. The patient should not be woken up to eat, but if he is awake, small snacks can be offered. The nurse should orient the patient to his surroundings. DIF: Cognitive Level: Application REF: 1145 OBJ: 5 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 14. The nurse explains that Alcoholics Anonymous (AA) consists of abstinent alcoholics who
help other alcoholics become and stay sober. What is the foundation of AA? a. Psychotherapy b. A 12-step program c. Treatment center d. Individual counseling
ANS: B
The foundation of AA is a 12-step program. DIF: Cognitive Level: Knowledge REF: 1147 OBJ: 5 TOP: Alcoholism KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 15. What severe side effect will occur if an alcoholic patient consumes alcohol while taking
disulfiram (Antabuse)? a. Nausea b. Blackouts c. Headaches d. Hypertension ANS: A
When a person who is taking Antabuse consumes alcohol, severe nausea, tachycardia, shortness of breath, confusion, and dizziness are experienced. The drug is used as a form of aversion therapy. DIF: Cognitive Level: Comprehension REF: 1145 OBJ: 5 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. If the patient tells the nurse, “I’m not an alcoholic. I can stop whenever I want to,” what
should be the nurse’s most therapeutic response? a. “Well, why don’t you?” b. “Hasn’t alcohol use interfered with your employment?” c. “A positive attitude like that is a good start.” d. “What would you call alcoholism?” ANS: B
When the addicted person presents in denial, the nurse should use techniques to set limits on that behavior. DIF: Cognitive Level: Analysis REF: 1146 OBJ: 1 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 17. When a patient denies any problems related to addiction, what is the nurse’s most
therapeutic response? a. “What do you call this hospitalization?” b. “How can anybody help you if you don’t see a problem?” c. “Would your family agree that you have no problems?” d. “Can you think of any time your behavior created an unpleasant situation in your life?” ANS: D
When the patient denies that his behavior is problematic, the nurse should ask the patient to recount incidences when the behavior had unpleasant consequences. DIF: Cognitive Level: Analysis REF: 1146 OBJ: 1 TOP: Addiction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity 18. Which drug is often used in date rape? a. Dalmane b. Xanax c. Narcan d. Rohypnol ANS: D
Rohypnol has been abused as a date-rape drug and has not been approved for use in the United States. DIF: Cognitive Level: Comprehension | Cognitive Level: Knowledge REF: 1149 OBJ: 6 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 19. A patient seems bewildered when he confides in the nurse that all of his friends and leisure
time have been centered on a drug culture. Which would be the best response by the nurse? a. “What other sort of activities might you enjoy?” b. “You will need to get new friends.” c. “Returning to those activities will get you back here and in trouble.” d. “You need to get a hobby.” ANS: A
Encouraging the patient to imagine new activities is a start toward seeking them. Giving advice is not therapeutic. DIF: Cognitive Level: Analysis REF: 1146 OBJ: 1 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 20. When a patient is admitted with an overdose of an opioid narcotic, the nurse should
anticipate an order for which drug to reverse the effects of the narcotic? a. Clonidine b. Narcan c. Orlaam d. Methadone ANS: B
Opioid overdose treatment involves administering Narcan as prescribed to reverse the effects of the narcotic. DIF: Cognitive Level: Application REF: 1149 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
21. The nurse concludes that a significant goal of the care plan for an alcoholic patient has
been met when the patient makes which statement? a. “I drink because I’m lonely.” b. “All my difficulties are related to my drinking.” c. “I wouldn’t need to drink if I had my family back.”
d. “My drinking helps me cope with the stress of my job.” ANS: B
A major goal for the successful treatment of alcoholics is to have them express responsibility for their behavior. DIF: Cognitive Level: Application REF: 1146 TOP: Addiction KEY: Nursing Process Step: Evaluation MSC: NCLEX: Psychosocial Integrity
OBJ: 5
22. While creating a methadone protocol for a patient rehabilitating from heroin addiction, the
nurse explains that the patient will take methadone for what length of time? a. Daily for the rest of his life. b. Daily until stabilized, then gradually reduce the dose to zero. c. Weekly for at least 6 months, then decrease the dose to once a month. d. Monthly for 6 to 10 months, then decrease the dose to zero. ANS: B
Methadone is given daily until the patient is stabilized. The methadone is reduced gradually until the patient does not need to take any. DIF: Cognitive Level: Application REF: 1150 OBJ: 5 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 23. A 22-year-old patient presents in the emergency department with the characteristics of
severe Parkinson disease. The nurse should suspect an overdose of what drug? a. Marijuana b. Cocaine c. Amphetamines d. Valium ANS: C
Over time, dopamine depletion in the brain can cause Parkinson-like symptoms to occur in people who abuse amphetamines. DIF: Cognitive Level: Comprehension REF: 1151 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
24. A college student has brought his hallucinating roommate to the college clinic. The young
man says his roommate has been experimenting with phencyclidine (PCP). How long should the nurse expect the hallucinations to last? a. 30 to 60 minutes b. 1 to 4 hours c. 4 to 6 hours d. 6 to 12 hours ANS: D
Some hallucinogenic effects of PCP can last 6 to 12 hours. DIF: Cognitive Level: Comprehension REF: 1151 TOP: Addiction KEY: Nursing Process Step: Assessment
OBJ: 6
MSC: NCLEX: Physiological Integrity 25. The mother of a young woman being treated for amphetamine overdose asks the nurse
when the manifestations will subside. What would be the most correct answer by the nurse? a. “Usually in 8 to 10 hours.” b. “She will snap out of it in a day or two.” c. “Usually in about 2 hours, but the effects will return in 2 to 3 days.” d. “The manifestations may be permanent.” ANS: D
The manifestations of overdose of amphetamines are frequently permanent. DIF: Cognitive Level: Comprehension REF: 1151 OBJ: 6 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 26. What nursing intervention should be included in the plan of care for a baby born to a
drug-addicted mother? a. Swaddle the baby closely. b. Place the baby in a brightly lit area. c. Hold and rock the baby frequently. d. Place the baby in a busy part of the nursery for stimulation. ANS: A
A baby born to a drug-addicted mother should be swaddled, placed in an area of low stimulation, and minimally handled. DIF: Cognitive Level: Application REF: 1151 OBJ: 6 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. What is the greatest problem with lysergic acid diethylamide (LSD) use? a. The drug is addictive. b. The drug stimulates drug-seeking behavior. c. The drug causes flashbacks. d. The drug sets off hypertensive episodes. ANS: C
LSD causes flashbacks, or “bad trips,” unpredictably, and the flashbacks may occur years after ingestion of the drug. LSD is not considered an addictive drug and does not stimulate drug-seeking behavior. Hypertension is not a typical side effect of LSD. DIF: Cognitive Level: Application REF: 1151 OBJ: 6 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 28. What should the nurse do to decrease the damage of bruxism seen in a patient who has
been abusing the drug ecstasy? a. Turn the patient to his right side. b. Elevate the head of the bed 30 degrees. c. Provide the patient with a pacifier.
d. Administer a muscle relaxant. ANS: C
The use of an infant pacifier will reduce the damage to the teeth for a patient who is manifesting bruxism (grinding of the teeth). DIF: Cognitive Level: Application REF: 1151 OBJ: 6 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. What should the nurse do when suspecting a coworker of abusing drugs while at work? a. Confront the abuser. b. Report observations to a supervisor. c. Call the state board of nursing. d. Discuss the problem with another coworker. ANS: B
The nurse’s observations should be reported objectively, preferably in writing, to the supervisor. DIF: Cognitive Level: Application REF: 1153 OBJ: 7 TOP: Impaired nurse KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 30. Which statement describes the impaired nurse who is in a peer assistance program? a. The nurse has a revoked nursing license. b. The nurse does not have to notify her employer. c. The nurse will be allowed to work as a nurse under supervision. d. The nurse will be reported to the Healthcare Integrity and Protection Data Bank. ANS: C
The peer assistance program allows the nurse to retain licensure and continue to work under supervision, although possibly in an area where access to controlled drugs is difficult. It is necessary for the employer to have information regarding the peer assistance assignment. Action is not reported to the Healthcare Integrity and Protection Data Bank until final adverse actions are taken, allowing the nurse to complete the peer assistance program. DIF: Cognitive Level: Application TOP: Impaired nurse MSC: NCLEX: N/A
REF: 1155 OBJ: 7 KEY: Nursing Process Step: N/A
MULTIPLE RESPONSE 1. During the initial intake assessment of a drug user, the nurse should attempt to obtain
which subjective data? (Select all that apply.) a. Usual pattern of use b. Specific drug c. Previous arrests d. Amount of drug used e. Time of last use
ANS: A, B, D, E
Determining the drug, strength, frequency, last use, and pattern of use is the basic database on a substance abuser. DIF: Cognitive Level: Application REF: 1144 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 4
2. The nurse should assess a patient for which criteria of addiction? (Select all that apply.) a. Excessive use of the substance b. Increase in social function c. Uncontrollable consumption d. Increase in economic function e. Psychological disturbances ANS: A, C, E
Criteria for addiction include excessive use of the substance, a decrease in social function, uncontrollable consumption, a decrease in economic function, and psychological disturbances. DIF: Cognitive Level: Application REF: 1140 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 1
3. A nurse suspects here a coworker is abusing drugs. Which of the following symptoms,
noticed in the coworker, would contribute to the suspicions? (Select all that apply.) a. Spending more time with coworkers b. Frequently absent from the unit c. Rapid changes in mood and performance d. Increased somatic complaints e. Patients report they did not receive their medications ANS: B, C, D, E
Signs of drug abuse in a nurse include the nurse becoming more isolated from coworkers, being frequently absent from the unit, rapidly changing mood and performance, increasing somatic complaints, and patients reporting they did not receive their medications. DIF: Cognitive Level: Comprehension TOP: Mental illness MSC: NCLEX: Psychosocial Integrity
REF: 1153 OBJ: 7 KEY: Nursing Process Step: Implementation
COMPLETION 1. When assessing an alcoholic patient, the nurse notes short-term memory loss, painful
extremities, foot drop, and muttered incoherent responses to questions. The nurse recognizes these symptoms as most likely related to a condition caused by long-term alcohol abuse, which is known as syndrome. ANS:
Korsakoff
Korsakoff syndrome is a permanent condition caused by long-term alcohol use. The patient mutters incoherently and experiences short-term memory loss, painful extremities, and foot drop. DIF: Cognitive Level: Comprehension REF: 1143 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
2. The nurse uses the CAGE questionnaire to assess a patient. The nurse suspects the patient
is an alcoholic if there are affirmative answers for
items on the questionnaire.
ANS:
two 2 An affirmative answer on two or more questions on the CAGE questionnaire is reason to assess more closely for possible alcohol abuse. DIF: Cognitive Level: Comprehension REF: 1144 TOP: Addiction KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 4
3. The nurse cautions that a person who chronically abuses drugs may experience mental
impairment. The area of the brain that can be affected and permanently damaged is the system. ANS:
limbic The most commonly abused drugs act on the limbic system of the brain and can cause permanent damage. DIF: Cognitive Level: Comprehension REF: 1148 OBJ: 4 TOP: Addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Chapter 37: Home Health Nursing Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. What became effective in 1966 by an act of legislation that revolutionized home care? a. Life insurance b. Medicare c. Private insurance d. Social Security ANS: B
When Medicare became effective in 1966, it revolutionized home care by changing it to a medical rather than nursing model of practice, defining and limiting services it would reimburse, and changing the payment source and even changing the reason home care was provided. DIF: Cognitive Level: Comprehension REF: 1160 TOP: Home health KEY: Nursing Process Step: N/A
OBJ: 2 MSC: NCLEX: N/A
2. A major change to Medicare reimbursement was implemented in 1983. The new system
paid a set rate according to diagnosis. What was the new payment system based upon? a. Interim payment systems b. Diagnosis-related groups c. Title XVIII d. Title XIX ANS: B
The new payment system introduced in 1983 provided reimbursement based upon set rates that were determined by diagnosis-related groups (DRGs). DIF: Cognitive Level: Application REF: 1160 TOP: Home health KEY: Nursing Process Step: N/A
OBJ: 2 MSC: NCLEX: N/A
3. How often must the home care treatment plan be recertified in order for the patient to
continue to receive services? a. Every 3 days b. Every 60 days c. Every 10 days d. Every 2 weeks ANS: B
Medicare and Medicaid home care services are based on the medical model of treatment and depend on the health care provider for entry into the formalized system. Medicare requires a plan of treatment signed by the health care provider, outlining all disciplines, treatment, frequency, and duration. These orders must be recertified every 60 days. DIF: Cognitive Level: Knowledge REF: 1164 TOP: Home health KEY: Nursing Process Step: N/A
OBJ: 2 MSC: NCLEX: N/A
4. Nurses who work in home settings rather than a hospital setting require a different level of
ability to be technically proficient, self-motivated, and innovative. This requires a higher level of what quality? a. Knowledge b. Performance c. Independence d. Cooperation ANS: C
The independence of home care practice can be difficult for nurses who depend on the security of the institutional setting. DIF: Cognitive Level: Application REF: 1164 TOP: Home health KEY: Nursing Process Step: N/A
OBJ: 7 MSC: NCLEX: N/A
5. The LPN/LVN may provide many services to the patient in the home. Several of these are
high-level skills. Under whose supervision should these high-level skills be directed and performed? a. Health care provider b. Family c. Facility supervisor d. RN ANS: D
The LPN/LVN must always work under the supervision of an RN. DIF: Cognitive Level: Comprehension REF: 1164 TOP: Home health KEY: Nursing Process Step: N/A
OBJ: 7 MSC: NCLEX: N/A
6. For physical therapy services to be reimbursed by Medicare, what must be the goal of the
therapy? a. Preventive b. Restorative c. Maintenance d. Educational ANS: B
The goals of treatment must be restorative in order for Medicare to provide reimbursement. In some cases, the goals can be preventive or maintenance for other payer sources. DIF: Cognitive Level: Comprehension REF: 1164 TOP: Services KEY: Nursing Process Step: N/A
OBJ: 5 MSC: NCLEX: N/A
7. Speech therapy goals include minimizing speech disorders and maximizing rehabilitation
of speech abilities. To be reimbursed by Medicare, who must provide these services? a. Bachelor’s-level clinician b. Speech therapist c. Master’s-level clinician d. Physiatrist ANS: C
To be reimbursed by Medicare, speech therapy must be provided by a master’s-prepared clinician. Other payers will sometimes reimburse services provided by a bachelor’s-level clinician. DIF: Cognitive Level: Comprehension REF: 1166 TOP: Services KEY: Nursing Process Step: N/A
OBJ: 5 MSC: NCLEX: N/A
8. Medical social services focus on the emotional and social aspects of illness. What is
another area of service? a. Home problems b. Marriage problems c. Crisis intervention d. Work problems ANS: C
Coping with stress and crisis intervention are also part of medical social workers’ services. DIF: Cognitive Level: Comprehension REF: 1166 TOP: Services KEY: Nursing Process Step: N/A
OBJ: 5 MSC: NCLEX: N/A
9. If solely for this reason, Medicare will not cover home health aide visits. What is that
reason? a. Physical assistance b. Health care provider orders c. Personal care d. Household chores ANS: D
Medicare will not pay for visits made solely for household chores. DIF: Cognitive Level: Comprehension REF: 1166 TOP: Services KEY: Nursing Process Step: N/A
OBJ: 5 MSC: NCLEX: N/A
10. The patient, family, social service agency, hospital, health care provider, or another agency
all can provide the entry point to the home health care system. What is the entry point for the home health care system called? a. Recommendation b. Survey c. Referral d. In-taking ANS: C
The entry point for home health care system is by referral. This can come from the patient, family, social service agency, hospital, health care provider, or another agency. DIF: Cognitive Level: Knowledge REF: 1167 TOP: Home health KEY: Nursing Process Step: N/A
OBJ: 5 MSC: NCLEX: N/A
11. The initial evaluation and admission visit is made by an RN, who has been provided with
general orders by a health care provider before the visit. This visit must be made within how many hours of the referral? a. 4 to 8
b. 12 to 15 c. 18 to 24 d. 24 to 48 ANS: D
The initial evaluation and admission visit made by an RN must be made within 24 to 48 hours of the referral. In some cases, if nursing will not be providing any services, the physical therapist may conduct the admission visit. DIF: Cognitive Level: Application REF: 1167 TOP: Home health KEY: Nursing Process Step: N/A
OBJ: 8 MSC: NCLEX: N/A
12. The evaluation and admission process for entry to the home health care system includes
physical and psychosocial examination, explanation of the patient’s rights, and evaluation of family, home, and nursing interventions. What is the normal minimum time for the admission visit? a. 30 minutes b. 1 hour c. 2 hours d. 3 hours ANS: B
The admission process typically takes a minimum of 1 hour. DIF: Cognitive Level: Knowledge REF: 1167 TOP: Home health KEY: Nursing Process Step: N/A
OBJ: 8 MSC: NCLEX: N/A
13. After the patient is admitted to the home health services system, a treatment plan is drafted
cooperatively with the health care provider and is signed. A separate, detailed care plan is always required for which disciplines? a. Registered nurse b. Physical therapist c. Home health aide d. LPN/LVN ANS: C
A separate, detailed care plan is always required for the home health aide. DIF: Cognitive Level: Application | Cognitive Level: Knowledge REF: 1167 OBJ: 5 TOP: Home health KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 14. How long is the average home health care visit by the skilled nurse? a. 10 to 15 minutes b. 20 to 30 minutes c. 30 to 45 minutes d. 45 to 60 minutes ANS: C
Skilled nursing visits typically take 30 to 45 minutes.
DIF: Cognitive Level: Knowledge REF: 1167 TOP: Home health KEY: Nursing Process Step: N/A
OBJ: 6 MSC: NCLEX: N/A
15. Complete documentation is essential and must include an accurate picture of the type and
quality of care given, as well as the effectiveness of the plan of care. Which model should be followed to best provide adequate documentation? a. Caretaker b. Nursing process c. Home health care d. Nursing efficiency ANS: B
Documentation that follows the nursing process model provides an accurate picture of the type and quality of care. DIF: Cognitive Level: Comprehension REF: 1168 TOP: Home health KEY: Nursing Process Step: N/A
OBJ: 8 MSC: NCLEX: N/A
16. When should discharge planning begin for a patient receiving home care services? a. A week before discharge b. Two days before discharge c. The day of discharge d. On admission ANS: D
Discharge planning for home care begins on admission. DIF: Cognitive Level: Knowledge REF: 1168 TOP: Discharge KEY: Nursing Process Step: N/A
OBJ: 8 MSC: NCLEX: N/A
17. When implementing quality assurance–specific criteria, measurements are developed for
three criteria: structural, process, and outcome. How is this method of assessment different from previous methods? a. It is objective. b. It is specific. c. It is subjective. d. It is generalized. ANS: A
In the past, measurements of quality in an agency, the care delivered, and the staff were all subjective. The quality assurance–specific criteria measurements are objective. DIF: Cognitive Level: Comprehension TOP: Quality assurance MSC: NCLEX: N/A
REF: 1169 OBJ: 4 KEY: Nursing Process Step: N/A
18. What is an eligibility requirement for an individual to qualify for Medicare services? a. Retired b. At least 65 years old c. Low-income d. Poor health
ANS: B
Beneficiaries of service must be at least 65 years of age. DIF: Cognitive Level: Knowledge TOP: Reimbursement MSC: NCLEX: N/A
REF: 1169 OBJ: 9 KEY: Nursing Process Step: N/A
19. Medicaid pays for home care services for people who have low incomes. Who administers
the Medicaid program? a. Federal government b. City government c. State government d. County government ANS: C
Medicaid is administered by the state. Medicare is a federal program. DIF: Cognitive Level: Comprehension TOP: Reimbursement MSC: NCLEX: N/A
REF: 1169 OBJ: 9 KEY: Nursing Process Step: N/A
20. During a time of acute illness, the family may become extremely distressed and neglect the
needs of other family members. On what does the family seem to focus? a. The outcomes b. The disease c. The health care provider d. The patient ANS: D
During times of acute illness, the family may become extremely distressed and focus only on the patient. The nurse can refer family members to an appropriate resource. DIF: Cognitive Level: Application TOP: Nursing process MSC: NCLEX: N/A
REF: 1171 OBJ: 8 KEY: Nursing Process Step: N/A
21. What should be the focus when the family and the patient work with the nurse to plan
interventions? a. Determining actions b. Participating in care c. Setting goals d. Celebrating achievements ANS: C
When planning interventions, it is important that the nurse work with the patient and the family on setting goals. DIF: Cognitive Level: Application REF: 1171 OBJ: 8 TOP: Nursing process KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
22. The nurse should provide the patient and family with accurate health information
concerning diagnoses and progress. What will accurate information help the family to become? a. Active participants b. Effective caregivers c. Encouraged supporters d. Active providers ANS: B
Providing accurate information about the diagnosis and progress helps the family to be effective caregivers. DIF: Cognitive Level: Application REF: 1171 OBJ: 8 TOP: Nursing process KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 23. Because many illnesses are now controlled rather than cured, the number of people with
chronic, debilitating illnesses has increased. What do home care nurses prevent by providing? a. Deaths b. Increased morbidity c. Increased hospitalization d. Acute episodes ANS: D
Home care provides assessment and evaluation of chronic illnesses to prevent acute episodes. DIF: Cognitive Level: Application REF: 1172 TOP: Home health KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 8
24. What is the fastest-growing group in the US population today? a. 30- to 40-year-olds b. 40- to 50-year-olds c. 50- to 65-year-olds d. Those 85 and older ANS: D
The age group older than 85 is the fastest-growing group in the United States today. DIF: Cognitive Level: Knowledge REF: 1172 TOP: Aging KEY: Nursing Process Step: N/A
OBJ: 8 MSC: NCLEX: N/A
25. By offering enteral, parenteral, intravenous, and blood transfusion therapies, what can
home care services prevent? a. Morbidity b. Hospitalization c. Hospice care d. Mortality ANS: B
Home care services can prevent hospitalization by offering enteral, parenteral, intravenous, and blood transfusion therapies. Morbidity, mortality, and hospice care cannot be prevented. DIF: Cognitive Level: Comprehension REF: 1172 TOP: Home health KEY: Nursing Process Step: N/A
OBJ: 6 MSC: NCLEX: N/A
26. What has been influenced by the increase in home health providers supporting healthy
living and illness prevention, and a movement toward deinstitutionalization of technology-dependent children and adults? a. Criteria for admission b. Age of eligibility c. Reimbursement criteria d. Length of financial support ANS: C
The increase in home health providers supporting healthy living and illness prevention and the movement toward deinstitutionalization of technology-dependent children and adults resulted from Medicare and third-party payers changing reimbursement criteria. DIF: Cognitive Level: Application REF: 1172 TOP: Home health KEY: Nursing Process Step: N/A
OBJ: 9 MSC: NCLEX: N/A
27. The licensed nurse can delegate which tasks to the home health assistive personnel? a. Bathing the patient b. Assessing ability to void c. Administering an injection d. Teaching about medications ANS: A
Bathing the patient is a task that can be delegated safely to the home health assistive personnel. Home health assistive personnel cannot assess, teach, or administer injections. DIF: Cognitive Level: Comprehension REF: 1167 OBJ: 5 TOP: Home health KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The home health nurse plans interventions to meet which general service goals? (Select all
that apply.) a. Restore function as is appropriate. b. Improve level of function. c. Maintain current health level. d. Ensure return of health. e. Teach healthy lifestyle. ANS: A, B, C, E
The general service goals are restoration, improvement, maintenance, and promotion of health.
DIF: Cognitive Level: Application REF: 1166 TOP: Home health KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
OBJ: 8
COMPLETION 1. The nurse describes a new technological service to the patient that will monitor several
assessments remotely. This new intervention is known as
services.
ANS:
telehealth A newer method of home care delivery is telehealth services. This approach allows for patient and care provider interaction and monitoring using telephone, computers, television, and two-way monitors. DIF: Cognitive Level: Comprehension REF: 1161 OBJ: 3 TOP: Telehealth services KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. When the decision is made with the family to place the patient on hospice care, the home
health nurse explains that the reimbursement changes from “fee per visit” to “fee per .” ANS:
diem Medicare-supported hospice care is billed on a fee per diem. DIF: Cognitive Level: Comprehension REF: 1163 TOP: Hospice KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
OBJ: 9
3. The nurse can best confirm that the patient understands the communication by obtaining
from the patient. ANS:
feedback Feedback confirms that the patient has understood the communication. DIF: Cognitive Level: Application REF: 1167 OBJ: 4 TOP: Communication KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance
Chapter 38: Long-Term Care Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. The home health nurse is assisting a family to select a long-term care facility for an
80-year-old widow in good health who no longer drives, loves to play cards, can ambulate with a walker, and is oriented. Which facility would be the best selection for this patient? a. Subacute unit setting b. Long-term care facility (nursing home) c. Assisted living center d. Continuing care retirement center (CCRC) ANS: C
The assisted living center provides meals, transportation, social interaction, and a homelike quality without the intrusion of the medical model. The patient’s age does not make her a reasonable candidate for a CCRC. The patient does not require acute skilled nursing care. DIF: Cognitive Level: Analysis REF: 1179 OBJ: 2 TOP: Long-term care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. The home health nurse helps an older adult couple plan changes in their home that will
facilitate care in their home as they age. What fraction of the US population live in a home setting? a. 1/4 b. 1/2 c. 1/3 d. 3/4 ANS: B
Approximately family setting.
(11.3 million) of the US population over the age of 65 live in a home or
DIF: Cognitive Level: Comprehension REF: 1176 OBJ: 2 TOP: Long-term care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. The nurse confirms that the cost of caring for a relatively unimpaired older adult in a
private home is approximately what fraction of the cost of placing the older adult in a long-term care facility? a. 1/4 b. 1/3 c. 1/2 d. 2/3 ANS: C
It costs approximately half as much to care for an older adult at home as it would cost in a long-term care facility.
DIF: Cognitive Level: Comprehension REF: 1177 OBJ: 4 TOP: Long-term care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. What is the goal for services provided by home health care agencies? a. Self-care b. Assisted living c. Rehabilitation d. Improved function ANS: C
Services provided by home health care agencies are aimed at rehabilitation. DIF: Cognitive Level: Comprehension REF: 1177 OBJ: 8 TOP: Home health KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. The nurse clarifies to the family of a patient that one of the roles of the LPN/LVN in the
home care setting is to evaluate the care provided to the patient by which provider? a. The family b. Other licensed care providers c. Nonlicensed staff d. The health care provider ANS: C
One of the roles of the LPN/LVN in the home care setting may be to evaluate the care provided by CNAs, HHAs, homemakers, and personal care attendants. DIF: Cognitive Level: Application | Cognitive Level: Comprehension REF: 1178 OBJ: 7 TOP: Home health KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. The family caring for an older adult in their home feels that they need assistance from a
hospice service. What is necessary for hospice service to be initiated? a. A family request b. A patient request c. Medical certification d. A referral by a hospice nurse ANS: C
Hospice agencies provide care at the end of life. Medical certification is required for terminal care. DIF: Cognitive Level: Application REF: 1178 OBJ: 8 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. The nurse suggests to a family caring for a member with early Alzheimer’s disease in their
home that they investigate the services of an adult day care center. What is a major benefit of adult day care centers?
a. b. c. d.
It takes the patient out on recreational outings. It can provide daily hygiene. It expands social interaction. It is free to the public.
ANS: C
Adult day care centers are open a large part of the day and offer several modalities to enhance social interaction and also give the family respite. DIF: Cognitive Level: Application REF: 1179 OBJ: 8 TOP: Adult day care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8. What differentiates the services of a long-term care facility from that of an assisted living
facility? a. Skilled nursing care b. Personal care services c. Weekly visits by the staff health care provider d. Intensive rehabilitation services ANS: B
Assisted living is a type of residential care setting where the resident receives personal care services. DIF: Cognitive Level: Application REF: 1179 OBJ: 8 TOP: Long-term care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. What would be the most appropriate guidance the nurse could provide an older adult
couple that is considering a continuing care retirement community (CCRC)? a. Admittance is limited to people who are relatively unimpaired. b. A contract is usually a lifetime commitment. c. A contract is an acceptable tax shelter. d. Contracts can be signed on a month-to-month basis. ANS: B
CCRCs offer a complete range of health care services, from independent living to 24-hour skilled nursing. In most cases, signing a contract with a CCRC is a lifetime commitment. DIF: Cognitive Level: Application REF: 1180 OBJ: 8 TOP: Long-term care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 10. An 82-year-old patient recovering from a hip replacement could be expected to move from
the acute care hospital to which setting for rehabilitation? a. A subacute care unit b. An assisted living center c. An adult day care center d. A continuing care retirement community ANS: A
Subacute units have a strong rehabilitative focus and a shorter length of stay than a long-term care center. DIF: Cognitive Level: Application REF: 1180 TOP: Subacute KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 1
11. What is the correct term for people who live in long-term care facilities? a. Patients, because they will be receiving acute care. b. Residents, because the facility has become their home. c. Patients, because they seek professional medical services. d. Customers, because they are purchasing care service. ANS: B
The older adult in a long-term care facility is referred to as a resident to reinforce the homelike environment. DIF: Cognitive Level: Knowledge REF: 1175 OBJ: 2 TOP: Long-term care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. Which statement is true concerning a 50-year-old patient recovering from a stroke who is
going to a long-term care facility for a short stay? a. Her regular hospitalization insurance will pay for the care. b. She will still have daily health care provider visits. c. She will need to contract outside physical therapy services. d. She will probably be discharged within 6 months. ANS: D
A short-stay resident in a long-term care facility for rehabilitation will have residential physical therapy services and will usually be discharged within 6 months. Regular hospitalization insurance does not cover long-term care. Daily health care provider visits do not occur in the long-term care facility. DIF: Cognitive Level: Application REF: 1181 OBJ: 2 TOP: Long-term care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 13. In the long-term care facility, health care professionals work together to meet the needs of
older adults and to go over the care plan with the resident and family members. What is this approach called? a. Team approach b. Individualized approach c. Interdisciplinary approach d. Outgoing approach ANS: C
The long-term care facility is an interdisciplinary setting. DIF: Cognitive Level: Comprehension TOP: Long-term care MSC: NCLEX: N/A
REF: 1181 OBJ: 7 KEY: Nursing Process Step: N/A
14. What is the time limit for the legal administration of medications? a. 30 minutes b. 1 hour c. 90 minutes d. 2 hours ANS: D
In long-term care, there is a 2-hour window for legal administration of medications, 1 hour before and 1 hour after the official administration time. DIF: Cognitive Level: Comprehension REF: 1182 OBJ: 3 TOP: Long-term care KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 15. The Omnibus Budget Reconciliation Act (OBRA) defines the requirements for which
aspect of care as it relates to long-term care? a. Nursing care b. Nutritional support c. Quality of care d. Staffing requirements ANS: C
OBRA defines requirements for the quality of care given to residents of long-term care facilities. DIF: Cognitive Level: Comprehension REF: 1182 OBJ: 3 TOP: Long-term care KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 16. The Health Care Financing Administration (HCFA) conducts unannounced institutional
surveys annually to assess the quality of life for the patients. The findings of the surveys are reported to: a. various licensing boards. b. facility administrators. c. the public. d. the US Department of Health and Human Services. ANS: C
Surveyors are required by law to visit the long-term care facility unannounced, on an annual basis and as needed, and the report is made public. DIF: Cognitive Level: Comprehension REF: 1182 OBJ: 3 TOP: Long-term care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 17. A 48-year-old long-term care facility resident expresses concern that the cost of his care
has used up his assets. For what program should the nurse suggest that the resident apply to cover the continued cost of living in a long-term facility? a. Medicare b. Hospitalization insurance c. Medicaid
d. Public health funds ANS: C
When adults have used all of their assets, they may then qualify for Medicaid. Medicaid is a federally funded, state-operated program of medical assistance for people with low incomes. DIF: Cognitive Level: Analysis TOP: Long-term care MSC: NCLEX: Psychosocial Integrity
REF: 1182 OBJ: 3 KEY: Nursing Process Step: Assessment
18. Although the Occupational Safety and Health Act (OSHA) increases the cost of care, what
is a benefit that it provides for long-term care? a. It ensures a safe environment for personnel. b. It ensures that medications are administered safely. c. It ensures that food is prepared safely. d. It ensures safe ambulation and transportation of patients. ANS: A
The OSHA guidelines significantly increase costs, but they also ensure a safe environment for personnel, which is mandatory today. DIF: Cognitive Level: Comprehension TOP: Long-term care MSC: NCLEX: N/A
REF: 1183 OBJ: 3 KEY: Nursing Process Step: N/A
19. A nurse helps a family understand that once hospice service is initiated, the focus of care
changes from rehabilitation and restoration to what type of care? a. Maintaining the patient at the optimal level b. Assisting with funeral planning c. Relieving the family of care d. Maintaining comfort as death approaches ANS: D
Hospice care is focused on the provision of comfort to the person who is approaching death. While hospice will assist with funeral planning as needed, it is not the focus of care. Hospice provides respite for the family, but hospice does not relieve the family of care duties. DIF: Cognitive Level: Application REF: 1178 OBJ: 8 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 20. What is included when the LVN/LPN completes the Resident Assessment Instrument
(RAI)? a. Minimum Data Set (MDS) and the signature of the health care provider b. Resident Assessment Protocols (RAPs) and the drug list c. Minimum Data Set, Resident Assessment Protocols, and the RN’s signature d. Resident Assessment Protocols and the signature of the administrator ANS: C
The RAI must be signed by the RN and contain the RAPs and MDS.
DIF: Cognitive Level: Application REF: 1183 OBJ: 3 TOP: Long-term care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 21. The nurse assesses a patient’s ability to perform self-care activities, as well as more
complex social and household activities. What is provided from this assessment? a. Physical status b. Emotional status c. Health status d. Functional status ANS: D
The functional status is related to activities of daily living (ADLs) and instrumental activities of daily living (IADLs). DIF: Cognitive Level: Application REF: 1184 OBJ: 2 TOP: Long-term care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 22. How often does the Omnibus Budget Reconciliation Act (OBRA) require that a summary
(including vital signs and weight) be obtained in the long-term care setting? a. Daily b. Weekly c. Monthly d. Yearly ANS: C
A summary, including vital signs and weight, is only required on a monthly basis. DIF: Cognitive Level: Application REF: 1182 OBJ: 3 TOP: Long-term care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 23. In a long-term care facility, the nurse takes an active part in formulating the resident’s plan
of care. How often is the plan of care revised? a. Weekly b. Every 90 days c. Monthly d. Every 6 months ANS: B
In long-term care, the resident’s plan of care is reviewed by the interdisciplinary team every 90 days for resolution of problems or revision of goals and interventions. DIF: Cognitive Level: Application REF: 1184 OBJ: 3 TOP: Nursing process KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 24. The nurse recognizes that an ongoing assessment will help set priorities in the nursing care
plan of a long-term care resident. What does this allow the planning process to become? a. Timely
b. Patient-centered c. Preferential d. Categorized ANS: B
The planning process must be patient-centered. DIF: Cognitive Level: Application REF: 1186 OBJ: 6 TOP: Nursing process KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 25. The long-term care facility nurse recognizes that visiting the resident, changing his or her
position, assessing for incontinence, providing skin care, and offering fluids are part of the nurse’s responsibility. What does the initiation of these interventions provide? a. Continuity b. Safety c. Prevention d. Reassurance ANS: B
Nursing interventions basic to long-term care include monitoring safety measures such as changing the resident’s position every 2 hours, assessing for incontinence, providing skin care when needed, and offering fluids. DIF: Cognitive Level: Application REF: 1176 OBJ: 6 TOP: Nursing process KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 26. How often should the long-term care facility nurse make rounds and monitor residents for
safety? a. Every 2 hours b. Every 4 hours c. Every 6 hours d. Once per shift ANS: A
Nursing interventions related to long-term care include making rounds and monitoring for resident safety every 2 hours. DIF: Cognitive Level: Application REF: 1185 OBJ: 7 TOP: Nursing process KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 27. When a patient asks why he must be transferred to a subacute unit from the hospital, what
would be an appropriate response by the nurse? a. Reimbursement guidelines limit adults’ stays in an acute setting. b. The health care provider can oversee care more closely in a subacute setting. c. Financial restrictions of insurance limit time spent in an acute care setting. d. Cost and services at the acute care setting are the same as at the hospital. ANS: A
In the acute care setting, strict rules about length of stay and limitations in cost reimbursement limit the amount of time adults can be hospitalized. These strict reimbursement rules for acute care do not apply, however, to subacute care provided in a skilled nursing facility setting. DIF: Cognitive Level: Application REF: 1180 OBJ: 3 TOP: Nursing process KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 28. Two unique members of the care giving team in a long-term care facility are the certified
medication aide/technician and the a. dental b. certified medication c. restorative nursing d. medical
assistant.
ANS: C
These two members of the care team are unique to the long-term care facility. Both have had extra training over and above that of the certified unlicensed assistive personnel. DIF: Cognitive Level: Knowledge TOP: Long-term care giving team MSC: NCLEX: N/A
REF: 1182 OBJ: 8 KEY: Nursing Process Step: N/A
MULTIPLE RESPONSE 1. The LPN/LVN performs which functions when working as a staffing coordinator of a
home health agency? (Select all that apply.) a. Scheduling appropriate care providers b. Reviewing documentation c. Verifying financial coverage d. Making referrals e. Performing comprehensive assessments ANS: A, C
Reviewing documentation may be done by an LPN/LVN but not in the role of staffing coordinator but as a medical chart auditor or reviewer. Scheduling care providers and verifying financial coverage are among the duties of the staffing coordinator. Making referrals and performing comprehensive assessments are duties of the RN. DIF: Cognitive Level: Application REF: 1182 OBJ: 8 TOP: Staffing coordinator KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. The LPN/LVN suggests to the RN that the nursing care plan be modified to include
referral to an adult day care center. What benefits should the patient expect to receive? (Select all that apply.) a. Overnight care b. Respite care for the family c. Social interaction for the patient d. Mental stimulation for the patient
e. Supporting maintenance of the ADLs ANS: B, C, D, E
Overnight care is usually not offered from a day care center. DIF: Cognitive Level: Application REF: 1178 OBJ: 8 TOP: Adult day care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. A daughter is assessing a nursing home before placing her mother there for what she feels
will be a long-term stay. Which of the following are important aspects of quality to consider when selecting a nursing home? (Select all that apply.) a. Privacy is respected. b. Staff members are task-focused. c. The staff welcomes family visits. d. There is a homelike environment. e. Rooms are maintained like a hospital. ANS: A, C, D
It is important that privacy is respected, family members are welcomed, and a homelike environment is maintained. Staff members should be resident-focused, not task-focused. Rooms should be maintained like a home instead of like a hospital. DIF: Cognitive Level: Application TOP: Quality indicators MSC: NCLEX: N/A
REF: 1180 OBJ: 7 KEY: Nursing Process Step: N/A
4. What impact will the Affordable Care Act have on nursing homes and long-term care
centers when fully implemented? (Select all that apply.) a. A weaker consumer complaint system b. Better training for state inspectors c. Program to support national criminal background checks d. Public disclosure of nursing home owners and operators e. Training of unlicensed assistive personnel in the care of people with dementia ANS: B, C, D, E
The Affordable Care Act will result in a stronger consumer complaint system, better training for state inspectors, a program to support national criminal background checks, public disclosure of nursing home owners and operators, and training for unlicensed assistive personnel in the care of people with dementia. DIF: Cognitive Level: Comprehension TOP: Federal regulations MSC: NCLEX: N/A
REF: 1183 OBJ: 3 KEY: Nursing Process Step: N/A
COMPLETION 1. The nurse explains to a patient that shopping, using a phone, and administering his own
medications are classified as ANS:
instrumental
activities of daily living.
IADLs are more complex skills than ADLs and indicate a higher level of independent functioning. DIF: Cognitive Level: Application REF: 1179 TOP: Instrumental activities of daily living (IADLs) KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
OBJ: 8
2. When a resident who is a Muslim becomes concerned about his religiously dictated dietary
requirements, the nurse may refer this concern to the long-term care department. ANS:
dietary Long-term facilities take into consideration the patient’s individual needs, including diet preferences. The dietary department is usually able to meet most requests. DIF: Cognitive Level: Application REF: 1176 OBJ: 7 TOP: Ethnic considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
Chapter 39: Rehabilitation Nursing Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse who is part of a team focused on restoring an individual to the fullest physical,
mental, social, vocational, and economic capacity is practicing what type of nursing? a. Holistic nursing b. Conscientious nursing c. Rehabilitation nursing d. Comprehensive nursing ANS: C
Rehabilitation is the process of restoring an individual to the fullest physical, mental, social, vocational, and economic capacity of which he or she is capable. DIF: Cognitive Level: Comprehension REF: 1188 OBJ: 1 TOP: Rehabilitation KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 2. The nurse recognizes that the rehabilitation process involves the efforts of various
disciplines. The focus of rehabilitation is to build on which area? a. A person’s losses b. A person’s long-term plans c. A person’s drives d. A person’s abilities ANS: D
The underlying philosophy of rehabilitation is to focus on the abilities of the patient. DIF: Cognitive Level: Application REF: 1188 OBJ: 1 TOP: Rehabilitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. The nurse should tell a paraplegic that the rehabilitation experience will consist of: a. relearning former skills. b. learning to walk. c. learning new skills to adapt to a different lifestyle. d. developing muscle strength. ANS: C
The type and the focus of rehabilitation are individualized to the patient, the injury, and abilities. Skills will be taught to enhance the patient’s adaptation to a new lifestyle. DIF: Cognitive Level: Application REF: 1189 | 1190 OBJ: 3 TOP: Rehabilitation KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. The nurse who helps a patient with a disability rejoice in the acquisition of the smallest
new skill is embracing which rehabilitation philosophy? a. Resolving impairments
b. Removing disabilities c. Increasing quality of life d. Eliminating complications ANS: C
A philosophy of rehabilitation is to increase the quality of life. Impairments may not be able to be resolved, disabilities may not be able to be completely removed, and complications may not be totally eliminated. However, with rehabilitation, the individual can learn to adjust to the new lifestyle. DIF: Cognitive Level: Application REF: 1189 OBJ: 1 TOP: Rehabilitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. A patient with quadriplegia resulting from a spinal cord injury says to the rehabilitation
nurse, “I’m sick of this therapy! What is an occupational therapist going to do for me? Can she give me an ‘occupation’?” What response by the nurse would be the most helpful? a. “No, but the occupational therapist can show you how to enjoy some recreational activities.” b. “Yes, in a way. The occupational therapist provides training that strengthens muscles you can still control.” c. “Maybe. The occupational therapist recommends adaptive equipment that will make you more independent.” d. “No, the voc-rehab counselor helps with employment. The occupational therapist helps train you for improved communication skills.” ANS: C
The occupational therapist recommends adaptive equipment or helps in modifying skills to enhance independence. DIF: Cognitive Level: Analysis TOP: Rehabilitation MSC: NCLEX: Psychosocial Integrity
REF: 1192 OBJ: 4 KEY: Nursing Process Step: Implementation
6. When caring for a patient with a disability, the rehabilitation nurse provides individual
treatment to help the patient stay focused on which goals? a. Returning to normal b. Independence c. Employment d. Promotion of health ANS: B
The focus on rehabilitation is on enabling the individual to move from a totally dependent state to a level of independence. DIF: Cognitive Level: Application REF: 1192 OBJ: 3 TOP: Rehabilitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. Following admission, how soon must a comprehension rehabilitation plan of care be
implemented on a rehabilitation patient? a. 12 hours
b. 24 hours c. 3 days d. 1 week ANS: B
A comprehensive rehabilitation plan must be initiated within 24 hours of admission to the rehabilitation service. The results of the interdisciplinary assessment provide the basis for development of the plan of care. The team has 3 days from admission to review and revise the plan of care. DIF: Cognitive Level: Application REF: 1190 OBJ: 4 TOP: Rehabilitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8. Which is a characteristic of the interdisciplinary approach to the rehabilitation team? a. Each discipline makes its own goals for the patient. b. There are clear boundaries between the disciplines. c. There is a combination of expanded problem solving beyond the boundaries of the
individual disciplines. d. Cross-trained people are used who have functional ability in two or more
disciplines. ANS: C
In the interdisciplinary approach, the team collaborates on the goals for the patient. In the multidisciplinary rehabilitation team approach, each discipline makes its own goals for the patient and there are clear boundaries between the disciplines. The transdisciplinary rehabilitation team is characterized by the blurring of boundaries between disciplines and the cross-training and flexibility to reduce a duplication of efforts. DIF: Cognitive Level: Application REF: 1191 OBJ: 4 TOP: Rehabilitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. When planning care for children, the nurse uses a concept that recognizes the pivotal role
of the family in the lives of children with disabilities or other chronic conditions. What is this philosophy called? a. Child-centered care b. Systems-centered care c. Family-centered care d. Individual-centered care ANS: C
Family-centered care is an evolving concept that uses the family as equal partners in the rehabilitation process. DIF: Cognitive Level: Comprehension REF: 1193 OBJ: 6 TOP: Rehabilitation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 10. What is the primary difference between the rehabilitation of children and the rehabilitation
of adults? a. Level of disability
b. Body part involved c. Degree of disability d. Developmental potential ANS: D
The primary difference between rehabilitation of children and rehabilitation of adults is the developmental potential of the child. DIF: Cognitive Level: Knowledge REF: 1200 OBJ: 10 TOP: Rehabilitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 11. The acquisition of adaptive skills and behaviors by an individual who has been disabled
since birth refers to: a. training. b. education. c. development. d. habilitation. ANS: D
Habilitation refers to developing skills and behaviors in people who did not have the skills originally. Children who are disabled from birth have no skills to relearn and are habilitated rather than rehabilitated. DIF: Cognitive Level: Comprehension REF: 1200 OBJ: 10 TOP: Habilitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. The nurse who is engaged in gerontological rehabilitation nursing has a dual challenge.
The gerontological rehabilitation nurse must assess not only the debilitating factors of disease but also which other factor? a. Advancing age b. Reduced ability to learn c. Limited energy d. Eroded interest level ANS: A
Gerontological rehabilitation nursing focuses on the unique requirements of older adult rehabilitation. The elderly, with their potential physical limitations, require specialized care. DIF: Cognitive Level: Application REF: 1200 | 1202 OBJ: 10 TOP: Rehabilitation KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 13. The nurse explains that the main roles of the gerontological rehabilitation nurse are to
provide rehabilitative care and what other role? a. Provide restoration. b. Teach prevention. c. Teach adaptive skills. d. Provide positive reinforcement.
ANS: B
Teaching prevention is the dual role of the geriatric rehabilitation nurse. Restoration, adaptive skills, and positive reinforcements are all part of providing rehabilitative care. DIF: Cognitive Level: Application REF: 1202 OBJ: 10 TOP: Rehabilitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 14. What should the nurse do to reduce the incidence of postural hypotension in a patient with
a spinal cord injury? a. Monitor diastolic blood pressure closely. b. Encourage the patient to remain in the bed. c. Raise the head of the bed for 15 to 20 minutes before transfer to a wheelchair. d. Encourage adequate intake of fluids to expand fluid volume. ANS: C
Raising the head of the bed before transfer allows for gradual vessel accommodation from the supine position to the upright position. It is important to check the patient’s blood pressure, but it will not reduce the incidence of postural hypotension. It is important to encourage the patient to get out of bed. Postural hypotension is related to a pooling of blood in the lower extremities and is not related to a fluid volume deficit. DIF: Cognitive Level: Application TOP: Rehabilitation MSC: NCLEX: Physiological Integrity
REF: 1197 | 1199 OBJ: 7 KEY: Nursing Process Step: Implementation
15. The nurse takes special care to be gentle in caring for patients with spinal cord injuries to
avoid stimulating the autonomic nervous system and triggering which condition? a. Paresis b. Heterotopic ossification c. Postural hypotension d. Autonomic dysreflexia ANS: D
Autonomic dysreflexia is a sudden and extreme elevation in blood pressure caused by a reflex action of the autonomic nervous system. It is the result of stimulation of the body below the level of the spinal cord injury. DIF: Cognitive Level: Application TOP: Rehabilitation MSC: NCLEX: Physiological Integrity
REF: 1199 OBJ: 7 KEY: Nursing Process Step: Implementation
16. The nurse instructs the mother of a 5-year-old who sustained a mild brain injury that
although all neurologic evaluations are normal, her child may exhibit postconcussive syndrome. What are common characteristics of this syndrome? a. Convulsions and high fever b. Irritability and memory deficits c. Muscular twitching and muscle pain d. Paresis of limbs and fatigue ANS: B
Mild brain injury is characterized by brief or no loss of consciousness. This type constitutes the majority of head injuries. Neurologic examinations are often normal. Postconcussive syndrome can persist for months, years, or indefinitely. Signs and symptoms include fatigue, headache, vertigo, lethargy, irritability, personality changes, cognitive deficits, decreased information processing speed and memory, understanding, learning, and perceptual difficulties. DIF: Cognitive Level: Application TOP: Rehabilitation MSC: NCLEX: Physiological Integrity
REF: 1199 OBJ: 7 KEY: Nursing Process Step: Implementation
17. When changing the position of a patient with a spinal cord injury at T4, the nurse should
recognize that what symptom is an indication of an episode of autonomic dysreflexia? a. Nausea b. Pallor c. Goose bumps d. Dizziness ANS: C
Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure injuries, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets. Other symptoms may include diaphoresis, shivering, goose bumps, flushing of the skin, and a severe pounding headache. DIF: Cognitive Level: Analysis TOP: Rehabilitation MSC: NCLEX: Physiological Integrity
REF: 1196 OBJ: 7 KEY: Nursing Process Step: Assessment
18. When assessing a patient with a traumatic brain injury, the nurse notes that his memory is
improving. The nurse should explain to the family that what other symptom may occur with memory improvement? a. Decrease in learning ability b. Depression c. Anger d. Increased concentration ANS: B
Generally, the more memory improves in a patient with a brain injury, the more the patient becomes depressed. DIF: Cognitive Level: Analysis TOP: Rehabilitation MSC: NCLEX: Psychosocial Integrity
REF: 1200 OBJ: 7 KEY: Nursing Process Step: Assessment
19. When caring for a 32-year-old Hispanic male who has become disabled, on what should
the rehabilitation team base the priority of treatment goals? a. Difficulty of the language barrier b. Cultural significance of the disability
c. Depth of the patient’s support system d. Attitude toward rehabilitation ANS: B
Culture defines the significance of disease and disability. Although all of the options must be addressed, the significance of the disability has highest priority. DIF: Cognitive Level: Analysis TOP: Rehabilitation MSC: NCLEX: Psychosocial Integrity
REF: 1194 OBJ: 2 KEY: Nursing Process Step: Assessment
20. What is the best way to define a handicap? a. Any loss of function b. A disability that interferes with one’s normal functioning c. Any loss of ability to perform activities of daily living d. An irreversible lifelong impairment ANS: B
A handicap is a disadvantage for a given individual from an impairment that limits his or her role performance. A particular handicap for one person might not pose any handicap for another with the same disability. An impairment is a loss of function. A functional limitation is a disability that interferes with one’s normal functioning. A chronic illness is an irreversible lifelong impairment. DIF: Cognitive Level: Comprehension REF: 1196 OBJ: 1 TOP: Rehabilitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 21. What should the nurse do to decrease the potential for a deep vein thrombosis (DVT) in a
patient who is a paraplegic from a spinal cord injury? a. Massage the patient’s legs daily. b. Perform passive range-of-motion exercises. c. Encourage frequent warm baths. d. Allow the patient’s legs to dangle for a period of 10 minutes several times a day. ANS: B
DVTs are a problem for patients with a spinal cord injury. Passive range-of-motion exercises manipulate the muscles, which improves venous return, reducing the probability of DVT. DIF: Cognitive Level: Application REF: 1199 OBJ: 5 TOP: Rehabilitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 22. When the nurse observes a patient experiencing a severe episode of autonomic dysreflexia,
what should be the initial intervention? a. Locate the cause of irritation. b. Assess the blood pressure. c. Cover the patient with several blankets. d. Raise the head of the bed to a high Fowler’s position. ANS: D
The head of the bed should be raised immediately. Raising the head of the bed will reduce the blood pressure. Finding the cause of the episode is secondary to preventing the possibility of a stroke from the hypertension. DIF: Cognitive Level: Analysis TOP: Rehabilitation MSC: NCLEX: Physiological Integrity
REF: 1197 | 1199 OBJ: 5 KEY: Nursing Process Step: Implementation
23. When speaking to a group of high school students, the rehabilitation nurse states that
spinal cord injuries resulting in paralysis occur mainly as the result of traumatic accidents in which group of individuals? a. Middle-aged men b. Older adult females c. Young males d. Young females ANS: C
Individuals paralyzed by spinal cord injuries are primarily young males. DIF: Cognitive Level: Comprehension REF: 1196 OBJ: 2 TOP: Rehabilitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 24. The spinal cord injury patient has paralysis of all extremities and bowel and bladder
disturbance. The nurse recognizes the injury as most likely occurring at what vertebral level? a. C1 to C2 b. C3 to C4 c. C2 to C7 d. C4 to C7 ANS: C
The vertebral level of injury for a cervical cord is C2 to C7 if the patient has paralysis of all extremities and trunk, and has lost control of bowel and bladder function. DIF: Cognitive Level: Application TOP: Rehabilitation MSC: NCLEX: Physiological Integrity
REF: 1196 OBJ: 2 KEY: Nursing Process Step: Assessment
25. The rehabilitation nurse can use basic rehabilitation skills regardless of the origin of the
disability. What intervention would be effective for a person with arthritis, a person with a brain injury, or a person with a spinal cord injury? a. Encouraging large fluid intake b. Seeking spiritual support from a higher being c. Using the spouse as a support system d. Positioning to maintain alignment ANS: D
Alignment preservation is an implementation that is appropriate for a variety of rehabilitation patients, regardless of the origin of their disability. DIF: Cognitive Level: Application
REF: 1192-1193
OBJ: 5
TOP: Rehabilitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 26. What should a nurse explain to a patient as a cause of triggering autonomic dysreflexia? a. Loud sound b. Distended bladder c. Leg cramp d. Sudden chilling ANS: B
Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure injuries, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets. DIF: Cognitive Level: Comprehension TOP: Rehabilitation MSC: NCLEX: Physiological Integrity
REF: 1199 OBJ: 5 KEY: Nursing Process Step: Implementation
27. The rehabilitation nurse stresses to the family of a patient with a brain injury that difficult
and painful rehabilitation will probably be required for what length of time? a. 1 to 2 years b. 2 to 4 years c. 5 to 10 years d. 6 to 12 years ANS: C
Most brain-related disabilities, including physical, cognitive, and psychosocial difficulties, call for at least 5 to 10 years of difficult and painful rehabilitation; many require lifelong treatment and attention. DIF: Cognitive Level: Knowledge REF: 1199 OBJ: 7 TOP: Rehabilitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 28. The rehabilitation nurse recognizes that the majority of patients with head injuries show no
abnormal neurologic findings and experience no loss of consciousness. How should the nurse categorize this type of brain injury? a. Mild b. Moderate c. Severe d. Catastrophic ANS: A
Mild brain injury is characterized by no loss of consciousness and no abnormal neurologic findings. DIF: Cognitive Level: Knowledge TOP: Rehabilitation MSC: NCLEX: Physiological Integrity
REF: 1199 OBJ: 2 KEY: Nursing Process Step: Assessment
29. A 33-year-old patient with a spinal cord injury says to the nurse, “I’ve let my family down.
I don’t know what to do.” What would be the best response by the nurse? a. “After your rehabilitation starts, you’ll feel better.” b. “You should be grateful you are alive.” c. “What does this injury mean to you?” d. “Technological advances are changing the future for spinal cord injury victims.” ANS: C
The patient should be encouraged to express his or her feelings about the disability. DIF: Cognitive Level: Analysis TOP: Rehabilitation MSC: NCLEX: Psychological Integrity
REF: 1198 OBJ: 5 KEY: Nursing Process Step: Assessment
30. The nurse used a diagnosis of impaired cognition for a 40-year-old patient with a brain
injury. Which assessment data would support the diagnosis? a. Frequently becomes violent. b. Becomes easily fatigued. c. Is depressed. d. Cannot add three numbers in his head. ANS: D
Impaired cognition includes problems in thinking, impaired concentration, and impaired information processing. DIF: Cognitive Level: Analysis TOP: Rehabilitation MSC: NCLEX: Physiological Integrity
REF: 1200 OBJ: 5 KEY: Nursing Process Step: Assessment
31. The patient with a brain injury is beginning to regain memory. The nurse explains to the
family that what will most likely occur? a. The patient will become less combative. b. The patient will become angrier. c. The patient will become more depressed. d. The patient will wish to retire. ANS: C
Generally, the more the memory improves, the more the patient becomes depressed. DIF: Cognitive Level: Comprehension TOP: Rehabilitation MSC: NCLEX: Psychosocial Integrity
REF: 1200 OBJ: 7 KEY: Nursing Process Step: Assessment
MULTIPLE RESPONSE 1. The nurse explains that the Americans with Disabilities Act of 1990 defines a person as
disabled if which criteria are met? (Select all that apply.) a. The person has a physical or mental impairment. b. The person is limited in at least one major life activity. c. The person has a medical record of the impairment.
d. The person is unemployed. e. The person needs assistance in completion of ADLs. ANS: A, B, C
The definition is that a disabled person may have a physical or mental impairment that limits the person in one or more major life activities and has a medical record of that disability. DIF: Cognitive Level: Comprehension REF: 1196 TOP: Americans with Disabilities Act (ADA) KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
OBJ: 2
2. The nurse is caring for a victim of posttraumatic stress syndrome. The nurse identifies
which techniques as examples of therapeutic communication? (Select all that apply.) a. Listening b. Reframing c. Characterizing d. Normalizing responses e. Working to develop trust ANS: A, B, D, E
The techniques of therapeutic communication that are important to use with the PTSD patient are listening, reframing, normalizing responses, and working to develop trust. DIF: Cognitive Level: Comprehension REF: 1196 OBJ: 9 TOP: PTSD KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1. The rehabilitation nurse assesses localized edema around the knee of a patient with
paraplegia. The nurse suspects that this is the first sign of
ossification.
ANS:
heterotopic Heterotopic ossification is a bony growth in joints of spinal cord injury patients below the injury that ultimately limits range of motion. DIF: Cognitive Level: Comprehension TOP: Rehabilitation MSC: NCLEX: Physiological Integrity
REF: 1199 OBJ: 7 KEY: Nursing Process Step: Assessment
2. A child who was struck by a car and suffered a closed head injury was unconscious for 24
hours before waking. The nurse recognizes this as a
brain injury.
ANS:
moderate A period of unconsciousness of 1 to 24 hours is characteristic of a moderate brain injury.
DIF: Cognitive Level: Application| Cognitive Level: Comprehension REF: 1199 OBJ: 7 TOP: Rehabilitation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse who assesses for cultural influences, values cultural diversity, and incorporates
cultural knowledge in practice is said to be culturally
.
ANS:
competent A culturally competent nurse includes knowledge of cultural values and influences in their nursing practice. DIF: Cognitive Level: Application REF: 1194 TOP: Culture KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 5
Chapter 40: Hospice Care Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. What is the overall objective of hospice service? a. Relieve symptoms of terminal disease. b. Educate the patient about the process of death. c. Keep the patient comfortable as death approaches. d. Relieve the family of the stress of death. ANS: C
Hospice is a philosophy of care that provides support and comfort to patients who are dying. DIF: Cognitive Level: Comprehension REF: 1204 OBJ: 1 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 2. Who was responsible for renewing the hospice philosophy in the 1960s? a. Cicely Saunders b. Lillian Wald c. Dorothea Dix d. Florence Nightingale ANS: A
The idea of hospice is originated in Europe. Dame Cicely Saunders renewed the idea of hospice in the 1960s. DIF: Cognitive Level: Knowledge REF: 1204 TOP: Hospice KEY: Nursing Process Step: N/A
OBJ: 1 MSC: NCLEX: N/A
3. The hospice nurse clarifies that hospice service is initiated when what type of treatment is
no longer effective? a. Proactive b. Palliative c. Alternative d. Curative ANS: D
Hospice care is appropriate when curative treatment is no longer effective. Hospice service is palliative, proactive, and an alternative to curative treatment. DIF: Cognitive Level: Comprehension REF: 1206 OBJ: 2 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 4. The nurse differentiates between curative and palliative care. What is true of curative
treatment? a. Curative treatment is centered on symptom control. b. Curative treatment is focused on prolonging life.
c. Curative treatment is not concerned with dying. d. Curative treatment is the only care covered by health insurance. ANS: B
Curative treatment is aggressive care that aims to cure disease and prolong life. Palliative care is not curative in nature and is centered on symptom control. Both types of care are typically covered by health insurance. DIF: Cognitive Level: Application REF: 1206 OBJ: 2 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 5. Because the family is confused about the meaning of palliative care, the hospice nurse
needs to explain the focus of care. What is the focus of palliative care? a. An aggressive approach to prolong life b. A protocol of pain relief c. A form of organized care, which relieves the family of responsibility d. An integrated service of support for alleviation of symptoms ANS: D
Palliative care is not curative but is an integrated plan designed to relieve pain and control symptoms. The goal is not to prolong life. While pain relief may be one aspect of hospice care, it is not what treatment is centered upon. The family is not relieved of their responsibility. DIF: Cognitive Level: Analysis REF: 1205-1206 OBJ: 2 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 6. The hospice nurse explains that to qualify for admission to a hospice, the attending health
care provider must certify that the patient has a life expectancy of fewer than how many months? a. 2 months b. 3 months c. 4 months d. 6 months ANS: D
The patient must meet certain criteria to be admitted to hospice, such as a prognosis of 6 months or fewer to live. DIF: Cognitive Level: Comprehension REF: 1206 OBJ: 3 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 7. The hospice nurse requests that the patient designate a primary caregiver for himself. What
is true of the primary caregiver? a. Must be a relative. b. Has complete control over the patient’s care. c. Assumes ongoing responsibility for health maintenance of the patient. d. Must have power of attorney.
ANS: C
A primary caregiver is one who assumes responsibility for health maintenance and therapy. It is not necessary that the primary caregiver be a relative. The primary caregiver does not have complete control over the patient’s care, and it is not necessary for the primary caregiver to have power of attorney. DIF: Cognitive Level: Application REF: 1207 OBJ: 3 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 8. Why is it important for the hospice nurse to provide time to confer with the patient and
family? a. To show concern b. To report changes in the plan of care designed by the team c. To confirm the ongoing reimbursement d. To plan for changes in the scope of care ANS: D
No changes should be made to the patient’s plan of care without first discussing it with the entire family. The family should be involved in planning the changes in the scope of care. DIF: Cognitive Level: Application REF: 1209 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 1
9. The patient informs the hospice nurse, “I’m not sold on this hospice thing. I’m not looking
for Jesus, I’m just dying.” What would be the most therapeutic response by the nurse? a. “Spiritualism is as you define it.” b. “Rejecting the spiritual aspect of yourself may not be in your best interest.” c. “Hospice service is about how to make your remaining time meaningful.” d. “Based on what you say, hospice service may not answer your needs.” ANS: C
The holistic approach of hospice pertains to the total patient care including physical, emotional, social, economic, and spiritual needs of the patient with no particular emphasis on any one of those aspects. DIF: Cognitive Level: Analysis REF: 1206 | 1207 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 1
10. What is the role of the hospice medical director? a. To design and direct the plan of care b. To evaluate the appropriateness of the care c. To function as mediator between the team and the attending health care provider d. To take the place of the patient’s attending health care provider ANS: C
The medical director is a mediator between the interdisciplinary team and the attending health care provider. The interdisciplinary team designs the plan of care. The primary team, along with the interdisciplinary team, evaluates the appropriateness of care. The medical director does not take the place of the attending health care provider, but instead acts as a consultant for the attending health care provider. DIF: Cognitive Level: Application REF: 1208 OBJ: 4 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 11. The hospice nurse tells the family that the nurse coordinator, an RN, will visit them. What
is the role of the nurse coordinator? a. Collect initial fees for the hospice service. b. Officially admit the patient to the hospice service. c. Assist with accessing community resources. d. Assist with funeral planning. ANS: B
The role of the nurse coordinator is to do the initial assessment, admit the patient, and develop the plan of care with the interdisciplinary team. The nurse coordinator would not be responsible for collecting fees at the initiation of services. The social worker would assist with community resources. The spiritual coordinator would assist with funeral planning. DIF: Cognitive Level: Application REF: 1208 | 1209 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 4
12. The social worker evaluates and assesses the psychosocial needs of the patient. To work in
a hospice, the social worker must have at least which degree? a. Associate b. Bachelor’s c. Master’s d. Doctorate ANS: B
The hospice social worker must have at least a bachelor’s degree. DIF: Cognitive Level: Knowledge REF: 1208 TOP: Hospice KEY: Nursing Process Step: N/A
OBJ: 4 MSC: NCLEX: N/A
13. The hospice spiritual coordinator can be affiliated with any religion, assists with the
spiritual assessment of the patient, and develops the plan of care regarding spiritual matters. To work in a hospice, what degree should the spiritual coordinator possess? a. Bachelor’s degree b. Master’s degree c. Seminary degree d. Associate degree ANS: C
The hospice spiritual coordinator must have a seminary degree.
DIF: Cognitive Level: Knowledge REF: 1208 TOP: Hospice KEY: Nursing Process Step: N/A
OBJ: 4 MSC: NCLEX: N/A
14. The hospice nurse introduced the family to the volunteer coordinator who will assign a
volunteer to the patient. What can a hospice volunteer do for a patient and caregiver? a. Give the family respite. b. Give necessary medication in the absence of the nurse. c. Be at the family’s disposal 16 hours a week. d. Bathe the patient. ANS: A
The volunteer coordinator assigns volunteers to the family to give the family respite. The volunteer cannot give medication. A dedicated number of hours per week are not mandated. It is not the role of the volunteer to provide personal care. DIF: Cognitive Level: Comprehension REF: 1208 | 1209 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 4
15. The hospice nurse instructs the family that they have access to a bereavement coordinator
who follows the plan of care focused on the caregiver after the death of the patient. For how long of a period of time will the caregiver and family have access to the bereavement coordinator? a. One week b. One month c. One year d. Two years ANS: C
The bereavement coordinator follows the plan of care for the caregiver for at least a year following the death of the patient. DIF: Cognitive Level: Comprehension REF: 1210 OBJ: 4 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 16. The hospice nurse instructs the family that they have access to a hospice pharmacist, who
is available for consultation on the drugs the hospice patient may be taking. What other role does the hospice pharmacist fill? a. Administer all drugs necessary for pain alleviation. b. Evaluate drug interactions with food and other medications. c. Evaluate the safety of the drug storage in the patient’s home. d. Monitor drug effectiveness by frequent phone interviews with the family. ANS: B
The hospice pharmacist is available to consult about drug interactions with other drugs or food. The pharmacist does not administer the drugs. The nurse would evaluate the safety of drug storage in the home and monitor the drug effectiveness. DIF: Cognitive Level: Analysis REF: 1210 OBJ: 4 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
17. Who conducts the nutritional assessment at the time of admission to hospice care? a. Health care provider b. Hospice nurse c. Caregiver d. Unlicensed assistive personnel ANS: B
The hospice nurse does the nutritional assessment during admission. DIF: Cognitive Level: Comprehension REF: 1210 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
18. When a deficiency in nutritional status of a patient is assessed, what action should be taken
by the hospice nurse? a. Make a comprehensive grocery list for the caregiver. b. Alert the licensed medical nutritionist. c. Seek culturally appropriate methods to increase nutrition. d. Instruct the caregiver to give the patient multivitamins. ANS: B
The hospice nurse can call on the nutritionist for assistance for the patient who is assessed as having a nutritional deficit. The nutritionist can then provide assistance with meal planning and diet counseling. DIF: Cognitive Level: Analysis REF: 1210 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
19. What symptom of hospice patients is the most dreaded and feared, and should be a priority
of symptom management? a. Fear b. Anger c. Grief d. Pain ANS: D
While hospice patients experience all of these symptoms, pain is the most dreaded and feared. Pain disrupts the quality, activities, and enjoyment of life. Pain should be a priority of symptom management in hospice care. DIF: Cognitive Level: Application REF: 1211 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 5
20. During a pain assessment, the patient tells the nurse that the pain is aching, stabbing, and
throbbing. What type of pain is the patient describing? a. Visceral b. Neuropathic c. Somatic d. Psychogenic
ANS: C
Somatic pain arises from the musculoskeletal system and is aching, stabbing, or throbbing. Visceral pain arises from the internal organs and is described as cramping, dull, or squeezing. Neuropathic pain arises from the neurologic system and is described as tingling, burning, or shooting. DIF: Cognitive Level: Application REF: 1212 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
21. What are the drugs of choice when caring for the hospice patient? a. Nonsteroidal antiinflammatory drugs b. Anticholinergic drugs c. Duragesic patches d. Morphine derivatives ANS: D
Morphine derivatives are popular drugs of choice when dealing with the hospice patient because they have a wide variety of modes of administration and provide good pain control. DIF: Cognitive Level: Application REF: 1212 OBJ: 6 TOP: Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The nurse should educate the patient and caregiver that large doses of narcotics are
required to control pain. What is the optimal dose for pain medications? a. The smallest amount possible to achieve some effects b. The dose that provides pain relief c. The dose that is not addictive d. The dose that works for most people ANS: B
The patient and caregiver should understand that pain can be controlled and that using large doses of opioids is common and necessary to achieve that control. It is good to educate the patient and caregiver that the dose that works is the dose that works. DIF: Cognitive Level: Analysis REF: 1212 | 1214 OBJ: 6 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse warns that nausea is a common side effect with opioid treatment. What is the
best treatment for nausea caused by opioids? a. Antiemetics b. Ice chips c. Dry crackers d. Ginger ale ANS: A
Rather than discontinuing the opioid, the nausea should be treated with an antiemetic. DIF: Cognitive Level: Application
REF: 1214
OBJ: 6
TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. When educating a patient concerning ways to prevent nausea, the nurse suggests that
eating slowly in a pleasant atmosphere will help, as well as taking an antiemetic before meals. How many minutes before meals should the patient take the antiemetic? a. 10 b. 20 c. 30 d. 60 ANS: C
Taking an antiemetic 30 minutes before meals reduces nausea and increases appetite. DIF: Cognitive Level: Application REF: 1214 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. What is the most common problem of the terminally ill patient that is caused by narcotics? a. Malnutrition b. Constipation c. Fluid retention d. Dehydration ANS: B
One of the most common opioid-induced problems of the terminally ill patient is constipation. DIF: Cognitive Level: Comprehension REF: 1214 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. The hospice nurse documents an assessment finding of cachexia in the patient record.
What does cachexia describe? a. Deep sleep and unresponsiveness b. Marked weakness and emaciation c. Total addiction to opioids d. Renewed energy ANS: B
Malnutrition marked by weakness and emaciation is called cachexia. DIF: Cognitive Level: Knowledge REF: 1215 TOP: Hospice KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
27. Which of the following is an expected part of the end-of-dying process? a. Denial b. Despair c. Anorexia d. Depression ANS: C
The nurse often has to reassure the patient and caregiver that anorexia is part of the end-of-dying process. DIF: Cognitive Level: Comprehension REF: 1215 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. Which medication relaxes the patient’s respiratory effort and thus increases the efficiency
of the patient’s respiratory status? a. Aminophylline b. Theophylline c. Epinephrine d. Morphine ANS: D
Respiratory distress may be relieved by morphine. DIF: Cognitive Level: Application REF: 1215 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. Why should the hospice nurse delay the use of oropharyngeal suctioning? a. It will decrease mucus production. b. It will be uncomfortable for the patient. c. It is not necessary. d. It puts the patient at risk for infection. ANS: B
Suctioning should only occur if the patient is choking because it causes an increase in mucus production and is uncomfortable for the patient. DIF: Cognitive Level: Application REF: 1215 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. The hospice nurse recommends that the patient prepare the document that provides
guidance to the family concerning the patient’s wishes regarding life-support measures and organ donation. What is this document called? a. Power of attorney b. Living will c. Advance directive d. Conservatorship ANS: C
An advance directive is a document prepared while the patient is alive and competent that provides guidance to the family and health care team in the event the person can no longer make decisions. DIF: Cognitive Level: Knowledge REF: 1217 OBJ: 8 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
31. The hospice nurse instructs caregivers in repositioning the patient because the patient
spends most of the time reclining. What problem can this cause? a. Contractures b. Pressure injuries c. Bruising d. Excoriation ANS: B
Increased weakness is noted in the last stages of a terminal illness. With increased weakness, activity intolerance increases, and the patient spends most of the time reclining. This leads to risk for skin impairment and the formation of pressure injuries. DIF: Cognitive Level: Application REF: 1216 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. When air hunger is assessed in the dying patient, the nurse can perform which
interventions? (Select all that apply.) a. Circulate the air with a fan. b. Use a tranquilizer to decrease anxiety. c. Provide good oral hygiene. d. Perform careful suctioning. e. Raise the head of the bed 30 degrees. ANS: A, B, C, E
Circulating the air with a fan, administering a tranquilizer to decrease anxiety, providing good oral hygiene, and raising the head of the bed 30 degrees are all interventions that can aid in relieving air hunger in the dying patient. Suctioning will increase mucus production, which will make the dyspnea worse. DIF: Cognitive Level: Application REF: 1215 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The hospice nurse educates the patient and family about the members of the
interdisciplinary team. Which caregivers are included? (Select all that apply.) a. Medical director b. Nurse coordinator c. Social worker d. Spiritual coordinator e. Psychologist ANS: A, B, C, D
The hospice interdisciplinary team includes the medical director, nurse coordinator, social worker, and spiritual coordinator. The interdisciplinary team does not include a psychologist. DIF: Cognitive Level: Comprehension REF: 1207 OBJ: 4 TOP: Hospice KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance 3. Which are signs and symptoms of approaching death? (Select all that apply.) a. Mottled extremities b. Significant increase in urine output c. Increased restlessness and pulling at bed linens d. Alteration in rhythmic respiration e. Increased pulse rate ANS: A, C, D, E
Mottled extremities, a significant decrease in urine output, an increased restlessness, alteration in rhythmic respirations, and increased pulse rate are all symptoms of approaching death. DIF: Cognitive Level: Application REF: 1217 OBJ: 7 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. What are the goals of hospice service? (Select all that apply.) a. Alleviating symptoms of approaching death b. Educating and supporting primary caregivers c. Using family input for designing a plan of care d. Encouraging patients and caregivers to enjoy life e. Focusing on the desires of the family in the plan of care ANS: A, B, C, D
The plan of care should focus on the desires of the patient, not the desires of the family members. DIF: Cognitive Level: Application REF: 1206 OBJ: 1 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1. When the dying patient becomes confused, the nurse should
him or her.
ANS:
reorient Reorientation regarding time, date, and location is the least distressing to the dying patient. DIF: Cognitive Level: Application REF: 1217 OBJ: 5 TOP: Hospice KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
Chapter 41: Introduction to Anatomy and Physiology Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. The anatomic term a. anterior b. posterior c. medial d. cranial
means toward the midline.
ANS: C
The term medial indicates an anatomic direction toward the midline. DIF: Cognitive Level: Knowledge TOP: Anatomic terminology MSC: NCLEX: Physiological Integrity
REF: 1221 OBJ: 2 KEY: Nursing Process Step: Assessment
2. What are the smallest living components in our body? a. Cells b. Organs c. Electrons d. Osmosis ANS: A
Cells are considered to be the smallest living units of structure and function in our body. DIF: Cognitive Level: Knowledge TOP: Structural levels of organization MSC: NCLEX: Physiological Integrity
REF: 1224 OBJ: 6 KEY: Nursing Process Step: N/A
3. What is the largest organelle, responsible for cell reproduction and control of other
organelles? a. Nucleus b. Ribosome c. Mitochondrion d. Golgi apparatus ANS: A
The nucleus is the largest organelle within the cell. DIF: Cognitive Level: Knowledge TOP: Parts of the cell MSC: NCLEX: Physiological Integrity
REF: 1225 OBJ: 8 KEY: Nursing Process Step: Assessment
4. When the patient complains of pain in the bladder, the patient will indicate discomfort in
which body cavity? a. Pelvic b. Mediastinum c. Dorsal d. Abdominal
ANS: A
A subdivision called the pelvic cavity contains the lower portion of the large intestine (lower sigmoid colon, rectum), urinary bladder, and internal structures of the reproductive system. DIF: Cognitive Level: Comprehension REF: 1223 TOP: Body cavity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
5. The four phases of cell division all occur in: a. diffusion. b. mitosis. c. osmosis. d. filtration. ANS: B
During mitosis, the cell goes through four phases: prophase, metaphase, anaphase, and telophase. DIF: Cognitive Level: Knowledge REF: 1227 TOP: Cell division KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 9
6. Telophase is which phase of cell reproduction during mitosis? a. First phase b. Latent phase c. Final phase d. Spindle phase ANS: C
During this final phase of cell division, the two nuclei appear and the chromosomes disperse. DIF: Cognitive Level: Knowledge REF: 1227 TOP: Cell division KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 9
7. The nurse is aware that which muscle group is both striated and involuntary? a. Skeletal b. Glial c. Cardiac d. Visceral ANS: C
The cardiac muscle is both striated and involuntary. DIF: Cognitive Level: Knowledge REF: 1229 TOP: Tissues KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 11
8. What is a group of several different kinds of tissues arranged so that together they can
perform a more complex function than any tissue alone?
a. b. c. d.
Organ System Cell Endoplasmic reticulum
ANS: A
When several kinds of tissues are united to perform a more complex function than any tissue alone, they are called organs. DIF: Cognitive Level: Knowledge REF: 1231 TOP: Organs KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 7
9. What traits describe visceral muscles? a. Smooth and voluntary b. Smooth and involuntary c. Striated and voluntary d. Striated and involuntary ANS: B
Visceral (smooth) muscles will not function at will; thus, they act involuntarily. DIF: Cognitive Level: Knowledge REF: 1229 TOP: Tissues KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 7
10. How are the thoracic and abdominal cavities separated? a. By the pleura b. By the diaphragm c. By the sagittal plane d. By the peritoneum ANS: B
The diaphragm (a muscle directly beneath the lungs) separates the ventral cavity into the thoracic (chest) and abdominal cavities. DIF: Cognitive Level: Knowledge TOP: Ventral cavity MSC: NCLEX: Physiological Integrity
REF: 1222 OBJ: 3 KEY: Nursing Process Step: Assessment
11. What is the broad section of biology dealing with the description of human structure? a. Hematology b. Anatomy c. Kinesiology d. Physiology ANS: B
Anatomy is the study, classification, and description of the structure and organs of the body. DIF: Cognitive Level: Knowledge TOP: Terminology MSC: NCLEX: Physiological Integrity
REF: 1221 OBJ: 1 KEY: Nursing Process Step: N/A
12.
explains the processes and functions of many structures of the body and how they interact with one another. a. Anatomy b. Mitosis c. Filtration d. Physiology ANS: D
Physiology explains the processes and functions of the various structures and how they interrelate with one another. DIF: Cognitive Level: Knowledge TOP: Terminology MSC: NCLEX: Physiological Integrity
REF: 1221 OBJ: 1 KEY: Nursing Process Step: N/A
13. The anatomic structure that is not in the thoracic cavity is/are the a. heart b. lungs c. blood vessels d. transverse colon
.
ANS: D
The transverse colon is located in the abdominal cavity. DIF: Cognitive Level: Comprehension TOP: Thoracic cavity MSC: NCLEX: Physiological Integrity
REF: 1223 OBJ: 5 KEY: Nursing Process Step: Assessment
14. When several organs and parts are grouped together for certain functions, they form: a. tissues. b. systems. c. cells. d. membranes. ANS: B
A system is an organization of varying numbers and kinds of organs arranged so that together they can perform complex functions for the body. DIF: Cognitive Level: Knowledge REF: 1224 TOP: Systems KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 7
15. What are the distinct surface proteins of the plasma membrane essential in determining? a. Tissue typing b. Blood count c. Effectiveness of a drug d. Sexual maturity ANS: A
The plasma membrane has distinct surface proteins as coming from one individual. This is the basis for the procedure of tissue typing to determine compatibility before an organ transplant. DIF: Cognitive Level: Comprehension REF: 1225 TOP: Cells KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
16. In anatomic terminology, posterior means toward the: a. tail. b. head. c. back. d. trunk. ANS: C
The posterior is toward the back. DIF: Cognitive Level: Knowledge TOP: Anatomic terminology MSC: NCLEX: Physiological Integrity 17.
REF: 1221 OBJ: 2 KEY: Nursing Process Step: Assessment
What does the transverse body plane divide? The front and back (coronal) of the body The body lengthwise (two equal halves) The superior and inferior portions of the body The body into axial and appendicular
a. b. c. d.
ANS: C
The transverse plane cuts the body horizontally into the sagittal and the frontal planes, dividing the body into caudal and cranial portions. DIF: Cognitive Level: Knowledge REF: 1222 TOP: Body planes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18. Caudal is defined as toward the a. head b. feet c. tail d. chest
OBJ: 3
.
ANS: C
Caudal is a directional word that indicates toward the “tail,” the distal portion of the spine. DIF: Cognitive Level: Knowledge TOP: Anatomic terminology MSC: NCLEX: Physiological Integrity
REF: 1221 OBJ: 3 KEY: Nursing Process Step: Assessment
19. What is the term for movement of water from an area of lower solute concentration to an
area of higher solute concentration? a. Absorption b. Filtration
c. Diffusion d. Osmosis ANS: D
Osmosis is the passage of water from less concentrated solution to more concentrated solution. DIF: Cognitive Level: Knowledge TOP: Transport process MSC: NCLEX: Physiological Integrity
REF: 1228 OBJ: 10 KEY: Nursing Process Step: Assessment
20. What is the type of tissue composed of cells that contract in response to a message from
the brain or spinal cord? a. Epithelial b. Connective c. Membrane d. Muscle ANS: D
Muscle tissue is composed of cells that contract in response to a message from the brain or spinal cord. DIF: Cognitive Level: Knowledge REF: 1229 TOP: Tissues KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 7
21. What is the type of tissue associated with the storage of fat? a. Areolar tissue b. Adipose tissue c. Osseous tissue d. Muscle tissue ANS: B
Adipose tissue is associated with the important function of storing fat. DIF: Cognitive Level: Knowledge REF: 1230 TOP: Tissues KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 11
22. What are the thin sheets of tissue that lubricate and line the body surfaces that open to the
outside environment? a. Mucous membranes b. Serous membranes c. Cytoplasm d. Involuntary visceral muscles ANS: A
Mucous membranes secrete mucus. They line the body surfaces that open to the outside environment. DIF: Cognitive Level: Knowledge REF: 1229 TOP: Tissues KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 7
23. What is the process by which a cell digests a foreign material by surrounding it? a. Pinocytosis b. Phagocytosis c. Absorption d. Diffusion ANS: B
Phagocytosis is the process that permits a cell to engulf or surround any foreign material and digest it. DIF: Cognitive Level: Knowledge TOP: Active Transport process MSC: NCLEX: Physiological Integrity
REF: 1227 OBJ: 10 KEY: Nursing Process Step: Assessment
24. Active transport in the movement of ions and other water-soluble particles across cell
membranes requires that the body uses its: a. rapid filtration. b. charged diffusion. c. a chemical pump. d. osmosis. ANS: C
Active transport of ions and other water-soluble particles of the cell membrane require a chemical pump, such as insulin, to move glucose into the cell. DIF: Cognitive Level: Comprehension TOP: Active Transport process MSC: NCLEX: Physiological Integrity
REF: 1227 OBJ: 10 KEY: Nursing Process Step: Assessment
25. What is the term for the passage of water containing dissolved materials through a
membrane as the result of a greater mechanical force on one side? a. Metabolism b. Mitosis c. Filtration d. Osmosis ANS: C
Filtration is the movement of water and particles through a membrane by a force from either pressure or gravity. DIF: Cognitive Level: Knowledge TOP: Passive Transport process MSC: NCLEX: Physiological Integrity
REF: 1228 OBJ: 10 KEY: Nursing Process Step: Assessment
26. The nurse is aware that when a patient complains of pain in the epigastric region, the
source of the pain is most likely to be a disorder involving the: a. gallbladder. b. transverse colon. c. stomach. d. appendix.
ANS: C
The epigastric region of the abdomen is comprised of parts of the right and left lobes of the liver and a large portion of the stomach. DIF: Cognitive Level: Comprehension TOP: Epigastric region MSC: NCLEX: Physiological Integrity
REF: 1223 OBJ: 5 KEY: Nursing Process Step: Assessment
27. What are tissues that cover the outside of the body and some internal structures? a. Connective b. Epithelial c. Nerve d. Muscle ANS: B
Epithelial tissue covers the outside of the body and some of the internal structures. DIF: Cognitive Level: Knowledge REF: 1228 TOP: Tissues KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 7
28. When the nurse assesses an arm in proximal to distal order, the assessment is performed
from: a. the shoulder to the fingers. b. front to back. c. fingers to the center of the body. d. center of the body to the fingers. ANS: A
Proximal is nearest the origin of the structure. Distal is farthest from the origin of the structure. DIF: Cognitive Level: Comprehension TOP: Anatomic terminology MSC: NCLEX: Physiological Integrity
REF: 1222 OBJ: 3 KEY: Nursing Process Step: Assessment
29. What is the function of epithelial membranes? a. Secretes mucus, lines ends of bones, and lines bursae. b. Lines ends of bones, secretes synovial fluid, and lines internal surfaces of organs. c. Covers the wall of lower digestive tract, secretes mucus, and lines lungs,
peritoneum, and pericardium. d. Lines lungs, peritoneum, and pericardium, and secretes synovial fluid. ANS: C
The epithelial membrane secretes mucus, lines the lungs, peritoneum, and pericardium, and covers the wall of the lower digestive tract. The synovial membrane secretes synovial fluid to prevent friction between joints and the ends of bones, and lines the bursae found between moving body parts. DIF: Cognitive Level: Knowledge REF: 1229 TOP: Tissues KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 7
30. The nurse explains that pinocytosis is a process by which cells: a. divide. b. take in extracellular fluid. c. use a chemical pump. d. convert mitochondria. ANS: B
Pinocytosis is a process by which the cell wall makes an indentation allowing extracellular fluid to fill in, then encloses it into the cell. DIF: Cognitive Level: Comprehension REF: 1227 OBJ: 10 TOP: Pinocytosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 31. What is the most complex structural level of organization of the body? a. Body as a whole b. Cellular c. Organs d. Chemical ANS: A
The structural levels of organization progress from the least complex (chemical) through cells, tissues, organs, systems to the most complex (the body as a whole). DIF: Cognitive Level: Comprehension TOP: Structural levels of organization MSC: NCLEX: N/A
REF: 1223 OBJ: 6 KEY: Nursing Process Step: N/A
32. Using a poster, the nurse demonstrates the protection of the nucleus. Which layer is the
most superficial? a. Endoplasmic reticulum b. Nuclear membrane c. Plasma membrane d. Cytoplasm ANS: C
The most superficial covering of the nucleus is the plasma membrane, under which is the cytoplasm containing the endoplasmic reticulum, nuclear membrane, and nucleus. DIF: Cognitive Level: Application TOP: Protective covering of nucleus MSC: NCLEX: Physiological Integrity
REF: 1225 OBJ: 8 KEY: Nursing Process Step: Implementation
MULTIPLE RESPONSE 1. Which are among the 11 body systems? (Select all that apply.) a. Lymphatic b. Cellular c. Digestive d. Reproductive
e. Accessory f. Spinal cord ANS: A, C, D
There are 11 body systems: integumentary, respiratory, skeletal, digestive, muscular, nervous, endocrine, urinary, reproductive, cardiovascular, and lymphatic. DIF: Cognitive Level: Knowledge TOP: Body systems MSC: NCLEX: Physiological Integrity
REF: 1226 OBJ: 7 KEY: Nursing Process Step: Assessment
2. Which of the following are characteristics of visceral muscles? (Select all that apply.) a. Involuntary b. Smooth c. Striated d. Independent from the spinal cord e. Voluntary f. Present in the blood vessels ANS: A, B, F
Smooth muscles are smooth, involuntary, and respond to messages from the spinal cord. DIF: Cognitive Level: Application TOP: Voluntary muscle MSC: NCLEX: Physiological Integrity
REF: 1229 OBJ: 7 KEY: Nursing Process Step: Assessment
3. Which of the following are passive transport mechanisms that move material across the
cell membranes? (Select all that apply.) a. Diffusion b. Evaporation c. Filtration d. Osmosis e. Mitosis f. Anaphase ANS: A, C, D
The passive transport systems are diffusion, filtration, and osmosis. DIF: Cognitive Level: Comprehension TOP: Passive transport system MSC: NCLEX: Physiological Integrity
REF: 1228 OBJ: 10 KEY: Nursing Process Step: Assessment
4. The nurse clarifies that the dorsal cavity is composed of the: (Select all that apply.) a. Descending colon b. Kidneys c. Gallbladder d. Brain e. Pancreas f. Spinal cavities ANS: D, F
The dorsal cavity is composed of the brain and the spinal cavities. The spinal cavities hold the cord and the meninges. DIF: Cognitive Level: Comprehension TOP: Dorsal cavity MSC: NCLEX: Physiological Integrity
REF: 1223 OBJ: 5 KEY: Nursing Process Step: Implementation
COMPLETION 1. The nurse clarifies that the three functions of epithelial tissue are protection,
,
and secretion. ANS:
absorption The function of epithelial tissue is protection by covering the body and preventing invasion; absorption by absorbing material; and secretion by secreting mucus to line and moisten the body surfaces. DIF: Cognitive Level: Comprehension TOP: Epithelial tissue function MSC: NCLEX: Physiological Integrity
REF: 1231 OBJ: 7 KEY: Nursing Process Step: Implementation
2. The nurse explains that
are small saclike structures inside the cell that digest compounds that have invaded the cell. ANS:
lysosomes Lysosomes are small saclike structures inside the cell that digest compounds that have invaded the cell. DIF: Cognitive Level: Knowledge REF: 1226 OBJ: 8 TOP: Lysosomes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The body plane that divides the body into the ventral and dorsal section is the
plane. ANS:
coronal The coronal plane divides the body into ventral and dorsal (front and back) sections. DIF: Cognitive Level: Comprehension TOP: Coronal plane MSC: NCLEX: Physiological Integrity
REF: 1222 OBJ: 3 KEY: Nursing Process Step: Assessment
Chapter 42: Care of the Surgical Patient Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. The patient who had a nephrectomy yesterday has not used the patient-controlled analgesia
(PCA) delivery system but admits to being in pain but fearful of addiction. What is the nurse’s best response? a. “Modern analgesic drugs do not cause addiction.” b. “Pain relief is worth a short period of addiction.” c. “Addiction rarely occurs in the brief time postsurgical analgesia is required.” d. “Addiction could be a real concern.” ANS: C
Addiction rarely occurs in the short time that it is required after surgery. Postsurgical analgesia, because of its brief application, does not usually produce a physical or a psychological dependence. DIF: Cognitive Level: Application TOP: Fear of addiction MSC: NCLEX: Physiological Integrity
REF: 1254 OBJ: 13 KEY: Nursing Process Step: Implementation
2. A 73-year-old patient with diabetes was admitted for below the knee amputation of his
right leg. Removal of his right leg is an example of which type of surgery? a. Palliative b. Diagnostic c. Reconstructive d. Ablative ANS: D
Ablative is a type of surgery where an amputation, excision of any part of the body, or removal of a growth and harmful substance is performed. DIF: Cognitive Level: Comprehension TOP: Types of surgeries MSC: NCLEX: Physiological Integrity
REF: 1236 OBJ: 2 KEY: Nursing Process Step: Assessment
3. In which situation might surgery be delayed? a. The patient has taken Dilantin today. b. An illegible signature is on the consent form. c. The patient is still taking anticoagulants. d. The admission office is unable to confirm insurance coverage. ANS: C
All medications should be cancelled before surgery, except for drugs such as phenytoin (Dilantin). Anticoagulant therapy increases the threat of hemorrhage and may be a cause for delay. DIF: Cognitive Level: Knowledge TOP: Anticoagulant therapy MSC: NCLEX: Physiological Integrity
REF: 1254 OBJ: 7 KEY: Nursing Process Step: Assessment
4. Which circumstance could prevent the patient from signing his informed consent for a
cholecystectomy? a. The patient complains of pain radiating to the scapula. b. The patient received an injection of Demerol, 75 mg IM, 1 hour ago. c. The patient is 85 years of age. d. The patient is concerned over his lack of insurance coverage. ANS: B
Informed consent should not be obtained if the patient is disoriented and under the influence of sedatives. Age, illegibility, and lack of insurance coverage do not prevent signing the consent. Pain into the scapula is a symptom of colitis. DIF: Cognitive Level: Application TOP: Informed consent MSC: NCLEX: Physiological Integrity
REF: 1243 OBJ: 7 KEY: Nursing Process Step: Assessment
5. The nurse anticipates that the patient will be given
anesthesia because of
the extensive tissue manipulation involved in a hysterectomy. a. general b. regional c. specific d. preoperative ANS: A
An anesthesiologist gives general anesthetics by IV and inhalation routes through four stages of anesthesia when the procedure requires extensive tissue manipulation. DIF: Cognitive Level: Knowledge REF: 1254 TOP: Anesthesia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 9
6. The nurse caring for a patient who had an epidural block for a vaginal repair should be
alert for: a. a flushing of the face and torso. b. numbness of the perineum. c. complaint of thirst. d. a sudden drop in blood pressure. ANS: D
Epidural anesthesia may cause a sudden drop in blood pressure or respiratory difficulty as the anesthetic agent moves up in the spinal cord. Elevating the patient’s torso may prevent respiratory paralysis. DIF: Cognitive Level: Comprehension TOP: Epidural block MSC: NCLEX: Physiological Integrity
REF: 1257 OBJ: 9 KEY: Nursing Process Step: Assessment
7. Why might the older adult patient not respond to surgical treatment as well as a younger
adult patient? a. Poor skin turgor b. Fear of the unknown
c. Response to physiologic changes d. Decreased peristalsis related to anesthesia ANS: C
Of specific concern in older adults is the body’s response to temperature changes, cardiovascular shifts, respiratory needs, and renal function. Fear of the unknown and decreased peristalsis are common to all ages. DIF: Cognitive Level: Application TOP: Older adult patients MSC: NCLEX: Physiological Integrity
REF: 1238 OBJ: 5 KEY: Nursing Process Step: Planning
8. The postoperative nursing intervention that would be contraindicated for a 45-year-old
patient who has had a repair of a cerebral aneurysm and is presenting signs of increased intracranial pressure (ICP) would be: a. coughing every 2 hours. b. turning every 2 hours. c. monitoring intravenous therapy at 50 mL/hr. d. assessing vital signs every 2 hours. ANS: A
Coughing increases ICP. DIF: Cognitive Level: Analysis TOP: Postoperative complications MSC: NCLEX: Physiological Integrity
REF: 1248 OBJ: 12 KEY: Nursing Process Step: Implementation
9. The nurse acting as a circulating nurse has a responsibility for: a. observing breaks in sterile technique. b. identifying and handling surgical specimens correctly. c. assisting with surgical draping of the patient. d. maintaining count of sponges, needles, and instruments during surgery. ANS: A
The circulating nurse is responsible for observing breaks in sterile technique. The scrub nurse handles the surgical specimens, drapes the patient, and maintains needle and sponge count during surgery, then does a final sponge and needle check with the circulating nurse before closing. DIF: Cognitive Level: Analysis REF: 1263 OBJ: 11 TOP: Duties of circulating nurse KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 10. Which statement made by a patient during a preoperative assessment would be significant
to report to the charge nurse and surgeon? a. “I have been taking an herbal product of feverfew for my migraines.” b. “I exercise for 3 hours a day.” c. “I drink 2 glasses of wine a day.” d. “I use atropine eye drops every day.” ANS: A
The herbal remedy of feverfew acts as an anticoagulant and increases the possibility of hemorrhage. The drug should be stopped before surgery, and bleeding and clotting times should be evaluated. DIF: Cognitive Level: Application TOP: Preoperative assessment MSC: NCLEX: Physiological Integrity
REF: 1240 | 1256 OBJ: 14 KEY: Nursing Process Step: Assessment
11. A patient is on postoperative day 2 after a nephrectomy. What is the most effective way to
increase her peristalsis? a. Ambulation b. An enema c. Encouraging hot liquids d. Administering a laxative ANS: A
Encouraging activity (turning every 2 hours, early ambulation) assists GI activity. DIF: Cognitive Level: Comprehension TOP: Postoperative complications MSC: NCLEX: Physiological Integrity
REF: 1270 OBJ: 13 KEY: Nursing Process Step: Planning
12. A patient is transferred from the operating room to the recovery room after undergoing an
open reduction and internal fixation (ORIF) of his left ankle. Which is the first assessment to make? a. Check ankle dressings for hemorrhage. b. Check airway for patency. c. Check intravenous site. d. Check pedal pulse. ANS: B
Evaluation of the patient follows the ABCs of immediate postoperative observation: airway, breathing, consciousness, and circulation. DIF: Cognitive Level: Application REF: 1264 OBJ: 12 TOP: Nursing assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 13. Frequent assessment of a postoperative patient is essential. What is one of the first signs
and symptoms of hemorrhage? a. Increasing blood pressure b. Decreasing pulse c. Restlessness d. Weakness, apathy ANS: C
A pulse that increases and becomes thready combined with a declining blood pressure, cool and clammy skin, reduced urine output, and restlessness may signal hypovolemic shock. DIF: Cognitive Level: Comprehension TOP: Postoperative complications
REF: 1265 OBJ: 12 KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 14. The nurse instructing a postsurgical patient in the use of thrombolytic deterrent stockings
would include which of the following instructions? a. Disregard appearance of edema above the stocking. b. Massage legs to smooth wrinkles out of stockings. c. Wring stockings thoroughly before hanging to dry. d. Hand wash stockings in warm water and mild soap. ANS: D
Stockings should be hand washed gently in warm water and mild soap and laid over a surface to dry. They should not be wrung out or hung. Massaging legs may dislodge a clot and the appearance of edema indicates the stockings are too restrictive. DIF: Cognitive Level: Comprehension TOP: Thrombolytic deterrent stockings MSC: NCLEX: Physiological Integrity
REF: 1253 OBJ: 13 KEY: Nursing Process Step: Implementation
15. The patient is brought into PACU still unconscious. What should the nurse do when the
nurse assesses an oral temperature of 94°F? a. Notify the charge nurse immediately. b. Offer warm fluids through a straw. c. Do nothing, this is a normal reaction to anesthesia. d. Cover with a warm blanket. ANS: D
Hypothermia is a frequent assessment postsurgery. A warm blanket or a ventilated cover would be applied to bring up the temperature. Vital signs are checked every 15 minutes until stable. DIF: Cognitive Level: Analysis TOP: Hypothermia MSC: NCLEX: Physiological Integrity
REF: 1263 OBJ: 13 KEY: Nursing Process Step: Planning
16. In which location are guidelines for ensuring that all nursing interventions on the day of
surgery completed and documented? a. In the nurse’s notes b. In the anesthesia record c. In the preoperative checklist d. In the progress notes ANS: C
When the nurse signs the preoperative checklist, that nurse assumes responsibility for all areas of care included on the list. DIF: Cognitive Level: Knowledge REF: 1259 OBJ: 6 TOP: Preoperative checklistKEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 17. While turning a patient who had a bowel resection yesterday, the wound eviscerated. What
is the initial nursing intervention? a. Place the patient in the high Fowler’s position.
b. Give the patient fluids to prevent shock. c. Replace the dressing with sterile fluffy pads. d. Apply a warm, moist normal saline sterile dressing. ANS: D
Cover the wound with a sterile towel moistened with sterile physiologic saline (warm). DIF: Cognitive Level: Application REF: 1266 OBJ: 13 TOP: Evisceration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. When should the nurse offer prescribed analgesics to a patient who is 24 hours
postoperative? a. Only when the patient asks. b. When the onset of pain is assessed. c. Sparingly to avoid drug dependence. d. Only when severe pain is assessed. ANS: B
The nurse should assess for pain frequently to medicate at the onset of pain. DIF: Cognitive Level: Application TOP: Medication administration MSC: NCLEX: Physiological Integrity
REF: 1268 OBJ: 14 KEY: Nursing Process Step: Planning
19. What should the nurse do to minimize the potential for venous stasis? a. Place pillows under the knee in a position of comfort. b. Assist patient to sit with feet flat on the floor. c. Assist with early ambulation. d. Perform gentle leg massage. ANS: C
Early ambulation has been a significant factor in hastening postoperative recovery and preventing postoperative complications. DIF: Cognitive Level: Application TOP: Venous stasis MSC: NCLEX: Physiological Integrity
REF: 1269 OBJ: 13 KEY: Nursing Process Step: Planning
20. The nurse clarifies that serum potassium levels are determined before surgery to: a. assess kidney function. b. determine respiratory insufficiency. c. prevent arrhythmias related to anesthesia. d. measure functional liver capability. ANS: C
Serum electrolytes are evaluated if extensive surgery is planned or the patient has extenuating problems. One of the essential electrolytes examined is potassium; if potassium is not available in adequate amounts, arrhythmias can occur during anesthesia. DIF: Cognitive Level: Analysis TOP: Preoperative assessment MSC: NCLEX: Physiological Integrity
REF: 1243 OBJ: 4 KEY: Nursing Process Step: Implementation
21. In performing the preoperative assessment, the nurse discovers that the patient is allergic
to latex. What should the nurse do initially? a. Notify the diet kitchen to omit peaches from diet tray. b. Apply a medical alert band to patient’s wrist. c. Tag chart with allergy alert. d. Place patient in an isolation room. ANS: B
The initial intervention would be to place a medical alert band on the patient, then tag the chart. The charge nurse and the surgeon should be notified in the event the surgeon wants to order a preoperative prophylactic treatment. DIF: Cognitive Level: Knowledge REF: 1245 OBJ: 13 TOP: Latex allergy KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 22. Which of the following early postoperative observations should be reported immediately? a. “Coffee ground” emesis b. Shivering c. Scanty urine output d. Evidence of pain ANS: A
Any emesis that is red or coffee ground should be reported immediately as it indicates GI bleeding. Shivering, scanty urine output, and evidence of pain are within normal expectation of a postsurgical patient. DIF: Cognitive Level: Application TOP: Postoperative assessment MSC: NCLEX: Physiological Integrity
REF: 1264-1265 OBJ: 10 KEY: Nursing Process Step: Assessment
23. When the postoperative patient complains of sudden chest pain combined with dyspnea,
cyanosis, and tachycardia, the nurse recognizes the signs of: a. hypovolemic shock. b. dehiscence. c. atelectasis. d. pulmonary embolus. ANS: D
Sudden chest pain combined with dyspnea, tachycardia, cyanosis, diaphoresis, and hypotension is a sign of pulmonary embolism. DIF: Cognitive Level: Analysis REF: 1267 OBJ: 13 TOP: Assessment and postoperative complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. The removal of a nondiseased appendix during a hysterectomy is classified as: a. major, emergency, diagnostic. b. major, urgent, palliative. c. minor, elective, ablative. d. minor, urgent, reconstructive.
ANS: C
Surgery is classified as elective, urgent, or emergency. Surgery is performed for various purposes, which include diagnostic studies, ablation (an amputation or excision of any part of the body or removal of a growth or harmful substance), and palliative (therapy to relieve or reduce intensity of uncomfortable symptoms without cure), reconstructive, transplant, and constructive purposes. DIF: Cognitive Level: Comprehension TOP: Types of surgeries MSC: NCLEX: Physiological Integrity
REF: 1235 OBJ: 2 KEY: Nursing Process Step: Planning
25. Which medication would cause surgery to be delayed if it had not been discontinued
several days before surgery? a. Analgesic agent b. Antihypertensive agent c. Anticoagulant agent d. Antibiotic agent ANS: C
Anticoagulants alter normal clotting factors and thus increase risk of hemorrhaging. They should be discontinued for 48 hours before surgery. DIF: Cognitive Level: Analysis REF: 1256 OBJ: 4 TOP: Individual’s ability to tolerate surgery KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 26. The most appropriate intervention by the nurse to decrease the pain of an abdominal
incision while coughing would be to: a. support the surgical site with a pillow. b. position patient in a side-lying position. c. medicate with prescribed narcotic before coughing. d. ask the patient to cross arms over the chest to increase force of cough. ANS: A
To ease the pressure on the incision, the nurse helps the patient support the surgical site with a pillow or rolled bath blanket. The heel of the hand can be used as well, but it is not the ideal method. DIF: Cognitive Level: Application TOP: Postoperative nursing interventions KEY: Nursing Process Step: Planning
REF: 1267
OBJ: 8
MSC: NCLEX: Physiological Integrity
27. The nurse would include the patient problem of deficient knowledge, postoperative, when
the patient scheduled for a bowel resection tomorrow remarks: a. “I am going to have adequate pain medication after surgery.” b. “I know you all are going to make me cough and walk soon after surgery.” c. “I am glad I will get to go home tomorrow evening.” d. “I will have to put up with dressing changes.” ANS: C
The patient’s lack of understanding about the length of time in the hospital following such a serious surgery indicates a knowledge deficit that needs to be addressed. DIF: Cognitive Level: Analysis REF: 1239 OBJ: 16 TOP: Nursing process KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 28. What instruction should a nurse give when teaching the patient to cough effectively after
surgery? a. Breathe through the nose, hold breath, and exhale slowly. b. Take three deep breaths and cough from the chest. c. Inhale while contracting the abdominal muscles and exhale while contracting the diaphragm. d. Take short, frequent panting breaths and cough from the throat to clear accumulated mucus. ANS: B
Because lung ventilation is vital, the nurse assists the patient to turn, cough, and breathe deeply every 1 to 2 hours until the chest is clear. Having practiced this combination preoperatively, the patient is usually adequately able to remove trapped mucus and surgical gases. DIF: Cognitive Level: Application REF: 1267 TOP: Prevention of postoperative complications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 8
29. What is the responsibility of the nurse as a witness to informed consent? a. Explain the surgical options. b. Explain the operative risks. c. Verify/obtain the patient’s signature. d. Verify the patient’s understanding of the procedure. ANS: C
A witness is only verifying that this is the person who signed the consent and that it was a voluntary consent. The witness (often a nurse) is not verifying that the patient understands the procedure. DIF: Cognitive Level: Knowledge REF: 1243 OBJ: 7 TOP: Informed consent KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 30. On the patient’s return to the medical-surgical unit, the nurse performing an abdominal
assessment can affirm an absence of bowel sounds after listening in each quadrant for at least: a. 30 seconds. b. 1 minute. c. 2 minutes. d. 3 minutes. ANS: D
Normal peristalsis is gauged by hearing 5 to 30 gurgles per minute. Absence of bowel sounds may be recorded if the nurse has listened to each quadrant 3 to 5 minutes. DIF: Cognitive Level: Knowledge TOP: Bowel sounds MSC: NCLEX: Physiological Integrity
REF: 1270 OBJ: 12 KEY: Nursing Process Step: Assessment
31. When the patient asks the nurse to make sure no one sees her with her dentures out, the
nurse recognizes the common preoperative fear of: a. anesthesia. b. loss of control. c. fear of separation from family. d. mutilation. ANS: B
Fear of loss of control may be partially related to concerns about anesthesia, but this patient’s concern is about self-image. Preoperative anxiety from any cause may affect the amount of anesthesia and postoperative analgesia needed. DIF: Cognitive Level: Assessment REF: 1239 OBJ: 4 TOP: Nursing process KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 32.
What is the ideal time for preoperative teaching? a. Immediately before surgery to eliminate fear b. 2 months in advance so the patient can prepare c. 1 to 2 days before the surgery when anxiety is not as high d. In the surgical holding area ANS: C
Preoperative teaching is provided when the surgery is scheduled if the patient is being seen in the surgeon’s office, when anxiety is not as high. DIF: Cognitive Level: Implementation REF: 1241 OBJ: 4 TOP: Preoperative teaching KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 33. In preparation for the return of the surgical patient, the patient’s bed and equipment should
be in what position? a. Lowest position with side rails elevated with oxygen and suction equipment available b. Highest position with side rails elevated with IV pole and pump at bedside c. Lowest position with side rails down on the receiving side d. Highest position with the side rails down on receiving side and up on opposite side ANS: D
In preparation for the return of the surgical patient, the patient’s bed should be in the highest position to be level with the surgical gurney and should have the side rail down on the receiving side, with the opposite side rail up to prevent the patient from falling out of bed during transfer. DIF: Cognitive Level: Implementation
REF: 1260
OBJ: 12
TOP: Postoperative preparation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 34. A patient is transferred from the operating room to the recovery room after undergoing an
amputation of his left foot. Which intervention is the last step for immediate assessment once the patient enters the PACU? a. System review b. Breathing c. Circulation d. Airway e. Level of consciousness ANS: A
The assessment of an adequate airway is primary in the postanesthesia assessment, followed by breathing assessment, level of consciousness, circulation, and finally system review. DIF: Cognitive Level: Application REF: 1263 OBJ: 12 TOP: Nursing assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 35. Which is the first step a patient should take to control coughing? a. Inhale deeply and hold breath for a count of three. b. Document exercise and patient reaction. c. Cough two or three times without inhaling then relax. d. Take several deep breaths. e. Inhale through nose. f. Exhale through pursed lips. ANS: D
The patient should be instructed to take several deep breaths, inhale through the nose, exhale through pursed lips, inhale deeply and hold for a count of three, cough two or three times without exhaling, relax. The procedure may be repeated before documentation. DIF: Cognitive Level: Application TOP: Controlled coughing MSC: NCLEX: Physiological Integrity
REF: 1249 OBJ: 13 KEY: Nursing Process Step: Implementation
MULTIPLE RESPONSE 1. A postoperative patient who had a left inguinal hernia repair is ready for his discharge
instructions. Which information should the nurse provide? (Select all that apply.) a. Care of the wound site and any dressings b. When he may operate a motor vehicle c. Signs and symptoms to report to the physician d. Call the physician’s office once he arrives home e. Report bowel movements to the physician f. Actions and side effects of any medications ANS: A, B, C, F
As the day of discharge approaches, the nurse should be certain that the patient has vital information. DIF: Cognitive Level: Analysis REF: 1273 OBJ: 15 TOP: Discharge instructions KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 2. Which of the following are considerations for the older adult surgical patient? (Select all
that apply.) a. The need for specific clear preoperative and postoperative teaching b. Awareness of lower morbidity and mortality rate c. Presence of coexisting conditions d. Increased risk of respiratory complications e. Expectation of normal recovery time ANS: A, C, D
Surgery places greater stress on older than on younger patients. Teaching should be given at the older person’s level of understanding. Teaching should be specific and clear. Presence of coexisting conditions may delay recovery time and response to surgery. DIF: Cognitive Level: Application TOP: Older adult considerations MSC: NCLEX: Physiological Integrity
REF: 1238 OBJ: 7 KEY: Nursing Process Step: Planning
3. Which of the following are preoperative conditions that may affect the patient’s response
to surgery? (Select all that apply.) a. Age b. Religion c. Mental status d. Occupation e. Nutritional status ANS: A, C, E
Each system of the body is affected by the patient’s age, health, nutritional status, and mental state. Religion and occupation do not affect the physiologic response to the surgery. DIF: Cognitive Level: Comprehension REF: 1240 OBJ: 4 TOP: Factors influencing toleration to surgery KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. Which interventions in preparing the patient for abdominal surgery may be delegated to
unlicensed assistive personnel (UAP)? (Select all that apply.) a. Vital signs b. Insertion of N/G tube c. Enema d. Height and weight e. Obtaining operative consent f. Sterile gowning ANS: A, C, D
Vital signs, enema, and height and weight can be safely performed by UAP. Insertion of an N/G tube, obtaining an operative consent, and sterile gloving are interventions requiring critical thinking and knowledge unique to a nurse. DIF: Cognitive Level: Application REF: 1237 OBJ: 3 TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1.
therapy is performed to alleviate or decrease uncomfortable symptoms without curing the problem. ANS:
Palliative Palliative therapy is designed to relieve or reduce intensity of uncomfortable symptoms without cure. DIF: Cognitive Level: Knowledge REF: 1236 OBJ: 1 TOP: Palliative therapy KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 2. Discharge planning for a surgical procedure begins in the preoperative period and
continues through the
period.
ANS:
recuperative When discharge planning is begun in the preoperative period and all through the postoperative period, the patient can assume greater responsibility for self-care and will experience less stress about going home. DIF: Cognitive Level: Comprehension REF: 1273 OBJ: 15 TOP: Discharge planning KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 3. The type of anesthesia that uses a combination of drugs to reduce the level of
consciousness and provides amnesia is conscious (or moderate)
.
ANS:
sedation Conscious/moderate sedation uses a combination of drugs to produce a reduced level of consciousness and amnesia, as well as pain control, but allows the patient to control his or her own breathing. The recovery is more rapid than with general anesthesia. DIF: Cognitive Level: Comprehension TOP: Conscious sedation MSC: NCLEX: Physiological Integrity
REF: 1258 OBJ: 10 KEY: Nursing Process Step: Planning
4. The nurse is aware that there is a loss of
during catabolism after severe tissue
injury. ANS:
potassium The injured cells loose potassium as catabolism (tissue breakdown) occurs. DIF: Cognitive Level: Knowledge REF: 1270 TOP: Catabolism KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 13
5. The nurse explains that to promote deep breathing and improve lung expansion and
oxygenation the patient should use the intervals during the day.
at regular
ANS:
incentive spirometer The incentive spirometer is a device to encourage deep breathing and lung expansion. The usual rate of usage is 10 breaths hourly during waking hours. DIF: Cognitive Level: Comprehension TOP: Incentive spirometer MSC: NCLEX: Physiological Integrity
REF: 1267 OBJ: 13 KEY: Nursing Process Step: Implementation
6. The nurse caring for a postsurgical patient is aware that the patient should void
hours postsurgery. ANS:
6 Urinary output should be obvious 6 to 8 hours postsurgery. If urinary output has not begun, a catheter may be inserted. DIF: Cognitive Level: Comprehension TOP: Resumption of urinary flow MSC: NCLEX: Physiological Integrity
REF: 1268 OBJ: 13 KEY: Nursing Process Step: Assessment
to 8
Chapter 43: Care of the Patient with an Integumentary Disorder Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. What should the nurse do when administering a therapeutic bath to a patient who has
severe pruritus? a. Use Burow’s solution to help promote healing. b. Rub the skin briskly to decrease pruritus. c. Limit bathing to three times a week. d. Ensure that bath area is at least 85 degrees and dehumidified. ANS: A
Pruritus is responsible for most of the discomfort. Wet dressings and using Burow’s solution help promote the healing process. A cool environment with increased humidity decreases the pruritus. Give daily baths with an application to cleanse the skin. DIF: Cognitive Level: Application REF: 1298 OBJ: 14 TOP: Pruritus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. A frail, older adult home health patient who had chickenpox as a child has been exposed to
varicella (chickenpox) several days ago. What should the nurse do? a. Assess frequently for herpes zoster. b. Be aware of the patient’s immunity to chickenpox. c. Encourage the patient to have a pneumonia vaccine. d. Arrange for the patient to receive gamma globulin. ANS: A
Herpes zoster is caused by the same virus that causes chickenpox (Herpes varicella). The greatest risk occurs to patients who have a lowered resistance to infection, such as those on chemotherapy, aging, or receiving large doses of prednisone, in whom the disease could be fatal because of the patient’s compromised immune system. DIF: Cognitive Level: Application REF: 1290 TOP: Shingles KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
3. A patient has herpes zoster (shingles) and is being treated with acyclovir (Zovirax). What
should the nurse do when administering this drug? a. Apply lightly, being careful not to completely cover the lesion. b. After application, wrap in warm wet dressings. c. Use gloves. d. Rub medication into lesions. ANS: C
The topical application requires that the nurse uses gloves, completely covers the lesion gently, then leaves it open to the air. DIF: Cognitive Level: Comprehension TOP: Anti-infective
REF: 1289 OBJ: 5 KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity 4. A child has been sent to the school nurse with pruritus and honey-colored crusts on the
lower lip and chin. The nurse believes these lesions most likely are: a. chickenpox. b. impetigo. c. shingles. d. herpes simplex type I. ANS: B
Impetigo is seen at all ages but is particularly common in children. The crust is honey-colored and easily removed and is associated with pruritus. The disease is highly contagious and spreads by contact. DIF: Cognitive Level: Comprehension REF: 1294 TOP: Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
5. A school nurse assesses a child who has an erythematous circular patch of vesicles on her
scalp with alopecia and complains of pain and pruritus. Why would the nurse use a Woods lamp? a. To dry out the lesions. b. To reduce the pruritus. c. To kill the fungus. d. To cause fluorescence of the infected hairs. ANS: D
Tinea capitis is commonly known as ringworm of the scalp. Microsporum audouinii is the major fungal pathogen. The use of the diagnostic Woods lamp causes the infected hairs to turn a brilliant blue green. DIF: Cognitive Level: Knowledge REF: 1296 TOP: Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
6. A patient, age 46, reports to his physician’s office with urticaria with elevated lesions that
are white in the center with a pale red border on hands and arms. He says, “It itches like crazy.” Which type of lesion would the nurse include in her documentation? a. Macules b. Plaques c. Wheals d. Vesicles ANS: C
Urticaria is the term applied to the presence of wheals or hives in an allergic reaction commonly caused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold. The lesions are elevated with a white center and a pale red border. DIF: Cognitive Level: Analysis REF: 1300 TOP: Urticaria KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
7. The home health nurse assessing skin lesions uses the PQRST mnemonic as a guide. What
does the S in this guide indicate? a. Severity of the symptoms b. Site of the lesions c. Symptomatology of the lesions d. Surface area of the lesions ANS: A
The mnemonic PQRST stands for Provocative factors (causes), Quantity, Region of the body, Severity of the symptoms, Time (length of time the disorder has been present). DIF: Cognitive Level: Knowledge TOP: Skin Assessment MSC: NCLEX: Physiological Integrity
REF: 1284 OBJ: 4 KEY: Nursing Process Step: Implementation
8. What would the nurse stress to the 17-year-old girl who has been prescribed Accutane for
her acne? a. Avoid alcoholic beverages. b. Drink at least 1000 mL of fluid daily. c. Use dependable birth control to avoid pregnancy. d. Avoid exposure to the sun. ANS: C
Accutane has a destructive effect on fetal development. Dependable birth control is important to avoid a pregnancy. DIF: Cognitive Level: Application TOP: Effects of Accutane MSC: NCLEX: Physiological Integrity
REF: 1302 OBJ: 6 KEY: Nursing Process Step: Implementation
9. A 30-year-old African American had surgery 6 months ago and the incision site is now
raised, indurated, and shiny. This is most likely which type of tissue growth? a. Angioma b. Keloid c. Melanoma d. Nevus ANS: B
Keloids, which originate in scars, are hard and shiny and are seen more often in African Americans than in whites. DIF: Cognitive Level: Knowledge REF: 1309 TOP: Keloid KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
OBJ: 9
10. A patient, age 37, sustained partial- and full-thickness burns to 26% of the body surface
area. When would the greatest fluid loss resulting from the burns occur? a. Within 12 hours after burn trauma b. 24 to 36 hours after burn trauma c. 24 to 48 hours after burn trauma d. 48 to 72 hours after burn trauma
ANS: A
In a burn injury, usually the greatest fluid loss occurs within the first 12 hours. DIF: Cognitive Level: Analysis TOP: Burns: fluid loss MSC: NCLEX: Physiological Integrity
REF: 1313 OBJ: 12 KEY: Nursing Process Step: Planning
11. Most of the deaths from burn trauma in the emergent phase that require a referral to a burn
center result from: a. infection. b. arrhythmias with cardiac arrest. c. hypovolemic shock and renal failure. d. adrenal failure. ANS: C
Hypovolemic shock is frequently lethal in the emergent period of a severe burn because of the transfer of fluids into the interstitial tissue from the circulating volume. DIF: Cognitive Level: Analysis TOP: Burns: infection MSC: NCLEX: Physiological Integrity
REF: 1313-1314 OBJ: 10 KEY: Nursing Process Step: Planning
12. The nurse takes into consideration that carbon monoxide intoxication secondary to smoke
inhalation is often fatal because carbon monoxide: a. binds with hemoglobin in place of oxygen. b. interferes with oxygen intake. c. is a respiratory depressant. d. is a toxic agent. ANS: A
Carbon monoxide poisoning is likely if the patient has been in an enclosed area. Carbon monoxide displaces oxygen by binding with hemoglobin. DIF: Cognitive Level: Analysis TOP: CO2 intoxication MSC: NCLEX: Physiological Integrity
REF: 1316 OBJ: 12 KEY: Nursing Process Step: Planning
13. A nurse arrives at an accident scene where the victim has just received an electrical burn.
What is the nurse’s primary concern? a. The extent and depth of the burn b. The sites of entry and exit c. The likelihood of cardiac arrest d. Control of bleeding ANS: C
Most electrical burns result in cardiac arrest, and the patient will require CPR or acute cardiac monitoring. DIF: Cognitive Level: Application REF: 1316 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 10
14. A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first
72 hours, the nurse will have to observe for the most common cause of burn-related deaths, which is: a. shock. b. respiratory arrest. c. hemorrhage. d. infection. ANS: D
Infection is the most common complication and cause of death after the first 72 hours. DIF: Cognitive Level: Analysis REF: 1317 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment
OBJ: 14
15. Two weeks after a severe burn of over 20% of the body, the patient vomits bright red
blood. Which condition is most likely? a. Curling ulcer b. Paralytic ileus c. Hypoglycemia perforation of the stomach by the NG tube d. Gastritis ANS: A
Curling ulcer is a duodenal ulcer that develops 8 to 14 days after severe burns on the surface of the body. The first sign is usually vomiting of bright red blood. DIF: Cognitive Level: Analysis TOP: Curling ulcer MSC: NCLEX: Physiological Integrity
REF: 1317 OBJ: 12 KEY: Nursing Process Step: Assessment
16. When providing the open method of treatment for a patient who is 52 years old with burns
to the lower extremities, what would a nurse include in the nursing plan? a. Change the dressing using good medical asepsis. b. Provide an analgesic immediately after the dressing change. c. Perform circulation checks every 2 to 4 hours. d. Keep the room temperature at 85°F (29.4°C) to prevent chilling. ANS: D
Chilling may be controlled by keeping the room temperature at 85°F (29.4°C). Strict surgical protocol is observed and analgesia should be given before the treatment. Frequent circulation checks are not a high priority with the open method. DIF: Cognitive Level: Application TOP: Burn treatment MSC: NCLEX: Physiological Integrity
REF: 1318 OBJ: 12 KEY: Nursing Process Step: Implementation
17. The nurse has staged a pressure injury that has a shallow crater with a dry pink wound bed
as a: a. stage 1. b. stage 2. c. stage 3. d. stage 4.
ANS: B
Stage 2 pressure injuries appear as a shallow open injury, usually shiny or dry, with a red-pink wound bed without slough. DIF: Cognitive Level: Analysis TOP: Pressure injuries MSC: NCLEX: Physiological Integrity
REF: 1285 OBJ: 4 KEY: Nursing Process Step: Assessment
18. What would the nurse dressing a necrotic pressure injury with a minimal exudate most
likely use? a. Hydrocolloid dressing b. Alginate dressing c. Hydrofiber dressing d. Transparent film ANS: A
Hydrocolloid dressings are useful in necrotic wounds with little exudate. Alginate and hydrofiber dressings are used for wounds with copious exudate. Transparent film is not absorbent. DIF: Cognitive Level: Application REF: 1287 TOP: Eczema KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 14
19. The nurse is caring for a 26-year-old male patient who was burned 72 hours ago. He has
partial-thickness burns to 24% of his body surface area. He begins to excrete large amounts of urine. What should the nurse do? a. Increase the IV rate and monitor for burn shock. b. Monitor for signs of seizure activity. c. Assess for signs of fluid overload. d. Raise the foot of the bed and apply blankets. ANS: C
As the blood volume increases, the cardiac output increases to increase renal perfusion. The result includes diuresis. However, a great risk for the patient includes fluid overload because of the rapid movement of fluid back into the intravascular space. DIF: Cognitive Level: Analysis REF: 1314 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
20. A patient with severe eczema is starting a coal tar derivative treatment. What should the
nurse include in the teaching plan for the patient relative to this treatment? a. Drink at least 1000 mL of fluid daily. b. Avoid exposure to sunlight for 72 hours after use. c. Bathe with an astringent soap. d. Reduce intake of high calcium foods. ANS: B
Persons using coal tar derivatives should avoid exposure to sunlight for 72 hours after use. The product stains clothes and bathroom fixtures.
DIF: Cognitive Level: Application REF: 1289 TOP: Eczema KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 6
21. What should the nurse examine in assessing a patient for tinea corporis? a. Soles of the feet b. Scalp c. Armpits d. Abdomen ANS: D
Tinea corporis is known as ringworm of the body. It occurs on parts of the body with little or no hair. DIF: Cognitive Level: Comprehension REF: 1296 OBJ: 7 TOP: Tinea corporis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 22. What is the initial intervention for relief of the pruritus of dermatitis venenata? a. Apply baking soda to lesions. b. Wash area with copious amounts of water. c. Apply cool compresses continuously. d. Expose area to air. ANS: B
In dermatitis venenata (poison oak or ivy), the patient should wash the affected part immediately after contact with the offending allergen. DIF: Cognitive Level: Comprehension REF: 1296 OBJ: 6 TOP: Pruritus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse débriding a burn wound explains that the purpose of débridement is to: a. increase the effectiveness of the skin graft. b. prevent infection and promote healing. c. promote suppuration of the wound. d. promote movement in the affected area. ANS: B
Débridement is the removal of damaged tissue and cellular debris from a wound or burn to prevent infection and to promote healing. DIF: Cognitive Level: Comprehension REF: 1318 OBJ: 12 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. A patient has been admitted to the hospital with burns to the upper chest. The nurse notes
singed nasal hairs. The nurse needs to assess this patient frequently for which condition? a. Decreased activity b. Bradycardia c. Respiratory complications
d. Hypertension ANS: C
Signs and symptoms of inhalation injury include singed nasal hairs. Breathing difficulties may take several hours to occur. DIF: Cognitive Level: Analysis REF: 1314 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
25. Which may indicate a malignant melanoma in a nevus on a patient’s arm? a. Even coloring of the mole b. Decrease in size of the mole c. Irregular border of the mole d. Symmetry of the mole ANS: C
Any change in color, size, or texture and any bleeding or pruritus of a nevus deserves investigation. A malignant melanoma is a cancerous neoplasm in which pigment cells or melanocytes invade the epidermis, dermis, and sometimes the subcutaneous tissue. DIF: Cognitive Level: Knowledge REF: 1310 TOP: Melanoma KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 8
26. A nurse can assess cyanosis in a dark-skinned patient by noting the color of the: a. conjunctiva. b. sclera. c. lips and mucous membranes. d. soles of the feet. ANS: C
Assessment of color is more easily made in areas where the epidermis is thin, such as the lips and mucous membranes. DIF: Cognitive Level: Comprehension REF: 1284 TOP: Cyanosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 4
27. A patient developed a severe contact dermatitis of the hands, arms, and lower legs after
spending an afternoon picking strawberries. The patient states that the itching is severe and cannot keep from scratching. Which instruction would be most helpful in managing the pruritus? a. Use cool, wet dressings and baths to promote vasoconstriction. b. Trim the fingernails short to prevent skin damage from scratching. c. Expose the areas to the sun to promote drying and healing of the lesions. d. Wear cotton gloves and cover all other affected areas with clothing to prevent environmental irritation. ANS: A
Wet dressings and using Burow’s solution help promote the healing process. Cold compresses may be applied to decrease circulation to the area (vasoconstriction). Short nails prevent skin damage, but not pruritus. DIF: Cognitive Level: Comprehension TOP: Contact dermatitis MSC: NCLEX: Physiological Integrity
REF: 1297-1298 OBJ: 6 KEY: Nursing Process Step: Implementation
28. What is the best instruction by the nurse regarding reducing the risk factors for melanoma? a. Avoid exposure to the sun and use protective measures when exposure occurs. b. Have all nevi removed. c. Watch for changes in moles, especially on the back. d. Use a sun lamp for tanning. ANS: A
Encourage the patient to protect skin from the sun by wearing protective clothing, including a hat with 4-in brim, applying sunscreen all over the body, and avoiding the midday sun from 10 a.m. to 4 p.m. Sun lamps are just as damaging as the sun. DIF: Cognitive Level: Application REF: 1311 OBJ: 8 TOP: Melanoma KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 29. Which patient instruction should the nurse include in the teaching plan relative to the
management of systemic lupus erythematosus? a. Maintain a balance between rest and activity. b. Increase activity to promote mobility. c. Increase exposure to the sun to increase vitamin D absorption. d. Increase sodium consumption. ANS: A
Balanced rest, activity, and diet will support medication management. Limited sunlight exposure is recommended to prevent photosensitivity. SLE often has kidney involvement, which would require reduction of sodium. DIF: Cognitive Level: Analysis REF: 1306 OBJ: 6 TOP: Systemic lupus erythematosus KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 30. Which patient statement indicates that more teaching is needed regarding antibiotic
therapy for the treatment of cellulitis? a. “My skin is cleared up. I don’t think I need the medication anymore.” b. “Cellulitis can come back at any time.” c. “If I had washed that scratch with soap and water, I probably would not have gotten cellulitis.” d. “Cellulitis is contagious.” ANS: A
The entire amount of antibiotic medication should be completed even if the symptoms have abated to ensure the eradication of the infectious agent. DIF: Cognitive Level: Comprehension
REF: 1294
OBJ: 6
TOP: Bacterial disorders of the skin MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step: Evaluation
31. What should a patient be assessed for upon the diagnosis of genital herpes? a. Hepatitis B b. Syphilis c. Human immunodeficiency virus (HIV). d. Cirrhosis ANS: C
Persons with genital herpes should be assessed for HIV because the therapy for herpes is suppressive; persons with HIV are not candidates for suppressant therapy. DIF: Cognitive Level: Implementation TOP: Genital herpes MSC: NCLEX: Physiological Integrity
REF: 1288 OBJ: 5 KEY: Nursing Process Step: Planning
32. The school nurse recognizes the signs of scabies when a child presents with: a. small fluid-filled blisters that sting when scratched. b. dry scaly patches in body creases that itch. c. wavy threadlike lines on the body and pruritus. d. cluster of papular lesions with pruritus. ANS: C
Scabies is manifested by brown threadlike lines on the body, especially the hands, anus, and body folds. Pruritus is severe. DIF: Cognitive Level: Comprehension TOP: Parasite disorders of the skin MSC: NCLEX: Physiological Integrity
REF: 1308 OBJ: 7 KEY: Nursing Process Step: Assessment
33. Melanocytes give rise to the pigment melanin, which is responsible for skin color. Where
can the melanocytes be found? a. Dermis b. Superficial fascia c. Epidermis d. Loose connective tissue ANS: C
A layer in the epidermis contains highly specialized cells called melanocytes. DIF: Cognitive Level: Comprehension TOP: Structure of the skin MSC: NCLEX: Physiological Integrity
REF: 1310 OBJ: 2 KEY: Nursing Process Step: Assessment
34. During the emergent phase of burn management, what is the first responder’s first
intervention? a. Transport victim to hospital. b. Cover victim with clean cloth or sheet. c. Stop, drop, and roll. d. Remove all nonadherent clothing and jewelry. e. Provide an open airway.
f.
Control any bleeding.
ANS: C
The primary concern is to stop the burning process, arrest skin damage, provide an open airway, control any bleeding, prevent infection by covering with a clean cloth, and obtain medical help by transporting to the nearest hospital. DIF: Cognitive Level: Analysis REF: 1316 OBJ: 12 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 35. What is the last intervention for a hospitalized severely burned victim during the emergent
phase? a. Tetanus prophylaxis. b. Insert Foley catheter. c. Insert nasogastric tube. d. Establish airway. e. Administer analgesics. f. Initiate fluid therapy. ANS: A
The priority of care should proceed from the establishment of an airway, initiation of fluid therapy, insertion of Foley and NG tube, administration of analgesics, and tetanus prophylaxis. DIF: Cognitive Level: Analysis REF: 1316 TOP: Burns KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
OBJ: 12
MULTIPLE RESPONSE 1. Which of the following are major functions of the skin? (Select all that apply.) a. Excretion of wastes b. Protection c. Vitamin C synthesis d. Temperature regulation e. Prevention of dehydration ANS: A, B, D, E
Functions of the skin include protection from the environment (pathogenic organisms, foreign substances, natural barrier against infection), temperature regulation, prevention of dehydration, excretion of waste products, and vitamin D synthesis. DIF: Cognitive Level: Knowledge TOP: Functions of the skin MSC: NCLEX: Physiological Integrity
REF: 1277 OBJ: 1 KEY: Nursing Process Step: Assessment
2. During primary survey assessment of a burn patient, the nurse checks for which of the
following as early signs of carbon monoxide poisoning? (Select all that apply.) a. Dizziness b. Urticaria
c. d. e. f.
Vomiting Headache Vertigo Unsteady gait
ANS: C, D, F
Early signs of carbon monoxide poisoning include headache, nausea, vomiting, and unsteady gait. DIF: Cognitive Level: Knowledge TOP: Carbon monoxide MSC: NCLEX: Physiological Integrity
REF: 1316 OBJ: 12 KEY: Nursing Process Step: Assessment
3. What is a common diagnostic criterion for identifying systemic lupus erythematosus
(SLE)? (Select all that apply.) a. Butterfly rash over nose and cheeks b. Photosensitivity c. Severe abdominal pain d. Skin ulcers e. Polyarthralgias and polyarthritis f. Immobility ANS: A, B, E
Butterfly rash on face, sensitivity to sunlight, polyarthralgias, and polyarthritis are some of the main criteria leading to the diagnosis of SLE. DIF: Cognitive Level: Knowledge TOP: Systemic lupus erythematosus MSC: NCLEX: Physiological Integrity
REF: 1304-1305 OBJ: 6 KEY: Nursing Process Step: Assessment
4. Which of the following are nursing interventions and patient teaching for the treatment of
head lice and scabies? (Select all that apply.) a. Clothing, linens, and bath articles thoroughly cleaned in hot water b. Stress nature and transmission of the disease c. Special carbohydrate diet to promote healing d. Complete isolation from the public ANS: A, B
Identify involved contacts while stressing importance of preventing transmission of disease. Washable and clothing items should be cleaned in hot water to prevent reinfection. No special diet is required. Isolation is not necessary once medical management is completed. DIF: Cognitive Level: Application REF: 1308 OBJ: 7 TOP: Parasitic diseases of the skin KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1. The most deadly skin cancer is ANS:
_.
melanoma Malignant melanoma is a cancerous neoplasm that invades the epidermis, dermis, and sometimes the subcutaneous tissue. DIF: Cognitive Level: Knowledge REF: 1310 OBJ: 8 TOP: Tumors of the skin KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. The three major glands of the skin are sudoriferous, ceruminous, and
.
ANS:
sebaceous Sudoriferous glands—sweat glands open into pores on the skin surface and excrete sweat. Ceruminous glands—secrete a waxlike substance called cerumen and are located in the external ear canal. Sebaceous glands—secrete their substance, sebum (an oily secretion), through the hair follicles distributed on the body. DIF: Cognitive Level: Comprehension TOP: Glands of the skin MSC: NCLEX: Physiological Integrity
REF: 1278 OBJ: 3 KEY: Nursing Process Step: Assessment
3. The nurse making the initial assessment of a burned patient in the emergency room
observes that the entire right arm (anterior and posterior), right anterior leg, chest, and abdomen are covered with reddened skin and blisters. Using the Rule of Nines, the nurse estimates the percentage of burn to be %. ANS:
36 Anterior and posterior are 9%, anterior leg = 9%, chest= 9%, abdomen = 9%. Total 36%. DIF: Cognitive Level: Application TOP: Rule of Nines MSC: NCLEX: Physiological Integrity
REF: 1314 OBJ: 11 KEY: Nursing Process Step: Assessment
Chapter 44: Care of the Patient with a Musculoskeletal Disorder Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. What is the movement of an extremity away from the midline of the body called? a. Abduction b. Adduction c. Flexion d. Extension ANS: A Abduction is movement of an extremity away from the midline of the body. DIF: Cognitive Level: Knowledge REF: 1332 OBJ: 6 TOP: Movements KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. What is the large, fan-shaped muscle that covers the anterior chest from the sternum to the proximal end of the humerus and acts on the joint of the shoulder to flex, adduct, and rotate? a. Serratus anterior b. Intercostal c. Transversus abdominis d. Pectoralis major ANS: D Pectoralis major is the large, fan-shaped muscle that covers the anterior chest and is an adductor muscle, which will cause the shoulder to flex. DIF: Cognitive Level: Knowledge TOP: Muscle functions MSC: NCLEX: Physiological Integrity
REF: 1330 OBJ: 4 KEY: Nursing Process Step: Assessment
3. What should the nurse instruct the patient before a magnetic resonance imaging (MRI) procedure? a. Void to completely empty the bladder. b. Omit all citrus food for 12 hours before the procedure. c. Remove all metal, such as jewelry, glasses, and hair clips. d. Wear only cotton garments for the procedure. ANS: C MRI procedures require that the patient remove all metal because it will become magnetized. DIF: Cognitive Level: Application TOP: Diagnostic examination MSC: NCLEX: Physiological Integrity
REF: 1333 KEY: Nursing Process Step: Assessment
4. The nurse instructs the patient who is to have a unicompartmental knee replacement that a major advantage of this partial knee replacement is that: a. the patient will be up and walking 2 to 3 hours after the operation. b. the kneecap is completely removed. c. the procedure is especially helpful in the treatment of rheumatoid arthritis. d. a small titanium disk replaces the worn cartilage. ANS: A Unicompartmental knee arthroplasty is also referred to as partial knee replacement in which the worn cartilage is replaced with a plastic disk. It is not as invasive as a full knee replacement and does not disturb the kneecap so that the patient can be up and walking in 2 to 3 hours after surgery. It is not recommended for RA patients. DIF: Cognitive Level: Comprehension REF: 1352 TOP: Unicompartmental knee replacement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. A patient who has had a right below the knee amputation continues to complain of unpleasant sensation in the right foot. What can the nurse explain about this “phantom pain”? a. It only exists in the mind. b. It is a complication following an amputation and can be clarified by the surgeon. c. It is related to the severed nerves that are still sending messages to the brain. d. It occurs when the person becomes focused on the loss of the limb. ANS: C Phantom pain (pain felt in the missing extremity as if it were still present) may occur and be frightening to the patient. Phantom pain occurs because the nerve tracts that register pain in the amputated area continue to send a message to the brain (this is normal). DIF: Cognitive Level: Analysis REF: 1385 KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Phantom pain
6. The patient that has a bipolar hip replacement following an intracapsular fracture has an order to be turned every 2 hours. The nurse understands that the correct nursing intervention is to keep the legs: a. together so they do not separate while turning. b. flexed to stabilize the prosthesis. c. abducted so the prosthesis does not become dislocated. d. adducted to prevent additional pain for the patient with turning. ANS: C Nursing interventions also involve postoperative maintenance of leg abduction by using an abduction splint for 7 to 10 days to prevent dislocation of the prosthesis. DIF: Cognitive Level: Application TOP: Maintaining abduction Implementation
REF: 1359 OBJ: 14 KEY: Nursing Process Step:
MSC: NCLEX: Physiological Integrity 7. A patient has been casted to stabilize a fracture of the right radius and ulna. The nurse assesses a capillary refill of 5 seconds and cold fingers of the right hand. Which initial intervention should the nurse deploy? a. Notify the charge nurse of a probable compartment syndrome. b. Apply a warm compress to the fingers to relieve swelling. c. Elevate the right hand to heart level to maintain arterial pressure. d. Cut the cast off to release constriction. ANS: C The nurse should first elevate the right hand to heart level and notify the charge nurse. Permanent damage can occur in as little time as 6 hours. DIF: Cognitive Level: Analysis TOP: Compartment syndrome Implementation MSC: NCLEX: Physiological Integrity
REF: 1366 KEY: Nursing Process Step:
8. A patient had an open reduction with internal fixation (ORIF) for a compound fracture of the left tibia and has been placed in a long leg cast. The assessments by the nurse are: left foot warm/pink, pedal pulse weaker than right, capillary refill 3 seconds, and small 1 cm area of blood on cast. What should the nurse do? a. Notify charge nurse of impending compartment syndrome. b. Document that all assessments are within normal limits. c. Inform charge nurse about probable hemorrhage. d. Place warm compresses on left foot. ANS: B All of the assessments are within normal limits. A small amount of blood on the cast is expected and should be monitored. DIF: Cognitive Level: Analysis TOP: Compound fracture MSC: NCLEX: Physiological Integrity
REF: 1378 KEY: Nursing Process Step: Assessment
9. When a patient recovering from a fractured tibia asks what callus formation is, the nurse tells her it is: a. when blood vessels of the bone are compressed. b. a part of the bone healing process after a fracture when new bone is being formed over the fracture site. c. the formation of a clot over the fracture site. d. when the hematoma becomes organized and a fibrin meshwork is formed. ANS: B Callus formation occurs when the osteoblasts continue to lay the network for bone buildup and osteoclasts destroy dead bone. DIF: Cognitive Level: Comprehension REF: 1362 KEY: Nursing Process Step: Implementation
TOP: Bone healing
MSC: NCLEX: Physiological Integrity 10. Which patient statement indicates the need for additional teaching for a patient with rheumatoid arthritis who is taking meloxicam (Mobic)? a. “I am keeping a daily record of my blood pressure.” b. “I take aspirin before I go to bed.” c. “I know I can take meloxicam with or without regard to meals.” d. “I weigh every day so I will be aware of any weight gain.” ANS: B Aspirin or products containing aspirin should be avoided while taking meloxicam. DIF: Cognitive Level: Application TOP: Rheumatoid arthritis MSC: NCLEX: Physiological Integrity
REF: 1339 OBJ: 9 KEY: Nursing Process Step: Evaluation
11. What should the nurse include in the plan of care for a patient following a myelogram? a. Position in a semi-Fowler’s position for 8 hours to reduce potential of headache. b. Place patient flat on back to compress puncture site. c. Ambulate for brief periods to lessen postmyelogram headache. d. Limit fluids to increase absorption of the dye. ANS: A The patient should be positioned in the semi-Fowler’s position for 8 hours to encourage the dye to stay in the lower spine and to reduce headache. DIF: Cognitive Level: Application REF: 1332 KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Myelogram
12. Which finding would delay a computed tomography (CT) scan? a. Patient’s allergy to shellfish b. Patient in first trimester of a pregnancy c. Patient’s allergy to milk products d. Patient’s gluten intolerance ANS: A Allergy to shellfish predicts an allergy to the contrast media used in the CT scan. DIF: Cognitive Level: Application KEY: Nursing Process Step: Assessment
REF: 1332 TOP: CT scan MSC: NCLEX: Physiological Integrity
13. Forty-eight hours after a patient sustained a fractured femur in a car accident, the nurse assessed a pulse of 110, respirations at 25, and labored crackles in both lung fields. The nurse immediately reports to the charge nurse the probability of a(n): a. impending pneumonia. b. atelectasis. c. fat embolism. d. anxiety attack. ANS: C
A pulmonary fat embolism involves the embolization of fat tissue with platelets and circulation of free fatty acids within the pulmonary circulation. Dyspnea, tachypnea, and chest pain are symptomatic of a fat embolus. DIF: Cognitive Level: Application KEY: Nursing Process Step: Assessment
REF: 1367-1368 TOP: Fat embolism MSC: NCLEX: Physiological Integrity
14. What is the first priority nursing intervention for an impending fat embolism? a. Administer oxygen in a respiratory emergency. b. Increase intravenous fluids. c. Position in flat to ease decreased blood pressure. d. Cover with warm blanket. ANS: A The airway is always the first priority. If hypoxia is present, the physician will order the administration of oxygen. It is important for the nurse to check the liter flow of oxygen and educate patients and their families as to safety precautions necessary when oxygen is administered. DIF: Cognitive Level: Analysis REF: 1368 KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Fat embolism
15. A patient, age 68, has suffered an intertrochanteric fracture of the right hip. Before surgery, to provide support and comfort, an immobilizing device of a is applied. a. Thomas splint b. Bryant traction c. Russell traction d. Buck traction ANS: D Buck traction is a form of traction used as a temporary measure to provide support and comfort to a fractured extremity until a more definite treatment is initiated. DIF: Cognitive Level: Knowledge REF: 1374 KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Fracture
16. Which foods should the home health nurse suggest for the patient with osteoporosis to help slow the disease? a. Leafy green vegetables b. Foods high in sodium c. Tea and coffee d. Vitamin A ANS: A To slow the bone loss, a patient with osteoporosis should eat green leafy vegetables, foods low in sodium, and avoid caffeine. Vitamin A helps with the absorption of calcium and stimulates bone formation.
DIF: Cognitive Level: Application TOP: Osteoporosis diet Implementation MSC: NCLEX: Physiological Integrity
REF: 1363 OBJ: 11 KEY: Nursing Process Step:
17. What should the nurse include in the teaching plan for a patient who is taking alendronate (Fosamax)? a. Take drug with any meal. b. Take drug first thing in the morning. c. Drink at least 5 oz of milk before taking drug. d. Take drug with an antacid to avoid heartburn. ANS: B Alendronate (Fosamax) should be taken on an empty stomach first thing in the morning with 6 oz of water, accompanied by no other medication. DIF: Cognitive Level: Application TOP: Osteoporosis drug MSC: NCLEX: Physiological Integrity
REF: 1358 OBJ: 8 KEY: Nursing Process Step: Planning
18. The patient has been diagnosed as having gouty arthritis. The patient asks the nurse to explain the cause of the inflammation of the great toe. What is the most appropriate nursing response? a. “You have calcium oxalate deposits that are seen in gouty arthritis.” b. “The inflammation is from small accumulations of uric acid crystals, which are called tophi.” c. “The small nodules are not related to the arthritis condition.” d. “You have fat deposits that are common with gouty arthritis.” ANS: B Gout is a metabolic disease resulting from an accumulation of uric acid in the blood. It is an acute inflammatory condition associated with ineffective metabolism of purines. DIF: Cognitive Level: Application REF: 1345-1346 KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Gouty arthritis
19. When the patient with rheumatoid arthritis complains about the daily exercise, the nurse encouragingly reminds the patient that exercises: a. keeps the joints from “freezing.” b. will ensure better sleep. c. should be vigorous for joint stimulation. d. need not be done daily. ANS: A Daily gentle exercises keep the joints from “freezing” and keep the muscles from weakening. DIF: Cognitive Level: Application TOP: Rheumatoid arthritis
REF: 1351 KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 20. The nurse clarifies to a patient who is being evaluated for possible rheumatoid arthritis that the elevated erythrocyte sedimentation rate indicates the presence of: a. immunoglobulin M. b. abnormal serum protein. c. increased inflammatory reaction in the body. d. C-reactive protein. ANS: C The ESR indicates an increase in the inflammatory reactions in the body. DIF: Cognitive Level: Comprehension TOP: Rheumatoid arthritis Implementation MSC: NCLEX: Physiological Integrity
REF: 1337 KEY: Nursing Process Step:
21. What should the nurse instruct the patient before the initiation of the antimalarial drug hydroxychloroquine (Plaquenil)? a. Get a complete blood count to assess anemia. b. Get a chest x-ray. c. Get an eye examination. d. Take prophylaxis for malaria. ANS: C An eye examination should be completed before starting the drug and an eye examination should be done every 6 months while on the drug, because the drug can damage the retina and lead to blindness. DIF: Cognitive Level: Comprehension REF: 1340 OBJ: 8 TOP: Gout KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. What should the nurse do when a patient with osteomyelitis is admitted with an open wound that is draining? a. Enforce a low-calorie diet. b. Initiate drainage and secretion precautions. c. Frequently do passive ROM on the elbow. d. Ambulate several times daily. ANS: B The patient with osteomyelitis should be at least in drainage and secretion precaution. The limb should be positioned for maximum comfort and left at rest. These patients are usually on bed rest and require a high-calorie, high-protein diet. DIF: Cognitive Level: Application REF: 1350 KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Osteomyelitis
23. A 16-year-old male patient presents in the emergency room with a pathologic fracture of the left femur and complains of pain on weight-bearing. These are cardinal indicators of: a. osteogenic sarcoma. b. osteoporosis. c. rheumatoid arthritis. d. osteochondroma. ANS: A Osteogenic sarcoma occurs in young men aged 10 to 25. They are malignant bone tumors that can cause a pathologic fracture and they are accompanied by pain on weight-bearing. Osteochondromas are benign and usually do not cause fractures. DIF: Cognitive Level: Application KEY: Nursing Process Step: Assessment
REF: 1383 TOP: Bone tumor MSC: NCLEX: Physiological Integrity
24. The 14-year-old boy who is scheduled for left leg amputation says to the nurse, “What in the world am I going to do with only one leg?” What is the nurse’s most therapeutic response? a. “What are you thinking about right now?” b. “With a prosthesis, you will be as good as new.” c. “It is way too early to be concerned about that now.” d. “When my brother had his leg removed, he did great!” ANS: A The patient’s concern should be acknowledged and the patient encouraged to express feelings. DIF: Cognitive Level: Analysis REF: 1385 KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
TOP: Fracture of hip
25. A patient has undergone a bipolar hip repair (hemiarthroplasty). Which is the most appropriate instruction? a. Sit in whatever position is most comfortable. b. Sit in a firm, straight-backed chair at a 90-degree angle. c. Avoid crossing the legs. d. Begin full weight-bearing as soon as tolerated. ANS: C Instructing the patient not to cross the legs is important because crossing the legs can adduct the affected extremity and dislocate the hip. DIF: Cognitive Level: Application TOP: Hip replacement Implementation MSC: NCLEX: Physiological Integrity
REF: 1388 OBJ: 14 KEY: Nursing Process Step:
26. The nurse explains to a patient who has had a knee replacement that warfarin (Coumadin) is ordered to: a. increase the red blood cells.
b. reduce the threat of hemorrhage. c. prevent formation of emboli. d. help stabilize the prosthesis. ANS: C Warfarin (Coumadin) is a standard postsurgical drug to prevent the formation of emboli. DIF: Cognitive Level: Analysis REF: 1358 therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Coumadin
27. What should the nurse stress to a post–hip replacement patient in quadriceps setting exercises? a. Push knee down to mattress and raise heel off the bed. b. Flex knee and extend foot. c. Adduct leg and flex foot. d. Lift leg and heel off the bed. ANS: A Pushing the knee down into the mattress and raising the heel will strengthen the quadriceps muscles. DIF: Cognitive Level: Application REF: 1358 OBJ: 14 TOP: Quad setting KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. What should the home health nurse include assessment for in the plan of care for an 82-year-old female with severe kyphosis from ankylosis? a. Urinary output b. Respiratory effort c. Sleep cycle d. Nutritional status ANS: B Severe kyphosis may hinder the patient’s ability to expand the rib cage and interfere with easy respiration. DIF: Cognitive Level: Analysis REF: 1342 KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Kyphosis
29. What should the nurse stress to a patient who has had a hip replacement and is beginning strengthening exercises for the unaffected leg? a. Flex the knee and flex the foot. b. Lift the leg from the mattress and rotate the foot. c. Pull knee to chest and extend the foot. d. Push foot down against the footboard for a count of five. ANS: D
The unaffected leg should be strengthened by pushing the foot down against the footboard for a count of five and repeating frequently during the day. DIF: Cognitive Level: Comprehension REF: 1358 OBJ: 13 TOP: Exercise KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. The office nurse has noted the presence of an increase in lumbar curvature in a 20-year-old female patient. What is this condition known as? a. Scoliosis b. Lordosis c. Kyphosis d. Spondylitis ANS: B Common deformities include an increase in the curve at the lumbar space region that throws the shoulder back, making the “lordly or kingly” appearance that is known as lordosis. Scoliosis involves the S curvature of the spine. Kyphosis is the rounding of the thoracic spine. DIF: Cognitive Level: Knowledge KEY: Nursing Process Step: Assessment
REF: 1386 TOP: Lordosis MSC: NCLEX: Physiological Integrity
31. How is rheumatoid arthritis distinguished from osteoarthritis? a. Rheumatoid arthritis is an autoimmune, systemic disease; osteoarthritis is a degenerative disease of the joints. b. Rheumatoid arthritis is an autoimmune, degenerative disease; osteoarthritis is a systemic inflammatory disease. c. People with osteoarthritis are considered to be genetically predisposed; there is no known genetic component to rheumatoid arthritis. d. Osteoarthritis is often caused by a virus; viruses play no part in the pathogenesis of rheumatoid arthritis. ANS: A RA is thought to be an autoimmune disorder. Degenerative joint disease is also known as osteoarthritis. DIF: Cognitive Level: Analysis TOP: Rheumatoid arthritis MSC: NCLEX: Physiological Integrity
REF: 1343 OBJ: 8 KEY: Nursing Process Step: Assessment
32. Which patient is most likely to develop osteoporosis? a. 43-year-old African American woman b. 57-year-old white woman c. 48-year-old African American man d. 62-year-old Latino woman ANS: B White women have a higher incidence of osteoporosis than Asian women, followed by African American women and Hispanic women.
DIF: Cognitive Level: Knowledge TOP: Osteoporosis MSC: NCLEX: Physiological Integrity
REF: 1347-1348 OBJ: 11 KEY: Nursing Process Step: Assessment
33. The patient, age 58, is diagnosed with osteoporosis after densitometry testing. She has been menopausal for 5 years and has been concerned about her risk for osteoporosis because her mother has osteoporosis. In teaching her about her osteoporosis, which information does the nurse include? a. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. b. Estrogen replacement therapy must be started to prevent rapid progression of her osteoporosis. c. With a family history of osteoporosis, there is no way to prevent or slow bone reabsorption. d. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. ANS: A To prevent osteoporosis, women are advised to have an adequate daily intake of calcium and vitamin D; exercise regularly; avoid smoking; decrease caffeine intake; decrease excess protein in the diet; and engage in regular moderate activity such as walking, bike riding, or swimming at least 3 days a week. A contributing factor may be use of steroids. DIF: Cognitive Level: Analysis REF: 1347-1348 KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Osteoporosis
34. Certain foods may increase the pain associated with gout. Which foods have the highest concentration of purines? a. Brain, liver, kidney b. Lettuce, corn, potatoes c. Beef, pork, chicken d. Fruits and fruit juices ANS: A Foods high in purines, such as brain, kidney, liver, and heart should be avoided, as well as alcohol. DIF: Cognitive Level: Analysis KEY: Nursing Process Step: Assessment
REF: 1345-1346 TOP: Gout MSC: NCLEX: Physiological Integrity
35. In order for a patient to flex the lower leg, which muscle must be contracted? a. Quadriceps b. Gastrocnemius c. Biceps femoris d. Rectus femoris ANS: C The contraction of the biceps femoris allows for the contraction of the lower leg.
DIF: Cognitive Level: Comprehension TOP: Muscle action Implementation MSC: NCLEX: Physiological Integrity
REF: 1330 OBJ: 4 KEY: Nursing Process Step:
36. Calcium is a mineral found in many foods that can slow bone loss during the aging process. Which food is high in calcium? a. Oranges b. Bananas c. Spinach d. Eggs ANS: C Spinach and green vegetables, as well as yogurt, are considered calcium-rich foods. Fresh oranges, bananas, and eggs are not good calcium choices. DIF: Cognitive Level: Analysis TOP: Osteoporosis Implementation MSC: NCLEX: Physiological Integrity
REF: 1358 OBJ: 11 KEY: Nursing Process Step:
37. A 56-year-old female patient is being seen for osteoarthritis of the knee in the clinic. What should the nurse recommend when discussing strengthening exercises? a. Jogging b. Walking rapidly on a treadmill c. Bicycling d. Aerobic exercises ANS: C Bicycling or swimming is recommended for osteoarthritis of the hip or knee. Jogging would put undue stress on knee joints. Climbing stairs should be avoided. Walking should be done on level ground, not up or down elevations. DIF: Cognitive Level: Analysis TOP: Osteoarthritis Implementation MSC: NCLEX: Physiological Integrity
REF: 1349 OBJ: 10 | 11 KEY: Nursing Process Step:
38. What does prolonged bed rest put the older adult at risk for? a. Ankylosing spondylitis b. Pathologic fractures c. Osteomyelitis d. Gout ANS: B Immobilization results in bone resorption, and the bone tissue becomes less dense. Prolonged bed rest puts the patient at risk for pathologic fracture. This is a serious concern for an older adult in terms of regaining mobility.
DIF: Cognitive Level: Comprehension REF: 1335 TOP: Disorders of musculoskeletal system KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 39. The nurse takes into consideration that a healing fracture progresses through several healing stages. Which is the third healing stage? a. Development of fibrin meshwork b. Collagen fibers collect calcium c. Osteoblasts home fracture site form d. Callus e. Formation of hematoma f. Clot formation g. Vascularization ANS: A The healing stages of a fracture start with a clot formation, which leads to a hematoma. The development of a fibrin meshwork, which traps osteoblasts to keep the fracture site firm, vascularization, collagen fibers collect calcium to make the callus. DIF: Cognitive Level: Analysis healing KEY: Nursing Process Step: Planning
REF: 1362
TOP: Fracture
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE 1. Which of the following are the main purposes of traction? (Select all that apply.) a. Align and stabilize a fracture. b. Prevent deformities. c. Relieve muscle spasms. d. Promote bed rest. e. Increase circulation to the rest of the body. ANS: A, B, C Skin and skeletal traction provide alignment and stabilize a fracture. This prevents deformities and relieves muscle spasms by putting muscles under tension until they are fatigued. DIF: Cognitive Level: Application KEY: Nursing Process Step: Assessment
REF: 1374 TOP: Traction MSC: NCLEX: Physiological Integrity
2. The characteristics of osteoarthritis that should be included in a teaching plan would include that osteoarthritis: (Select all that apply.) a. will cause the formation of Heberden nodes. b. can involve other organs. c. results from wear and tear. d. may affect only one side of the body. e. may cause constitutional symptoms of fatigue and fever. f. will cause marked erythema and edema of hands. ANS: A, C, D
Osteoarthritis is a disease caused by wear and tear of the joints, causing the appearance of Heberden nodes on the fingers without marked edema or erythema. The disease may only affect one side of the body and does not cause constitutional symptoms. DIF: Cognitive Level: Application TOP: Osteoarthritis MSC: NCLEX: Physiological Integrity
REF: 1344 OBJ: 10 KEY: Nursing Process Step: Planning
3. What are the three vital functions muscles perform when they contract? (Select all that apply.) a. Absorb uric acid b. Maintenance of posture c. Motion d. Store minerals e. Production of heat f. To assist in return of venous blood to the left side of the heart ANS: B, C, E The three vital functions muscles perform when they contract are maintenance of posture, motion, and production of 85% of body heat. DIF: Cognitive Level: Comprehension TOP: Functions of muscular system MSC: NCLEX: Physiological Integrity
REF: 1329 KEY: Nursing Process Step: Assessment
4. Which instructions should the nurse include in a teaching plan for a person with gouty arthritis? (Select all that apply.) a. Avoid excessive alcohol. b. Maintain rest and immobility while disease is symptomatic. c. Check urine and urine output for possible kidney stones. d. Include food high in purine in the diet. e. Use bed cradle to support linens. ANS: A, B, C, E The person with gout should avoid alcohol and food with high purine content, maintain rest and immobility while symptomatic, and check urine and urine output for possible kidney stones. DIF: Cognitive Level: Application REF: 1346 KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Gout
COMPLETION 1. The division of the skeletal system that comprises the skull, hyoid, vertebral column, and thorax is the division. ANS: axial
The axial division of the skeletal system is comprised of the skull, hyoid, vertebral column, and the thorax. DIF: Cognitive Level: Knowledge REF: 1328 divisions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Skeletal
2. A patient’s patellar-femoral cartilage has deteriorated due to arthritis. The medial and lateral cartilage is undamaged. This patient is likely to undergo partial or knee replacement surgery. ANS: unicompartmental Unicompartmental knee arthroplasty is also referred to as partial knee replacement and is performed on patients who have only one of the compartments of the knee affected by arthritis. DIF: Cognitive Level: Comprehension TOP: Partial knee replacement MSC: NCLEX: Physiological Integrity
REF: 1352 KEY: Nursing Process Step: Planning
3. The emergency department nurse assesses the two cardinal signs of a hip fracture in a newly admitted patient, which are the shortening of the injured leg and the rotation of that same leg. ANS: external The two cardinal signs of a fractured hip are the appearance of the shortening of the affected leg and the external rotation of that same leg. DIF: Cognitive Level: Application TOP: Signs of hip fracture MSC: NCLEX: Physiological Integrity
REF: 1356 KEY: Nursing Process Step: Assessment
4. The nurse administering the drug colchicine for gout will give 0.5 mg hourly for hours. ANS: 12 Colchicine is given orally in a dose of 0.5 mg for a period of 12 hours or until relief from pain is achieved or diarrhea occurs. DIF: Cognitive Level: Comprehension REF: 1346 KEY: Nursing Process Step: Implementation
TOP: Colchicine
MSC: NCLEX: Physiological Integrity 5. The nurse explains that the use of the fracture to be mobile.
brace allows a person with a cervical
ANS: halo Halo braces attach to the skull with pins, which stabilize a cervical vertebral fracture, allowing the patient to be mobile. DIF: Cognitive Level: Knowledge REF: 1366 OBJ: 15 TOP: Halo brace KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Chapter 45: Care of the Patient with a Gastrointestinal Disorder Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse clarifies that the end product of carbohydrate metabolism is absorbed and put into the bloodstream by the: a. gastric lining of the stomach. b. villi of the small intestine. c. bile of the liver in the large intestine. d. excretion from the cecum. ANS: B The inner surface of the small intestine contains millions of tiny, fingerlike projections called villi, which contain small blood vessels. They are responsible for absorbing the products of digestion. DIF: Cognitive Level: Comprehension REF: 1394 TOP: Digestive KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 2
2. A 56 -year-old man is admitted to the emergency room with an acute attack of diverticulitis. The patient has a temperature of 102°F, and has an elevated white count. Which assessment would alert the nurse to impending septic shock? a. Chest pain b. Seizure c. Tachycardia d. Massive diarrhea ANS: C The patient with diverticulitis who has fever and an elevated white count has an infection that could lead to septic shock, which will present as tachycardia and hypotension. DIF: Cognitive Level: Comprehension TOP: Diverticulitis MSC: NCLEX: Physiological Integrity
REF: 1429 OBJ: 9 KEY: Nursing Process Step: Assessment
3. Because bowel contents from an ileostomy are virtually liquid, what should the nurse include in the plan of care? a. Evaluation and assessment of dietary intake of fiber b. Evaluation and assessment of patient cleanliness c. Evaluation and assessment of peristomal skin integrity d. Evaluation and assessment of the adequacy of the collection device ANS: C The nurse should assess the peristomal skin for impairment of integrity. The fecal material is liquid and has a potential for severe skin excoriation from the digestive enzymes.
DIF: Cognitive Level: Application TOP: Ulcerative colitis MSC: NCLEX: Physiological Integrity
REF: 1424 OBJ: 8 KEY: Nursing Process Step: Assessment
4. The home health nurse caring for a patient who has dysarthria related to radiation therapy for an oral cancer would recommend that the family provide: a. a tablet and pencil as a communication aid. b. a TV for diversion. c. a bell to summon help. d. a walkie-talkie. ANS: A The provision of an alternative method of communicating will lessen the frustration of the patient who has trouble speaking understandably. The call bell would be helpful also, but without a way to communicate, the bell is not as essential as a method of communication. DIF: Cognitive Level: Application TOP: Cancer of esophagus MSC: NCLEX: Physiological Integrity
REF: 1402 OBJ: 5 KEY: Nursing Process Step: Assessment
5. Which recommendation is most appropriate for a patient who has had an esophageal dilation related to achalasia? a. Consume only liquid. b. Avoid fruit juices. c. Drink 10 oz of fluid with each meal. d. Lie down for 30 minutes after each meal. ANS: C The patient should drink fluid with each meal to increase lower esophageal pressure to push food into the stomach. DIF: Cognitive Level: Comprehension TOP: Esophageal dilation Implementation MSC: NCLEX: Physiological Integrity
REF: 1406 OBJ: 5 KEY: Nursing Process Step:
6. A patient who is being evaluated for episodes of hematemesis and dyspepsia tells the nurse that pain occurs when he eats, but pain does not waken him. The nurse recognizes a diagnostic sign of which condition? a. Duodenal ulcer b. Gastritis c. Achalasia d. Peptic ulcer ANS: D A significant subjective data assessment for a peptic ulcer is the patient report that pain is associated with eating. With duodenal ulcers the patient often complains of pain 1 to 2 hours after eating.
DIF: Cognitive Level: Knowledge REF: 1408 TOP: Peptic ulcer KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
7. The nurse anticipates that the patient who has had a subtotal gastrectomy will need supplemental: a. protein due to the loss of some of the digestive processes. b. vitamin B12 due to the loss of the intrinsic factor. c. bulk to prevent constipation. d. vitamin A due to the loss of the gastric lining. ANS: B It is recommended that all patients with a gastrectomy have a blood serum vitamin B12 level measured every 1 to 2 years. Decreased absorption of vitamin B12 may cause pernicious anemia. DIF: Cognitive Level: Application REF: 1416 TOP: Gastrectomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
8. The home health nurse is caring for a patient who has frequent bouts of diverticulitis accompanied by increased flatulence, diarrhea, and nausea. Which of the following is the most appropriate suggestion to lessen these symptoms? a. Eat a diet high in fiber content. b. Increase dietary fat intake. c. Exercise to increase intraabdominal pressure. d. Take daily laxatives. ANS: A The symptoms of diverticulitis can be reduced or prevented by eating a high-fiber diet, reduction of meat and fats in the diet, and avoiding activities that increase intraabdominal pressure. Although laxatives might be prescribed sparingly, daily laxatives are not recommended. DIF: Cognitive Level: Analysis REF: 1439 OBJ: 9 TOP: Diverticulitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. The nurse caring for a patient with a peptic ulcer who has had a nasogastric tube inserted notes bright blood in the tube; the patient complains of pain and has become hypotensive. Which condition should the nurse recognize these as signs of? a. Hiatal hernia b. Gastritis c. Perforation d. Bowel obstruction ANS: C
Perforation of the gastric wall causes pain, hypotension, and hematemesis. Immediate reporting to the charge nurse/physician is essential as peritonitis, potentially lethal, is the result of a perforation. DIF: Cognitive Level: Analysis TOP: Ulcer perforation MSC: NCLEX: Psychosocial Integrity
REF: 1408 OBJ: 5 KEY: Nursing Process Step: Assessment
10. Dumping syndrome after a Billroth II procedure occurs when high-carbohydrate foods are ingested over a period of less than 20 minutes. What would the nurse suggest to reduce the risk of dumping syndrome? a. Eating a high-carbohydrate diet b. Drinking 10 oz of fluids with meals c. Remaining upright for 2 hours after meals d. Eating six small daily meals high in protein and fat ANS: D Treatment for dumping syndrome includes eating six small meals daily that are high in protein and fat, and low in carbohydrates. Fluids should be avoided during meals. If possible, the patient should lie down for 1 hour after meals. DIF: Cognitive Level: Analysis TOP: Dumping syndrome MSC: NCLEX: Physiological Integrity
REF: 1416 OBJ: 4 KEY: Nursing Process Step: Planning
11. The patient has come to the PACU following an ileostomy for the treatment of ulcerative colitis. The patient is conscious and has a nasogastric tube in place and a pouch over the stoma. What should be the nurse’s initial action? a. Turn patient to right side. b. Give patient ice chips to moisten mouth. c. Attach NG tube to suction. d. Irrigate NG tube. ANS: C Initially, the NG tube should be attached to suction to decompress the stomach and prevent nausea. Assessing the tube for the need of future irrigation will be part of the postoperative care. DIF: Cognitive Level: Application REF: 1425 TOP: Appendicitis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 4
12. The home health nurse evaluates a patient being treated for a peptic ulcer with Riopan (antacid) and famotidine (histamine receptor blocker). Which statement made by the patient indicates a need for further instruction? a. “I know famotidine will not interfere with my Coumadin.” b. “I take the Riopan at least 2 hours after any of my other drugs.” c. “Boy! That Riopan keeps my stomach happy!” d. “I take both those meds at the same time every morning.”
ANS: D Antacids should not be taken with other drugs, because the absorption of the other drugs may be affected. DIF: Cognitive Level: Analysis KEY: Nursing Process Step: Evaluation
REF: 1410 TOP: Pharmacology MSC: NCLEX: Physiological Integrity
13. What should a nurse do when obtaining a stool specimen to be examined for ova and parasites? a. Use an oil retention enema to facilitate collection. b. Refrigerate the specimen immediately. c. Obtain three different stool specimens on subsequent days. d. Check the specimen for the presence of occult blood. ANS: C Diagnosing a parasitic infection requires three different stool specimens on subsequent days. Use only normal saline or tap water enemas to prevent alteration of results. DIF: Cognitive Level: Knowledge TOP: Diagnostic studies Implementation MSC: NCLEX: Physiological Integrity
REF: 1417 OBJ: 3 KEY: Nursing Process Step:
14. The nurse explains to the patient with Crohn disease that the tube feedings allow for: a. rapid absorption in the upper GI tract. b. decompression of the stomach. c. reduction of diarrheic episodes. d. a permanent nutritional support. ANS: A The tube feedings allow for rapid absorption of the nutrients in the upper GI tract. The tube feedings are not permanent and will be followed by oral intake of a low-residue, high-protein, high-calorie diet. DIF: Cognitive Level: Comprehension TOP: Crohn disease Implementation MSC: NCLEX: Physiological Integrity
REF: 1427 OBJ: 7 KEY: Nursing Process Step:
15. A patient with a large inguinal hernia has abdominal distention and inguinal pain. The nurse recognizes these as indicators of which type of hernia? a. Strangulated b. Hiatal c. Ventral d. Umbilical ANS: A The hernia is strangulated when the blood supply and intestinal flow are occluded, which results in pain and distention.
DIF: Cognitive Level: Knowledge TOP: Inguinal hernia MSC: NCLEX: Physiological Integrity
REF: 1432 OBJ: 10 KEY: Nursing Process Step: Assessment
16. A patient with a ruptured diverticulum in the descending colon has undergone a transverse loop colostomy. The patient is upset and says, “I didn’t know it was going to be this awful. I hate this!” Which response made by the nurse would be most helpful? a. “This is a temporary solution. It will be closed in 6 weeks.” b. “This seems awful now, but you won’t have the problems you had before.” c. “If everything goes well the surgeon can close this colostomy in about a year.” d. “With the appropriate pouch and loose clothing, no one will notice a thing.” ANS: A The loop colostomy is a temporary colostomy that allows for complete bowel rest. It can be closed in as short a time as 6 weeks. DIF: Cognitive Level: Analysis TOP: Diverticulum Implementation MSC: NCLEX: Psychosocial Integrity
REF: 1430 | 1437 OBJ: 8 KEY: Nursing Process Step:
17. A male patient complains that he will never adjust to his colostomy. Which is the best action for the nurse in this situation? a. Encourage him to express his concern. b. Suggest that he discuss his concerns with his physician. c. Counsel him that everything will be all right. d. Assure him that his concerns will diminish when he is able to care for his colostomy. ANS: A When a colostomy is performed, the patient or significant other should be able to verbalize and demonstrate understanding of ostomy care to the nurse. DIF: Cognitive Level: Analysis REF: 1430 OBJ: 8 TOP: Colostomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 18. In caring for a patient with gastric bleeding who has a nasogastric tube in place, the nurse should include in the plan of care to ensure that the NG tube is: a. clamped for 10 minutes every hour. b. kept patent with irrigation. c. frequently repositioned to the opposite nostril. d. changed every 72 hours. ANS: B Irrigating the NG tube PRN will keep the tube patent and ensure effective decompression. DIF: Cognitive Level: Application REF: 1435 OBJ: 4 TOP: NG tube KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 19. What should the nurse include in a teaching plan for a patient with a hiatal hernia to reduce the frequency of heartburn? a. Drinking 10 oz of milk with every meal b. Lie down after eating c. Panting through mouth when symptoms begin d. Eating small meals ANS: D Taking care not to overeat is the best defense again pyrosis (heartburn) for the person with a hiatal hernia. DIF: Cognitive Level: Knowledge TOP: Hiatal hernia Implementation MSC: NCLEX: Physiological Integrity
REF: 1433 OBJ: 10 KEY: Nursing Process Step:
20. The nurse points out which of the following as an example of a nonmechanical bowel obstruction? a. A paralytic ileus b. Narrowed bowel lumen from an inflammatory process c. Tumor of the bowel d. Fecal impaction ANS: A A nonmechanical bowel obstruction can be caused by a paralytic ileus. DIF: Cognitive Level: Comprehension REF: 1433 OBJ: 4 TOP: Cancer KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 21. Bowel sound assessment on a patient with an obstruction who has distention, nausea, and visible peristaltic waves would be: a. loud and clearly audible. b. high pitched. c. hyperactive. d. absent. ANS: B Because there are visible peristaltic waves, there will be bowel sounds that will be faint and high pitched. DIF: Cognitive Level: Comprehension TOP: Bowel obstruction MSC: NCLEX: Physiological Integrity
REF: 1434 OBJ: 11 KEY: Nursing Process Step: Assessment
22. The patient with a peptic ulcer has been placed on regular doses of bismuth salicylate (Pepto-Bismol) to combat Helicobacter pylori. What color will this drug turn the stool? a. Gray-black
b. Dark green c. Red-orange d. Yellow ANS: A Bismuth products turn the stool gray-black. DIF: Cognitive Level: Knowledge REF: 1410 TOP: Shock KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 4
23. Which of the following should be included in the patient teaching of a patient with a peptic ulcer? a. Introducing irritating foods in minute amounts to desensitize the stomach b. Restricting fluid to 1000 mL per day c. Eating 6 small meals a day d. Drinking alcohol and caffeine in moderation ANS: C The patient with a peptic ulcer should eat frequently to keep food in the stomach. Eating 6 small meals daily is helpful. Restriction of fluid is not necessary and irritating foods, alcohol, and caffeine should be discouraged. DIF: Cognitive Level: Analysis REF: 1409 TOP: Peptic ulcer KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
OBJ: 4
24. Which of the following would be the most helpful nursing intervention to increase the comfort of a patient with appendicitis? a. Application of ice bag b. Administration of small tap water enema c. Warm compress over entire abdomen d. Ambulate for short periods in the room ANS: A Application of an ice bag will decrease the flow of blood to the area and impede the inflammatory process. DIF: Cognitive Level: Application REF: 1428 OBJ: 9 TOP: Appendicitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. To assist a family with a bowel-training program to reduce fecal incontinence, the nurse would suggest the use of a at an optimal time to stimulate defecation. a. warm bath b. a tap water enema c. glycerin suppository d. large glass of warm lemonade ANS: C
The use of a glycerin suppository for fecal stimulation is a helpful aid in a bowel-training program. The suppository is administered at what the family and patient have determined is the optimal time for a bowel movement. DIF: Cognitive Level: Comprehension TOP: Bowel training Implementation MSC: NCLEX: Physiological Integrity
REF: 1441 OBJ: 13 KEY: Nursing Process Step:
26. What is the most lethal complication of a peptic ulcer? a. Bleeding b. Perforation c. Severe pain d. Gastric outlet obstruction ANS: B Perforation is considered the most lethal complication of peptic ulcer. Bleeding may occur when the ulcer erodes into a blood vessel; however, perforation occurs when the ulcer crater penetrates the entire thickness of the wall of the stomach or duodenum. Gastric outlet obstruction can occur at any time and can be relieved by NG aspiration of stomach contents. DIF: Cognitive Level: Comprehension TOP: Disorders of the stomach MSC: NCLEX: Physiological Integrity
REF: 1408 OBJ: 4 KEY: Nursing Process Step: Planning
27. The nurse takes into consideration that a proton pump inhibitor drug, such as , will completely eradicate gastric acid production. a. omeprazole (Prilosec) b. ranitidine (Zantac) c. sucralfate (Carafate) d. olsalazine (Dipentum) ANS: A Omeprazole (Prilosec) is a proton pump inhibitor that interferes with the production of gastric acid. DIF: Cognitive Level: Comprehension TOP: Disorders of the stomach MSC: NCLEX: Physiological Integrity
REF: 1409 OBJ: 4 KEY: Nursing Process Step: Planning
28. Which of the following is the purpose of antibiotic therapy in treating peptic ulcers? a. It eradicates H. pylori. b. It inhibits gastric acid secretion. c. It protects the gastric mucosa. d. It neutralizes or reduces the acidity of stomach contents. ANS: A Antibiotic therapy eradicates H. pylori.
DIF: Cognitive Level: Knowledge REF: 1409 TOP: Peptic ulcer KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
29. Why are peptic ulcers a common problem of aging? a. Because of overuse of antibiotics b. Because of overuse of antacids c. Because of overuse of NSAIDs d. Because of overuse of laxatives ANS: C Medications such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) taken for arthritis or degenerative joint conditions may contribute to ulcer formation. DIF: Cognitive Level: Comprehension TOP: Disorders of the stomach MSC: NCLEX: Physiological Integrity
REF: 1433 OBJ: 4 KEY: Nursing Process Step: Assessment
30. The patient with irritable bowel syndrome tells the home health nurse she is going to an acupuncturist for therapy for her condition. Which of the following would be the best nursing response? a. “Go for it. Alternative medicine does great things.” b. “YIKES! An acupuncturist?” c. “It may help, but there has been no clinical proof of its effectiveness.” d. “You should confirm that the acupuncturist is licensed.” ANS: C While it is true that some have found relief, there is no evidence that these therapies relieve the symptoms of IBS. DIF: Cognitive Level: Comprehension TOP: Alternative therapy Implementation MSC: NCLEX: Physiological Integrity
REF: 1420 KEY: Nursing Process Step:
31. The nurse uses a poster to show the process of bowel obstruction from diverticulitis. What is the third sequential pathophysiologic event? a. Increase in intraabdominal pressure b. Weakened wall of sigmoid c. Pouch fills with fecal matter d. Pouch protrudes through smooth muscle e. Narrowing of bowel lumen f. Inflammation of diverticula ANS: D Bowel obstruction from diverticulitis follows a sequential path: The wall of the bowel is weakened (usually the sigmoid), increase in abdominal pressure from such activities as bending and carrying heavy loads causes a pouch to protrude through the smooth muscle of the colon, the pouch fills with fecal matter, becomes inflamed, and narrows the lumen of the bowel causing obstruction.
DIF: Cognitive Level: Analysis REF: 1428-1429 OBJ: 9 TOP: Bowel obstruction KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 32. Celiac sprue in the adult can lead to systemic problems. What is the last pathophysical event of this in order of appearance? a. Malabsorption b. Weight loss/vitamin deficiency c. Systemic involvement d. Diarrhea e. Ingestion of gluten f. Destruction of villi in the small intestine ANS: C The ingestion of gluten in the small intestine damages the villi, which leads to malabsorption and diarrhea. Weight loss and vitamin deficiency, which occur from altered nutrition, can expand into systemic involvement. DIF: Cognitive Level: Analysis REF: 1419 TOP: Celiac sprue KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 4
MULTIPLE RESPONSE 1. Which of the following are indicators of colorectal cancer? (Select all that apply.) a. Constant diarrhea b. Excessive flatulence c. Cachexia d. Cramps e. Rectal bleeding f. Anemia ANS: B, C, D, E, F The indicators for colorectal cancer are changing bowel habits between diarrhea and constipation, flatulence, cachexia, cramps, rectal bleeding, and anemia. DIF: Cognitive Level: Analysis TOP: Colorectal cancer Implementation MSC: NCLEX: Physiological Integrity
REF: 1432 OBJ: 12 KEY: Nursing Process Step:
2. How should the nurse counsel the 34-year-old woman who has been prescribed sulfasalazine (Azulfidine) for Crohn disease? (Select all that apply.) a. Expose her to sunlight at least 30 minutes a day for vitamin D synthesis. b. Tell her to drink at least 1500 mL of fluid a day. c. Advise assessing self for rash. d. Use alternate birth control methods to oral contraception. e. Take drug on an empty stomach.
ANS: B, C, D Cautionary information about sulfasalazine (Azulfidine) would include having adequate fluid intake to prevent crystallization in the kidneys, avoiding exposure to the sun, and using alternate birth control methods as oral contraception is made unreliable by this drug. The drug should be taken with meals and the patient should be assessing for rash. DIF: Cognitive Level: Analysis REF: 1411 OBJ: 7 TOP: Crohn disease KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 3. In designing a teaching plan to present to a group of older adults regarding the prevention of esophageal cancer, the nurse would include information about the significance of: (Select all that apply.) a. cessation of smoking. b. good oral care. c. regular checkups if dysphagia is present. d. reducing excessive weight. e. limiting alcohol consumption. f. reduction of consumption of citrus fruits. ANS: A, B, C, E Preventive measures include cessation of smoking and alcohol consumption, good oral care, and medical evaluation of dysphagia. Weight and reduction of citrus fruits are noncontributory to prevention of esophageal cancer. DIF: Cognitive Level: Application REF: 1404-1405 OBJ: 6 TOP: Esophageal cancer KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 4. Which activities should the home health nurse suggest to an elderly patient to avoid constipation? (Select all that apply.) a. Schedule toileting after meals b. Taking bulk-forming laxatives c. Increasing fiber intake d. Drinking at least 1000 mL fluid e. Taking a daily stool softener f. Using tap water enemas for persons with altered mobility ANS: A, B, C, D Inactivity and changes in diet and fluid intake can contribute to constipation. A nutritional diet high in fiber and bulk-forming foods can promote normal elimination. Increasing fluids to 8 to 10 glasses per day will be beneficial in preventing constipation. A daily bowel routine will also benefit elimination. Use of daily stool softeners is no longer recommended for the older adult. Tap water enemas for persons with altered mobility are helpful. DIF: Cognitive Level: Analysis TOP: Disorders of intestine Implementation
REF: 1425 OBJ: 4 KEY: Nursing Process Step:
MSC: NCLEX: Physiological Integrity 5. The home health nurse is caring for a patient who has frequent abdominal pain and diarrhea. The nurse uses the Rome Criteria to direct assessment for irritable bowel syndrome. What is included in the Rome Criteria? (Select all that apply.) a. Discomfort at least 3 days a month b. Blood in stool c. Pain relieved by defecation d. Excessive flatulence e. Nausea and vomiting associated with onset f. Onset associated with change in stool consistency or frequency ANS: A, C, F The Rome Criteria include that the patient experience discomfort at least 3 days a month within the last 3 months, pain relieved by defecation, onset associated with change in stool frequency, and onset in association with a change in stool appearance. Although increased flatus is associated with diverticulitis, it is not part of the Rome Criteria. DIF: Cognitive Level: Application TOP: Rome Criteria MSC: NCLEX: Physiological Integrity
REF: 1420 OBJ: 5 KEY: Nursing Process Step: Assessment
COMPLETION 1. Flexible sigmoidoscopy should be performed every
years.
ANS: 5 five Flexible sigmoidoscopy should be performed every 5 years. Endoscopy of the lower GI tract allows visualization and, if indicated, access to obtain biopsy specimens of tumors, polyps, or ulcerations of the anus, rectum, and sigmoid colon. The lower GI tract is difficult to visualize radiographically, but sigmoidoscopy allows direct visualization. DIF: Cognitive Level: Knowledge TOP: Screening for colorectal cancer MSC: NCLEX: Physiological Integrity
REF: 1436 OBJ: 3 KEY: Nursing Process Step: Planning
2. The nurse explains that , the chief enzyme of gastric juice, is activated by hydrochloric acid to begin digestion of protein. ANS: pepsin Pepsin is activated by the hydrochloric acid to break down protein for digestion. DIF: Cognitive Level: Knowledge REF: 1393 OBJ: 2 TOP: Pepsin KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 3. The nurse caring for a patient with Crohn disease will closely monitor the urinary output to ensure that the patient is excreting at least mL/day. ANS: 1500 The output of 1500 mL a day indicates good kidney perfusion. The disease allows such dramatic fluid loss that a constant watch on I&O is a major nursing intervention. DIF: Cognitive Level: Comprehension TOP: Crohn disease MSC: NCLEX: Physiological Integrity
REF: 1443 OBJ: 7 KEY: Nursing Process Step: Assessment
4. The nurse takes into consideration that long-term use of antibiotics can cause an antibiotic-associated pseudomembranous colitis from the organism . ANS: Clostridium difficile C. difficile causes a type of colitis from long-term antibiotic use to which older adults are extremely susceptible. DIF: Cognitive Level: Knowledge REF: 1417 TOP: C. difficile KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 4
5. Due to frequent bouts of constipation, the nurse examines the bedfast nursing home resident for ulceration of the anus, called anal . ANS: fissure Ulceration and laceration of the anal skin can occur because of overstretching with the passing of constipated stool. DIF: Cognitive Level: Knowledge REF: 1440 TOP: Anal fissure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: N/A
Chapter 46: Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse clarifies that unconjugated bilirubin, which is made up of broken-down red cells, is: a. stored in the gallbladder to make bile. b. water-insoluble bilirubin that must be converted by the liver. c. a by-product which is excreted directly into the bowel for excretion. d. necessary for digestion of fats. ANS: B Unconjugated bilirubin is a water-insoluble product that must be converted in the liver to conjugated bilirubin (water soluble) so that it may be excreted through the bowel. DIF: Cognitive Level: Analysis REF: 1445 OBJ: 1 TOP: Bilirubin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The patient with cirrhosis has an albumin of 2.8 g/dL. The nurse is aware that normal is 3.5 to 5 g/dL. Based on these findings, what would the nurse expect the patient to exhibit? a. Jaundice b. Edema c. Copious urine output d. Pallor ANS: B Low serum albumin levels result also from excessive loss of albumin into urine or into third-space volumes, causing ascites or edema. DIF: Cognitive Level: Analysis REF: 1446 TOP: Cirrhosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
3. What is an essential nursing measure to prevent injury to the patient who is to receive a paracentesis? a. Have patient sign a permit. b. Pad side rails. c. Check for allergy to contrast media or to shellfish. d. Have patient void immediately before procedure. ANS: D To prevent the puncturing of the bladder, the patient must void immediately before the procedure. A permit is required but it is not a safety precaution for the patient. There is no contrast media used in a paracentesis.
DIF: Cognitive Level: Application REF: 1449 OBJ: 2 TOP: Paracentesis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. What should the nurse expect of a patient with a malabsorption of vitamin K? a. Lowered hemoglobin b. Elevated hematocrit c. Increased prothrombin time d. Diminished white blood cell count ANS: C Prothrombin times are increased because malabsorption of vitamin K or inability to produce the clotting factors VII, IX, and X cause the patient to have bleeding tendencies. DIF: Cognitive Level: Analysis REF: 1452 TOP: Cirrhosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 3
5. A patient was scheduled for a laparoscopic cholecystectomy, but complications developed and he underwent an open cholecystectomy with a T tube inserted into the common bile duct. What is the purpose of the T tube? a. To decompress the duct and relieve pain caused by stimulation of the sphincter of Oddi. b. To improve diaphragmatic expansion and prevention of atelectasis. c. To shorten postoperative recovery and hasten the healing process. d. To keep the duct open and allow drainage of the bile until edema resolves. ANS: D If the stones are in the common bile duct and edema is present, a biliary drainage tube, or T tube, will be inserted to keep the duct open and allow drainage of the bile until the edema resolves. DIF: Cognitive Level: Comprehension TOP: Cholecystectomy Implementation MSC: NCLEX: Physiological Integrity
REF: 1465 OBJ: 8 KEY: Nursing Process Step:
6. The nurse caring for a patient who has had an open cholecystectomy with a T Tube will: a. open the T tube to the air so that it will drain freely. b. position and secure the drainage bag at the chest level. c. place the collection bag so the tube is not kinked. d. irrigate the T tube with normal saline to ensure the free flow of bile. ANS: B The T tube is placed below the level of the common bile duct to prevent the reflux of bile. The bag must be positioned so the tube is not kinked, or bile cannot drain from the liver. Normally T tubes are not irrigated. DIF: Cognitive Level: Application TOP: Cholecystectomy
REF: 1465 OBJ: 8 KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity 7. Which nursing intervention should be completed immediately after the physician has performed a needle liver biopsy? a. Assisting to ambulate for the bathroom b. Keeping the patient on the right side for a minimum of 2 hours c. Taking vital signs every 4 hours d. Keeping the patient on the left side for a minimum of 4 hours ANS: B Keep the patient lying on the right side with a rolled towel against the puncture site for minimum of 2 hours to splint the puncture site. It compresses the liver capsule against the chest wall to decrease the risk of hemorrhage or bile leak. Vital signs are taken every 15 minutes for 30 minutes, then every 30 minutes for 2 hours. DIF: Cognitive Level: Application REF: 1448 OBJ: 2 TOP: Liver biopsy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. Immediately following a liver biopsy, the patient becomes dyspneic, the pulse increases to 100, and no breath sounds can be heard on the affected side. What should the nurse suspect? a. Peritonitis b. Pneumothorax c. Hemorrhage of the liver d. Pleural effusion ANS: B Pneumothorax is a possible complication of paracentesis. The patient’s head of the bed should be raised slightly but kept on the right side. Oxygen should be administered and the assessment reported to the charge nurse and documented. DIF: Cognitive Level: Comprehension TOP: Pneumothorax Implementation MSC: NCLEX: Physiological Integrity
REF: 1448 OBJ: 1 KEY: Nursing Process Step:
9. Which patient statement indicates that the patient requires additional teaching about an endoscopic retrograde cholangiopancreatography? a. “Right after the test, I want breakfast with black coffee.” b. “The instrument will be put down my throat.” c. “I haven’t had anything to eat or drink since 9 p.m. last night.” d. “My doctor said I could have medicine to relax me before the test.” ANS: A After the procedure, keep the patient NPO until the gag reflex returns. DIF: Cognitive Level: Analysis TOP: Diagnostic procedures
REF: 1450 OBJ: 1 KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity 10. The nurse assisting in the treatment of a patient with ruptured esophageal varices who has received vasopressin IV will carefully assess for: a. muscular twitching/spasm. b. hematuria. c. macular rash on trunk and arms. d. evidence of cardiac ischemia. ANS: D Vasopressin is a strong vasoconstrictor given to try to stop the hemorrhage of the varices. Unfortunately it also constricts all vessels and may cause cardiac ischemia. DIF: Cognitive Level: Application REF: 1451 TOP: Vasopressin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 3
11. What should the nurse point out as a significant advantage of the laparoscopic cholecystectomy? a. Slightly more invasive, but there is less pain b. Can be performed on all patients of any age c. Can be performed even when there are large stones present in the bile duct d. Less invasive procedure ANS: D The laparoscopic cholecystectomy is less invasive and causes less pain and a quick recovery. If there are large stones present, a sphincterotomy is done before the laparoscopic cholecystectomy. Persons with bleeding tendencies, pathologic conditions of the abdomen, stones in the bile duct, and extensive adhesions are not good candidates. DIF: Cognitive Level: Application TOP: Laparoscopic cholecystectomy Implementation MSC: NCLEX: Physiological Integrity
REF: 1465 OBJ: 2 KEY: Nursing Process Step:
12. What should the nurse explain is the major purpose of the Sengstaken-Blakemore tube (S/B tube)? a. Decompress the stomach. b. Control esophageal varices bleeding. c. A route for tube feedings. d. Obtain specimen for gastric analysis. ANS: B The major purpose of the S/B tube is to control bleeding by pressure against the vessels in the esophagus. The two balloons of the tube are inflated to put direct pressure on the esophagus and are anchored by the inflated balloon in the stomach. The tube can suction blood from the stomach as well. DIF: Cognitive Level: Analysis REF: 1454 OBJ: 2 TOP: SB tube KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 13. The patient’s cirrhosis of the liver has also caused a dilation of the veins of the lower esophagus secondary to portal hypertension, resulting in the development of the complication of: a. esophageal varices. b. diverticulosis. c. Crohn disease. d. esophageal reflux (GERD). ANS: A Esophageal varices (a complex of longitudinal, tortuous veins at the lower end of the esophagus) enlarge and become edematous as the result of portal hypertension. DIF: Cognitive Level: Analysis REF: 1453 TOP: Cirrhosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 3
14. The patient with cirrhosis has a rising ammonia level and is becoming disoriented. The patient waves to the nurse as she enters the room. How should the nurse interpret this? a. As an attempt to get the nurse’s attention b. As asterixis c. As an indication of respiratory obstruction from varices d. As spasticity ANS: B Asterixis is the “flapping tremor” seen as the patient deteriorates into ammonia intoxication or hepatic encephalopathy. DIF: Cognitive Level: Application TOP: Encephalopathy MSC: NCLEX: Physiological Integrity
REF: 1455 OBJ: 3 KEY: Nursing Process Step: Assessment
15. How does the administration of neomycin (Mycifradin) reduce the production of ammonia? a. By assisting the hepatic cells to regenerate b. By reducing ascites c. By decreasing the bacteria in the gut d. By helping to digest fats and proteins ANS: C The buildup of ammonia can be prevented with the use of lactulose (Chronulac) and neomycin. Ammonia is produced in the gut by bacterial action. By reducing the bacteria, less ammonia is produced. DIF: Cognitive Level: Application TOP: Encephalopathy Implementation MSC: NCLEX: Physiological Integrity
REF: 1455 OBJ: 3 KEY: Nursing Process Step:
16. What is the most common procedure for the removal of the gallbladder? a. Laparoscopic cholecystectomy b. Cholangiography c. Open cholecystectomy d. Choledochostomy ANS: A The most recently developed operative procedure, which is now the most common treatment for cholecystitis and cholelithiasis, is done by way of endoscopy. It is called laparoscopic cholecystectomy and uses laser cautery to remove the gallbladder. DIF: Cognitive Level: Knowledge TOP: Laparoscopic cholecystectomy MSC: NCLEX: Physiological Integrity
REF: 1465 OBJ: 8 KEY: Nursing Process Step: Planning
17. What should the nurse do to prepare a patient for an oral cholecystography? a. Ensure that the patient drinks 500 mL of water before testing. b. Give 4 Oragrafin (ipodate) 5 minutes apart starting at 6 a.m. c. Administer 6 Telepaque (iopanoic acid) tablets 5 minutes apart after the evening meal. d. Give a fatty meal hour before the test is started. ANS: C The patient is held NPO and given 6 tablets 5 minutes apart the evening before the procedure after the evening meal. A fatty meal is given to the patient after the test is started to stimulate emptying of the gallbladder. DIF: Cognitive Level: Application TOP: Oral cholecystography Implementation MSC: NCLEX: Physiological Integrity
REF: 1446 OBJ: 1 KEY: Nursing Process Step:
18. Which of the following is a classic symptom of cholecystitis? a. Substernal, radiating to the left shoulder and arm b. Epigastric, radiating to the back c. Right upper abdomen, radiating to the back or right scapula d. Left upper abdomen, radiating to the jaw and neck ANS: C It localizes in the right upper quadrant epigastric region. The pain radiates around the mid torso to the right scapular area. DIF: Cognitive Level: Analysis TOP: Cholecystitis MSC: NCLEX: Physiological Integrity
REF: 1464 OBJ: 2 KEY: Nursing Process Step: Assessment
19. What should the nurse avoid contamination from to prevent the transmission of hepatitis A? a. Food or water b. Blood transfusion
c. Needles d. Sexual contact ANS: A Hepatitis A virus is transmitted when a person puts something in his or her mouth that is contaminated with fecal material (called fecal-oral transmission). Teach patients the importance of good hand washing after the bathroom or changing a diaper, as well as proper food preparation, to prevent the spread of HAV. DIF: Cognitive Level: Comprehension REF: 1459 TOP: Hepatitis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 5
20. What is the most appropriate method used by high-risk health workers to prevent hepatitis B? a. Hepatitis B vaccine b. Diligent hand washing c. Wearing protective gear d. Hb immune globulin injections ANS: A The best preventive measure against the contraction of hepatitis B is HBV vaccine. DIF: Cognitive Level: Knowledge REF: 1459 TOP: Hepatitis B KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment
OBJ: 5
21. The nurse explains that the use of cyclosporine as an immunosuppressant has been successful in the reduction of rejection of liver transplants because the drug: a. increases the rate of the regeneration of liver cells. b. can overcome complications presented by hepatitis C. c. increases blood supply to transplant. d. does not suppress bone marrow. ANS: D Cyclosporine is an immunosuppressant that does not cause bone marrow suppression nor does it impede healing. DIF: Cognitive Level: Analysis TOP: Liver transplant Implementation MSC: NCLEX: Physiological Integrity
REF: 1461 OBJ: 7 KEY: Nursing Process Step:
22. A male patient states that he returned from a 2-week camping trip a few days ago. He complains of nausea and anorexia, and dark urine. What additional information would assist in diagnosing hepatitis A? a. Exposure to blood b. Recent ingestion of raw fish c. History of intravenous drug use d. Multiple sex partners
ANS: B Hepatitis A spreads by direct contact through the oral-fecal route, usually by food and water contaminated with feces. DIF: Cognitive Level: Analysis REF: 1458 TOP: Hepatitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
23. When caring for an extremely jaundiced patient with cirrhosis, what should the nurse include provisions for in the plan of care? a. Encouraging consumption of a high-fat diet b. Skin care to relieve pruritus c. Offering foods rich in fat-soluble vitamins d. Meticulous foot care ANS: B Jaundice causes pruritus and can lead to skin lesions and pressure injury. DIF: Cognitive Level: Comprehension REF: 1456 TOP: Cirrhosis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 1
24. The nurse is aware that an elevated serum amylase is diagnostic of pancreatitis at an early stage as an elevation can be assessed as early as after the onset of pancreatic disease. a. 2 hours b. 8 hours c. 24 hours d. 36 hours ANS: A An increase in the serum amylase can be detected as early as 2 hours after the onset of pancreatic disease. In simple acute pancreatitis, the level returns to normal in about 36 hours. In chronic disease, it remains elevated. DIF: Cognitive Level: Analysis TOP: Serum amylase MSC: NCLEX: Physiological Integrity
REF: 1449 OBJ: 1 KEY: Nursing Process Step: Assessment
25. The 100 lb patient who has been exposed to hepatitis A is to receive an injection of immune serum globulin. What should the dose (.02 mL/kg) be? a. 0.9 mL b. 1.4 mL c. 1.6 mL d. 1.8 mL ANS: A 100 lb/2.2 = 45.4. 45.4 0.02 = 0.90. DIF:
Cognitive Level: Application
REF: 1460
OBJ: 2
TOP: Immune serum globulin Implementation MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step:
26. A family member of a patient asks the nurse about the protein-restricted diet ordered because of advanced liver disease with hepatic encephalopathy. What statement by the nurse would best explain the purpose of the diet? a. “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.” b. “The liver heals better with a high-carbohydrate diet rather than with a diet high in protein.” c. “Most people have too much protein in their diets. The amount in this diet is better for liver healing.” d. “Because of portal hypertension, the blood flows around the liver, and ammonia made from protein collects in the brain, causing hallucinations.” ANS: A The patient with hepatic encephalopathy is on a very low-protein to no-protein diet. The goal of management of hepatic encephalopathy is the reduction of ammonia formation in the intestines. DIF: Cognitive Level: Analysis REF: 1455 OBJ: 3 TOP: Cirrhosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The nurse would make provisions in the plan of care for a person who has had a liver transplant to prevent: a. fluid congestion. b. fatigue. c. infection. d. urinary retention. ANS: C A critical aspect of nursing care following liver transplantation is monitoring for infection. The major postoperative complications of a liver transplant are rejection and infection. DIF: Cognitive Level: Analysis TOP: Liver transplant MSC: NCLEX: Physiological Integrity
REF: 1461 OBJ: 1 KEY: Nursing Process Step: Planning
28. The nurse is aware that the hepatitis A immunization provides immunity in: a. 5 days. b. 10 days. c. 15 days. d. 30 days. ANS: D Primary immunization with hepatitis A vaccine provides immunity within 30 days.
DIF: Cognitive Level: Application REF: 1460 TOP: Hepatitis A KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 8
29. What is the challenge in encouraging coughing and deep breathing for a postoperative patient who had an open cholecystectomy? a. High placement of incision b. Excessive nausea c. Weakened abdominal muscles d. Poor oxygenation ANS: A The high placement of the incision of the cholecystectomy makes the patient reluctant to cough. Splinting the incision is beneficial. DIF: Cognitive Level: Application TOP: Cholecystectomy Implementation MSC: NCLEX: Physiological Integrity
REF: 1466 OBJ: 2 KEY: Nursing Process Step:
30. Why is it advantageous for a live person to be a liver donor? a. Because the donor is not at risk for any complication. b. Because the recipient is more likely to avoid rejection. c. Because the donor donates only a part of the liver. d. Because the blood supply is more dependable in the donated liver. ANS: C A live donor may donate only a portion of their liver and within weeks the donor’s liver has grown to the size to meet the body’s needs. The same is true for the recipient. DIF: Cognitive Level: Knowledge TOP: Liver transplant MSC: NCLEX: Physiological Integrity
REF: 1461 OBJ: 7 KEY: Nursing Process Step: Assessment
31. Which factors are most commonly associated with pancreatitis? a. Coronary artery disease b. Alcoholism and biliary tract disease c. Cirrhosis d. History of myocardial infarction ANS: B Alcoholism and biliary tract disease are the two factors most commonly associated with pancreatitis. DIF: Cognitive Level: Knowledge REF: 1468 TOP: Pancreatitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 2
32. A patient with pancreatitis is NPO. The patient asks the nurse why he is unable to have anything by mouth. Which of the following is the best response?
a. “Diagnostic tests depend on you not eating anything.” b. “The pancreas is stimulated whenever you eat or drink and causes pain.” c. “Eating causes the need for a bowel movement, which excretes your medication too rapidly.” d. “Resting your GI tract will cure your pancreatitis.” ANS: B Food and fluids are withheld to avoid stimulating pancreatic activity, and IV fluids are administered. DIF: Cognitive Level: Analysis REF: 1468 OBJ: 2 TOP: Pancreatitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. Why is morphine contraindicated in the patient with pancreatitis? a. Demerol (meperidine) is less expensive. b. Tylenol is more effective at managing this type of pain. c. Morphine may cause spasms of the sphincter of Oddi. d. These patients do not experience pain. ANS: C A common complaint is constant, severe pain; in such cases, meperidine (Demerol) PCA is often administered. Morphine may cause spasms of the sphincter of Oddi. DIF: Cognitive Level: Knowledge REF: 1464 TOP: Pancreatitis KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
OBJ: 2
34. Which factors may increase a patient’s risk of developing cancer of the pancreas? a. Diet high in carbohydrates and dairy products b. Cardiovascular disease and glaucoma c. Tea and cola consumption d. Cigarette smokers and people with diabetes mellitus ANS: D The cause of cancer of the pancreas is unknown, but it is diagnosed more often in cigarette smokers, people exposed to chemical carcinogens, and people with diabetes mellitus and pancreatitis. DIF: Cognitive Level: Knowledge TOP: Cancer of the pancreas MSC: NCLEX: Physiological Integrity
REF: 1469 OBJ: 2 KEY: Nursing Process Step: Assessment
35. Which assessment would indicate possible gallbladder disease in an older adult? a. Dull pain in the right upper quadrant region b. Changes in color of urine or stool c. Distention of veins in upper part of body d. Aching muscles and tenderness in the liver ANS: B
The incidence of cholelithiasis increases with aging. Assess older adults for history of changes in stool or urine color. Cirrhosis of the liver may cause distention in veins in the upper part of the body. DIF: Cognitive Level: Knowledge TOP: Age-related changes MSC: NCLEX: Physiological Integrity
REF: 1467 OBJ: 2 KEY: Nursing Process Step: Assessment
36. What should the nurse monitor in caring for the patient undergoing a paracentesis? a. The urinary output b. Hypervolemia c. Fluid removal over at least 30 minutes d. Seizure ANS: C The fluid removed during a paracentesis is removed over a period of 30 to 90 minutes to prevent sudden changes in blood pressure leading to syncope. The bed should be in a high Fowler’s position. Food and fluid restriction is usually not necessary. DIF: Cognitive Level: Analysis REF: 1453 TOP: Paracentesis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 1
37. A patient with a T tube for an open cholecystectomy has resumed oral intake. The T tube is clamped 2 hours before meals and unclamped 2 hours after meals to aid in the digestion of fat. During the time the tube is clamped the patient complains of abdominal pain and nausea. Which intervention is most appropriate? a. Notify the physician. b. Unclamp the tube immediately. c. Increase the IV fluids. d. Change the T-tube dressing. ANS: B While the tube is clamped, the patient may show signs of abdominal pain, nausea, vomiting, etc. Unclamp the tube immediately to allow for drainage and relief of both nausea and pain. DIF: Cognitive Level: Analysis TOP: Cancer of the pancreas Implementation MSC: NCLEX: Physiological Integrity
REF: 1464 OBJ: 8 KEY: Nursing Process Step:
38. The nurse clarifies that deterioration progresses through stages before presenting with liver disease. The first stage is destruction. What is the last stage? a. Liver disease b. Inflammation c. Hepatic insufficiency d. Destruction e. Fibrotic regeneration
ANS: A Liver deterioration follows a pattern of stages: destruction, inflammation, fibrotic regeneration; hepatic insufficiency then presents as liver disease. DIF: Cognitive Level: Comprehension REF: 1450 TOP: Pseudocyst KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 2
39. What is the second step in the normal process of protein metabolism? a. Protein enters the bloodstream. b. Excreted by kidney. c. Portal vein delivers blood to the liver. d. Conversion to urea. e. Ammonia produced in the bowel. ANS: E Protein products enter the bloodstream and are changed in the bowel to ammonia; the products then pass through the portal vein to the liver where the ammonia is converted to urea, which is then excreted by the kidneys. DIF: Cognitive Level: Analysis TOP: Liver destruction Implementation MSC: NCLEX: Physiological Integrity
REF: 1448 OBJ: 2 KEY: Nursing Process Step:
MULTIPLE RESPONSE 1. What are the indications for a liver transplant? (Select all that apply.) a. Congenital biliary abnormalities b. Hepatic malignancy c. Chronic hepatitis d. Cirrhosis due to alcoholism e. Gallbladder disease ANS: A, B, C Indications for liver transplantation include congenital biliary abnormalities, inborn errors of metabolism, hepatic malignancy (confined to the liver), sclerosing cholangitis, and chronic end-stage liver disease. DIF: Cognitive Level: Comprehension TOP: Liver transplant MSC: NCLEX: Physiological Integrity
REF: 1460 OBJ: 7 KEY: Nursing Process Step: Assessment
2. Which medical interventions and management systems control the bleeding of esophageal varices? (Select all that apply.) a. Transfusions b. Sengstaken-Blakemore tube c. Band ligation d. Cryotherapy
e. Portacaval shunt f. Large doses of vitamin B12 ANS: B, C, E Band ligation, insertion of the S/B tube, and various shunting surgeries are helpful in stopping the hemorrhage. Transfusions and water-soluble vitamins are not beneficial. DIF: Cognitive Level: Comprehension TOP: Esophageal varices MSC: NCLEX: Physiological Integrity
REF: 1454 OBJ: 3 KEY: Nursing Process Step: Assessment
3. Dietary teaching for a patient who is treated conservatively for cholecystitis is necessary to keep the patient comfortable. Which foods should be avoided? (Select all that apply.) a. Peanut butter b. Grilled chicken c. Rice and pasta d. Bananas, apples, oranges e. Whole milk f. Glazed chocolate doughnuts ANS: A, E, F Peanut butter, nuts, chocolate, whole milk, fried foods, and cream and other fatty foods should be avoided. DIF: Cognitive Level: Comprehension TOP: Cholecystitis and cholelithiasis MSC: NCLEX: Physiological Integrity
REF: 1467 OBJ: 2 KEY: Nursing Process Step: Assessment
4. Viral hepatitis may be treated at home. What should be taught to the patient’s family? (Select all that apply.) a. Clothes should be laundered separately with hot water. b. Personal items and drinking glasses should not be shared. c. Articles soiled with feces do not require extra care. d. Hands need to be thoroughly washed after toileting. e. Contaminated items may be disposed of with regular trash. ANS: A, B, D For the patient with viral hepatitis being cared for in the home, the family needs to be taught necessary precautions. Clothes should be laundered separately with hot water. Personal items used by the patient should not be shared. Articles soiled with feces must be disinfected. Any contaminated items should be disposed of properly. DIF: Cognitive Level: Analysis REF: 1462 OBJ: 5 TOP: Hepatitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is aware that the liver synthesizes products essential to health. Which products are synthesized by the liver? (Select all that apply.) a. Intrinsic factor b. Protein
c. Vitamin K d. Red blood cells e. Albumin ANS: B, E The liver synthesizes protein and albumin. DIF: Cognitive Level: Analysis TOP: Products synthesized by liver MSC: NCLEX: Physiological Integrity
REF: 1446 OBJ: N/A KEY: Nursing Process Step: Planning
6. What should the nurse do as part of the preparation for an endoscopic retrograde cholangiopancreatography (ERCP)? (Select all that apply.) a. Confirm that a recent chest x-ray is on file. b. Confirm the presence of a consent form. c. Warn patient that the procedure will take about 3 hours. d. Confirm the presence of a prothrombin time/INR. e. Withhold food and drink for 4 hours. ANS: B, D Before the ERCP, the patient will be held NPO for 8 hours. It is necessary that a consent form be signed as well as evidence of a prothrombin time INR. DIF: Cognitive Level: Application REF: 1450 OBJ: 1 TOP: ERCP KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment COMPLETION 1.
is a condition characterized by yellowing of the sclera and the skin. ANS: Jaundice Jaundice is the discoloration of body tissues caused by abnormally high blood levels of bilirubin. DIF: Cognitive Level: Knowledge REF: 1445 TOP: Jaundice KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
2. The disease that is on the increase because of the growing obesity population and is associated with coronary artery disease and use of corticosteroids is ANS: nonalcoholic fatty liver disease (NAFLD) nonalcoholic fatty liver disease NAFLD
.
NAFLD is a disease that is on the rise due to the increasing population of obese persons. The disease is also associated with CAD and the use of corticosteroids. DIF: Cognitive Level: Comprehension REF: 1450 TOP: NAFLD KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 2
3. The tumor marker that is elevated in patients with pancreatic cancer is
.
ANS: CA19-9 The tumor marker CA19-9 is elevated in the presence of pancreatic cancer. DIF: Cognitive Level: Knowledge REF: 1470 TOP: CA19-9 KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 4. Hepatitis D is usually seen as a coinfection with
OBJ: 1
.
ANS: hepatitis B Hepatitis D is usually seen as a coinfection with hepatitis B. DIF: Cognitive Level: Knowledge REF: 1458 TOP: Hepatitis KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 6
5. A occurs when the body encapsulates the autodigestive debris in the pancreatic tissue, frequently becoming an abscess. ANS: pseudocyst A pseudocyst occurs when the body encapsulates the autodigestive debris in the pancreatic tissue. DIF: Cognitive Level: Comprehension REF: 1468 TOP: Pseudocyst KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 2
Chapter 47: Care of the Patient with a Blood or Lymphatic Disorder Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. What is the process by which certain cells engulf and digest microorganisms and cellular debris? a. Erythrocytosis b. Hematocrit c. Phagocytosis d. Hemostasis ANS: C Phagocytosis is the process by which bacteria, cellular debris, and solid particles are destroyed and removed. DIF: Cognitive Level: Comprehension TOP: Diagnostic procedures MSC: NCLEX: Physiological Integrity
REF: 1478 OBJ: 3 KEY: Nursing Process Step: Assessment
2. The nurse explains that because it is a reliable and predictable indicator of the body’s level of infection or recovery the is a common diagnostic tool. a. hemoglobin b. hematocrit c. mean cell volume (MCV) d. differential ANS: D A differential white blood cell count is an examination in which the different kinds of WBCs are counted and reported as percentages of the total examined. It is a common diagnostic tool because of its reliability and the predictability of the body’s response to infection or its progress in recovery. DIF: Cognitive Level: Analysis REF: 1478 OBJ: 4 TOP: Differential KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse assessing a differential sees an increase in immature neutrophils (bands) and is aware that this indicates: a. a significant hemorrhage. b. aplastic anemia. c. an overwhelming bacterial infection. d. beginning recovery from an infection. ANS: C An increase in immature neutrophils (bands) is called bandemia, and it indicates an overwhelming bacterial infection. DIF:
Cognitive Level: Application
REF: 1478
OBJ: 1
TOP: Bandemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. B cells and T cells fit under which classification? a. Erythrocytes b. Basophils c. Lymphocytes d. Monocytes ANS: C B cells and T cells, the major players in the antigen/antibody conflict, are both lymphocytes. DIF: Cognitive Level: Knowledge TOP: Lymphocytes MSC: NCLEX: Physiological Integrity
REF: 1479 OBJ: 1 KEY: Nursing Process Step: Assessment
5. The nurse explains that in the event of an invasion of an allergen, the basophils release a strong vasodilator, which is: a. lysozyme. b. prothrombin. c. hematocrit. d. histamine. ANS: D Histamine is released by the basophils during the invasion of an allergen. DIF: Cognitive Level: Comprehension REF: 1478 OBJ: 1 TOP: Leukocytes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The presence of excess bands in the peripheral blood that indicate severe infection is called: a. shift to the left. b. shift to the right. c. bone marrow aspiration. d. thrombocytosis. ANS: A The presence of excess bands in the peripheral blood is called a shift to the left (i.e., a shift toward immature cells) and indicates severe infection. DIF: Cognitive Level: Analysis TOP: Diagnostic procedures MSC: NCLEX: Physiological Integrity
REF: 1478 OBJ: 8 KEY: Nursing Process Step: Assessment
7. A patient who had a Schilling test shows a 20% excretion of the radioactive vitamin B12. What would this indicate? a. The patient has a low reserve of iron and has iron-deficiency anemia. b. The patient has a normal finding and does not have pernicious anemia.
c. The patient has a deficiency of thrombocytes and has a clotting disorder. d. The patient has an excess of RBCs and has polycythemia. ANS: B The Schilling test is a laboratory blood test for diagnosing pernicious anemia. The normal reading 24 hours after the administration of radioactive vitamin B12 is 8% to 40%. The test measures the absorption of radioactive vitamin B12. DIF: Cognitive Level: Analysis TOP: Schilling test MSC: NCLEX: Physiological Integrity
REF: 1482 OBJ: 8 KEY: Nursing Process Step: Assessment
8. In an adult, where are erythrocytes continuously produced? a. Yellow bone marrow b. Lymphatic system c. Spleen d. Red bone marrow ANS: D Erythrocytes are continuously produced in the red bone marrow, principally in the vertebrae, ribs, and sternum. DIF: Cognitive Level: Knowledge TOP: Diagnostic procedures MSC: NCLEX: Physiological Integrity
REF: 1476 OBJ: 9 KEY: Nursing Process Step: Planning
9. What does the elevation in the eosinophil count to 10% indicate? a. Anemia b. Allergy c. Infection d. Hypoxia ANS: B Normal values of eosinophils are 1% to 4%. An elevation to 10% would indicate the presence of an allergic reaction. DIF: Cognitive Level: Comprehension REF: 1477 TOP: Eosinophils KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
10. What would a nurse include in a teaching plan for a home health patient with a hemoglobin of 8.4 mg? a. Exercising for periods of 30 minutes daily b. Limiting fluid intake c. Alternating activity with rest periods d. Avoiding the use of oxygen ANS: C Severely anemic persons need to conserve their energy. Observing a rest period after a period of activity will reduce hypoxia. Oxygen may be used as necessary.
DIF: Cognitive Level: Knowledge REF: 1478 TOP: Anemia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 1
11. Approximately how much blood is stored in the spleen that can be released in a hypovolemic emergency? a. 100 mL b. 300 mL c. 500 mL d. 1000 mL ANS: C The spleen stores 1 pint of blood, approximately 500 mL, which can be released during emergencies. DIF: Cognitive Level: Knowledge REF: 1481 TOP: Spleen KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 11
12. The nurse caring for a patient with pernicious anemia should make provisions for: a. frequent iced drinks. b. lightweight blanket. c. a fan to circulate the air. d. reverse isolation. ANS: B Persons with pernicious anemia are especially sensitive to cold. The provision of a light blanket is beneficial. DIF: Cognitive Level: Knowledge TOP: Pernicious anemia MSC: NCLEX: Physiological Integrity
REF: 1486 OBJ: 11 KEY: Nursing Process Step: Planning
13. When instructing the patient taking an oral liquid iron preparation, what should the nurse include? a. Information relative to taking the iron with milk b. Information relative to the bowel movement color changing to dark red c. Information relative to taking preparation through a straw to prevent staining of teeth d. Information relative to taking a drug with meals or a snack ANS: C Liquid iron preparations should be drunk through a straw to prevent tooth staining. All oral iron preparations should be taken before meals. Dairy products interfere with the absorption of iron. DIF: Cognitive Level: Application TOP: Oral iron administration MSC: NCLEX: Physiological Integrity
REF: 1491 OBJ: 9 KEY: Nursing Process Step: Planning
14. When the 14-year-old African American boy comes into the emergency room in sickle cell crisis, what should be the primary focus of care? a. Instruct patient about transfusion procedure b. Starting of IV fluids c. Pain control d. Relief of dyspnea ANS: C Pain control during the crisis is the focus. Continuous opioids are the mainstay of pain management. Certainly IV fluids to reduce viscosity of blood and oxygen for relief of dyspnea are important, but pain control is paramount in the acute phase. DIF: Cognitive Level: Analysis REF: 1492 TOP: Leukemia KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity
OBJ: 9
15. The mother of a 4-year-old child with leukemia says to the nurse, “I don’t understand why he is crying about his legs hurting.” The nurse’s most informative response would be based on the information that bone pain is related to: a. elevated WBCs in differential. b. long periods of inactivity. c. splenomegaly. d. bone marrow congested with white cells. ANS: D Long bone pain is the result of bone marrow that is congested with immature white cells. DIF: Cognitive Level: Application REF: 1493 OBJ: 9 TOP: Leukemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What must a patient undergo before a bone marrow transplant? a. A thorough nutritional plan to support new marrow b. Total body irradiation to kill all the marrow cells c. A physical therapy program to strengthen the body d. Inhalation therapy to reduce possible pathogens in the lungs ANS: B Before the actual marrow transplant, the patient must undergo total body irradiation or chemotherapy to kill all the marrow cells and the leukemic cells. The patient is at a major risk for infection at this time. DIF: Cognitive Level: Application TOP: Marrow transplant MSC: NCLEX: Physiological Integrity
REF: 1496 OBJ: 12 KEY: Nursing Process Step: Planning
17. The 9-year-old child with leukemia who is on palliative care has drawn a picture of a boy under a huge black cloud that has lightning coming out of it. Which of the following would be an appropriate intervention for the nurse? a. “What is this picture about?”
b. “Are you afraid of lightning?” c. “I bet this is a picture of you, isn’t it?” d. “Is it about to rain in your picture?” ANS: A Asking what the child has drawn is a neutral and nonthreatening question. Drawings can give a clue to perceptions and emotions that a young child may not be able to verbalize. The nurse should not try to interpret the drawing. DIF: Cognitive Level: Application REF: 1496 OBJ: 12 TOP: Leukemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The home health nurse recommends to the mother of a 12-year-old child with leukemia that the child should have: a. the series for prevention of hepatitis B. b. an annual influenza vaccine. c. an annual pneumococcal vaccine. d. vitamin B12 shots. ANS: B Children with leukemia should have an annual influenza vaccine and a pneumococcal vaccine every 5 years. DIF: Cognitive Level: Application REF: 1498 OBJ: 9 TOP: Pneumococcal vaccine KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 19. Which patient statement from a 15-year-old girl with thrombocytopenia would require more assessment to report to the charge nurse? a. “I think these red spots on my skin are going away.” b. “I am so bored lying in bed I could scream.” c. “I can’t tell if the corticosteroids are helping.” d. “For some reason I seem to have bad constipation.” ANS: D A teen-aged or adult thrombocytopenia patient must understand the process of the disease and receive instructions on signs, symptoms, and preventive measures for it. Constipation is a common symptom that should be reported to the health care provider if it develops. DIF: Cognitive Level: Analysis TOP: Thrombocytopenia MSC: NCLEX: Physiological Integrity
REF: 1500 OBJ: 16 KEY: Nursing Process Step: Assessment
20. A 23-year-old male patient with hemophilia A says, “How can I keep my children from having hemophilia A?” Which of the following is the most informative response? a. “You need to select a very dependable mode of birth control.” b. “You can only pass hemophilia B to your sons.”
c. “Your daughter may be a carrier and her children may have hemophilia A. Your son is not at risk.” d. “Your sons should have coagulation studies.” ANS: C Hemophilia A is an X-linked trait. Females are carriers; therefore, the patient’s daughter could pass the disease to her sons. The patient’s sons are not at risk for hemophilia A. DIF: Cognitive Level: Analysis TOP: Hemophilia A Implementation MSC: NCLEX: Physiological Integrity
REF: 1501 OBJ: 13 KEY: Nursing Process Step:
21. A child with hemophilia is hospitalized with hemarthrosis. Which of the following should the nurse caring for that child include in the plan of care? a. Remain aware of any erythema, cuts, or bruising—of any size—that the child experiences or reports. b. Apply warm compresses to reduce hemorrhage in the joint. c. Use analgesia sparingly. d. Encourage vigorous ROM exercises several times a day to keep knee flexible. ANS: A Remaining aware of any erythema, cuts, or bruising—of any size—that the child experiences or reports is important. The nurse should also monitor the child’s temperature and reports of pain. DIF: Cognitive Level: Comprehension TOP: Hemarthrosis MSC: NCLEX: Physiological Integrity
REF: 1499 | 1501 OBJ: 13 KEY: Nursing Process Step: Planning
22. In caring for a patient with multiple myeloma, what should the nurse include in the daily care? a. Provisions for limiting fluid intake to less than 1000 mL/day b. Provisions for close supervision and assistance when ambulating c. Provisions for straining all urine d. Provisions for limiting use of an analgesic ANS: B Because of the constant threat of pathologic fractures, ambulation should be carefully supervised and assisted. Uric acid is increased and may crystalize in the kidney, but straining is not necessary. Analgesia is necessary for relief of bone pain. DIF: Cognitive Level: Application TOP: Multiple myeloma Implementation MSC: NCLEX: Physiological Integrity
REF: 1505 OBJ: 15 KEY: Nursing Process Step:
23. The nurse is aware that a person with Hodgkin disease, who has two or more abnormal lymph nodes on the same side of the diaphragm and cancer extending locally from one lymph node area into a nearby organ, would be in:
a. b. c. d.
stage I. stage II. stage III. stage IV.
ANS: B Stage II indicates that there are two or more abnormal lymph nodes on the same side of the diaphragm and cancer that extends from a lymph node area into a nearby organ. DIF: Cognitive Level: Analysis TOP: Hodgkin disease MSC: NCLEX: Physiological Integrity
REF: 1508 | 1509 OBJ: 15 KEY: Nursing Process Step: Assessment
24. The nurse explains that a positron emission tomography (PET) has been ordered to: a. assess bone marrow depression. b. measure bone density. c. radiate and destroy diseased lymph nodes. d. determine the extent of possible metastasis. ANS: D The PET can aid in the staging of disease by determining the extent of any metastasis in the liver, lungs, or bones. DIF: Cognitive Level: Comprehension REF: 1509 TOP: PET KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 15
25. Which of the following foods would the nurse recommend to a person with iron-deficiency anemia as an excellent meat source for erythropoiesis? a. Dark meat of chicken b. Cured ham c. Pork chops d. Processed meat ANS: A The dark meat of poultry is a good meat source for erythropoiesis. DIF: Cognitive Level: Analysis TOP: Iron-deficiency anemia MSC: NCLEX: Physiological Integrity
REF: 1490 OBJ: 9 KEY: Nursing Process Step: Planning
26. The peripheral smear is a diagnostic test that: a. assesses the level of hemoglobin. b. measures antibody production. c. examines the shape and structure of RBCs. d. identifies infection. ANS: C The peripheral smear allows the study of the size, structure, and shape of RBCs. DIF:
Cognitive Level: Comprehension
REF: 1482
OBJ: 8
TOP: Peripheral smear MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step: Assessment
27. The typical medical treatment of polycythemia vera involves repeated phlebotomies and medications such as busulfan (Myleran) in order to: a. stimulate bone marrow. b. inhibit bone marrow activity. c. increase hemoglobin. d. reduce gout. ANS: B Repeated phlebotomy decreases blood viscosity, and myelosuppressive agents such as busulfan (Myleran) are often given to inhibit bone marrow activity. DIF: Cognitive Level: Comprehension TOP: Polycythemia vera MSC: NCLEX: Physiological Integrity
REF: 1493 OBJ: N/A KEY: Nursing Process Step: Planning
28. Which of the following would the nurse explain as a type of leukemia that affects noticeably more children and teens than adults? a. Chronic lymphocytic leukemia (CLL) b. Acute myeloid leukemia (AML) c. Acute lymphocytic leukemia (ALL) d. Chronic myeloid leukemia (CML) ANS: C Of the 6000 Americans diagnosed with the fast-advancing ALL in 2013, just over half were children and teens. DIF: Cognitive Level: Analysis REF: 1495 OBJ: 12 TOP: Leukemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. The nurse is aware that persons of the Jehovah’s Witness faith accept which types of blood transfusions? a. No type of blood transfusion b. Blood that has been blessed by their religious leader c. Transfusions only for persons who have not yet been baptized d. Autologous blood transfusions ANS: D Jehovah’s Witness followers are accepting of autologous blood transfusions and some will accept volume expanders such as colloids. DIF: Cognitive Level: Application TOP: Jehovah’s Witness MSC: NCLEX: Physiological Integrity
REF: 1484 OBJ: 9 KEY: Nursing Process Step: Assessment
30. Which mandatory practice is the most effective and significant nursing practice to prevent the spread of infection?
a. Strict and frequent hand washing by all people having contact with the patient b. Placement of patients in private rooms with high-efficiency particulate air (HEPA) filtration c. Administration of combinations of prophylactic antibiotics d. Creation of a “sterile” environment for the patient with the use of laminar airflow rooms ANS: A Meticulous hand washing by medical and nursing personnel and strict asepsis are mandatory. DIF: Cognitive Level: Application REF: 1495 OBJ: 12 TOP: Hand washing KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 31. What is the average lifespan of an erythrocyte? a. 7 days b. 60 days c. 120 days d. Up to several years ANS: C The lifespan of an RBC is 120 days. A WBC’s lifespan is days to several years. Platelets live 5 to 9 days. DIF: Cognitive Level: Knowledge REF: 1476 TOP: Anatomy and physiology of blood cells KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 2
32. Because older adults suffer from conditions such as colonic diverticula, hiatal hernia, and ulcerations that can cause occult bleeding, the nurse should assess for symptoms of: a. leukemia. b. iron-deficiency anemia. c. sickle cell anemia. d. polycythemia. ANS: B Blood loss is a major cause of iron-deficiency in adults. The major sources of chronic blood loss are from the GI and genitourinary systems. DIF: Cognitive Level: Knowledge REF: 1489 TOP: Anatomy and physiology of blood cells KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 9
33. The nurse explains that the treatment of hemophilia has been revolutionized with the advent of the use of: a. corticosteroids.
b. large doses of testosterone. c. recombinant factors VIII and IX. d. transfusion with packed red cells. ANS: C Recombinant factor VIII and recombinant factor IX have been major forward steps in the treatment of hemophilia. DIF: Cognitive Level: Analysis REF: 1502 OBJ: 13 TOP: Hemophilia KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 34. From which location would the bone marrow sample come in the aspiration of a 25-year-old patient? a. Sternum b. Posterior superior iliac crest c. Posterior iliac crest d. Femur ANS: C The preferred site for bone marrow aspiration puncture in adults is the posterior iliac crest. DIF: Cognitive Level: Knowledge TOP: Bone marrow aspiration Implementation MSC: NCLEX: Physiological Integrity
REF: 1482 OBJ: 8 KEY: Nursing Process Step:
35. Which is the first step in the process of hemostasis? a. Release of clotting factor from injured tissue b. Formation of thrombin c. Formation of fibrin d. Trapping of RBC and platelets e. Clot f. Release of thromboplastin ANS: A Clotting factors are released from the injured tissue causing the release of thromboplastin, which acts with calcium to form thrombin; fibrin is formed, which traps red cells and platelets to make the clot. DIF: Cognitive Level: Analysis TOP: Clot formation MSC: NCLEX: Physiological Integrity
REF: 1479 OBJ: 5 KEY: Nursing Process Step: N/A
36. Which is the last step of the process that stimulates the increase in the production of red blood cells? a. Kidneys release erythropoietic factor b. Increase in red blood cell production c. Enzyme stimulates red bone marrow
d. Oxygen delivery increased to the tissues e. Oxygen delivery decreased to the tissues f. Decrease in red blood cell production ANS: F When the tissues of the body register a decrease of oxygen, the kidneys release the erythropoietic factor that stimulates the bone marrow to produce more RBCs, which increases the oxygen delivery to the tissues which then signals the bone marrow to decrease the RBC production. DIF: Cognitive Level: Analysis TOP: Erythropoiesis MSC: NCLEX: Physiological Integrity
REF: 1476 OBJ: 2 KEY: Nursing Process Step: N/A
MULTIPLE RESPONSE 1. What are the most likely matches for a bone marrow transplant to a 10 year old with leukemia? (Select all that apply.) a. Uncle b. Self c. Mother d. Brother e. Sister f. Father ANS: B, D, E Specimens from twins, siblings, or self (autologous) while in remission are preferred. DIF: Cognitive Level: Comprehension TOP: Bone marrow transplant MSC: NCLEX: Physiological Integrity
REF: 1488 OBJ: 12 KEY: Nursing Process Step: Planning
2. The spleen is a highly vascularized organ located in the left upper quadrant of the abdominal cavity. What are the main functions of the spleen? (Select all that apply.) a. Serve as reservoir for blood. b. Destroy worn-out RBCs. c. Promote phagocytosis. d. Responsible for development of T lymphocytes. e. Continuously produce RBCs during lifetime. ANS: A, B, C The spleen stores 1 pint of blood, which can be released during emergencies, such as hemorrhage, in less than 60 seconds. The main functions of the spleen are (1) to serve as a reservoir for blood; (2) to form lymphocytes, monocytes, and plasma cells; (3) to destroy old or imperfect RBCs; (4) to remove bacteria by phagocytosis (engulfing and digesting); and (5) to produce RBCs before birth (the spleen is believed to produce RBCs after birth only in cases of extreme hemolytic anemia). DIF: Cognitive Level: Knowledge REF: 1481 OBJ: 2 TOP: Anatomy and Physiology of the Hematological and Lymphatic System
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
3. The nurse examines the complete blood count (CBC) to assess: (Select all that apply.) a. hematocrit. b. red cell count. c. differential white blood cell count. d. plasma level. e. blood type. f. hemoglobin. ANS: A, B, C, F The CBC gives information relative to RBC, WBC, hematocrit, hemoglobin, erythrocyte indexes, WBC differential, and examination of the peripheral blood cells. DIF: Cognitive Level: Application REF: 1482 OBJ: 8 TOP: CBC KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Which of the following are necessary factors that support healthy erythropoiesis? (Select all that apply.) a. Dietary magnesium b. Healthy bone marrow and kidney function c. Adequate oxygen source d. Vitamin B12 e. Amino acids f. Vitamin B2 ANS: B, D, E, F Erythropoiesis, red blood cell production, is dependent on the availability of healthy bone marrow and kidney function, dietary supply of copper and iron, amino acids, vitamins B12 and B2, folic acid, and pyridoxine. DIF: Cognitive Level: Analysis TOP: Erythropoiesis Implementation MSC: NCLEX: Physiological Integrity
REF: 1476 OBJ: 2 KEY: Nursing Process Step:
5. The nurse caring for a patient in the emergency room with suspected internal injuries will assess for hypovolemic shock, which is evidenced by: (Select all that apply.) a. irritability. b. restlessness. c. slow bounding pulse. d. decreased respirations. e. pallor. f. hypotension. ANS: A, B, E, F Indicators of hypovolemia are restlessness, irritability, rapid thready pulse, increasing respirations, pale, cool moist skin, and hypotension, Should the blood loss continue, the patient could go into hypovolemic shock.
DIF: Cognitive Level: Application TOP: Hypovolemia MSC: NCLEX: Physiological Integrity
REF: 1484 OBJ: 10 KEY: Nursing Process Step: Assessment
6. Which of the following are “B” symptoms of a patient with Hodgkin disease? (Select all that apply.) a. Hematuria b. Night sweats c. Severe diarrhea d. Weight gain from edema e. Fever f. Persistent dry cough ANS: B, E The “B” symptoms of Hodgkin disease are night sweats, fever, and weight loss. These symptoms are associated with a poor prognosis. DIF: Cognitive Level: Comprehension TOP: “B” symptoms Assessment MSC: NCLEX: Physiological Integrity
REF: 1508 KEY:
OBJ: 15 Nursing Process Step:
COMPLETION 1.
are leukocytes that destroy and remove cellular waste, bacteria, and solid particles. ANS: Neutrophils Neutrophils (granular circulating leukocytes essential for phagocytosis, the process by which bacteria, cellular debris, and solid particles are destroyed and removed) ingest bacteria and dispose of dead tissue. DIF: Cognitive Level: Knowledge REF: 1478 TOP: Leukocytes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 1
2. The person with aplastic anemia is said to be because all three major blood elements (RBCs, WBCs, and platelets) are diminished or absent. ANS: pancytopenic Persons with aplastic anemia are deficient in all three of the major blood elements, a condition known as pancytopenia. DIF:
Cognitive Level: Knowledge
REF: 1505
OBJ: 9
TOP: Aplastic anemia MSC: NCLEX: Physiological Integrity 3. The nurse clarifies that ferrous blood cell production.
KEY: Nursing Process Step: Assessment
replaces iron stores needed for red
ANS: sulfate Ferrous sulfate replaces iron stores needed for red blood cell production. DIF: Cognitive Level: Knowledge TOP: Ferrous sulfate MSC: NCLEX: Physiological Integrity 4. Neutrophils release
REF: 1497 OBJ: 9 KEY: Nursing Process Step: Assessment
, an enzyme that destroys certain bacteria.
ANS: lysozyme Lysozyme is an enzyme released by the neutrophils that kills certain bacteria when the bacteria is recognized in the body. DIF: Cognitive Level: Comprehension REF: 1478 TOP: Lysozyme KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 1
5. The Reed-Sternberg cell is the hallmark diagnostic indicator for disease. ANS: Hodgkin The Reed-Sternberg cell, large abnormal multinucleated cells in the lymph nodes, is diagnostic of Hodgkin disease. DIF: Cognitive Level: Knowledge TOP: Reed-Sternberg cells MSC: NCLEX: Physiological Integrity
REF: 1508 OBJ: 15 KEY: Nursing Process Step: N/A
Chapter 48: Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse is aware that the muscle layer of the heart, which is responsible for the heart’s contraction, is the: a. endocardium. b. pericardium. c. mediastinum. d. myocardium. ANS: D The myocardium is the specialized muscle layer that allows the heart to contract. DIF: Cognitive Level: Comprehension REF: 1520 OBJ: 2 TOP: Myocardium KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse clarifies that the master pacemaker of the heart is the: a. left ventricle. b. atrioventricular (AV) node. c. sinoatrial (SA) node. d. bundle of His. ANS: C The SA node is the master pacemaker of the heart. DIF: Cognitive Level: Application TOP: Acute myocardial infarction MSC: NCLEX: Physiological Integrity
REF: 1518 OBJ: 10 KEY: Nursing Process Step: Planning
3. The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in women because acute chest pain is not present. Women are frequently misdiagnosed as having: a. hepatitis A. b. indigestion. c. urinary infection. d. menopausal complications. ANS: B Indigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses for women having an MI. DIF: Cognitive Level: Application TOP: MIs in women MSC: NCLEX: Physiological Integrity
REF: 1536-1537 OBJ: 16 KEY: Nursing Process Step: Planning
4. The nurse identifies the “lub” sound of the “lub/dub” of the cardiac cycle as the sound of the: a. AV valves closing. b. closure of the semilunar valves. c. contraction of the papillary muscles. d. contraction of the ventricles. ANS: A The lub is the first sound of a low pitch heard when the AV valves close. DIF: Cognitive Level: Application REF: 1519 TOP: Lub sound KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
5. A patient is admitted from the emergency department. The emergency department physician notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV. This indicates the patient’s condition as: a. moderate heart failure. b. severe heart failure. c. congestive heart failure. d. negligible heart failure. ANS: B Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina or symptoms of cardiac inefficiency may develop at rest. DIF: Cognitive Level: Knowledge TOP: Classification of heart failure MSC: NCLEX: Physiological Integrity
REF: 1548 OBJ: 9 KEY: Nursing Process Step: Assessment
6. The nurse assesses that the home health patient has no signs or symptoms of heart failure, but does have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus. The nurse is aware that using the American College of Cardiology and the American Heart Association (ACC/AHA) staging, this patient would be a: a. stage A. b. stage B. c. stage C. d. stage D. ANS: A The ACC/AHA staging describes stage A as a person without symptoms of heart failure, but with primary conditions associated with the development of the disease. DIF: Cognitive Level: Analysis REF: 1548 TOP: Heart failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 9
7. The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry recognizes the need for added instruction when the patient says: a. “I can ambulate in the hallway with this gadget on.”
b. “I always take off the telemetry device when I shower.” c. “My EKG is being watched by one of the nurses in CCU on the home unit.” d. “I am able to sleep just fine with this device on.” ANS: B Remote telemetry allows the patient to be on a separate unit, but be monitored in a central location. The patients can be ambulatory and can sleep with the monitor on. They should not remove the monitor to shower. DIF: Cognitive Level: Application TOP: Remote telemetry MSC: NCLEX: Physiological Integrity
REF: 1523 OBJ: 6 KEY: Nursing Process Step: Evaluation
8. The nurse assesses pitting edema that can be depressed approximately in 15 seconds. The nurse would document this assessment as: a. +1 edema. b. +2 edema. c. +3 edema. d. +4 edema. ANS: B A +2 edema can be documented if the skin can be depressed 15 seconds. DIF: Cognitive Level: Analysis TOP: Pitting edema MSC: NCLEX: Physiological Integrity
in and refills
in and respond within
REF: 1548 OBJ: 9 KEY: Nursing Process Step: Assessment
9. What do dark or “cold” spots on a thallium scan indicate? a. Tissue with adequate blood supply b. Dilated vessels c. Areas of neoplastic growth d. Tissue that has inadequate perfusion ANS: D Thallium scans show adequate perfused areas by the collection of thallium. Dark spots or “cold spots” indicate tissues that have inadequate perfusion. DIF: Cognitive Level: Application TOP: Thallium scan MSC: NCLEX: Physiological Integrity
REF: 1523 OBJ: 6 KEY: Nursing Process Step: Planning
10. The nurse recognizes the echocardiogram report that shows an ejection factor of 42% as an indication of: a. normal heart action. b. mild heart failure. c. moderate heart failure. d. severe heart failure. ANS: C
An ejection fraction (cardiac output) of 42% indicates moderate heart failure. DIF: Cognitive Level: Comprehension REF: 1523 TOP: Heart failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
11. The nurse takes into consideration that age-related changes can affect the peripheral circulation because of: a. sclerosed blood vessels. b. hypotension. c. inactivity. d. poor nutrition. ANS: A Aging causes sclerotic changes in the blood vessels that lead to decreased elasticity and narrowing of the vessel lumen. DIF: Cognitive Level: Comprehension REF: 1526 TOP: Endocarditis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 16
12. The nurse assessing a cardiac monitor notes that the cardiac complexes each have a P wave followed by a QRS and a T. The rate is 120. The nurse recognizes this arrhythmia as: a. sinus bradycardia. b. atrial fibrillation. c. sinus tachycardia. d. ventricular tachycardia. ANS: C Sinus tachycardia has a P wave followed by the QRS and the T. All the components of the complex are present and in the correct order, but the rate is over 100 beats/min. DIF: Cognitive Level: Application REF: 1528 TOP: Arrhythmias KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 8
13. After an influenza-like illness, the patient complains of chills and small petechiae in his mouth and his legs. A heart murmur is detectable. These are characteristic signs of: a. congestive heart failure. b. heart block. c. aortic stenosis. d. infective endocarditis. ANS: D Collection of subjective data includes noting patient complaints of influenza-like symptoms with recurrent fever, undue fatigue, chest pain, and chills. Objective data may reveal the significant signs of petechiae in the conjunctiva and mouth. Both subjective data and objective data are indicative of infective endocarditis.
DIF: Cognitive Level: Analysis REF: 1560 TOP: Endocarditis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
14. The nurse notes a run of three ventricular contractions (PVC) that are not preceded by a P wave. This particular arrhythmia can progress into: a. atrial fibrillation and possible emboli. b. sinus tachycardia and syncope. c. ventricular tachycardia and death. d. sinus bradycardia and fatigue. ANS: C PVCs are capable of progressing into ventricular tachycardia and death. DIF: Cognitive Level: Application REF: 1531 TOP: PVCs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 10
15. The nurse reminds the patient who is on Coumadin for the treatment of atrial fibrillation that the ideal is to maintain the international normalized ratio (INR) at between: a. 1 and 2. b. 2 and 3. c. 3 and 4. d. 4 and 5. ANS: B The desired INR for the monitoring of anticoagulant therapy is between 2 and 3. DIF: Cognitive Level: Knowledge REF: 1530 OBJ: 8 TOP: INR KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What should a person with unstable angina avoid? a. Walking outside b. Eating red meat c. Swimming in warm pool d. Shoveling snow ANS: D The person with angina should avoid exposure to cold, heavy exercise, eating heavy meals, and emotional stress. DIF: Cognitive Level: Application REF: 1536-1537 TOP: Angina KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 9
17. The elderly patient with angina pectoris says she is unsure how she should take nitroglycerin when she has an attack. The nurse’s most helpful response would be: a. “Continue to take nitroglycerin sublingually at 5-minute intervals until the pain is relieved.”
b. “If the pain is not relieved after three doses of nitroglycerin at 5-minute intervals, call your physician and come to the hospital.” c. “When nitroglycerin is not relieving the pain, lie down and rest.” d. “Use oxygen at home to relieve pain when nitroglycerin is not successful.” ANS: B Administer prescribed nitroglycerin. Repeat every 5 minutes, three times. If pain is unrelieved, notify the physician. Nitroglycerin administered sublingually usually relieves angina symptoms but does not relieve the pain from an MI. Administering nitroglycerin more than three times will probably not relieve the pain. DIF: Cognitive Level: Application TOP: Angina pectoris Implementation MSC: NCLEX: Physiological Integrity
REF: 1537 OBJ: 9 KEY: Nursing Process Step:
18. The patient has been hospitalized for hypertensive episodes three times in the last months. While preparing the discharge teaching plan, the nurse assesses that he does not comply with his medication regimen. The nurse’s immediate course of action would be to: a. reteach him about his medications. b. have a serious talk with him and his family about compliance. c. arrange for home visits after discharge. d. collect more information to identify his reasons for noncompliance. ANS: D Nursing interventions include measures to prevent disease progression and complications. Reteaching about medication will not identify the cause of noncompliance. DIF: Cognitive Level: Application REF: 1550 OBJ: 18 TOP: Noncompliance KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 19. What is the major cause of cardiac valve disease? a. Rheumatic fever b. Long history of malnutrition c. Drug abuse d. Obesity ANS: A Rheumatic fever, a streptococcal infection, is the major cause of cardiac valve disease. DIF: Cognitive Level: Comprehension TOP: Valvular disease Implementation MSC: NCLEX: Physiological Integrity
REF: 1555 OBJ: 10 KEY: Nursing Process Step:
20. The patient has a total cholesterol of 190 with a high-density lipid (HDL) of 110 and a low-density lipid (LDL) of 80. The nurse’s reaction is one of:
a. satisfaction. This is good cholesterol control. b. determination. This is evidence that more instruction is necessary. c. inquiry. This needs to clarified as to the cause of noncompliance with the drug protocol. d. regret. This shows very poor cholesterol control. ANS: A Total cholesterol of less than 200 is desirable. The higher the number of HDLs the better. A high number of LDLs puts the patient at risk for heart disease. DIF: Cognitive Level: Analysis TOP: Lipid studies MSC: NCLEX: Physiological Integrity
REF: 1525 | 1527 OBJ: 6 KEY: Nursing Process Step: Planning
21. A patient, age 72, was admitted to the medical unit with a diagnosis of angina pectoris. Characteristic signs and symptoms of angina pectoris include: a. substernal pain that radiates down the left arm. b. epigastric pain that radiates to the jaw. c. indigestion, nausea, and eructation. d. fatigue, shortness of breath, and dyspnea. ANS: A The pain often radiates down the left inner arm to the little finger and also upward to the shoulder and jaw. DIF: Cognitive Level: Comprehension TOP: Angina pectoris MSC: NCLEX: Physiological Integrity
REF: 1537 OBJ: 9 KEY: Nursing Process Step: Assessment
22. A patient admitted to the emergency room with a possible myocardial infarction (MI) has reports back from the laboratory. Which laboratory report is specific for myocardial damage? a. CK-MB b. Elevated white count c. Elevated sedimentation rate d. Low level of sodium ANS: A The CK-MB is elevated when there is infarcted myocardial muscle. The elevated white count, low sodium, and ESR are nonspecific. DIF: Cognitive Level: Application REF: 1543 TOP: CK-MB KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
23. The patient, age 26, is hospitalized with cardiomyopathy. While obtaining a nursing history from her, the nurse recognizes that the increased incidence of cardiomyopathy in young adults who have minimal risk factors for cardiovascular disease is related to which factor(s)? a. Cocaine use
b. Viral infections c. Vitamin B1 deficiencies d. Pregnancy ANS: A Cardiomyopathy caused by cocaine abuse triggers intense vasoconstriction of the coronary arteries and peripheral vasoconstriction. Cocaine also causes high circulating levels of catecholamines, which may further damage myocardial cells, leading to ischemic or dilated cardiomyopathy. The cardiomyopathy produced is difficult to treat. Interventions deal mainly with the HF that ensues. DIF: Cognitive Level: Analysis TOP: Cardiomyopathy MSC: NCLEX: Physiological Integrity
REF: 1561 OBJ: 14 KEY: Nursing Process Step: Assessment
24. The patient has become very dyspneic, respirations are 32, and the pulse is 100. The patient is coughing up frothy red sputum. What should be the initial nursing intervention? a. Lay the patient flat to reduce hypotension and the symptoms of cardiogenic shock. b. Place patient in side-lying position to reduce the symptoms of atrial fibrillation. c. Place patient upright with legs in dependent position to reduce the symptoms of pulmonary edema. d. Lay the patient flat and elevate the feet to increase venous return in cardiogenic shock. ANS: C Signs and symptoms of pulmonary edema are restlessness; vague uneasiness; agitation; disorientation; diaphoresis; severe dyspnea; tachypnea; tachycardia; pallor or cyanosis; cough producing large quantities of blood-tinged, frothy sputum; audible wheezing and crackles; and cold extremities. The legs in a dependent position will decrease venous return and ease the pulmonary edema. DIF: Cognitive Level: Analysis TOP: Pulmonary edema Implementation MSC: NCLEX: Physiological Integrity
REF: 1554 OBJ: 12 KEY: Nursing Process Step:
25. The nurse caring for a patient recovering from a myocardial infarction (MI) teaches which method to avoid the Valsalva’s maneuver during a bowel movement? a. Mouth breathing b. Pursing the lips and whistling c. Taking a deep breath and holding it d. Breathing rapidly through the nose ANS: A Mouth breathing will lessen the severity of straining and will decrease the effect of the Valsalva’s maneuver on intrathoracic pressure. DIF: Cognitive Level: Application REF: 1545 OBJ: 9 TOP: MI KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 26. The nurse reminds the patient that the American Heart Association recommends a lipid study every years. a. 2 b. 2 to 3 c. 4 d. 4 to 6 ANS: D The American Heart Association recommends a lipid study every 4 to 6 years for all Americans, but especially for the older adult. DIF: Cognitive Level: Comprehension REF: 1526 OBJ: 6 TOP: Lipid studies KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 27. During a health interview by the home health nurse, which patient complaint suggests left-sided heart failure? a. “I have to sleep in my recliner and I have this hacking cough.” b. “I have no appetite and I have lost 3 lb in the last week.” c. “I have to urinate every 2 hours, even during the night.” d. “I go barefoot most of the time because my feet are so hot.” ANS: A Left ventricular failure is often among the first of signs and symptoms of decreased cardiac output. The second is pulmonary congestion. Signs and symptoms of this condition include dyspnea, orthopnea, pulmonary crackles, hemoptysis, and cough. DIF: Cognitive Level: Analysis REF: 1547 TOP: Heart failure KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 9
28. The home health nurse caring for a patient with infective endocarditis overhears the patient making a dental appointment for an extraction next month. Which question is most important for the nurse to ask? a. “Do you have a toothache?” b. “Have you contacted your physician about your dental appointment?” c. “Is your dentist board certified?” d. “Do you think you should wait that long for your tooth extraction?’ ANS: B Patients with endocarditis are put on a protocol of prophylactic antibiotics for any invasive procedure. The dentist and physician should be contacted before the extraction. DIF: Cognitive Level: Application REF: 1558 | 1560 OBJ: 13 TOP: Endocarditis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
29. The home health nurse warns the patient who is taking warfarin (Coumadin) for anticoagulant therapy for thrombophlebitis to stop taking the herbal remedy of ginkgo because ginkgo can: a. cause severe episodes of diarrhea. b. cause a severe skin eruption if taken with Coumadin. c. increase the action of the Coumadin. d. cause the Coumadin to be less effective. ANS: C Herbal remedies such as ginkgo, garlic, angelica, and red clover can increase (potentiate) the action of the Coumadin. DIF: Cognitive Level: Comprehension REF: 1571 OBJ: 21 TOP: Coumadin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. What is the difference between primary and secondary hypertension? a. Secondary hypertension is caused by another disorder like renal disease. b. Secondary hypertension is related to hereditary factors. c. Secondary hypertension cannot be treated effectively. d. Secondary hypertension is no real threat to health. ANS: A Secondary hypertension is a consistently elevated blood pressure that is caused by another disorder, such as renal disease, diabetes, or Cushing syndrome. DIF: Cognitive Level: Analysis TOP: Secondary hypertension MSC: NCLEX: Physiological Integrity
REF: 1568 OBJ: 18 KEY: Nursing Process Step: Planning
31. The nurse is treating a patient who had a pacemaker inserted 8 years ago for the correction of atrial fibrillation. Which diagnostic test may no longer be available to the patient because of this older model implanted device? a. MRI b. CT scan c. Thallium scan d. PET ANS: A Patients who have pacemakers placed in the last several years can have MRI testing without difficulty. A model that has been in place for some time might be affected by the large magnets in the MRI cabinet. In either case, the patient should always report the use of a pacemaker before having an MRI. DIF: Cognitive Level: Application REF: 1535 TOP: Pacemaker KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 10
32. Which assessment would lead the nurse to examine the leg closely for evidence of a stasis ulcer?
a. b. c. d.
Cool dry lower limb Edematous, red scaly skin on medial surface of the leg Lack of hair and shiny appearance of the lower leg Lack of a pedal pulse
ANS: B Suggestion of a stasis ulcer in the making is an edematous, dry scaly area on the medial surface of the lower leg that has a darker pigmentation (rubor). Cool hairless limbs with absent or weak pedal pulses are indicative of arterial insufficiency. DIF: Cognitive Level: Application REF: 1565 TOP: Medications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 21
33. What is the patient goal of the walking exercise program designed for the rehabilitation of a post-MI patient? a. Walk 2 miles in less than 60 minutes after 12 weeks. b. Jog mile in less than 30 minutes after 12 weeks. c. “Fast walk” 1 mile in less than 20 minutes after 12 weeks. d. Walk 1 mile in 15 minutes without dyspnea after 12 weeks. ANS: A The goal of the 12-week walking program is that the patient can walk 2 miles in less than 60 minutes. DIF: Cognitive Level: Knowledge REF: 1546 OBJ: 11 TOP: Cardiac rehab KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 34. The postsurgical patient has a painful and swollen right calf that appears to be larger than the calf of the left leg. What is the nurse assessing for when she flexes the patient’s right leg and dorsiflexes the foot? a. Pain, which would be a positive Homans’ sign b. Muscular spasm, which would be a sign of hypocalcemia c. Rigidity, which would be a sign of ankylosis d. Crepitus, which would be a sign of a joint disorder ANS: A A positive Homans’ sign for deep vein thrombosis (DVT) is a report of pain when the affected leg is flexed and the foot is dorsiflexed. DIF: Cognitive Level: Application REF: 1578 TOP: DVT KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 21
35. How should the nurse advise a patient with an international normalized ratio (INR) of 5.8? a. Make arrangements to go to the emergency room immediately. b. Increase fluid intake to 2000 mL/day. c. Stop taking the anticoagulant and notify health care provider.
d. Add more leafy green vegetables to patient diet. ANS: C The INR that is desired should be maintained between 2 and 3. A reading of 5.8 puts the patient at risk for hemorrhage. The patient should stop taking the anticoagulant and contact the physician for further instruction. DIF: Cognitive Level: Application TOP: Myocardial infarction MSC: NCLEX: Physiological Integrity
REF: 1524 OBJ: 6 KEY: Nursing Process Step: Assessment
36. The nurse making a teaching plan for a patient with Buerger disease (thromboangiitis obliterans) will focus on the need for: a. reduction of alcohol intake. b. avoiding cold remedies. c. cessation of smoking. d. weight reduction. ANS: C The hazards of cigarette smoking and its relationship to Buerger disease are the primary focus of patient teaching. None of the palliative treatments are effective if the patient does not stop smoking. Nowhere are the cause and effect of smoking so dramatically seen as with Buerger disease. DIF: Cognitive Level: Knowledge TOP: Buerger disease MSC: NCLEX: Physiological Integrity
REF: 1575 OBJ: 20 KEY: Nursing Process Step: Assessment
37. Which statement would lead the nurse to offer more instruction about taking warfarin (Coumadin)? a. “I eat a banana every morning with breakfast.” b. “I try to eat more green leafy vegetables, especially broccoli, spinach, and kale.” c. “I try to eat a well-balanced, low-fat diet.” d. “I don’t drink alcohol or caffeine.” ANS: B Avoid marked changes in eating habits, such as dramatically increasing foods high in vitamin K (e.g., broccoli, spinach, kale, greens). Limit alcohol intake to small amounts. DIF: Cognitive Level: Comprehension REF: 1579 OBJ: 10 TOP: Warfarin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 38. The nurse caring for a 92-year-old patient with pneumonia who is receiving IV carefully monitors the flow rate of the IV infusion because rapid infusion can cause: a. hypotension. b. thrombophlebitis. c. pulmonary emboli. d. heart failure. ANS: D
Heart failure can result from rapid infusion of intravenous fluids in older adults. DIF: Cognitive Level: Knowledge REF: 1526 TOP: Heart failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 9
39. The nurse making the schedule for the daily dose of furosemide (Lasix) would schedule the administration for which of the following times? a. Late in the afternoon b. At bedtime c. With any meal d. In the morning ANS: D Diuretics should be scheduled for morning administration to avoid causing the patient nocturia. DIF: Cognitive Level: Analysis REF: 1551 TOP: Lasix KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 12
40. What is the third step in the impulse pattern of conduction through the heart? a. Atrial wall b. Atrial-ventricular (AV) node c. Purkinje fibers d. Sinoatrial (SA) node e. Bundle branches f. Bundle of His ANS: B The conduction begins with the impulse from the SA node that travels down the atrial wall to the AV node, to the Bundle of His, to the bundle branches, and finally to the Purkinje fibers. DIF: Cognitive Level: Analysis REF: 1518-1519 TOP: Conduction KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 3
41. What is the second step in the path of blood through the coronary circulation? a. Right atrium b. Pulmonary artery c. Tricuspid valve d. Right ventricle e. Superior and inferior vena cava f. Pulmonary vein g. Left atrium h. Mitral valve ANS: A
The blood travels through the vena cava to the right atrium, through the tricuspid valve to the right ventricle, through the pulmonary artery to the lungs. The pulmonary veins deliver the blood to the left atrium, then through the mitral valve to the left ventricle and out the aorta to the body. DIF: Cognitive Level: Analysis TOP: Path of blood through heart MSC: NCLEX: Physiological Integrity
REF: 1520-1521 OBJ: 5 KEY: Nursing Process Step: N/A
MULTIPLE RESPONSE 1. The nurse would assess closely for signs of right-sided heart failure which include: (Select all that apply.) a. cough. b. increasing abdominal girth. c. shortness of breath. d. edema of feet and ankles. e. distended jugular veins. f. orthopnea. ANS: B, D, E Indicators of right-sided heart failure are distended jugular veins, anorexia, abdominal distention from ascites, liver enlargement with right upper quadrant pain, and edema of feet and ankles. DIF: Cognitive Level: Analysis TOP: Right-sided heart failure MSC: NCLEX: Physiological Integrity
REF: 1549 OBJ: 9 KEY: Nursing Process Step: Assessment
2. The nurse would design teaching for a patient with Raynaud disease to include which of the following? (Select all that apply.) a. Warming hands and feet with a heating pad b. Using mittens in cold weather c. Practicing stress-reducing techniques d. Complete smoking cessation e. Using caution when cleaning the refrigerator or freezer ANS: B, C, D, E Nursing interventions include patient teaching in techniques for stress reduction, avoiding exposure to cold, and techniques for smoking cessation. DIF: Cognitive Level: Analysis TOP: Raynaud disease MSC: NCLEX: Physiological Integrity
REF: 1576-1577 OBJ: 20 KEY: Nursing Process Step: Planning
3. Which information should be taught to patients starting on anticoagulant therapy for a valvular disorder? (Select all that apply.) a. Increase the dose of aspirin for better therapy. b. Take medication at the same time each day.
c. Report to physician cuts that do not stop bleeding with direct pressure. d. No restrictions for food or drink. e. Report for prescribed blood tests (PTT, INR, CBC, blood sugar). ANS: B, C Aspirin should not be used with anticoagulant therapy because it will increase bleeding. Gums, nosebleeds, excessive bruising, and cuts that do not stop bleeding with direct pressure should be reported to the physician. Alcohol and dark green and yellow vegetables should be avoided because they contain vitamin K. Normal blood tests for anticoagulant therapy are PTT, INR, and PT. DIF: Cognitive Level: Analysis TOP: Anticoagulant therapy Planning MSC: NCLEX: Physiological Integrity
REF: 1573 KEY:
OBJ: 10 Nursing Process Step:
4. What is the transesophageal echocardiogram (TEE) used for? (Select all that apply.) a. Detect thrombi before a cardioversion. b. Check for cardiac arrhythmias. c. Visualize vegetation on the heart valves. d. Measure effectiveness of diuretic therapy. e. Visualize abscesses on the heart valves. ANS: A, C, E The TEE is used to check for thrombi before cardioversion, and to visualize vegetation and abscesses on the valves of the heart. DIF: Cognitive Level: Knowledge REF: 1530 TOP: TEE KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 16
5. Which patient teaching would help to prevent venous stasis? (Select all that apply.) a. Dangle legs when sitting. b. Avoid crossing the legs at the knee. c. Elevate legs when lying in bed or sitting. d. Massage extremities to help maintain blood flow. e. Wear elastic stockings when ambulating. ANS: B, C, E Avoid prolonged sitting or standing. Avoid crossing the legs at the knee. Elevate legs when sitting. Wear elastic stockings when ambulatory. Do not massage extremities because of danger of embolization of clots (thrombus breaking off and becoming an embolus). DIF: Cognitive Level: Analysis TOP: Thrombophlebitis MSC: NCLEX: Physiological Integrity
REF: 1577 OBJ: 16 KEY: Nursing Process Step: Planning
6. The nurse points out which of the following as modifiable risks for coronary artery disease (CAD)? (Select all that apply.)
a. b. c. d. e. f.
Diabetes mellitus Heredity Smoking Hypertension Hyperlipidemia Age
ANS: A, C, D, E Modifiable risks for the development of CAD include smoking, hyperlipidemia, hypertension, diabetes mellitus, obesity, sedentary lifestyle, and stress. DIF: Cognitive Level: Analysis TOP: Modifiable risks for CAD Implementation MSC: NCLEX: Physiological Integrity
REF: 1526 OBJ: 7 KEY: Nursing Process Step:
7. The nurse outlines which of the following as conditions that would disqualify a candidate for a heart transplant? (Select all that apply.) a. Recent malignancy b. Dilated cardiomyopathy c. Peptic ulcer disease d. Diabetes type 2 e. Severe obesity f. Inoperable coronary artery disease ANS: A, C, E Contraindications for candidacy for cardiac transplant include recent malignancy, active peptic ulcer disease, severe obesity, diabetes type 1 with end-organ damage. Dilated cardiomyopathy and inoperable coronary artery disease are indications for transplant. DIF: Cognitive Level: Application REF: 1562 TOP: Contraindications for cardiac transplant KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 15
8. When assessing a patient with a possible MI, what should the nurse assess for? (Select all that apply.) a. Pain radiating to left arm and jaw b. Hypertension c. Pallor d. Diaphoresis e. Erratic behavior f. Cardiac rhythm changes ANS: B, C, D, E, F Hypertension, vomiting, diaphoresis, hypotension, pallor, and cardiac rhythm changes are objective data seen in patients with an MI. DIF: Cognitive Level: Analysis TOP: Myocardial infarction
REF: 1542 OBJ: 10 KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance 9. Which of the following are signs of digoxin (Lanoxin) toxicity? (Select all that apply.) a. Ringing in the ears b. Bradycardia c. Headache d. Visual disturbance e. Hematuria f. Gastrointestinal complaints ANS: B, C, D, F Major signs of digoxin toxicity are nausea, bradycardia (HR <60), headache, and visual disturbances, as well as fatigue and arrhythmias. DIF: Cognitive Level: Application TOP: Digoxin toxicity MSC: NCLEX: Physiological Integrity
REF: 1551 OBJ: 10 KEY: Nursing Process Step: Assessment
10. The nurse encourages the patient who is recovering from a myocardial infarct (MI) to ask the health care provider to prescribe a cardiac rehabilitation series in order to learn to: (Select all that apply.) a. improve stamina. b. strengthen muscles. c. plan an appropriate diet. d. select herbal remedies. e. reduce risk of further problems. f. understand heart condition. ANS: A, B, E, F Cardiac rehabilitation offers exercise programs to increase strength and increase stamina. Educational opportunities are offered on reduction of risk and understanding the disease process. DIF: Cognitive Level: Application REF: 1546 OBJ: 11 TOP: Cardiac rehab KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 11. Following an angiogram with the insertion site of the left groin, the nurse will include in the plan of care provisions for: (Select all that apply.) a. checking pedal pulses. b. ambulating with assistance 2 hours after recovery. c. checking color and warmth of left leg frequently. d. sandbagging over insertion site. e. placing patient in semi-Fowler’s position. ANS: A, C, D
The pulses below the insertion site are checked to ensure patency of the vessels; the color and warmth of the left extremity is checked to ensure adequate circulation. A sandbag or other pressure device is placed over the insertion site. The patient is maintained in a supine position for several hours postprocedure. DIF: Cognitive Level: Application REF: 1546 | 1553 OBJ: 6 TOP: Angiogram KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. The cardiac marker myocardial contractile protein.
rises 3 hours after a myocardial infarct and measures
ANS: troponin I Troponin I is a serum cardiac marker that rises 3 hours after an MI and can measure myocardial contractile tissue. Troponin I is not affected by skeletal muscle injury as is troponin T. DIF: Cognitive Level: Comprehension REF: 1543 TOP: Troponin I KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
2. The life support system that uses special techniques, ventilation equipment, and therapies for emergency situations is . ANS: advanced cardiac life support (ACLS) advanced cardiac life support ACLS ACLS is a life support system that uses special techniques, ventilation equipment, and therapies for emergency situations. DIF: Cognitive Level: Knowledge REF: 1534 TOP: ACLS KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 9
3. The nurse explains that the heart has the ability to contract in a rhythmic pattern that is called . ANS: automaticity Automaticity is the special ability of the myocardium to contract in a rhythmic pattern. DIF:
Cognitive Level: Knowledge
REF: 1518
OBJ: 2
TOP: Automaticity MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step: Assessment
4. The patient with congestive heart failure who is on a diuretic drug shows a weight loss of 6.6 lb. The nurse is aware that the patient has lost L of fluid. ANS: 3 A liter of fluid equals 2.2 lb. A loss of 6.6 lb would mean the loss of 3 L of fluid. DIF: Cognitive Level: Comprehension REF: 1549 TOP: Fluid loss KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 9
5. The pain that a person with arterial insufficiency feels on exertion, which is relieved by rest, is . ANS: intermittent claudication Intermittent claudication is a pain caused by ischemia when a person with arterial insufficiency exerts to the point that the tissues have inadequate oxygen-rich blood. The pain is relieved by rest. DIF: Cognitive Level: Knowledge TOP: Intermittent claudication MSC: NCLEX: Physiological Integrity
REF: 1564 OBJ: 9 KEY: Nursing Process Step: Assessment
6. The process by which a heart is shocked from a persistent arrhythmia back into sinus rhythm is called a . ANS: cardioversion Cardioversion is the restoration of the heart’s normal sinus rhythm with the delivery of synchronized electric shock. DIF: Cognitive Level: Knowledge TOP: Cardioversion MSC: NCLEX: Physiological Integrity
REF: 1524 OBJ: 10 KEY: Nursing Process Step: N/A
Chapter 49: Care of the Patient with a Respiratory Disorder Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. What is the purpose of the cilia? a. Warm and moisturize inhaled air. b. Sweep debris toward nasal cavity. c. Stimulate cough reflex. d. Produce mucus. ANS: B The cilia are fine hairlike processes on the outer surfaces of small cells that produce a motion that sweeps the debris toward the nasal cavity. Large particles that are swept away stimulate the cough reflex, but not the cilia themselves. DIF: Cognitive Level: Knowledge REF: 1590 TOP: Secretions KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 2
2. What happens when there is a decrease in the oxygen level in the blood? a. Pituitary stimulates the respiratory system to increase respiratory rate. b. The alveoli diffuse more oxygen into the blood. c. Chemoreceptors in the carotid body and aortic body stimulate the respiratory centers to modify respiratory rates. d. The parietal pleura increases the negative pressure. ANS: C The chemoreceptors in the carotid bodies and the aortic bodies send a message to the respiratory centers to modify respirations. DIF: Cognitive Level: Application TOP: Respiratory rate modification MSC: NCLEX: Physiological Integrity
REF: 1592 OBJ: 1 KEY: Nursing Process Step: Assessment
3. A patient problem for the patient with a new laryngectomy would be Social isolation related to impaired verbal communication related to removal of the larynx. What is an appropriate nursing intervention? a. Complete care quickly. b. Provide a pad and pencil or magic slate. c. Refrain from conversations with the patient to reduce stress level. d. Offer books or jigsaw puzzles for entertainment. ANS: B Provide patient with implements for communication. Rapidly completing care and provision of solitary activities does not reduce social isolation. DIF: Cognitive Level: Application TOP: Laryngectomy
REF: 1605 OBJ: 10 KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity 4. A 55-year-old man comes to the health nurse at his place of work with epistaxis. He reports he has frequent nosebleeds that he can usually control himself. What would be the most helpful assessment after the nurse has stopped the bleeding? a. Obtain a blood pressure. b. Record the approximate amount of blood lost. c. Inquire about a headache. d. Record the last episode of epistaxis. ANS: A Check the blood pressure for hypotension to assess for hypovolemic shock. Adults can lose as much as 1 L of blood in an hour with heavy epistaxis. DIF: Cognitive Level: Application REF: 1599 OBJ: 9 TOP: Epistaxis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse assessing an 11 year old who is having an asthma attack expects to hear adventitious sounds of: a. friction rub. b. sibilant wheezes. c. crackles. d. sonorous wheezes. ANS: B The narrowed bronchioles characteristic of an asthma attack would produce sibilant wheezes, which are high-pitched whistling sounds. DIF: Cognitive Level: Application REF: 1593 TOP: Asthma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 16
6. How will the kidneys behave in respiratory acidosis? a. Retain bicarbonate to increase the pH. b. Excrete more urine to reduce potassium. c. Concentrate the urine to conserve circulating fluid in the bloodstream. d. Lower the pH by excretion of bicarbonate. ANS: A In respiratory acidosis, the pH is low. The kidneys will retain bicarbonate to increase the pH. DIF: Cognitive Level: Analysis TOP: Respiratory acidosis MSC: NCLEX: Physiological Integrity
REF: 1597 OBJ: 11 KEY: Nursing Process Step: Assessment
7. An 83-year-old patient is admitted with a temperature of 102°F (38.8°C), chest pain, and fatigue. What is the infected fluid that the physician removes called?
a. b. c. d.
Emboli Emphysema Sputum Empyema
ANS: D If the fluid between the lung and the membrane lining the pleural cavity becomes infected, it is called empyema. DIF: Cognitive Level: Knowledge REF: 1621 | 1623 TOP: Empyema KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 11
8. Which instruction by the nurse is inappropriate for teaching the proper technique for collection of a sputum specimen? a. Bring the sputum up from the lungs. b. Rinse mouth with water before expectorating in specimen cup. c. Collect specimens after meals. d. Send specimen to the lab without delay. ANS: C Collecting specimens before meals will avoid possible emesis from coughing after eating. DIF: Cognitive Level: Application TOP: Diagnostic procedures Implementation MSC: NCLEX: Physiological Integrity
REF: 1596 OBJ: 12 KEY: Nursing Process Step:
9. When assessing the SaO2 with a pulse oximeter, the nurse will place the oximeter on a finger: a. on the same side as the blood pressure cuff. b. while exercising the arm to stimulate circulation. c. that is a normal temperature. d. on the same side as an arterial catheter. ANS: C The pulse oximeter should be placed on a finger of the hand that is normal temperature because hypothermia will affect the reading. The device should not be put on a finger on the same side as a blood pressure cuff or arterial line. DIF: Cognitive Level: Analysis TOP: Pulse oximeter MSC: NCLEX: Physiological Integrity
REF: 1598 OBJ: 9 KEY: Nursing Process Step: Assessment
10. A patient, age 69, has emphysema. On assessment, the nurse notes the presence of a “barrel chest.” What does this pathology result from? a. An increase in the lateromedial area from hypertrophy of mucous glands in the bronchi b. An increased anteroposterior diameter caused by overinflation of the alveoli
c. A decrease in anteroposterior diameter caused by chronic dilation of the bronchi d. A widening of the sternocostal area secondary to chronic constriction of smooth muscles in the airways leading to bronchospasms ANS: B The patient will eventually appear barrel chested (an increased anteroposterior diameter caused by overinflation). DIF: Cognitive Level: Comprehension REF: 1636 TOP: Emphysema KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 16
11. A patient, age 22, is admitted with acute asthma. The patient shows a pulse oximetry level of SaO2 of 82%. How should the nurse interpret this? a. Only 82% of the red blood cells are able to use oxygen. b. There is only 82% of oxygen bound to the hemoglobin compared with the amount available. c. Eighteen percent of oxygen is not dissolved in the blood. d. The muscular respiratory effort is only 18% effective. ANS: B An SaO2 of 82% indicates that only 82% of the available oxygen is bound to the hemoglobin. DIF: Cognitive Level: Analysis REF: 1597 TOP: SaO2 KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 8
12. What is the appropriate nursing intervention for a patient, age 40, who is diagnosed with active tuberculosis? a. Place the patient in drainage and secretion precautions. b. Place the patient in acid-fast bacillus (AFB) Isolation Precautions. c. Maintain the patient in enteric isolation. d. Place the patient in any Isolation Precautions. ANS: B If TB is suspected, permission to place the patient in acid-fast bacillus (AFB) Isolation Precautions should be requested immediately. DIF: Cognitive Level: Analysis REF: 1615 OBJ: 13 TOP: Tuberculosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 13. How should the newly diagnosed patient who has been prescribed isoniazid (INH) for the treatment of active tuberculosis (TB) be advised? a. Report redness and swelling of extremities. b. Accept that the therapy is long term. c. Monitor renal function every several months. d. Rise slowly to avoid dizziness.
ANS: B INH therapy is long term. The patient should be advised to get regular liver studies and report tingling and numbness of the extremities. DIF: Cognitive Level: Application REF: 1616 TOP: INH KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
OBJ: 13
14. The patient has advanced emphysema and complains of dyspnea and fatigue. What would the most appropriate nursing intervention be for the patient problem of activity intolerance related to an imbalance between the oxygen supply and demand? a. Direct patient in vigorous independent ROM. b. Allow to exercise until respirations are over 20 breaths/min over baseline. c. Plan care to provide optimum rest. d. Provide frequent cool showers. ANS: C Nursing interventions will be directed at attempting to decrease the patient’s anxiety and promote optimal air exchange. The nurse should allow sufficient rest periods and should assist the patient in activities of daily living. DIF: Cognitive Level: Application REF: 1637 OBJ: 16 TOP: Chronic obstructive pulmonary disease (COPD) KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 15. A patient is on postoperative day 2 after undergoing a total hip replacement. The patient suddenly complains of chest pain and is coughing up blood-tinged sputum. What should be the nurse’s initial intervention? a. Report signs to the charge nurse. b. Elevate head of bed and administer oxygen. c. Prevent patient from excessive coughing. d. Increase IV flow rate. ANS: B When a pulmonary embolus is suspected, the head of the bed should be elevated to facilitate respiration and oxygen is administered. The charge nurse and the physician should be notified, but only after the patient is stabilized and oxygenated. DIF: Cognitive Level: Comprehension TOP: Pulmonary embolism Implementation MSC: NCLEX: Physiological Integrity
REF: 1637 OBJ: 15 KEY: Nursing Process Step:
16. What is true about activities such as walking for the patient with emphysema? a. Repair dilated alveoli. b. Increase capacity to use oxygen. c. Lessen the oxygen needs. d. Lessen metabolic oxygen needs. ANS: B
Aerobic exercises such as walking will increase the body’s ability to use oxygen through sustained rhythmic contractions of large muscles. DIF: Cognitive Level: Analysis REF: 1637 OBJ: 16 TOP: Emphysema KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The patient with long-term emphysema is admitted with a secondary diagnosis of cor pulmonale. What should the nurse anticipate? a. The patient will present with edema of the lower extremities and extended neck veins due to hypertension of the pulmonary circulation. b. The patient will present with a dry hacking cough and chest pain due to constriction of the pulmonary vein. c. The patient will present with hypertension and a headache related to pulmonary hypertension. d. The patient will present with unlabored respiration and cyanosis around the mouth. ANS: A COPD can lead to cor pulmonale, an abnormal cardiac condition characterized by hypertrophy of the right ventricle of the heart as a result of hypertension of the pulmonary circulation. Cor pulmonale results in the presence of edema in the lower extremities, as well as in the sacral and perineal area, distended neck veins, and enlargement of the liver with ascites. DIF: Cognitive Level: Analysis REF: 1636 TOP: Chronic obstructive pulmonary disease (COPD) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 16
18. What is a major advantage of video-assisted thoracoscopic surgery (VATS)? a. The surgeon can record entire surgical procedure on a video. b. The surgeon can remove tumors of the lung through a small keyhole incision. c. The surgeon can x-ray and excise tumor in the same procedure. d. The surgeon can avoid the use of a closed chest drainage system after surgery. ANS: B The video-assisted thoracoscopic surgery allows surgeons to remove tumors through a small keyhole incision. Although the incisions are small, a closed chest drainage system will still be necessary after the surgery. DIF: Cognitive Level: Analysis REF: 1629 OBJ: 19 TOP: VATS KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. How would the nurse examining a patient with pleurisy document a low-pitched grating lung sound? a. Sonorous wheeze b. Friction rub c. Coarse crackles d. Crackles
ANS: B A low-pitched grating sound in the presence of an inflammatory disorder is a friction rub. DIF: Cognitive Level: Application TOP: Adventitious sounds MSC: NCLEX: Physiological Integrity
REF: 1593 OBJ: 6 KEY: Nursing Process Step: Assessment
20. What is inspiratory capacity? a. The amount of air in the lung after a maximal inhalation b. The amount of air moved with each normal inhalation and expiration c. The amount of air that can be inhaled in one breath from the resting expiratory level d. The amount of air that can be forcefully exhaled after maximum inhalation ANS: C Inspiratory capacity is the volume of air that can be inhaled in one breath from the resting expiratory level. DIF: Cognitive Level: Knowledge TOP: Inspiratory capacity Implementation MSC: NCLEX: Physiological Integrity
REF: 1594 OBJ: 7 KEY: Nursing Process Step:
21. The older adult patient with long-term emphysema complains of a sharp pleuritic pain after a severe period of coughing. The patient’s heart rate and respiratory rate have increased. Auscultation reveals no breath sounds on the left side. These are signs and symptoms of what condition? a. Pulmonary embolus b. Spontaneous pneumothorax c. Early signs of unilateral pneumonia d. An attack of asthma ANS: B Spontaneous pneumothorax can be caused by a ruptured bleb in a patient with long-term emphysema. The disorder causes chest pain, dyspnea, and anxiety associated with air hunger. DIF: Cognitive Level: Application TOP: Postoperative complications MSC: NCLEX: Physiological Integrity
REF: 1626 OBJ: 11 KEY: Nursing Process Step: Assessment
22. Which important precaution should the nurse include when instructing an emphysema patient on the use of home oxygen? a. Use oxygen only when extremely short of breath. b. Keep the home oxygen regulator set on 6 L. c. Use home oxygen at night while sleeping. d. Limit to 1 to 2 L oxygen flow. ANS: D
Low-flow oxygen therapy is required for patients with COPD, because higher oxygen concentrations depress the body’s own respiratory regulatory centers and can cause respiratory failure. DIF: Cognitive Level: Application REF: 1637 TOP: Chronic obstructive pulmonary disease (COPD) KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
OBJ: 16
23. The young man who had a bronchoscopy 1 hour ago asks when he can eat. Which response would be most helpful? a. In 24 hours, but must take cold liquids for the rest of the day b. If there is no blood in his sputum c. In 8 hours after a period of nothing by mouth d. When the gag reflex returns ANS: D Following a bronchoscopy, the patient can eat as soon as the gag reflex returns, usually in about 2 hours. DIF: Cognitive Level: Application TOP: Bronchoscopy Implementation MSC: NCLEX: Physiological Integrity
REF: 1619 OBJ: 7 KEY: Nursing Process Step:
24. The nurse caring for a patient who has a closed chest drainage system notes that there is fluctuation (tidaling) in the water seal chamber. What is the most appropriate nursing action based on this assessment? a. Document the tidaling. b. Elevate the head of the bed and notify charge nurse of malfunction of drainage system. c. Add more sterile water to the water seal chamber. d. Turn patient to the affected side. ANS: A Tidaling or fluctuation in the water seal drainage is an indicator that the negative pressure is preserved and the system is working normally. Document this normal finding. DIF: Cognitive Level: Analysis TOP: Closed chest drainage MSC: NCLEX: Physiological Integrity
REF: 1625 OBJ: 14 KEY: Nursing Process Step: Assessment
25. How does pursed lip breathing assist patients with asthma during an attack? a. It distracts the patient with breathing technique to reduce anxiety. b. It gets rid of CO2 faster. c. It opens bronchioles by backflow air pressure. d. It increases PACO2. ANS: C
The resistance or the expiration through the pursed lips causes a backflow of air and helps to open the bronchioles. DIF: Cognitive Level: Application REF: 1638 | 1639 OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. How do leukotriene modifiers reduce the symptoms of asthma? a. By drying up mucus b. By causing bronchodilation and anti-inflammation effects c. By suppressing cough d. By liquefying mucus ANS: B Leukotriene modifiers reduce the symptoms of asthma by causing bronchodilation and anti-inflammatory processes. DIF: Cognitive Level: Application REF: 1641 TOP: Asthma KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 11
27. How should a patient be positioned after a thoracentesis is completed and the dressing applied? a. High Fowler b. Semi-Fowler c. Side lying on unaffected side d. Prone ANS: C After a thoracentesis, the patient is placed in a side-lying position on the unaffected side. DIF: Cognitive Level: Application TOP: Pleural Effusion Implementation MSC: NCLEX: Physiological Integrity
REF: 1596 OBJ: 11 KEY: Nursing Process Step:
28. What should the nurse do to keep the chest tubes from becoming occluded? a. Irrigate tubes as needed. b. Prevent dependent loops. c. Loop the tube over the bed rail. d. “Milk” the tube frequently. ANS: B To keep the tubes patent, the tubes should be kept straight without dependent loops. These tubes are not irrigated and should not be milked frequently. DIF: Cognitive Level: Application TOP: Closed chest drainage MSC: NCLEX: Physiological Integrity
REF: 1625 OBJ: 1 | 14 KEY: Nursing Process Step: Planning
29. Which patient assessment indicates the most severe respiratory distress? a. Nasal flaring, symmetrical chest wall expansion, SaO2 88% b. Abdominal breathing, SaO2 97% c. Substernal retraction, SaO2 84% d. Substernal retraction, SaO2 90% ANS: C Observe the patient’s facial expressions and signs of respiratory distress, such as flaring nostrils, substernal or clavicular retractions, asymmetrical chest wall expansion, and abdominal breathing. The lower the SaO2, the more severe the respiratory distress. DIF: Cognitive Level: Application TOP: Pneumothorax MSC: NCLEX: Physiological Integrity
REF: 1644 OBJ: 5 KEY: Nursing Process Step: Assessment
30. The nurse traces the path of unoxygenated blood through the respiratory system to the distribution of oxygenated blood to the body. What is the second step in the reoxygenation process? a. Pulmonary artery takes blood to capillary system of the alveoli. b. Blood enters the left atria via the pulmonary vein. c. Blood enter the left ventricle. d. Unoxygenated blood enters the right ventricle. e. Blood enters the aorta. f. CO2 diffused and oxygen infused into the blood in alveoli. g. Unoxygenated blood enters the right atrium. ANS: D The unoxygenated blood enters the right atria via the vena cava, then to the right ventricle and out the pulmonary artery into the capillary bed of the alveoli, CO2 and O2 are exchanged in the alveoli, the CO2 being exhaled and the oxygenated blood continues to the right atria via the pulmonary vein, then to the left ventricle and out the aorta to the body. DIF: Cognitive Level: Analysis TOP: Reoxygenation of blood Implementation MSC: NCLEX: Physiological Integrity
REF: 1641 KEY: Nursing Process Step:
31. The nurse describes the pathophysiologic process of an asthma attack. What is the second step in the process? a. Inflammatory process in the mast cells of the lungs b. Increase in edema and mucus production in the bronchioles c. Release of histamine d. Narrowing of the airways e. Exposure to allergen ANS: A The allergen activates the mast cells in the lungs, which release histamine, causing an increase in edema and mucus production that narrows the airways and causes the classic signs of asthma.
DIF: Cognitive Level: Analysis REF: 1641 OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Which preoperative teaching should a nurse include for a person scheduled for a partial laryngectomy? (Select all that apply.) a. Tracheal suction will be frequent. b. The presence of a temporary tracheotomy. c. That isolation will be required for 24 hours. d. The surgery involves removal of a diseased vocal cord. e. Some speech will be retained. f. The sense of smell and taste will be lost. ANS: A, B, D, E A partial laryngectomy involves the removal of the diseased cord and possible thyroid cartilage. There will be a temporary tracheostomy that will be closed once edema is under control. Tracheal suctioning will be done frequently. There will be some vocal ability retained. Isolation is not required. Sense of smell and taste are lost with a total laryngectomy. DIF: Cognitive Level: Comprehension TOP: Patient teaching MSC: NCLEX: Physiological Integrity
REF: 1604 OBJ: 10 KEY: Nursing Process Step: Assessment
2. Which independent nursing measures are effective in aiding a patient to expectorate? (Select all that apply.) a. Positioning in orthopneic position b. Suctioning c. Assisting to cough d. Providing hydration e. Starting IV fluids f. Starting mucolytic agents ANS: A, B, C, D Independent nursing intervention to help a patient to expectorate would include positioning, assisting to cough, suctioning, and providing hydration IV therapy; provision of a mucolytic agent requires a physician’s order and is not an independent nursing action. DIF: Cognitive Level: Application TOP: Assisting expectoration MSC: NCLEX: Physiological Integrity
REF: 1621 | 1637 OBJ: 12 KEY: Nursing Process Step: Planning
3. Identify the purposes of chest drainage. (Select all that apply.) a. Drains air, blood, and fluid from pleural space. b. Restores positive pressure in chest cavity.
c. Restores negative intrapleural pressure. d. Allows lung to collapse and rest. e. Allows route for medication administration. ANS: A, C A chest tube or tubes may be inserted for continuous drainage of fluid, blood, or air from the pleural cavity and for medication instillation. To prevent the lung from collapsing, a closed drainage system is used, which maintains the lung cavity’s normal negative pressure. The chest tubes are connected to a pleural drainage system with collection, water seal, and suction control chambers to drain secretions and reestablish negative pressure in the pleural space. DIF: Cognitive Level: Application TOP: Closed chest drainage MSC: NCLEX: Physiological Integrity
REF: 1623 OBJ: 14 KEY: Nursing Process Step: Planning
4. What are age-related changes in the older adult that make them at risk for respiratory diseases? (Select all that apply.) a. Moist mucous membranes b. Kyphosis c. Decrease in pulmonary blood flow d. Stasis pooling of secretions e. Reduced number of cilia ANS: B, C, D, E Age-related changes that affect the respiratory system are dryer mucous membranes, which reduce ability to humidify inspired air, kyphosis, which restricts the expansion of the lung, stasis pooling of respiratory secretions, and reduced number of cilia, which make infection of the upper and lower airway more likely. DIF: Cognitive Level: Application REF: 1620 TOP: Pneumonia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 9
5. The nurse explains to the person with pneumonia in the left lung that being positioned in the “good lung down” offers the advantage of: (Select all that apply.) a. PaO2 rising in the good lung. b. blood flow to “bad lung” being increased. c. the dependent lung being better perfused. d. dyspnea disappearing. e. decreased hypoxia. ANS: A, C, E The “good lung down” position increases the PaO2 in the good lung and also allows for better perfusion, consequently decreasing hypoxia, although dyspnea may still be evident. DIF: Cognitive Level: Application REF: 1621 OBJ: 11 TOP: Pneumonia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
COMPLETION 1. The
are the structures of the lung in which gas exchange occurs.
ANS: alveoli The end structures of the bronchial tree are called alveoli. It is in these terminal structures of the bronchial tree that gas exchange takes place. DIF: Cognitive Level: Knowledge TOP: Lower respiratory tract MSC: NCLEX: Physiological Integrity
REF: 1625 OBJ: 2 KEY: Nursing Process Step: Assessment
2. The nurse prepares a patient for the procedure of a(n) , which will remove the fluid from around the lung to improve respiration and obtain a specimen. ANS: thoracentesis Often a thoracentesis will be done not only to obtain a specimen for culture to identify the causative agent, but also to relieve the dyspnea and discomfort. DIF: Cognitive Level: Comprehension TOP: Thoracentesis Implementation MSC: NCLEX: Physiological Integrity
REF: 1623 OBJ: 7 KEY: Nursing Process Step:
3. The nurse explains that the opening between the vocal cords is the
.
ANS: glottis The glottis is the opening between the vocal cords. DIF: Cognitive Level: N/A REF: 1589 OBJ: 2 TOP: Glottis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse recognizes that the reading in an arterial gas report indicates the amount of oxygen dissolved in the plasma. ANS: PaO2 The PaO2 reading indicates the amount of oxygen dissolved in the plasma. DIF:
Cognitive Level: Comprehension
REF: 1597
OBJ: 8
TOP: Blood gases KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The nurse explains that the diagnostic test that can scan the chest and the abdomen in less than 30 seconds is the CT scan. ANS: spiral The spiral or helical CT scan can scan the chest and the abdomen in less than 30 seconds. This test is faster and more accurate. DIF: Cognitive Level: Knowledge TOP: Spiral or helical CT scan Implementation MSC: NCLEX: Physiological Integrity
REF: 1594 OBJ: 7 KEY: Nursing Process Step:
Chapter 50: Care of the Patient with a Urinary Disorder Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. What is the hormone from the posterior pituitary gland that influences the amount of water that is eliminated with the urine? a. Pitocin b. Renin hormone c. Antidiuretic hormone (ADH) d. ACTH ANS: C ADH causes the cells of the distal convoluted tubules to increase their rate of water reabsorption. DIF: Cognitive Level: Knowledge TOP: Urine production MSC: NCLEX: Physiological Integrity
REF: 1651 OBJ: 3 KEY: Nursing Process Step: Assessment
2. As the body breaks down protein, nitrogen wastes are broken down into urea, ammonia, and: a. nitrogen. b. uric acid. c. nitrates. d. creatinine. ANS: D As proteins break down, nitrogenous wastes—urea, ammonia, and creatinine—are produced. DIF: Cognitive Level: Analysis REF: 1648 TOP: Physiology KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
3. Because the kidneys are located in proximity to the vertebrae and are protected by the ribs, their location in documentation is referred to as: a. retroperitoneal. b. diaphragm-vertebral. c. costovertebral. d. urachal-peritoneal. ANS: A The kidneys lie behind the parietal peritoneum (retroperitoneal). DIF: Cognitive Level: Knowledge TOP: Location of kidneys MSC: NCLEX: Physiological Integrity
REF: 1648 OBJ: 1 KEY: Nursing Process Step: Assessment
4. A home health patient with end-stage renal disease (ESRD) has a patient problem of powerlessness related to life-altering disease. Which nursing intervention would be most helpful? a. Ensure restricted protein intake to prevent nitrogenous product accumulation. b. Include the patient in making the plan of care. c. Counsel patient about end-of-life provisions. d. Write out a detailed schedule of health care provider’s appointments. ANS: B Listen to the patient and allow time for discussion about concerns and the plan of care to return some sense of control. End-of-life discussions are premature. DIF: Cognitive Level: Analysis REF: 1687 TOP: ESRD KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 12
5. What portion of the nephron is involved with filtration? a. Glomerulus of the Bowman capsule b. Henle loop c. Proximal convoluted tubule d. Distal convoluted tubule ANS: A Filtration of water and blood products occurs in the glomerulus of the Bowman capsule. DIF: Cognitive Level: Application REF: 1649 OBJ: 8 TOP: Coping KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 6. When the home health patient is started on dialysis, the home health nurse refers the patient to a community support group that assists with the adjustments necessary to living with dialysis. Which group offers this service? a. National Kidney Foundation b. American Association of Kidney Patients c. American Red Cross d. Veterans Administration ANS: B The American Association of Kidney Patients offer support to the patient and family as they adapt to living with dialysis. DIF: Cognitive Level: Comprehension TOP: Community resources MSC: NCLEX: Psychosocial Integrity
REF: 1693 OBJ: 11 KEY: Nursing Process Step: Planning
7. The nurse is aware that as a person ages there is a loss of the mechanism of the kidney due to a decrease in blood supply to the kidneys and loss of nephrons. a. filtering b. reabsorption c. sterile water
d. concentrating ANS: A The filtering mechanism is most affected with aging. By the age of 70, the filtering mechanism is only 50% as efficient as at 40 years of age. DIF: Cognitive Level: Knowledge TOP: Effect of aging MSC: NCLEX: Physiological Integrity
REF: 1652 OBJ: 5 KEY: Nursing Process Step: Planning
8. A patient who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP) complains of “spasm-like” pain over his lower abdomen. What should the initial intervention be by the nurse? a. Inform the nurse in charge. b. Decrease the continuous bladder irrigation flow. c. Administer the prescribed analgesic. d. Check the catheter and drainage system for obstruction. ANS: D The patient who has a TURP may have continuous closed bladder irrigation or intermittent irrigation to prevent occlusion of the catheter with blood clots, which would cause bladder spasms. DIF: Cognitive Level: Application REF: 1677 TOP: Transurethral resection of prostate (TURP) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 8
9. A 56-year-old patient with cancer of the bladder is recovering from a cystectomy with an ileal conduit. What is an important aspect in nursing interventions of the patient with an ileal conduit? a. Instructing the patient to void when the urge is felt b. Maintaining skin integrity c. Limiting oral intake to 1000 mL/day d. Limiting acid-ash foods ANS: A Care of the patient with an ileal conduit is a nursing challenge because of the continual drainage of urine through the stoma. Complications of this procedure are wound infection, dehiscence, and urinary leakage. The patient is urged to drink adequate fluids to flush the conduit. DIF: Cognitive Level: Application REF: 1693 OBJ: 8 TOP: Cystectomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. It is 2 days after a 42-year-old male patient’s urinary diversion surgery. He continues to be critical of the hospital and the nursing care, even though the staff has spent time explaining the care to him. What is the most likely explanation for his behavior? a. He is angry about hospital policy.
b. He is feeling neglected by the nursing staff. c. He is in denial of the effects of the surgery. d. He is reacting to the loss of self-esteem and altered body image. ANS: D Persons with altered body image may react to the loss of self-esteem by behaving in a critical or derogatory manner. DIF: Cognitive Level: Analysis REF: 1694 TOP: Coping KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 10
11. What should the nurse encourage, barring any other contraindication, when teaching a patient how to decrease the chance of further problems with urolithiasis? a. Increase his fluid intake. b. Increase intake of dairy products. c. Restrict his protein intake. d. Take one baby aspirin daily. ANS: A Fluid intake should be encouraged to at least 2000 mL of fluid in 24 hours, unless contraindicated. DIF: Cognitive Level: Application REF: 1658 OBJ: 8 TOP: Urolithiasis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse notes the amount and color of the urine the patient with urolithiasis has voided. While using Standard Precautions, what should be the nurse’s next action? a. Discard the urine. b. Add the urine to a 24-hour collector. c. Send the urine to the laboratory. d. Strain the urine. ANS: D All urine should be strained. Because stones may be any size, even the smallest speck must be saved for assessment by the laboratory. DIF: Cognitive Level: Application REF: 1672 TOP: Urolithiasis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 8
13. The nurse assessing a patient who is taking furosemide (Lasix) finds an irregular pulse. This is likely a sign of: a. hypomagnesemia. b. hypernatremia. c. hypokalemia. d. hypercalcemia. ANS: C
The loop diuretic prototype, furosemide (Lasix), affects electrolytes and causes hypokalemia; the deficiency of the electrolyte can cause arrhythmias and muscle weakness. DIF: Cognitive Level: Analysis REF: 1657 TOP: Medications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 7
14. The patient with nephrosis complains about the need for bed rest. How would the nurse explain the benefit of bed rest? a. The recumbent position may initiate diuresis. b. It preserves the skin integrity. c. It lowers the level of albuminuria. d. It saves stress on joints. ANS: A It is believed that the recumbent position helps initiate diuresis. DIF: Cognitive Level: Application TOP: Diagnostic procedures Implementation MSC: NCLEX: Physiological Integrity
REF: 1682 OBJ: 8 KEY: Nursing Process Step:
15. What should the nurse instruct the patient to do before obtaining the urine specimen for a urine culture? a. Collect the urine for a 24-hour period. b. Obtain a clean-catch specimen. c. Bring in an early morning specimen. d. Limit fluid intake to concentrate the urine. ANS: B Urine cultures are dependent on a clean-catch or catheterized specimen. DIF: Cognitive Level: Knowledge TOP: Diagnostic procedures Implementation MSC: NCLEX: Physiological Integrity
REF: 1667 OBJ: 8 KEY: Nursing Process Step:
16. The patient is scheduled for a transurethral resection of the prostate. During preoperative teaching, what should the nurse emphasize about what the patient can expect after the procedure? a. Red drainage from the catheter b. Limited intake of fluids c. A sodium-restricted diet d. Incisional drainage ANS: A The patient and family need to know that hematuria is expected after prostatic surgery. DIF:
Cognitive Level: Analysis
REF: 1677
OBJ: 8
TOP: Transurethral resection of prostate (TURP) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. A male patient, age 71, has benign prostatic hypertrophy. He is recovering from a trans-urethral prostatic resection. The health care provider orders removal of the indwelling catheter 2 days after the TURP procedure. What might the patient experience after the catheter is removed? a. Burning on urination b. Passing of blood clots in the urine c. Dribbling of urine d. Coffee-colored urine ANS: C The patient is informed that initially he may experience frequency and voiding small amounts with some dribbling. There should be no hematuria or clots after 2 days. DIF: Cognitive Level: Application REF: 1678 TOP: Transurethral resection of prostate (TURP) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 8
18. A patient, age 69, is admitted to the hospital with gross hematuria and history of a 20-lb weight loss during the last 3 months. The health care provider suspects renal cancer. In obtaining a nursing history from this patient, the nurse recognizes which of the following as a significant risk factor for renal cancer? a. High caffeine intake b. Cigarette smoking c. Use of artificial sweeteners d. Chronic cystitis ANS: B Risk factors include smoking; familial incidence; and preexisting renal disorders, such as adult polycystic kidney disease and renal cystic disease secondary to renal failure. DIF: Cognitive Level: Application TOP: Renal cancer MSC: NCLEX: Physiological Integrity
REF: 1673 OBJ: 8 KEY: Nursing Process Step: Assessment
19. As the nurse and the dietitian review a female patient’s diet plan with her, she shouts that with her diabetes and now the kidney failure, there is just nothing she can eat. She says she might as well eat what she wants, because there is nothing she can do to help herself. Based on the patient’s response, which patient problem does the nurse identify? a. Noncompliance, risk for, related to feelings of anger b. Imbalanced nutrition less than body requirements, related to knowledge deficit c. Anticipatory grieving, related to actual and perceived losses d. Ineffective coping, related to sense of powerlessness ANS: D
Ineffective coping due to the feeling of powerlessness against the multiorgan failure may result in aggressive or infantile behavior. DIF: Cognitive Level: Analysis REF: 1674 TOP: Coping KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity
OBJ: 12
20. The patient is on postoperative day 1 after having undergone a TURP procedure. He has continuous bladder irrigation (CBI). Actual urine output during continuous bladder irrigation is calculated by: a. measuring and recording all fluid output in the drainage bag. b. measuring the total output and deducting the total of the irrigating and intravenous solutions. c. adding the total of the intravenous and irrigating solutions and then deducting the amount of output. d. measuring total output and deducting the amount of irrigating solution used. ANS: D To determine urine output, the nurse will subtract the amount of irrigation fluid used with the Foley catheter output to calculate urine output. DIF: Cognitive Level: Application REF: 1678 TOP: Transurethral resection of prostate (TURP) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: 8
21. A patient has nephrotic syndrome. Which statement made by the patient indicates understanding of the necessary diet modifications? a. “I will need to increase protein and decrease sodium intake.” b. “I will need to drink more milk to get my calcium.” c. “Carbohydrate restriction will be difficult.” d. “Potassium restriction won’t be hard since I don’t like fruit.” ANS: A Medical management for nephrotic syndrome depends on the extent of tissue involvement and may include the use of corticosteroids and a low-sodium, high-protein diet. DIF: Cognitive Level: Analysis TOP: Nephrotic syndrome MSC: NCLEX: Physiological Integrity
REF: 1682 OBJ: 8 KEY: Nursing Process Step: Evaluation
22. What should the patient be encouraged to eat during the active phase of acute renal failure? a. A diet high in sodium b. A diet high in potassium c. A diet high in fats d. A diet high in fluid sources ANS: C
The patient with acute glomerulonephritis would need a high carbohydrate, high-fat diet to maintain weight. Potassium and sodium are restricted as well as excess fluids. DIF: Cognitive Level: Analysis TOP: Diagnostic procedures Implementation MSC: NCLEX: Physiological Integrity
REF: 1685 OBJ: 9 KEY: Nursing Process Step:
23. The patient has end-stage renal disease (ESRD) and is admitted to the hospital with a blood urea nitrogen (BUN) level of 48 mg/dL. An excessive elevation of BUN could result from: a. dehydration. b. disorientation. c. edema. d. catabolism. ANS: B If the BUN is elevated, preventive nursing measures should be instituted to protect the patient from possible disorientation or seizures. DIF: Cognitive Level: Analysis REF: 1686 TOP: ESRD KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 8
24. An intravenous pyelogram confirms the presence of a large renal calculus in the proximal left ureter of a newly admitted patient. The patient is not a candidate for conservative measures, so surgical correction is ordered. A temporary stent is inserted. In addition to observing the patient for hemorrhage, what should be the nurse’s postsurgical interventions include for this patient? a. Providing aseptic care of the surgical site b. Addressing anxiety related to unclear outcome of condition c. Watching out for prostatic hypertrophy d. Recommending appropriate oral analgesics to the health care provider ANS: A After surgery, observe the patient for hemorrhage, provide aseptic care of the surgical site, and provide a safe environment to prevent injury and infection. DIF: Cognitive Level: Application TOP: Renal calculi MSC: NCLEX: Physiological Integrity
REF: 1671 OBJ: 8 KEY: Nursing Process Step: Planning
25. A patient is receiving chlorothiazide (Diuril), a thiazide diuretic for hypertension. What nursing action is most important for prevention of complications? a. Measure output. b. Increase fluid intake. c. Assess for hypokalemia. d. Assess for hypernatremia. ANS: C
The thiazide diuretic, chlorothiazide (Diuril), affects electrolytes to cause hypokalemia (extreme potassium depletion in blood). DIF: Cognitive Level: Analysis REF: 1657 TOP: Medications KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 7
26. A patient with cystitis is receiving phenazopyridine (Pyridium) for pain and is voiding a bright red-orange urine. What should the nurse do? a. Report this immediately. b. Explain to the patient that this is normal. c. Increase fluid intake. d. Collect a specimen. ANS: B Pyridium will turn the urine reddish-orange. DIF: Cognitive Level: Analysis REF: 1665 OBJ: 7 TOP: Cystitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The patient, age 43, has cancer of the urinary bladder. He has received a cystectomy with an ileal conduit. Which characteristics would be considered normal for his urine? a. Hematuria b. Clear amber with mucus shreds c. Dark bile-colored d. Dark amber ANS: B There will be mucus present in the urine from the intestinal secretions. DIF: Cognitive Level: Analysis REF: 1693 TOP: Ileal conduit KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 6
28. A patient, age 78, has been admitted to the hospital with dehydration and electrolyte imbalance. She is confused and incontinent of urine on admission. Which nursing intervention does the nurse include in developing a plan of care? a. Restrict fluids after the evening meal. b. Insert an indwelling catheter. c. Assist the patient to the bathroom every 2 hours. d. Apply absorbent incontinence pads. ANS: D Use of protective undergarments may help to keep the patient and the patient’s clothing dry. Confused patients are high risk for falls. Restricting fluids will only decrease incontinence during the night and will exacerbate the dehydration and electrolyte imbalance. DIF:
Cognitive Level: Analysis
REF: 1663
OBJ: 8
TOP: Incontinence KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. The home health nurse suggests the use of complementary and alternative therapies to prevent and/or treat urinary tract infections (UTIs). Which of the following is an example of such therapies? a. Grape juice b. Caffeine c. Tea d. Cranberry juice ANS: D Cranberry (Cranberry Plus, Ultra Cranberry) has been used to prevent urinary tract infections (UTIs), particularly in women prone to recurrent infection. It has also been used to treat acute UTI. Monitor patients for lack of therapeutic effect. Caffeine and tea will increase diuresis but not prevent UTI. DIF: Cognitive Level: Application REF: 1666 OBJ: 7 TOP: Complementary and alternative therapy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 30. Which action can reduce the risk of skin impairment secondary to urinary incontinence? a. Decreasing fluid intake b. Catheterization of the elderly patient c. Limiting the use of medication (diuretics, etc.) d. Frequent toileting and meticulous skin care ANS: D Frequent toileting of the incontinent patient will prevent retained moisture in undergarments and bed linens and will preserve the integrity of the skin. DIF: Cognitive Level: Analysis TOP: Urinary frequency MSC: NCLEX: Physiological Integrity
REF: 1652 OBJ: 8 KEY: Nursing Process Step: Assessment
31. Why are pediatric patients, especially girls, susceptible to urinary tract infections? a. Genetically females have a weaker immune system. b. Females have a short and proximal urethra in relation to the vagina. c. Girls are more sexually active than males. d. Girls have a weakened musculature and sphincter tone. ANS: B Pediatric patients, especially girls, are susceptible to urinary tract infections because of the short urethra. DIF: Cognitive Level: Analysis TOP: Urinary anatomy MSC: NCLEX: Physiological Integrity
REF: 1694 OBJ: 1 KEY: Nursing Process Step: Assessment
32. Which foods should the home health nurse counsel hypokalemic patients to include in their diet? a. Bananas, oranges, cantaloupe b. Carrots, summer squash, green beans c. Apples, pineapple, watermelon d. Winter squash, cauliflower, lettuce ANS: A The use of most diuretics, with the exception of the potassium-sparing diuretics, requires adding daily potassium sources (e.g., baked potatoes, raw bananas, apricots, or navel oranges, cantaloupe, winter squash). DIF: Cognitive Level: Application TOP: Hypokalemia Implementation MSC: NCLEX: Physiological Integrity
REF: 1657 OBJ: 7 KEY: Nursing Process Step:
33. To help a patient control incontinence, what should the nurse recommend the patient avoid? a. Spicy foods b. Citrus fruits c. Organ meats d. Shellfish ANS: A Incontinence may be improved by omitting spicy foods, alcohol, and caffeine from the diet. DIF: Cognitive Level: Analysis REF: 1663 OBJ: 8 TOP: Incontinence KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 34. What should the nurse counsel the young man with chronic prostatitis to avoid? a. Cessation of intercourse b. Warm baths c. Stool softeners d. Continuing antibiotics when symptoms abate ANS: A Frequent intercourse may be beneficial to the treatment of chronic prostatitis. Warm baths, stool softeners, and antibiotic therapy are also part of the medical treatment. DIF: Cognitive Level: Analysis REF: 1669 TOP: Urinalysis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 8
35. What is the second step of blood flow in order of flow through the nephron? a. Reabsorption in loop of Henle b. Efferent arteriole c. Filtration in the glomerulus
d. Reabsorption in proximal convoluted tubule e. Afferent arteriole f. Secretion in the distal convoluted tubule ANS: C The blood enters the nephron via the afferent arteriole, is filtered through the glomerulus, reabsorption occurs in the proximal convoluted tubule, then the loop of Henle, then the distal convoluted tubule, and then out the efferent arteriole. DIF: Cognitive Level: Analysis TOP: Nephron action MSC: NCLEX: Physiological Integrity
REF: 1649 OBJ: 2 KEY: Nursing Process Step: Assessment
MULTIPLE RESPONSE 1. The nurse reassures the patient recovering from acute glomerulonephritis that after all other signs and symptoms of the disease subside, it is normal to have some residual: (Select all that apply.) a. proteinuria. b. oliguria. c. hematuria. d. anasarca. e. oliguria. ANS: A, C Proteinuria and hematuria may exist microscopically even when other symptoms subside. DIF: Cognitive Level: Application TOP: Acute glomerulonephritis Implementation MSC: NCLEX: Physiological Integrity
REF: 1649 OBJ: 8 KEY: Nursing Process Step:
2. Why are urinary tract infections (UTI) common in older adults? (Select all that apply.) a. Older adults have weakened musculature in the bladder and urethra. b. Older adults have urinary stasis. c. Older adults have increased bladder capacity. d. Older adults have diminished neurologic sensation. e. The effects of medications such as diuretics that many older adults take. ANS: A, B, D, E Urinary frequency, urgency, nocturia, retention, and incontinence are common with aging. These occur because of weakened musculature in the bladder and urethra, diminished neurologic sensation combined with decreased bladder capacity, and the effects of medications such as diuretics. Older women are at risk for stress incontinence because of hormonal changes and weakened pelvic musculature. Inadequate fluid intake (less than 1000 to 2000 mL per 24 hours) can lead to urinary stasis. DIF: Cognitive Level: Knowledge TOP: Urinary frequency
REF: 1652 OBJ: 8 KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 3. Which of the following are signs of fluid overload in the patient with nephrosis? (Select all that apply.) a. Increase in pulse rate b. Increase in daily weight c. Clear lung sounds d. Edema e. Labored respirations ANS: A, B, D, E Signs and symptoms of fluid overload: changes in pulse rate, respirations, cardiac sounds, and lung fields. Increase in daily morning weights. DIF: Cognitive Level: Comprehension TOP: Fluid overload MSC: NCLEX: Physiological Integrity
REF: 1657 OBJ: 7 KEY: Nursing Process Step: Assessment
4. The nurse is reviewing the urinalysis report on an assigned patient. The nurse recognizes which findings to be normal? (Select all that apply.) a. Turbidity clear b. pH 6.0 c. Glucose negative d. Red blood cells, 15 to 20 e. White blood cells ANS: A, C The type and size of urinary catheter are determined by the location and cause of the urinary tract problem. DIF: Cognitive Level: Analysis REF: 1659 TOP: Urinalysis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 4
COMPLETION 1. Exercises to increase muscle tone of the pelvic floor are known as exercises. ANS: Kegel Women with weakened structures of the pelvic floor are prone to stress incontinence. For the female patient, Kegel exercises are helpful; 10 repetitions, 5 to 10 times a day, are suggested to improve muscle tone. DIF: Cognitive Level: Knowledge TOP: Kegel exercises MSC: NCLEX: Physiological Integrity
REF: 1662 OBJ: 8 KEY: Nursing Process Step: Assessment
2.
is a term for severe generalized edema. ANS: Anasarca The patient with nephritic syndrome has severe generalized edema (anasarca), anorexia, fatigue, and impaired renal function. DIF: Cognitive Level: Knowledge REF: 1682 TOP: Key term KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 8
3. Acute glomerulonephritis is commonly a result of a preexisting infection of b-hemolytic . ANS: streptococci The health history commonly reveals that the onset of acute glomerulonephritis is preceded by b-hemolytic streptococcal infection. DIF: Cognitive Level: Comprehension TOP: Acute glomerulonephritis MSC: NCLEX: Physiological Integrity
REF: 1683 OBJ: 8 KEY: Nursing Process Step: Assessment
4. The prostatectomy technique, which involves an incision through the abdomen and the bladder, is a prostatectomy. ANS: suprapubic A suprapubic prostatectomy involves an incision through the abdomen and the bladder with removal of the gland with the finger. DIF: Cognitive Level: Knowledge TOP: Prostatectomy MSC: NCLEX: Physiological Integrity 5.
REF: 1670 OBJ: 3 KEY: Nursing Process Step: Assessment
is a prostatic pain without evidence of infection or inflammation. ANS: Prostatodynia Prostatodynia is a prostatic pain without evidence of infection or inflammation. DIF: Cognitive Level: Knowledge TOP: Prostatodynia MSC: NCLEX: Physiological Integrity
REF: 1668 OBJ: 8 KEY: Nursing Process Step: Assessment
6. In the nephrotic syndrome, the glomeruli are damaged by inflammation and allow small to pass through into the urine. ANS: proteins In nephrotic syndrome, the glomeruli are damaged by inflammation and allow small proteins such as albumin to enter the urine. This creates a deficit of protein in the circulation volume (hypoalbuminemia), which leads to massive edema. DIF: Cognitive Level: Comprehension TOP: Nephrotic syndrome MSC: NCLEX: Physiological Integrity
REF: 1682 OBJ: 8 KEY: Nursing Process Step: Assessment
Chapter 51: Care of the Patient with an Endocrine Disorder Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse explains that the negative feedback inhibition controls hormone release by
communication between: a. the pituitary and the target organ. b. the thymus and the bloodstream. c. lymphatic system and the target organ. d. central nervous system and the bloodstream. ANS: A
The amount of hormone released is controlled by negative feedback inhibition. The negative feedback inhibition process is when a gland releases a primary hormone, which stimulates target cells to release a secondary hormone; the gland slows the release of the primary hormone as it senses the rise of the secondary hormone. Information is constantly being exchanged via the bloodstream between target organs and endocrine glands. DIF: Cognitive Level: Implementation REF: 1699 TOP: Anatomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 2
2. Which diagnostic test for diabetes mellitus provides a measure of glucose levels for the
previous 8 to 12 weeks? a. Fasting blood sugar (FBS) b. Oral glucose tolerance test (OGT) c. Glycosylated hemoglobin (HbA1c) d. Postprandial glucose test (PPBG) ANS: C
Glycosylated hemoglobin (HbA1c)—This blood test measures the amount of glucose that has become incorporated into the hemoglobin within an erythrocyte. Because glycosylation occurs constantly during the 120-day lifespan of the erythrocyte, this test reveals the effectiveness of diabetes therapy for the preceding 8 to 12 weeks. DIF: Cognitive Level: Knowledge TOP: Glucose monitoring MSC: NCLEX: Physiological Integrity
REF: 1726 OBJ: 8 KEY: Nursing Process Step: Assessment
3. Which test will furnish immediate feedback for a newly diagnosed diabetic who is not yet
under control? a. Fasting blood sugar (FBS) b. Glycosylated hemoglobin (HbA1c) c. Oral glucose tolerance test (OGTT) d. Clinitest ANS: A
Diabetics should do a finger-stick blood glucose level test before each meal and at bedtime each day until their disease is under control. The HbA1c serum test reveals the effectiveness of diabetes therapy for the preceding 8 to 12 weeks. DIF: Cognitive Level: Comprehension TOP: Diabetes mellitus MSC: NCLEX: Physiological Integrity
REF: 1737 OBJ: 9 KEY: Nursing Process Step: Planning
4. To which diet should a patient with Cushing syndrome adhere? a. Less sodium b. More calories c. Less potassium d. More carbohydrates ANS: A
The diet should be lower in sodium to help decrease edema. DIF: Cognitive Level: Analysis TOP: Cushing syndrome MSC: NCLEX: Physiological Integrity
REF: 1720 OBJ: 5 KEY: Nursing Process Step: Planning
5. The patient is a 20-year-old college student who has type 1 diabetes and normally walks
each evening as part of an exercise regimen. The patient plans to enroll in a swimming class. Which adjustment should be made based on this information? a. Time the morning insulin injection so that the peak action will occur during swimming class. b. Delete normal walks on swimming class days. c. Delay the meal before the swimming class until the session is over. d. Monitor glucose level before, during, and after swimming to determine the need for alterations in food or insulin. ANS: D
Exercise can reduce insulin resistance and increase glucose uptake for as long as 72 hours, as well as reducing blood pressure and lipid levels. However, exercise can carry some risks for patients with diabetes, including hypoglycemia. DIF: Cognitive Level: Analysis TOP: Diabetes mellitus MSC: NCLEX: Physiological Integrity
REF: 1728 OBJ: 11 KEY: Nursing Process Step: Planning
6. What is a long-term complication of diabetes mellitus? a. Diverticulitis b. Renal failure c. Hypothyroidism d. Hyperglycemia ANS: B
Long-term complications of diabetes include blindness, cardiovascular problems, and renal failure. DIF: Cognitive Level: Analysis TOP: Diabetes mellitus
REF: 1735 OBJ: 15 KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 7. A patient has returned to his room after a thyroidectomy with signs of thyroid crisis.
During thyroid crisis, exaggerated hyperthyroid manifestations may lead to the development of the potentially lethal complication of: a. severe nausea and vomiting. b. bradycardia. c. delirium with restlessness. d. congestive heart failure. ANS: D
In thyroid crisis, all the signs and symptoms of hyperthyroidism are exaggerated. The patient may develop congestive heart failure and die. DIF: Cognitive Level: Analysis TOP: Thyroidectomy MSC: NCLEX: Physiological Integrity
REF: 1712 OBJ: 7 KEY: Nursing Process Step: Assessment
8. In diabetes insipidus, a deficiency of which hormone causes clinical manifestations? a. Antidiuretic hormone (ADH) b. Follicle-stimulating hormone (FSH) c. Thyroid-stimulating hormone (TSH) d. Adrenocorticotropic hormone (ACTH) ANS: A
Diabetes insipidus develops when there is a decrease in production of ADH from the posterior pituitary or the action of ADH is diminished. DIF: Cognitive Level: Knowledge TOP: Diabetes insipidus MSC: NCLEX: Physiological Integrity
REF: 1703 OBJ: 5 KEY: Nursing Process Step: Assessment
9. What is an appropriate patient problem for a patient who has recently been diagnosed with
acromegaly? a. Ineffective coping b. Activity intolerance c. Risk for trauma d. Chronic low self-esteem ANS: C
Nursing interventions are mainly supportive. The presence of muscle weakness, joint pain, or stiffness warrants assessment of the ability to perform activities of daily living (ADLs). DIF: Cognitive Level: Analysis REF: 1703 TOP: Acromegaly KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment
OBJ: 5
10. The purpose of the use of radioactive iodine in the treatment of hyperthyroidism is to: a. stimulate the thyroid gland. b. depress the pituitary. c. destroy some of the thyroid tissue. d. alter the stimulus from the pituitary.
ANS: C
Radioactive iodine 131 destroys some of the hyperactive thyroid gland to produce a more normally functioning gland. DIF: Cognitive Level: Application TOP: Radioactive iodine 131 MSC: NCLEX: Physiological Integrity
REF: 1710 OBJ: 5 KEY: Nursing Process Step: Implementation
11. Which precaution(s) should the nurse take when caring for a patient who is being treated
with radioactive iodine 131 (RAIU)? a. Initiate radioactive safety precautions. b. Avoid assigning any young woman to the patient. c. Wait 3 days after dose before assigning a pregnant nurse to care for this patient. d. Advise visitors to sit at least 10 ft away from the patient. ANS: C
The dose is patient specific and at a very low level. No radioactive safety precautions are necessary and pregnant nurses can be assigned 3 days after the dose. RAIU is not harmful to nonpregnant women. DIF: Cognitive Level: Knowledge TOP: Thyroid disorders MSC: NCLEX: Physiological Integrity
REF: 1710 OBJ: 5 KEY: Nursing Process Step: Assessment
12. Why would a patient with hyperthyroidism be prescribed the drug methimazole
(Tapa-zole)? a. To limit the effect of the pituitary on the thyroid. b. To destroy part of the hyperactive thyroid tissue. c. To stimulate the pineal gland. d. To block the production of thyroid hormones. ANS: D
Medical management for hyperthyroidism may include administration of drugs that block the production of thyroid hormones, such as propylthiouracil or methimazole. DIF: Cognitive Level: Application TOP: Hyperthyroidism MSC: NCLEX: Physiological Integrity
REF: 1710 OBJ: 5 KEY: Nursing Process Step: Implementation
13. What is the postoperative position for a person who has had a thyroidectomy? a. Prone b. Semi-Fowler c. Side-lying d. Supine ANS: B
Postoperative management of this patient includes keeping the bed in a semi-Fowler’s position, with pillows supporting the head and shoulders. There should be a suction apparatus and tracheotomy tray available for emergency use. DIF: Cognitive Level: Application TOP: Thyroidectomy
REF: 1711 OBJ: 7 KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 14. What extra equipment should the nurse provide at the bedside of a new postoperative
thyroidectomy patient? a. Large bandage scissors b. Tracheotomy tray c. Ventilator d. Water-sealed drainage system ANS: B
There should be a suction apparatus and tracheotomy tray available for emergency use. DIF: Cognitive Level: Analysis TOP: Thyroidectomy MSC: NCLEX: Physiological Integrity
REF: 1711 OBJ: 7 KEY: Nursing Process Step: Planning
15. As the nurse is shaving a patient who is 2 days postoperative from a thyroidectomy, the
patient has a spasm of the facial muscles. What should the nurse recognize this as? a. Chvostek sign b. Montgomery sign c. Trousseau sign d. Homans’ sign ANS: A
The spasm of facial muscles when stimulated is the Chvostek sign, an indication of hypocalcemic tetany. DIF: Cognitive Level: Analysis TOP: Chvostek sign MSC: NCLEX: Psychosocial Integrity
REF: 1712 OBJ: 5 KEY: Nursing Process Step: Assessment
16. The human insulin whose onset of action occurs within a. 30 b. 60 c. 15 d. 45
minutes is lispro (Humalog).
ANS: C
Humalog begins to take effect in less than half the time of regular, fast-acting insulin. The new formula can be injected 15 minutes before a meal. DIF: Cognitive Level: Knowledge REF: 1720 TOP: Insulin KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 13
17. What should the nurse caution a type I diabetic about excessive exercise? a. It can increase the need for insulin and may result in hyperglycemia. b. It can decrease the need for insulin and may result in hypoglycemia. c. It can increase muscle bulk and may result in malabsorption of insulin. d. It can decrease metabolic demand and may result in metabolic acidosis. ANS: B
The patient with diabetes should exercise regularly. Exercise can reduce insulin resistance and increase glucose uptake for as long as 72 hours, as well as reducing blood pressure and lipid levels. However, exercise can carry some risks for patients with diabetes, including hypoglycemia. DIF: Cognitive Level: Application TOP: Diabetes mellitus MSC: NCLEX: Physiological Integrity
REF: 1728 OBJ: 11 KEY: Nursing Process Step: Implementation
18. What do the Chvostek sign and the Trousseau sign indicate? a. Low levels of serum calcium b. High levels of blood sugar c. Low levels of serum sodium d. High levels of serum aldosterone ANS: A
Low levels of blood calcium may cause the Chvostek sign and Trousseau sign. DIF: Cognitive Level: Knowledge TOP: Chvostek sign MSC: NCLEX: Physiological Integrity
REF: 1713 OBJ: 6 KEY: Nursing Process Step: Assessment
19. A patient has undergone tests that indicate a deficiency of the parathyroid hormone
secretion. She should be informed of which potential complication? a. Osteoporosis b. Lethargy c. Laryngeal spasms d. Kidney stones ANS: C
Decreased parathyroid hormone levels in the bloodstream cause a decreased calcium level. Severe hypocalcemia may result in laryngeal spasm, stridor, cyanosis, and increased possibility of asphyxia. DIF: Cognitive Level: Comprehension TOP: Hypoparathyroidism MSC: NCLEX: Physiological Integrity
REF: 1717 OBJ: 5 KEY: Nursing Process Step: Implementation
20. The nurse caring for a 75-year-old man who has developed diabetes insipidus following a
head injury will include in the plan of care provisions for: a. limiting fluids to 1500 mL a day. b. encouraging physical exercise. c. protecting patient from injury. d. discouraging daytime naps. ANS: C
The patients need protection from injury because they are often exhausted from sleep deprivation and having to get up frequently at night. Fluids should not be limited and their energy should be preserved. DIF: Cognitive Level: Application TOP: Diabetes insipidus
REF: 1707 OBJ: 5 KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment 21. The health care provider orders an 1800-calorie diabetic diet and 40 units of (Humulin N)
insulin U-100 subcutaneously daily for a patient with diabetes mellitus. Why would a mid-afternoon snack of milk and crackers be given? a. To improve nutrition. b. To improve carbohydrate metabolism. c. To prevent an insulin reaction. d. To prevent diabetic coma. ANS: C
Humulin N insulin starts to peak in 4 hours. The nurse should be alert for signs of hypoglycemia (low blood glucose) at the peak of action of whatever type of insulin the patient is receiving. DIF: Cognitive Level: Analysis TOP: Diabetes mellitus MSC: NCLEX: Physiological Integrity
REF: 1729 OBJ: 13 KEY: Nursing Process Step: Implementation
22. The nurse teaching a patient with type 1 diabetes mellitus (IDDM) about early signs of
insulin reaction would include information about: a. abdominal pain and nausea. b. dyspnea and pallor. c. flushing of the skin and headache. d. hunger and a trembling sensation. ANS: D
The patient should be instructed to notify a member of the nursing staff if any signs of hypoglycemic (low insulin) reaction occur: excessive perspiration or trembling. DIF: Cognitive Level: Application TOP: Insulin reaction MSC: NCLEX: Physiological Integrity
REF: 1731 OBJ: 9 KEY: Nursing Process Step: Implementation
23. The nurse discovers the type 1 diabetic (IDDM) patient drowsy and tremulous, the skin is
cool and moist, and the respirations are 32 and shallow. These are signs of: a. hypoglycemic reaction; give 6 oz of orange juice. b. hyperglycemic reaction; give ordered regular insulin. c. hyperglycemic hyperosmolar nonketotic reaction; squeeze glucagon gel in buccal cavity. d. hypoglycemic reaction; give ordered insulin. ANS: A
Hypoglycemic reaction is due to not enough food for the insulin. Quick acting carbohydrates—such as orange juice or longer acting foods such as milk, crackers, and cheese—are beneficial. DIF: Cognitive Level: Comprehension TOP: Diabetes mellitus complications MSC: NCLEX: Physiological Integrity
REF: 1737 OBJ: 9 KEY: Nursing Process Step: Assessment
24. A patient has come to the clinic because of enlarged hands and feet, amenorrhea, and
increased hair growth. These symptoms most likely indicate problems with the: a. pituitary gland. b. adrenal glands. c. thyroid gland. d. pancreas. ANS: A
The pituitary gland may produce an overabundance of growth hormone. This overproduction of hormones may cause changes throughout the patient’s body, including enlargement of the pituitary gland and hands and feet. Female patients may develop a deepened voice, increased facial hair growth, and amenorrhea. DIF: Cognitive Level: Analysis REF: 1702 TOP: Acromegaly KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
25. What instructions should a nurse give to a diabetic patient to prevent injury to the feet? a. Soak feet in warm water every day. b. Avoid going barefoot and always wear shoes with soles. c. Use of commercial keratolytic agents to remove corns and calluses are preferred to
cutting off corns and calluses. d. Use a heating pad to warm feet when they feel cool to the touch. ANS: B
Sturdy, properly fitting shoes should be worn. Use of corn removers and heating pads is not beneficial to preserve the health of a diabetic’s feet. DIF: Cognitive Level: Analysis REF: 1734 OBJ: 8 TOP: Foot care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 26. The health care provider prescribes glyburide (Micronase, DiaBeta, Glynase) for a patient,
age 57, when diet and exercise have not been able to control type 2 diabetes. What should the nurse include in the teaching plan about this medication? a. It is a substitute for insulin and acts by directly stimulating glucose uptake into the cell. b. It does not cause the hypoglycemic reactions that may occur with insulin use. c. It is thought to stimulate insulin production and increase sensitivity to insulin at receptor sites. d. It lowers blood sugar by inhibiting glucagon release from the liver, preventing gluconeogenesis. ANS: C
Oral hypoglycemics are compounds that stimulate the cells in the pancreas to increase insulin release. DIF: Cognitive Level: Analysis REF: 1741 TOP: Medications KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 8
27. A 27-year-old patient with hypothyroidism is referred to the dietitian for dietary
consultation. What should nutritional interventions include? a. Frequent small meals high in carbohydrates b. Calorie-restricted meals c. Caffeine-rich beverages d. Fluid restrictions ANS: B
A high-protein, high-fiber, lower calorie diet is given. DIF: Cognitive Level: Analysis TOP: Hypothyroidism MSC: NCLEX: Physiological Integrity
REF: 1740 OBJ: 5 KEY: Nursing Process Step: Planning
28. What instructions should be included in the discharge instructions for a 47-year-old patient
with hypothyroidism? a. Taking medication whenever symptoms cause discomfort b. Decreasing fluid and fiber intake c. Consuming foods rich in iron d. Seeing the health care provider regularly for follow-up care ANS: D
Regular checkups are essential, because drug dosage may have to be adjusted from time to time. DIF: Cognitive Level: Application REF: 1714 OBJ: 5 TOP: Hypothyroidism KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 29. How should the nurse administer insulin to prevent lipohypertrophy? a. At room temperature b. At body temperature c. Straight from the refrigerator d. After rolling bottle between hands to warm ANS: A
In fact, it is now believed that insulin should be administered at room temperature, not straight from the refrigerator, to help prevent insulin lipohypertrophy. DIF: Cognitive Level: Application TOP: Diabetes mellitus MSC: NCLEX: Physiological Integrity
REF: 1731 OBJ: 8 KEY: Nursing Process Step: Implementation
30. A patient with a history of Graves disease is admitted to the unit with shortness of breath.
The nurse notes the patient’s vital signs: T 103°F, P 160, R 24, BP 160/80. The nurse also notes distended neck veins. What does the patient most likely have? a. Pulmonary embolism b. Hypertensive crisis c. Thyroid storm d. Cushing crisis ANS: C
In a thyroid crisis, all the signs and symptoms of hyperthyroidism are exaggerated. Additionally, the patient may develop nausea, vomiting, severe tachycardia, severe hypertension, and occasionally hyperthermia up to 41°C (106°F). Extreme restlessness, cardiac arrhythmia, and delirium may also occur. The patient may develop heart failure and may die. DIF: Cognitive Level: Analysis TOP: Hyperthyroidism MSC: NCLEX: Physiological Integrity
REF: 1712 OBJ: 8 KEY: Nursing Process Step: Assessment
31. What is the master gland of the endocrine system? a. Thyroid b. Parathyroid c. Pancreas d. Pituitary ANS: D
The pituitary gland, located in the brain, is the master gland of the endocrine system. It has been called the “master gland” because through the negative feedback inhibition, it exerts its control over the other endocrine glands. DIF: Cognitive Level: Knowledge TOP: Pituitary gland MSC: NCLEX: Physiological Integrity
REF: 1699 OBJ: 1 KEY: Nursing Process Step: Assessment
32. What information should be obtained from the patient before an iodine-131 test? a. Presence of metal in the body b. Allergy to sulfa drugs c. Status of possible pregnancy d. Use of prescription drugs for hypertension ANS: C
Iodine-131 is not a radiation hazard to the nonpregnant patient but is absolutely contraindicated during pregnancy. Pregnant nurses should not care for this patient for several days. DIF: Cognitive Level: Knowledge REF: 1710 TOP: Iodine-131 KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
33. The patient being treated for hypothyroidism should be instructed to eat well-balanced
meals including intake of iodine. Which of the following foods contains iodine? a. Eggs b. Pork c. White bread d. Skinless chicken ANS: A
The hypothyroid diet should be adequate in intake of iodine, in foods such as saltwater fish, milk, and eggs; fluids should be increased to help prevent constipation. DIF: Cognitive Level: Application
REF: 1714
OBJ: 8
TOP: Hypothyroidism MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step: Assessment
34. The nurse is caring for a patient who is receiving calcium gluconate for treatment of
hypoparathyroid tetany. Which assessment would indicate an adverse reaction to the drug? a. Increase in heart rate b. Flushing of face and neck c. Drop in blood pressure d. Urticaria ANS: C
Indications of an adverse effect of calcium gluconate are dyspnea, bradycardia, and hypotension. DIF: Cognitive Level: Application TOP: Calcium gluconate for tetany MSC: NCLEX: Physiological Integrity
REF: 1718 OBJ: 5 KEY: Nursing Process Step: Assessment
35. The nurse cautions the patient who is being instructed on self-medication with insulin to
be aware that there are 25-, 30-, 50-, and 100-unit syringes. How is the 100-unit syringe marked? a. 1-unit increments b. 2-unit increments c. 4-unit increments d. 5-unit increments ANS: B
The 100-unit syringe is marked in 2-unit increments while the smaller syringes are marked in 1-unit increments. DIF: Cognitive Level: Knowledge TOP: Insulin administration MSC: NCLEX: Physiological Integrity
REF: 1731 OBJ: 14 KEY: Nursing Process Step: Implementation
MULTIPLE RESPONSE 1. Which of the following are signs and symptoms of hypoglycemia? (Select all that apply.) a. Irritability b. Dry mouth c. Tremors d. Diaphoresis e. Fruity breath f. Deep respirations ANS: A, C, D
Hypoglycemic reaction: rapid shallow respirations, irritability, tremors, excessive perspiration, and possibly loss of consciousness. DIF: Cognitive Level: Application TOP: Hypoglycemia MSC: NCLEX: Physiological Integrity
REF: 1737 OBJ: 9 KEY: Nursing Process Step: Assessment
2. What are the three major life-threatening complications postoperatively of a
thyroidectomy? (Select all that apply.) a. Hemorrhaging b. Seizures c. Tetany d. Hypoglycemia e. Thyroid crisis (storm) f. SIADH ANS: A, C, E
The nurse must be alert for signs of internal or external bleeding. In addition to hemorrhage, two significant postoperative complications exist after thyroidectomy. The first is tetany. The second is thyroid crisis. Manipulation of the thyroid during surgery may cause the release of large amounts of thyroid hormones into the bloodstream, creating a thyroid crisis (storm). DIF: Cognitive Level: Comprehension TOP: Thyroidectomy MSC: NCLEX: Physiological Integrity
REF: 1711 OBJ: 7 KEY: Nursing Process Step: Assessment
3. The adrenal cortex secretes glucocorticoids. The most important is cortisol. What is it
involved in? (Select all that apply.) a. Glucose metabolism b. Releasing androgens and estrogens c. Providing extra reserve energy during stress d. Decreasing the level of potassium in the bloodstream e. Increasing retention of sodium in the bloodstream ANS: A, C
Cortisol is involved in glucose metabolism and provides extra reserve energy in times of stress. DIF: Cognitive Level: Comprehension TOP: Adrenal cortex MSC: NCLEX: Physiological Integrity
REF: 1701 OBJ: 3 KEY: Nursing Process Step: Assessment
4. What should the nurse include in provisions for the postoperative care of the patient who
had a thyroidectomy? (Select all that apply.) a. Assessing ability to speak by asking him or her to recite name and address every hour b. Maintaining anatomic position of the head when moving a patient c. Assisting a patient to hyperextend the head to assess for muscle damage d. Doing voice check every 2 hours e. Turning, coughing every hour f. Checking for bleeding at the sides and the back of the head ANS: B, D, F
The nurse should hold the head in an anatomic position when moving the patient to prevent tension on the suture line, do a voice check every 2 to 4 hours by asking the patient to say “ah”; the patient is not turned nor is coughing recommended immediately after a thyroidectomy.
DIF: Cognitive Level: Application TOP: Postoperative thyroidectomy MSC: NCLEX: Physiological Integrity
REF: 1711 OBJ: 7 KEY: Nursing Process Step: Planning
5. The nurse would instruct a patient with hyperthyroidism (Graves disease) to select which
of the following nutritious foods because of the increased metabolism related to the disease? (Select all that apply.) a. Coffee with cream b. Lean meat c. White bread d. Leafy green vegetables e. Supplemental vitamin D ANS: B, D, E
Nutritious food sources, such as food high in protein (e.g., lean meat), sources of vitamin B (e.g., leafy green vegetables), and vitamin D supplements are helpful to meet the metabolic needs of the patient with hyperthyroidism. DIF: Cognitive Level: Application REF: 1714 OBJ: 5 TOP: Diet for hyperthyroidism KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. The nurse would instruct a patient who is hypocalcemic from hypoparathyroidism about a
diet that should include: (Select all that apply) a. high phosphorus foods. b. canned fish with the bones. c. cucumbers. d. tofu. e. bananas. f. vitamin D supplements. ANS: B, C, D, F
The hypocalcemic patient should eat a high-calcium, low-phosphorus diet that includes canned fish, cucumbers, tofu, and vitamin D supplements as an aid to the absorption of the calcium. DIF: Cognitive Level: Application TOP: Diet for hypocalcaemia MSC: NCLEX: Physiological Integrity
REF: 1718 OBJ: 5 KEY: Nursing Process Step: Implementation
COMPLETION 1. The nurse is administering long-acting insulin once a day, which provides insulin coverage
for 24 hours. This insulin is
.
ANS:
Lantus Lantus is a long-acting synthetic (recombinant DNA origin, human-made) human insulin. It is used once a day at bedtime and works around the clock for 24 hours.
DIF: Cognitive Level: Implementation REF: 1729 TOP: Insulin KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 3
2. Another term for hyperglycemic reaction is diabetic
.
ANS:
ketoacidosis Hyperglycemic reaction—the body eliminates the excess glucose by the kidneys releasing it in the urine. Diabetic ketoacidosis (DKA) (acidosis accompanied by an accumulation of ketones in the blood), formerly called diabetic coma, may develop and the patient could die. DKA is a severe metabolic disturbance caused by an acute insulin deficiency, decreased peripheral glucose use, and increased fat mobilization and ketogenesis. DIF: Cognitive Level: Knowledge TOP: Hyperglycemia MSC: NCLEX: Physiological Integrity 3. Only
REF: 1735 | 1737 OBJ: 10 KEY: Nursing Process Step: Assessment
insulin can be administered intravenously.
ANS:
regular Insulin is given subcutaneously, although intravenous (IV) administration of regular insulin can be done when immediate onset of action is desired. DIF: Cognitive Level: Knowledge REF: 1728 TOP: Insulin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
4. A condition with a deficiency in growth hormone is called
dwarfism.
ANS:
hypopituitary A condition with a deficiency in growth hormone is called hypopituitary dwarfism. Most cases are idiopathic, but a small number can be attributed to an autosomal-recessive trait. In some cases, there is also a lack of adrenocorticotropic hormone (ACTH), TSH, and the gonadotropins. DIF: Cognitive Level: Knowledge REF: 1705 TOP: Dwarfism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 5
is the term that describes a condition of normal thyroid function.
5. ANS:
Euthyroid
Euthyroid is the term that describes a condition of normal thyroid function. DIF: Cognitive Level: Knowledge REF: 1710 TOP: Euthyroid KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 5
6. When the nurse inflates the sphygmomanometer cuff exceeding the systolic blood pressure
and observes a carpal spasm, this is a(n)
sign.
ANS:
Trousseau Trousseau’s sign is a carpal spasm brought on by pressure of a cuff. This is an indicator for hypocalcemia and hypomagnesemia. DIF: Cognitive Level: Application TOP: Trousseau sign MSC: NCLEX: Physiological Integrity
REF: 1712 OBJ: 6 KEY: Nursing Process Step: Assessment
Chapter 52: Care of the Patient with a Reproductive Disorder Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. Which condition would prevent the use of a vaginal hysterectomy? a. A woman with more than four pregnancies b. Large uterine fibroids c. Menorrhagia for over 6 months d. Women over the age of 50 ANS: B
In the case of large uterine fibroids, a vaginal hysterectomy is not an option. DIF: Cognitive Level: Application TOP: Hysterectomy MSC: NCLEX: Physiological Integrity
REF: 1784 OBJ: 14 KEY: Nursing Process Step: Implementation
2. On the second postoperative day, a patient who has had an abdominal hysterectomy
complains of gas and abdominal distention. Which intervention would be most appropriate to stimulate a bowel movement? a. Offering carbonated beverages b. Encouraging ambulation at least four times per day c. Administering a 1000-mL soapsuds enema d. Applying an abdominal binder ANS: B
Early ambulation is very helpful to return the bowel to normal function. DIF: Cognitive Level: Analysis TOP: Hysterectomy MSC: NCLEX: Physiological Integrity
REF: 1784 OBJ: 14 KEY: Nursing Process Step: Implementation
3. The young husband of a patient who has been scheduled for a hysterectomy because of the
discovery of ovarian cancer in both ovaries says to the nurse, “Please go talk to my wife. She is real upset and says she won’t be a ‘woman’ anymore.” What is the nurse’s most therapeutic response? a. “Don’t be concerned. All young women get upset before this kind of surgery.” b. “Certainly, I will be glad to tell her about hormone replacement.” c. “She will get over this feeling soon.” d. “No matter what I may say to her, it is you that needs to listen to her concerns and assure her.” ANS: D
Assisting patients with recognizing and clarifying fears and with developing coping strategies for those fears by listening is helpful. DIF: Cognitive Level: Application TOP: Ovarian cancer MSC: NCLEX: Psychosocial Integrity
REF: 1783 | 1791 OBJ: 12 KEY: Nursing Process Step: Implementation
4. A patient, age 41, has had a total abdominal hysterectomy and bilateral
salpingo-oophorectomy for endometriosis. She asks the nurse if she will have “hot flashes.” What knowledge will guide the nurse’s response? a. Only the uterus was removed, and the ovaries are still producing estrogen and she will not have hot flashes. b. The patient is too young to have hot flashes associated with menopause. c. The uterus, ovaries, and fallopian tubes were removed, and she will have surgically induced menopause and may have hot flashes. d. The uterus and fallopian tubes were removed, and she will not experience “hot flashes.” ANS: C
A total abdominal hysterectomy with bilateral salpingo-oophorectomy is the removal of the uterus, fallopian tubes, and ovaries. If the ovaries are removed in these surgeries, the surgery will induce menopause and hot flashes may occur. DIF: Cognitive Level: Analysis TOP: Hysterectomy MSC: NCLEX: Physiological Integrity
REF: 1783 OBJ: 14 KEY: Nursing Process Step: Implementation
5. On the fourth postoperative day after a modified radical mastectomy, the nurse finds the
patient with her back to the nurse. She is crying and tells the nurse she feels ugly and is worried that her husband will not be in love with her anymore. The nurse bases subsequent nursing interventions on what diagnosis? a. Disturbed body image related to removal of her breast b. Deficient knowledge related to inadequate education c. Impaired social interaction related to depression d. Fear related to the cancer diagnosis and surgical intervention ANS: A
After losing a breast, many patients experience grief over the loss of a body part. The process of grieving is essential for personal adaptation to the loss. The nurse can assist the patient to find helpful coping mechanisms. DIF: Cognitive Level: Analysis REF: 1794 TOP: Mastectomy KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity
OBJ: 18
6. Why would the nurse encourage the patient who is recovering from a modified radical
mastectomy to exercise the affected arm? a. To reduce pain. b. To stimulate appetite. c. To reduce lymphedema. d. To increase muscle tension. ANS: C
An exercise regimen, built up gradually, can help reduce lymphedema following a modified radical mastectomy. DIF: Cognitive Level: Application TOP: Postmastectomy exercises MSC: NCLEX: Physiological Integrity
REF: 1793 OBJ: 19 KEY: Nursing Process Step: Planning
7. A 20-year-old patient presents in the emergency room with a temperature of 103°F, blood
pressure of 92/58, headache, and desquamation of both palms. What should the nurse make sure to ask about during the interview? a. Any recent traveling outside the country b. Immunization against influenza c. Method of birth control d. Use of tampons ANS: D
These are signs of toxic shock frequently brought on by leaving a tampon in place too long. The nurse should inquire about tampon use, headache, muscle pain, and fatigue. DIF: Cognitive Level: Application TOP: Toxic shock syndrome (TSS) MSC: NCLEX: Physiological Integrity
REF: 1773 OBJ: 6 KEY: Nursing Process Step: Assessment
8. At what age should a male be taught testicular self-examination (TSE)? a. 10 b. 13 c. 15 d. 20 ANS: C
Young men should be taught to perform TSE monthly beginning at 15 years of age. DIF: Cognitive Level: Application REF: 1799 OBJ: 22 TOP: Testicular self-examination KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 9. Which statement made by a patient who has been taught the technique of testicular
self-examination indicates the need for further teaching? a. “The testes feel smooth and egg-shaped.” b. “The best time to perform TSE is after a shower.” c. “I will examine my scrotum after every ejaculation.” d. “The epididymis feels like a soft tube.” ANS: C
It is not recommended for a patient to perform a testicular self-examination after every ejaculation. Perform testicular self-examination after a bath or shower when the scrotum is warm and most relaxed. The testes should feel smooth and be firm to the touch. The epididymis feels like a soft tube. DIF: Cognitive Level: Analysis REF: 1799-1800 OBJ: 22 TOP: Testicular self-examination KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance 10. Which patient is most at risk for the infection of epididymitis? a. 17-year-old athlete who trains for several hours a day b. 22-year-old who has been exposed to mumps c. 45-year-old who was circumcised at the age of 10 d. 50-year-old who has smoked for 30 years
ANS: A
Symptoms can occur after trauma to the genital area, after instrumentation of the urethra and cystoscopy, and after physical exertion or prolonged sexual activity. DIF: Cognitive Level: Knowledge REF: 1798 TOP: Epididymitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 20
11. A patient, age 26, has had a tubal insufflation (Rubin test) to ascertain whether her
fallopian tubes are patent. She complains of pain in her right shoulder. Which response is most appropriate? a. “Don’t worry, that is a normal reaction.” b. “I’ll report the findings immediately to the head nurse.” c. “That is a symptom that resulted from your position on the operating table.” d. “That is from the carbon dioxide passing from the fallopian tubes into your abdomen.” ANS: D
The Rubin insufflation test determines tubal patency. Carbon dioxide escapes into the abdominal cavity through the patent left fallopian tube. DIF: Cognitive Level: Application TOP: Diagnostic procedures MSC: NCLEX: Physiological Integrity
REF: 1758 OBJ: 4 KEY: Nursing Process Step: Assessment
12. The nurse provides discharge teaching for a patient regarding her activity level as she
recovers from her modified radical mastectomy. Which statement by her indicates to the nurse that the teaching has been successful? a. “I should sleep on the side opposite my mastectomy.” b. “I should keep my right arm supported in a sling when I am up and around until my incision is healed.” c. “I can do whatever exercises and activities I want as long as I don’t elevate my right hand above my head.” d. “I should take aspirin before moving or exercising my arm to prevent pain during the exercises.” ANS: A
The patient should be instructed to avoid sleeping on the involved arm. DIF: Cognitive Level: Analysis REF: 1793 TOP: Mastectomy KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
OBJ: 18
13. A female patient, age 48, is undergoing a routine physical examination for the first time in
5 years. Which procedure would be included in this examination? a. Culdoscopy b. Colposcopy c. Cervical biopsy d. Papanicolaou smear ANS: D
The American Cancer Society highly recommends that every woman begin annual Pap tests within 3 years of becoming sexually active or no later than 21 years of age. Women should be tested every year or every 3 years. Women age 30 years or older may choose to have Pap screening every 3 years or if combined with HPV screening, every 5 years. Women age 65 years or older who have had screening over the past 10 years with normal findings may decide to stop having cervical screenings altogether. DIF: Cognitive Level: Comprehension REF: 1780 OBJ: 5 TOP: Routine examination KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 14. What is the recommended age range for a baseline mammogram? a. 25 and 30 years b. 31 and 34 years c. 35 and 39 years d. 40 and 45 years ANS: C
The American Cancer Society recommends that mammograms be performed on women starting between ages 40 and 44 years. From age 55 women in consultation with their health care provider may opt to have mammograms annually or every other year. DIF: Cognitive Level: Knowledge REF: 1787 OBJ: 5 TOP: Routine examination KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 15. What does the diagnosis of secondary infertility refer to? a. Has never conceived. b. Is infertile because of repeated infection. c. Has conceived but is now unable to do so. d. Is over the age of 38. ANS: C
Secondary infertility refers to a woman who has conceived in the past and now is unable to do so. DIF: Cognitive Level: Comprehension REF: 1769 OBJ: 7 TOP: Infertility KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What instruction should a nurse give a patient with congenital herpes who does not have
lesions at the present? a. “Continued use of acyclovir (Zovirax) will prevent reinfection by the virus.” b. “Condoms should be used during all sexual activity to prevent transmission of the virus, even when lesions are not present.” c. “Acyclovir ointment should be applied to the lesions to increase comfort and speed healing.” d. “Recurrent genital herpes is promoted by any sexual stimulation.” ANS: B
Sexual transmission of HSV (genital herpes, a virus) has been documented even in the absence of clinical lesions, and the use of condoms should be encouraged. Acyclovir does not cure the disease but makes the attacks less virulent. DIF: Cognitive Level: Application REF: 1801 OBJ: 23 TOP: Genital herpes KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 17. The patient reports that she is free of gonorrhea and can now engage in sexual activity.
Which response is most appropriate? a. “If you have been free of symptoms for 2 weeks you are cured.” b. “You should get a rapid plasma reagin (RPR) just to make sure.” c. “No case is considered cured until you have had three consecutive negative cervical smears.” d. “To confirm your cure, you should get a Venereal Disease Research Lab (VDRL).” ANS: C
No case of gonorrhea is considered cured until you have had three consecutive negative cervical smears. The RPR and the VDRL are tests for syphilis. DIF: Cognitive Level: Analysis TOP: Pelvic inflammatory disease (PID) MSC: NCLEX: Physiological Integrity
REF: 1804 OBJ: 8 KEY: Nursing Process Step: Assessment
18. A Gram stain smear of the patient’s discharge reveals the presence of Neisseria
gonorrhoeae. He tells the nurse that he had sexual contact with a new girlfriend but does not think he was exposed to gonorrhea because she did not appear to have any disease. Which information should the nurse include in response to his comment? a. “Women do not develop gonorrhea infections but can serve as carriers to spread the disease to males.” b. “When gonorrhea infections occur in women, the disease affects only the ovaries and not the other genital organs.” c. “Many women are not aware that they have gonorrhea because they often do not have symptoms of infection.” d. “Women develop subclinical cases of gonorrhea that do not cause tissue damage or symptoms.” ANS: C
Most women remain asymptomatic but may show a greenish-yellow discharge from the cervix. DIF: Cognitive Level: Application TOP: Infectious disease MSC: NCLEX: Physiological Integrity
REF: 1804 OBJ: 23 KEY: Nursing Process Step: Planning
19. The patient who had a colporrhaphy for the repair of a cystocele and rectocele asks that the
catheter be removed as it is bothersome to her. How should the nurse explain the reason for the catheter? a. It replaces uncomfortable gauze packing. b. It will prevent adhesions and will be in place for about 2 weeks.
c. It allows for quick urine sample collection. d. It keeps the bladder empty and prevents stress on the sutures. ANS: D
A retention catheter is usually inserted into the bladder to keep it empty and prevent pressure on sutures. DIF: Cognitive Level: Analysis TOP: Postoperative care MSC: NCLEX: Physiological Integrity
REF: 1777 OBJ: 14 KEY: Nursing Process Step: Assessment
20. Why is a mammogram the most useful method of diagnosing breast cancer? a. It is the most reliable method of detecting breast cancer before it becomes
palpable. b. It is inexpensive and covered by most medical insurance plans. c. It involves no radiation and takes only a few minutes. d. It involves no pain or discomfort and is readily available. ANS: A
Mammography is radiography of the soft tissue of the breast to allow identification of various benign and neoplastic processes, especially those not palpable on physical examination. DIF: Cognitive Level: Analysis REF: 1757 OBJ: 5 TOP: Diagnostic procedures KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 21. The patient, age 52, is recovering from a modified radical mastectomy. Why is
postoperative elevation of the patient’s arm important after this procedure? a. To prevent vascular and lymph stasis, thus lymphedema. b. To prevent drainage accumulation at the incisional site. c. To prevent wound infection and dehiscence. d. To prevent pleural effusion and respiratory distress. ANS: A
If the arm is not restricted by dressings, it may be elevated on a pillow with the hand and wrist higher than the elbow and the elbow higher than the shoulder joint. This will facilitate the flow of fluids through the lymph and venous routes and prevent lymphedema. DIF: Cognitive Level: Application REF: 1793 OBJ: 18 TOP: Mastectomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. A patient, age 46, is recovering from an abdominal hysterectomy. Postoperative nursing
assessment findings include a urinary output of 100 mL in 4 hours. What should the nurse do? a. Force fluids. b. Report urinary retention to the charge nurse. c. “Milk” the urinary catheter. d. Turn the patient onto her right side. ANS: B
Postoperative nursing interventions for patients with abdominal hysterectomy focus on monitoring vital signs and preventing urinary retention. The patient should have an output of at least 30 mL/hr. Anything less than that should be reported. DIF: Cognitive Level: Application TOP: Hysterectomy MSC: NCLEX: Physiological Integrity
REF: 1793 OBJ: 14 KEY: Nursing Process Step: Implementation
23. When should postmenopausal women be instructed to perform breast self-examination
(BSE)? a. On the same date of their choice each month b. Every 3 months c. Every day, because they are at high risk for breast cancer d. Whenever they begin to take estrogen supplements ANS: A
More than 90% of breast cancers are detected by the patient. BSE for postmenopausal women should be done on the same day of the month each month. DIF: Cognitive Level: Analysis REF: 1787 OBJ: 15 TOP: Breast self-examination (BSE) KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 24. Which statement indicates that the patient who has had an abdominal hysterectomy needs
further home teaching? a. “I understand I can lift as much as 20 lb.” b. “I’m leaving today to stay with my daughter, who lives 20 miles away. My husband plans to drive the family car.” c. “The health care provider said I can’t have sexual intercourse for 4 to 6 weeks.” d. “I’m going to miss wearing my girdle or knee-high hose.” ANS: A
If there has been an abdominal incision, there may be further restrictions on heavy lifting (nothing over 10 lb). DIF: Cognitive Level: Analysis TOP: Hysterectomy MSC: NCLEX: Physiological Integrity
REF: 1785 OBJ: 14 KEY: Nursing Process Step: Evaluation
25. The patient with a swollen scrotum is amazed that diagnosis of the condition of hydrocele
is such a simple thing as: a. placing the scrotum on a warm pad. b. shining light through scrotum. c. squatting and letting the scrotum hang dependently. d. packing the scrotum in ice. ANS: B
Shining a flashlight from behind the scrotum and visualizing the testes surrounded by fluid is called transillumination. That process is the simple diagnostic test for hydrocele. DIF: Cognitive Level: Application REF: 1798 TOP: Hydrocele KEY: Nursing Process Step: Assessment
OBJ: 11
MSC: NCLEX: Physiological Integrity 26. A patient, age 36, is scheduled for a unilateral orchiectomy for treatment of testicular
cancer. He is withdrawn and does not initiate interaction with the nurse. What is the most appropriate nursing action at this time? a. Carefully explain the postoperative activity restrictions. b. Show him a diagram of what the orchiectomy will accomplish. c. Assure him that he will have adequate future sexual functioning. d. Assess his concerns related to his diagnosis and treatment. ANS: D
An appropriate patient problem for a patient with a reproductive disorder is disturbed body image and ineffective coping. It is beneficial to listen to the concerns about this treatment. DIF: Cognitive Level: Analysis TOP: Orchiectomy MSC: NCLEX: Psychosocial Integrity
REF: 1759 OBJ: 20 KEY: Nursing Process Step: Assessment
27. Which of the following statements is TRUE regarding diagnostic tests for cervical cancer? a. All persons who have a cervix remaining should be screened up to the age of 75. b. Cervical cancer screening should begin about 3 years following the
commencement of intercourse, but no later than 21 years of age. c. Traditional Pap tests are less than 30% accurate in screening for cervical cell
abnormalities d. False-positive and false-negative results rarely occur with traditional Pap
diagnostic tests. ANS: B
The American Cancer Society recommends that cervical cancer screening begin approximately 3 years after a woman begins having vaginal intercourse, but no later than 21 years of age. Pap tests are less than 100% accurate in screen for abnormalities. DIF: Cognitive Level: Comprehension REF: 1780 TOP: Anatomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
OBJ: 12
28. A male patient, age 23, seeks care at the health clinic because he has developed a profuse,
purulent urethral discharge, and urination is painful. During assessment of the patient, it is most important that the nurse gather information related to his history of: a. recent urinary infections. b. episodes of prostatitis. c. contagious diseases like mumps. d. present and past sexual partners and notify them to get treatment. ANS: D
The nurse should encourage notification of present and past sexual partners of the diagnosis and stress the need for them promptly to seek medical care. DIF: Cognitive Level: Analysis REF: 1802 OBJ: 23 TOP: Sexually transmitted diseases (STDs) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
29. A 25-year-old woman comes to the clinic with a yellowish-green malodorous vaginal
discharge. She says it makes her itch and makes it hard to urinate. After a microscopic examination that confirms trichomoniasis, the patient is placed on metronidazole (Flagyl) for 7 days. How should the nurse advise the patient? a. Avoid alcohol while on Flagyl. b. Be aware that her urine may turn blue and will stain clothing. c. Wear snug underwear during treatment. d. Be aware that she need not notify her sexual partners as trichomoniasis is not contagious. ANS: A
Alcohol should be avoided as it can cause disorientation, cramps, and possibly convulsions. DIF: Cognitive Level: Comprehension TOP: Trichomoniasis MSC: NCLEX: Physiological Integrity
REF: 1805 OBJ: 23 KEY: Nursing Process Step: Implementation
30. The young woman comes to the free clinic for the complaint of stomach cramps. During
the examination, the nurse recommends that she be tested for chlamydia. The woman says “I don’t need any test…I don’t have any symptoms for a sexual infection…I just came for my stomach.” Which response is most informative? a. “Well, if you get more symptoms come back for testing.” b. “The health care provider may have to order medicine for syphilis and chlamydia. You probably have that too. You need to be tested today!” c. “Testing is not mandatory…I probably wouldn’t bother either since you have no symptoms.” d. “That stomachache may be part of a chlamydia infection. Many women do not have a discharge but are carriers.” ANS: D
Chlamydia frequently displays no signs or symptoms in women. The Centers for Disease Control and Prevention (CDC) recommends an annual screening for all women over 25 who are at risk for STDs. DIF: Cognitive Level: Analysis REF: 1806 OBJ: 14 TOP: Chlamydia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 31. What factor influences older women’s reluctance to seek medical care for problems of the
reproductive system? a. Embarrassment and cultural factors b. Denial c. Religious convictions d. Lack of free time ANS: A
Many older women are reluctant to seek medical care for problems of the reproductive system. This may be related to cultural factors, embarrassment, or lack of knowledge. DIF: Cognitive Level: Analysis REF: 1752 TOP: Age KEY: Nursing Process Step: Assessment
OBJ: N/A
MSC: NCLEX: Physiological Integrity 32. Although menopause is a normal part of aging, why do many women enter menopause at
an earlier age? a. Having become sexually active at an early age b. Living at high altitudes c. Excessive use of alcohol d. Morbid obesity ANS: B
Early menopause may be brought on at an earlier age because of living in high altitudes, smoking, cancer treatment, and family history. DIF: Cognitive Level: Application TOP: Early menopause MSC: NCLEX: Physiological Integrity
REF: 1751 OBJ: 5 KEY: Nursing Process Step: N/A
33. Why do false-negative results in mammography occur in specific age-groups? a. Older women have greater density of breast tissue. b. Older women have less density of breast tissue. c. Younger women have greater density of breast tissue. d. Younger women have less density of breast tissue. ANS: C
Because of the greater density of breast tissue, mammography is less sensitive in younger women, which may result in more false-negative results. DIF: Cognitive Level: Application TOP: Diagnostic tests MSC: NCLEX: Physiological Integrity
REF: 1788 OBJ: 5 KEY: Nursing Process Step: Planning
34. What is the sixth step in the process of the menstrual cycle to produce menses? a. Egg matures in the graafian follicle. b. Corpus luteum is formed from old follicle. c. Estrogen from the maturing follicle causes vascularization of the uterine lining. d. Anterior pituitary releases luteinizing hormone (LH), releasing the ovum. e. Anterior pituitary releases follicle-stimulating hormone (FSH). f. Corpus luteum releases estrogen and progesterone. g. Corpus luteum disintegrates causing a decrease in progesterone. h. Lining of uterus is shed as menses. ANS: F
The anterior pituitary releases FHS, which allows the egg to mature in the graafian follicle; estrogen from the maturing follicle causes vascularization of the uterine lining; the anterior pituitary releases LS to release the ovum into the fallopian tubes and into the uterus; corpus luteum (made up of the old graafian follicle) releases estrogen and progesterone. The corpus luteum disintegrates, causing a decrease in progesterone and the lining of the uterus is shed as menses. DIF: Cognitive Level: Analysis TOP: Menstrual cycle MSC: NCLEX: Physiological Integrity
REF: 1751 OBJ: 2 KEY: Nursing Process Step: N/A
35. The nurse gives discharge instructions to a person who has had a modified radical
mastectomy of the right side to perform the “elbow pull-in.” What is the first step of the exercise? a. Pull elbows forward until they touch. b. Lower and straighten the arms. c. Extend arms sideways to shoulder level. d. Bring elbows back and extend arms. e. Clasp hands behind neck. ANS: C
The exercise requires that you bring the arms out at shoulder level, clasp hands behind head and bring elbows to touch, then bring elbows back and extend arms lower and straighten arms. DIF: Cognitive Level: Application REF: 1794 OBJ: 19 TOP: Postmastectomy exercises KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Vaginal fistulas are caused by an ulcerating process resulting from: (Select all that apply.) a. cancer. b. radiation. c. poor hygiene. d. multiple sexual partners. e. weakening of tissue from pregnancies. f. surgical interventions. ANS: A, B, E, F
Vaginal fistulas are caused by an ulcerating process resulting from cancer, radiation, weakening of tissue by pregnancies, and surgical interventions. DIF: Cognitive Level: Analysis TOP: Vaginal fistulas MSC: NCLEX: Physiological Integrity
REF: 1775 OBJ: 10 KEY: Nursing Process Step: Assessment
2. Select the interventions that should be performed with caution, in the affected arm, on
patients who have undergone a modified radical mastectomy. (Select all that apply.) a. Vaccinations b. Taking of blood pressure or samples c. Insertion of IV line d. Physical therapy on uninvolved arm e. Wear watch and jewelry on involved arm f. Carry purse on involved arm or shoulder ANS: A, B, C
Patients should be taught not to have any procedures involving the arm on the affected side—BP readings, injections, intravenous infusion of fluids, or the drawing of blood, which may cause edema or infection—and to guard against infections from burns, needle pricks (sewing), and gardening injuries.
DIF: Cognitive Level: Application TOP: Radical mastectomy MSC: NCLEX: Physiological Integrity
REF: 1793 OBJ: 18 KEY: Nursing Process Step: Planning
3. What are some advantages of a vaginal hysterectomy over the abdominal hysterectomy?
(Select all that apply.) a. Less postoperative discomfort b. Reduced hospital stay c. Less expensive d. Better visualization of the intrapelvic area e. Faster recovery ANS: A, B, C, E
The vaginal approach allows for less postoperative discomfort, a reduced hospital stay, is less expensive, and offers a faster recovery. DIF: Cognitive Level: Comprehension TOP: Vaginal hysterectomy MSC: NCLEX: Physiological Integrity
REF: 1783-1784 OBJ: 7 KEY: Nursing Process Step: Implementation
4. The nurse instructs a group of women who attend the health clinic that persons who are
particularly at risk for cervical cancer are persons who: (Select all that apply.) a. smoke. b. wear tampons. c. have been sexually active since their teens. d. have multiple sexual partners. e. had chickenpox as a child. f. have a history of sexually transmitted diseases (STD). ANS: A, C, D, F
Women who have been sexually active since their teens, have multiple sexual partners, and have a history of STDs are more at risk for cancer of the cervix. DIF: Cognitive Level: Comprehension REF: 1779 OBJ: 7 TOP: Cervical cancer KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. Which of the following are true of the Gardasil vaccine? (Select all that apply.) a. It requires two more immunizations at 6 months after the first dose. b. It reduces incidence of cervical cancer. c. It reduces the incidence of human papilloma virus (HPV). d. It can be given only to females. e. It should be given before a person becomes sexually active. f. It is safe for people as young as 8 years of age. ANS: A, B, C, E
Gardasil is a vaccine that is effective against HPV and reduces the incidence of cervical cancer; it can be given to males and females before they become sexually active. It is not recommended for children under 11 years of age. DIF: Cognitive Level: Application
REF: 1780
OBJ: 7
TOP: Gardasil KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 1. A
is performed to evaluate living tissue to establish or confirm a diagnosis or to follow the course of a disease. ANS:
biopsy Biopsies are procedures in which samples of tissue are taken for evaluation to confirm or locate a lesion. DIF: Cognitive Level: Application REF: 1755 TOP: Biopsy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 14
2. The nurse is assisting the health care provider in removing a small sample of tissue from
the patient’s cervix to have it evaluated. This procedure is called a cervical . ANS:
conization Conization of the cervix is indicated when eroded or infected tissue is to be removed or when there is a need for confirmation of cervical cancer. A cone-shaped section is removed when the mass is confined to the epithelial tissue. DIF: Cognitive Level: Application REF: 1755 OBJ: 6 TOP: Conization KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
are the most benign tumors of the uterus and arise from the uterine
3.
muscle tissue. ANS:
Fibroids Fibroids are benign tumors arising from the muscle tissue of the uterus. DIF: Cognitive Level: Application REF: 1777 OBJ: N/A TOP: Fibroids KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
are produced in the seminiferous tubules and stored in the epididymis.
4. ANS:
Sperm
The two oval testes (gonads) are enclosed in the scrotum, a saclike structure that lies suspended from the exterior abdominal wall. This position keeps the temperature in the testes below normal body temperature, which is necessary for viable sperm production and storage. Each testis contains one to three coiled seminiferous tubules that produce the sperm cells. DIF: Cognitive Level: Knowledge TOP: Male reproductive tract MSC: NCLEX: Physiological Integrity 5. An alternative remedy,
REF: 1747 OBJ: 1 KEY: Nursing Process Step: Assessment
, is used by men for the treatment of impotence.
ANS:
yohimbine, Pausinystalia yohimbe yohimbine Pausinystalia yohimbe Yohimbine is an alternative remedy for the treatment of male impotence. DIF: Cognitive Level: Knowledge TOP: Alternative remedy MSC: NCLEX: Physiological Integrity
REF: 1811 OBJ: 21 KEY: Nursing Process Step: N/A
6. When the veins in the scrotum become dilated, and the scrotum becomes enlarged and
dilated, the condition is called a
.
ANS:
varicocele A varicocele is a condition in which the scrotum becomes enlarged and dilated, from obstructed vessels. DIF: Cognitive Level: Knowledge REF: 1799 TOP: Varicocele KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 21
Chapter 53: Care of the Patient with a Visual or Auditory Disorder Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse is aware that the patient has 20/40 vision. This means that the patient can see at
20 ft what the normal eye can see at a. 10 b. 20 c. 30 d. 40
ft.
ANS: B
The Snellen Eye Chart tests visual acuity. A vision evaluation of 20/40 means that the patient can see at 20 ft what the person with normal vision can see at 40 ft. DIF: Cognitive Level: Application TOP: Snellen evaluation MSC: NCLEX: Physiological Integrity
REF: 1819 OBJ: 7 KEY: Nursing Process Step: Assessment
2. The patient tells the nurse that he is legally blind. How would this information impact the
nurse’s plan of care for this patient? a. The patient would be considered totally blind. b. This patient probably has some light perception, but no usable vision. c. This patient has some usable vision, which enables function at an acceptable level. d. The nurse would need to determine how this patient’s visual impairment affects normal functioning. ANS: D
“Legal blindness” refers to individuals with a maximum visual acuity of 20/200 with corrective eyewear and/or visual field sight capacity reduced by 20 degrees. Categories have been established to help determine the exact extent of the vision loss and what assistive measures are appropriate for the individual. The nurse will need more information as to the exact extent of the vision loss for this patient. DIF: Cognitive Level: Analysis TOP: Legal blindness MSC: NCLEX: Physiological Integrity
REF: 1820 OBJ: N/A KEY: Nursing Process Step: Planning
3. One of the housekeepers splashes a chemical in the eyes. What should be the first priority? a. Transport to a health care provider immediately. b. Cover the eyes with a sterile gauze. c. Irrigate with H2O for 5 minutes. d. Irrigate with normal saline solution for 20 minutes. ANS: D
Burns are medically treated with a prolonged, 15- to 20-minute or longer normal saline flush immediately after burn exposure. DIF: Cognitive Level: Analysis TOP: Chemical burn of eye
REF: 1840 OBJ: 11 KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 4. What does a tympanoplasty correct? a. Conductive hearing loss b. Sensorineural hearing loss c. Congenital hearing loss d. Functional hearing loss ANS: A
Tympanoplasty can correct a conductive hearing loss. DIF: Cognitive Level: Knowledge TOP: Tympanoplasty MSC: NCLEX: Physiological Integrity
REF: 1852 OBJ: 17 KEY: Nursing Process Step: Implementation
5. The 62-year-old home health patient who is recovering from eye surgery complains of a
feeling of “grittiness” in the eye and is having blurred vision. The eyes are reddened and have stringy mucus. What do these complaints indicate? a. Sjögren syndrome b. Early cataracts c. Macular degeneration d. Retinal detachment ANS: A
The Sjögren syndrome of “dry eye” frequently appears after eye surgery. There is insufficient production of tears. Excessive use of antihistamines, antidepressants, and decongestants may cause this syndrome to appear. DIF: Cognitive Level: Application TOP: Sjögren syndrome MSC: NCLEX: Physiological Integrity
REF: 1827 OBJ: 8 KEY: Nursing Process Step: Assessment
6. Four hours after a stapedectomy, the patient complains that hearing has not improved at
all. What knowledge would the nurse use to shape a response? a. A large percentage of stapedectomies are not successful. b. It will take at least 10 days for the graft to heal. c. Hearing will not return until edema subsides. d. Hearing will improve after irrigation of the ear. ANS: C
Hearing improvement will not be noted until edema subsides and the packing is removed. DIF: Cognitive Level: Application TOP: Stapedectomy MSC: NCLEX: Physiological Integrity
REF: 1857 OBJ: 17 KEY: Nursing Process Step: Implementation
7. What is a common mistake that hinders communication when communicating with the
hearing impaired? a. Overaccentuating words b. Facing the patient when speaking c. Speaking in conversational tones d. Speaking into the ear with the hearing aid
ANS: A
Do not overaccentuate words. Speak in a normal tone; do not shout or raise the pitch of voice. DIF: Cognitive Level: Analysis TOP: Communication MSC: NCLEX: Physiological Integrity
REF: 1847 OBJ: 14 KEY: Nursing Process Step: Implementation
8. What is the process when the lens of the eye changes its curvature to focus on the retina? a. Accommodation b. Constriction c. Convergence d. Refraction ANS: A
The ability of the lens to alter its curvature as it focuses on the retina is accommodation. DIF: Cognitive Level: Knowledge TOP: Accommodation MSC: NCLEX: Physiological Integrity
REF: 1818 OBJ: 16 KEY: Nursing Process Step: Implementation
9. When the newly blind male home health patient asks the nurse how he might get
assistance, who might the nurse suggest he contact? a. American Red Cross b. American Foundation for the Blind for a list of agencies c. Local hospital social worker d. The public health department ANS: B
The American Foundation for the Blind has lists of agencies to assist and educate the visually impaired patient. DIF: Cognitive Level: Analysis REF: 1821 OBJ: 15 TOP: Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse clarifies that the difference between a photorefractive keratectomy (PRK) and a
laser in-situ keratomileusis (LASIK) is that a LASIK: a. reshapes the central cornea. b. makes partial-thickness radial incisions in the cornea. c. removes some internal layers of the cornea. d. implants intracorneal rings. ANS: C
The LASIK procedure removes some of the internal layers of the cornea affecting the central zone of vision. DIF: Cognitive Level: Knowledge TOP: Visual acuity MSC: NCLEX: Physiological Integrity
REF: 1823 OBJ: 11 KEY: Nursing Process Step: Implementation
11. What does the cataract treatment of phacoemulsification involve?
a. b. c. d.
“Drying” the cataract with hypertonic saline Removing the lens through the anterior capsule The insertion of a new lens Breaking the cataract with ultrasound
ANS: D
Phacoemulsification uses ultrasound to break up the cataract. DIF: Cognitive Level: Analysis TOP: Infections/inflammatory disorders MSC: NCLEX: Physiological Integrity
REF: 1829 OBJ: 11 KEY: Nursing Process Step: Planning
12. Which complaint made by a 64-year-old patient during a health interview would alert the
nurse to the possibility of cataracts? a. Pain in the eyes b. Difficulty driving at night c. Loss of peripheral vision d. Dry eyes ANS: B
Blurring of vision and difficulty driving at night is often the first subjective symptom reported by a patient who has cataracts. DIF: Cognitive Level: Application REF: 1829 TOP: Cataracts KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 9
13. What should a patient who has had a cataract repair avoid? a. The use of eye patches b. The use of sunglasses c. The lifting of heavy objects d. Reading for long periods of time ANS: C
Postcataract patients should avoid any activity that increases the intraocular pressure, such as lifting heavy objects, stooping, and bending. DIF: Cognitive Level: Comprehension REF: 1830 TOP: Blindness KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 11
14. What does diabetes retinopathy result from? a. Capillaries in retina hemorrhage b. Long-term overdosing of insulin c. Retinal detachment d. Aging ANS: A
Retinopathy is caused when the capillaries in the retina have aneurysms or hemorrhage. DIF: Cognitive Level: Comprehension REF: 1831 TOP: Glaucoma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 9
15. When the patient in the emergency room complains of seeing flashing lights and a curtain
down over his right eye, the nurse recognizes this as a symptom of which condition? a. Detached retina b. Macular degeneration c. Early sign of cataract d. Diabetic retinopathy ANS: A
The standard complaint of a detached retina is the report of seeing flashing lights and having a curtain being drawn over the eyes. DIF: Cognitive Level: Knowledge TOP: Detached retina MSC: NCLEX: Physiological Integrity
REF: 1834 OBJ: 9 KEY: Nursing Process Step: Assessment
16. The nurse will assess for
when the older adult home health patient complains that the entire right side of his head hurts and he cannot chew without pain. a. mumps b. external otitis c. otitis media d. labyrinthitis ANS: B
The symptoms of painful head, painful chewing, and pain when the auricle is moved all indicate external otitis, frequently caused by compacted cerumen. DIF: Cognitive Level: Knowledge TOP: External otitis MSC: NCLEX: Physiological Integrity
REF: 1849 OBJ: 16 KEY: Nursing Process Step: Assessment
17. The nurse takes into consideration that the Weber test indicated a conductive hearing loss
in a patient because the patient reported hearing the tone: a. equally in both ears. b. as a shrill noise. c. louder in his affected ear. d. very faintly. ANS: C
A conductive hearing loss can be diagnosed by the Weber test. A person with a conductive loss will hear the noise louder in his affected ear. DIF: Cognitive Level: Analysis REF: 1847 TOP: Weber test KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 16
18. What should the nurse remind the hearing aid wearer to do when the nurse hears a
whistling hearing aid? a. Reinsert the ear mold. b. Change the battery. c. Recharge the hearing aid. d. Wash the ear mold with warm water.
ANS: A
The whistling hearing aid is usually caused by a poor fit of the ear mold. Reinsertion of the ear mold usually stops the whistling. DIF: Cognitive Level: Comprehension REF: 1848 OBJ: 13 TOP: Hearing aid KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. What should the nurse advise the 20 year old to do who has been put on cefaclor (Ceclor)
for a resistant otitis media? a. Store suspension at room temperature. b. Discontinue drug when symptoms abate. c. Avoid alcoholic beverages. d. Take with meals only. ANS: C
Drinking alcohol is discouraged while on Ceclor. The drug should be taken in its entirety and stored in the refrigerator. The drug can be taken with or without meals. DIF: Cognitive Level: Knowledge REF: 1850 OBJ: 16 TOP: Ceclor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. How should the nurse advise a patient who has severe vertigo from labyrinthitis? a. Lean against a wall and not head forward until vertigo lessens. b. Bend at the waist and take several deep breaths. c. Drink an iced drink slowly. d. Lie immobile and hold the head in one position until the vertigo lessens. ANS: D
Lying immobile and holding the head in one position will lessen vertigo. DIF: Cognitive Level: Application REF: 1853 OBJ: 16 TOP: Vertigo KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. What do miotic eye drops do for a patient with glaucoma? a. Dilate the pupil and sharpen vision. b. Lubricate and moisten the dry eye. c. Irrigate the surface of the eye. d. Constrict the pupil and open the canal of Schlemm. ANS: D
Miotic eye drops allow the pupil to constrict and open the canal of Schlemm to drain the excess fluid. DIF: Cognitive Level: Application REF: 1836 TOP: Aging KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment
OBJ: 4
22. What should the nurse include in the plan of care following a tympanoplasty? a. Elevating head of bed with operative side facing upward
b. Enforcing bed rest for 72 hours c. Frequent turning, coughing, and deep breathing d. Continuous irrigation of the ear canal with antibiotic solutions ANS: A
Postoperative management for patients who have had a tympanoplasty consists of bed rest until the next morning. The head of the bed is elevated 40 degrees, and the operative side faces upward. DIF: Cognitive Level: Analysis REF: 1857 OBJ: 17 TOP: Otitis media KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. When the patient stares at the black dot on an Amsler grid, what should the nurse ask him
to report? a. Any color visible on the grid b. Fading of the edges of the grid c. Any distortion of the grid d. Movement of the black dot ANS: C
Amsler grid, a diagnostic tool for retinal disorders, requires that the patient look at the dot on the grid and report any distortion in the grid lines. DIF: Cognitive Level: Application REF: 1819 TOP: Aging KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 9
24. A patient who had an enucleation of the right eye has been admitted PACU. What should
the nurse include in the plan of care? a. Turn, cough, and deep breathe every 3 hours. b. Apply a pressure dressing over the right eye socket. c. Document dressing assessment every 2 hours. d. Turn on the affected side. ANS: B
A pressure dressing will be applied to the right eye socket and the dressing should be checked every hour for the first 24 hours. DIF: Cognitive Level: Application TOP: Infections/inflammatory disorders MSC: NCLEX: Physiological Integrity
REF: 1827 OBJ: 11 KEY: Nursing Process Step: Assessment
25. What must a patient do following a left vitrectomy? a. Remain flat in bed for 48 hours. b. Position self in a face-down position for 4 to 5 days. c. Assume a side-lying position with the left side down for 3 days. d. Keep head upright and cushioned with pillows for 24 hours. ANS: B
Following a vitrectomy, the patient must assume a face-down position or turn the face to the right side for 4 to 5 days.
DIF: Cognitive Level: Application REF: 1842 TOP: Vitrectomy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 11
26. How would the nurse explain the purpose of photocoagulation to a diabetic patient with
diabetic retinopathy? a. The procedure will destroy the retina, which is not getting enough blood supply. b. The procedure will reduce edema in the macula of the eye. c. The procedure will vaporize fatty deposits that appear in the retina. d. The procedure will destroy new blood vessels, seal leaking vessels, and help prevent retinal edema. ANS: D
Photocoagulation is useful in diabetic retinopathy to cauterize hemorrhaging vessels and to destroy new vessels. DIF: Cognitive Level: Analysis TOP: Diabetic retinopathy MSC: NCLEX: Physiological Integrity
REF: 1842 OBJ: 9 KEY: Nursing Process Step: Implementation
27. What is the first indication of macular degeneration? a. The loss of peripheral vision b. The loss of central vision c. The loss of color discrimination d. Eye fatigue ANS: B
Macular degeneration is characterized by the slow loss of central and near vision. DIF: Cognitive Level: Analysis TOP: Macular degeneration MSC: NCLEX: Physiological Integrity
REF: 1832 OBJ: 9 KEY: Nursing Process Step: Assessment
28. Which is a sign of acute angle closure glaucoma (AACG)? a. Large fixed pupil b. Nystagmus c. Bluish color in sclera d. Drooping eyelid ANS: A
Signs of AACG would be eye pain, large fixed pupil with reddened sclera, decreased vision, nausea, and vomiting. DIF: Cognitive Level: Comprehension REF: 1836 TOP: Glaucoma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 9
29. Why is otitis media found more frequently in children 6 to 36 months? a. Eustachian tubes in children are shorter and straighter. b. Infection descends via the eustachian tube to the throat. c. Children’s eustachian tubes are more vertical and longer.
d. Otitis media is seen equally in both children and adults. ANS: A
Children’s shorter and straighter eustachian tubes provide easier access of the organisms from the nasopharynx to travel to the middle ear. DIF: Cognitive Level: Analysis REF: 1843 TOP: Otitis media KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
OBJ: 16
30. Why would the nurse encourage a group of teenagers to protect their eyes with dark
sunglasses while using a UV lamp? a. The lamp can cause cataracts. b. The lamp can cause presbycusis. c. The lamp can cause keratitis. d. The lamp can cause ectropion. ANS: A
The proteins in the lens of the eye are vulnerable to UV light and can develop cataracts. DIF: Cognitive Level: Comprehension REF: 1859 OBJ: 9 TOP: Health promotion KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 31. The nurse counsels the 16-year-old boy that playing his music at high volume can result in
impairment in hearing related to: a. damaged tympanic membrane. b. protective buildup of cerumen. c. damage of the fine hair cells in the organ of Corti. d. rupture of the oval window. ANS: C
Long-term exposure to loud noises can damage the fine hair cells in the organ of Corti, which causes a conductive hearing loss. DIF: Cognitive Level: Knowledge REF: 1844 OBJ: 12 TOP: Health promotion KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 32. What is the most interior part of the eye? a. Choroid b. Cornea c. Aqueous humor d. Retina e. Lens f. Iris ANS: A
The cornea is the outermost, followed by the aqueous humor, iris, lens, retina, and the choroid. DIF: Cognitive Level: Application TOP: Eye structure
REF: 1817 OBJ: 2 KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity 33. What is the first nursing intervention step for the immediate care of a patient with a
penetrating wound of the eye? a. Assess eye, do not remove object. b. Cover both eyes with an eye shield or cup. c. Lay the patient down flat. d. Check for the irregularity of the pupil. e. Obtain medical attention immediately. ANS: C
The patient should be placed on his back to prevent loss of the aqueous humor, assessment of the eye for the location of the object and whether the pupil is regular, cover the eye to prevent movement, and obtain medical attention immediately. DIF: Cognitive Level: Analysis TOP: Penetrating wound of the eye MSC: NCLEX: Physiological Integrity
REF: 1842 OBJ: 10 KEY: Nursing Process Step: Implementation
MULTIPLE RESPONSE 1. Select all the conditions that may cause conductive hearing loss. (Select all that apply.) a. Buildup of cerumen b. Foreign bodies c. Otosclerosis of external auditory canal d. Trauma e. Exposure to ototoxic drugs f. Otitis media with effusion ANS: A, B, C, F
Common causes of conductive hearing loss are buildup of cerumen and otitis media with effusion (escape of effusion). Other conditions that may result in conductive hearing loss are foreign bodies, otosclerosis, and stenosis of the external auditory canal. Sensorineural hearing loss is usually due to trauma, infectious processes, or exposure to ototoxic drugs. DIF: Cognitive Level: Knowledge REF: 1846 TOP: Hearing loss KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 12
2. Which may contribute to otitis media? (Select all that apply.) a. Exposure to cigarette smoke b. Allergies c. Upper respiratory infections d. Swimming e. Trauma f. Prolonged exposure to loud noise ANS: A, B, C
Otitis media is usually caused by an upper respiratory infection with gram-negative bacteria, such as Proteus, Klebsiella, and Pseudomonas. In addition, allergy, exposure to cigarette smoke, mycoplasma, and several viruses may be factors.
DIF: Cognitive Level: Comprehension REF: 1849 TOP: Otitis media KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 16
3. What factors must the nurse consider when assessing readiness to learn when teaching
health promotion practices for the visually and hearing impaired? (Select all that apply.) a. Cultural beliefs b. Values c. Habits d. Income e. Occupation ANS: A, B, C
The nurse must consider the patient’s culture, beliefs, values, and habits, as well as the special needs of the older adult. DIF: Cognitive Level: Knowledge REF: 1859 OBJ: N/A TOP: Health promotion KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. Which of the following are causes of cataracts? (Select all that apply.) a. Long-term use of corticosteroids b. Hypotension c. Congenital from exposure to maternal rubella d. Diabetes mellitus e. Exposure to sand and dust f. Smoking ANS: A, C, D, F
Among the many causes of cataracts are long-term corticosteroid use, maternal rubella, diabetes mellitus, and smoking. DIF: Cognitive Level: Application REF: 1829 TOP: Cataracts KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 9
5. What would a nurse do when the patient arrives in the PACU after a left stapedectomy?
(Select all that apply.) a. Turn the patient to his right side. b. Change dressing as it becomes soiled. c. Turn patient every 2 hours. d. Leave the bed flat. e. Medicate immediately on the complaint of nausea. ANS: A, D, E
The bed is left in the flat position and the patient is positioned with the operated side facing up, the patient is not turned, and the dressing is not changed by the nurse. The patient should be medicated immediately on complaint of nausea to prevent vomiting and possible disruption of graft. DIF: Cognitive Level: Analysis
REF: 1857
OBJ: 17
TOP: Stapedectomy MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step: Implementation
6. What should the nurse do when assisting a blind person to walk in an unfamiliar hospital
environment? (Select all that apply.) a. Discourage the use of the cane. b. Advise the patient to walk quickly. c. Describe the surroundings. d. Encourage the patient to ask for verbal cues. e. Place patient hand on nurse’s shoulder or elbow. ANS: C, D, E
The patient should be given verbal cues about the environment. Allow the patient to hold the nurse’s shoulder or elbow while the nurse walks in front and encourage the use of a cane to let the patient “examine” the boundaries and obstacles. DIF: Cognitive Level: Application TOP: Assisting blind to walk MSC: NCLEX: Physiological Integrity
REF: 1821 OBJ: N/A KEY: Nursing Process Step: Implementation
COMPLETION 1. The home health patient complains of tearing and a feeling of dryness in the right eye. The
nurse assesses that the eyelid is turned inward and the sclera is red. The nurse documents the presence of a(n) . ANS:
entropion An entropion is the abnormal turning in of the eyelid, causing irritation and tearing of the eye. DIF: Cognitive Level: Application REF: 1828 TOP: Entropion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 8
2. The nurse explains that a pneumatic retinopexy is a repair of a retinal detachment using a
bubble of
to put pressure on the damaged retina.
ANS:
gas A pneumatic retinopexy uses a bubble of gas to put pressure on the damaged retina. DIF: Cognitive Level: Knowledge TOP: Pneumatic retinopexy MSC: NCLEX: Physiological Integrity 3. The total removal of an eye is a(n) ANS:
REF: 1835 OBJ: 11 KEY: Nursing Process Step: Implementation
.
enucleation The surgical removal of the eyeball is an enucleation. DIF: Cognitive Level: Knowledge REF: 1841 TOP: Enucleation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 9
4. The surgical incision into the eardrum with either a knife or a heated wire loop to relieve
pressure in the middle ear is a(n)
.
ANS:
myringotomy The opening of the eardrum with a specialized knife or a heated wire loop to relieve pressure in the middle ear is a myringotomy. DIF: Cognitive Level: Knowledge TOP: Myringotomy MSC: NCLEX: Physiological Integrity
REF: 1857 OBJ: 17 KEY: Nursing Process Step: Assessment
5. Progressive deafness caused by the ankylosis of the stapes is the condition of ANS:
otosclerosis Progressive deafness related to the ankylosis of the stapes is diagnosed as otosclerosis. DIF: Cognitive Level: Knowledge REF: 1853 TOP: Otosclerosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 16
.
Chapter 54: Care of the Patient with a Neurologic Disorder Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. What are the two divisions of the nervous system? a. Somatic and the autonomic b. Cerebellum and the brainstem c. Medulla oblongata and the diencephalon d. Central and the peripheral ANS: D
The central and the peripheral are the two divisions of the nervous system. The autonomic and the somatic are the division of the peripheral nervous system. DIF: Cognitive Level: Knowledge TOP: Anatomy and physiology MSC: NCLEX: Physiological Integrity
REF: 1869 OBJ: 1 KEY: Nursing Process Step: Assessment
2. What is the cranial nerve that supplies most of the organs in the thoracic and abdominal
cavities and carries motor fibers to glands that produce digestive juices and other secretions? a. Somatic motor nerve b. Visceral sensory nerve c. Abducens nerve d. Vagus nerve ANS: D
The vagus nerve extends from the throat, larynx, and organs in the thoracic and abdominal cavities. It is responsible for sensations and will accelerate peristalsis when stimulated. DIF: Cognitive Level: Knowledge TOP: Anatomy and physiology MSC: NCLEX: Physiological Integrity
REF: 1868 OBJ: 5 KEY: Nursing Process Step: Assessment
3. The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder
has gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible. What is the most appropriate position for the patient? a. Neck placed in a neutral position. b. Head raised slightly with hips flexed. c. Supine in gravity neutral position. d. Turn on right side with head elevated. ANS: A
Place the neck in a neutral position (not flexed or extended) to promote venous drainage. DIF: Cognitive Level: Application TOP: Intracranial pressure (ICP) MSC: NCLEX: Physiological Integrity
REF: 1882 OBJ: 12 KEY: Nursing Process Step: Planning
4. Which question is likely to elicit the most valid response from the patient who is being
interviewed about a neurologic problem? a. “Do you have any sensations of pins and needles in your feet?” b. “Does the pain radiate from your back into your legs?” c. “Can you describe the sensations you are having?” d. “Do you ever have any nausea or dizziness?” ANS: C
For patients with suspected neurologic conditions, the presence of many symptoms or subjective data may be significant. Offering leading questions is not beneficial and may allow the patient to give misinformation. Questions should be specific about symptoms. DIF: Cognitive Level: Application REF: 1870 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 8
5. What is the cardinal sign of increased intracranial pressure in a brain injured patient? a. Pupil changes b. Ipsilateral paralysis c. Vomiting d. Decrease in the level of consciousness ANS: D
Collection of objective data includes a change in level of consciousness. A change in the level of consciousness is the earliest sign of increased intracranial pressure. DIF: Cognitive Level: Analysis TOP: Intracranial pressure (ICP) MSC: NCLEX: Physiological Integrity
REF: 1876 OBJ: 12 KEY: Nursing Process Step: Assessment
6. The nurse is aware that when assessing a patient by the FOUR score coma scale, the
patient is assessed in four categories: eye response, brainstem reflexes, motor response, and respiration. How are these results reported? a. As a sum of the scores of the four categories b. As part of the Glasgow Coma Scale c. As individual scores in each category d. As progressive scores during a 24-hour period ANS: C
The FOUR score coma scale assesses the patient in four categories: eye response, brainstem reflexes, motor response, and respiration. The scores are reported as individual scores in each category. It is frequently done in conjunction with or as an alternative to the Glasgow Coma Scale, not part of it. DIF: Cognitive Level: Comprehension TOP: FOUR Score Coma Scale MSC: NCLEX: Physiological Integrity
REF: 1872 | 1908 OBJ: 11 KEY: Nursing Process Step: Assessment
7. As the result of a stroke, a patient has difficulty discerning the position of his body without
looking at it. In the nurse’s documentation, which would best describe the patient’s inability to assess spatial position of his body? a. Agnosia
b. Proprioception c. Apraxia d. Sensation ANS: B
Patients may experience a loss of proprioception with a stroke. This may include apraxia and agnosia (a total or partial loss of the ability to recognize familiar objects or people). DIF: Cognitive Level: Application REF: 1908 TOP: Stroke KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 19
8. A patient, age 45, is to have a myelogram to confirm the presence of a herniated
intervertebral disk. Which nursing action should be planned with respect to this diagnostic test? a. Obtain an allergy history before the test. b. Ambulate the patient when returned to the room after the test. c. Use heated blanket to keep patient warm after procedure. d. Keep NPO for 6 to 8 hours after the test. ANS: A
Before the dye is injected, patients must be asked whether they have any allergies, specifically whether they have had any anaphylactic or hypotensive episodes from other dyes. DIF: Cognitive Level: Application TOP: Diagnostic procedures MSC: NCLEX: Physiological Integrity
REF: 1875 OBJ: 11 KEY: Nursing Process Step: Planning
9. A patient has recently suffered a stroke with left-sided weakness and has problems with
choking, especially when drinking thin liquids. What nursing interventions would be most helpful in assisting this patient to swallow safely? a. Use a straw. b. Tuck chin when swallowing. c. Take a sip of liquid with each bite. d. Turn head to the left. ANS: B
The patient should sit at a 90-degree angle with the head up and chin slightly tucked. DIF: Cognitive Level: Application REF: 1885 OBJ: 16 TOP: Stroke KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. What are surgical navigational systems? a. Computerized devices that guide the surgeon b. A set of detailed anatomic maps pinpointing specific areas of the brain c. A written set of progressive processes for the resection of small brain tumors d. The use of radioactive materials to pinpoint small tumors of the brain ANS: A
Surgical navigational systems are computerized devices that guide the surgeon and make possible the resection of tumors that were once thought to be inoperable. DIF: Cognitive Level: Comprehension REF: 1917 TOP: Hematoma KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 30
11. A family member of a patient who has just suffered a tonic-clonic seizure is concerned
about the patient’s deep sleep. What is this behavior called? a. Convalescent period b. Neural recovery period c. Sombulant period d. Postictal period ANS: D
Seizures are followed by a rest period of variable length, called a postictal period. DIF: Cognitive Level: Knowledge REF: 1887 OBJ: 14 TOP: Seizures KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. How would a nurse record the behavior when a patient with Alzheimer’s disease attempts
to eat using a napkin rather than a fork? a. Apraxia b. Agnosia c. Aphasia d. Dysphagia ANS: B
Agnosia is a total or partial loss of the ability to recognize familiar objects or people through sensory stimuli as a result of organic brain damage. DIF: Cognitive Level: Comprehension REF: 1886 TOP: Agnosia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 13
13. Which symptom is specific to migraine headaches? a. Tachycardia b. They become worse in the evening c. They involve the entire head d. They are preceded by an aura ANS: D
Migraine headaches are unusual in that signs and symptoms occur before the acute attack. DIF: Cognitive Level: Application REF: 1877 TOP: Headaches KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 9
14. The nurse assures an anxious family member of a 92-year-old patient who is
demonstrating signs of dementia that many causes of dementia are reversible and preventable. What is one example?
a. b. c. d.
Hypotension Alzheimer’s disease Diabetes Parkinson disease
ANS: A
Some forms of dementia are reversible. Dementia caused by hypotension, anemia, drug toxicity, metabolic disturbance, and malnutrition can all be corrected to abolish the dementia. DIF: Cognitive Level: Application TOP: Causes of dementia MSC: NCLEX: Physiological Integrity
REF: 1870 OBJ: 17 KEY: Nursing Process Step: Implementation
15. What is the nurse assessing when asking the patient, “Who is the president of the United
States?” during a level of consciousness assessment? a. Orientation b. Memory c. Calculation d. Fund of knowledge ANS: D
Fund of knowledge is tested by questions such as “Who is the president?” or asking about current events. DIF: Cognitive Level: Comprehension TOP: Level of Consciousness MSC: NCLEX: Physiological Integrity
REF: 1871 OBJ: 9 KEY: Nursing Process Step: Implementation
16. What Glasgow Coma Scale rating would a patient receive who opens the eyes
spontaneously, but has incomprehensible speech and obeys commands for movement? a. 8 b. 10 c. 11 d. 12 ANS: D
The Glasgow Coma Scale was developed in 1974, and it consists of three parts of the neurologic assessment: eye opening, best motor response, and best verbal response. This patient gets a 4 for eye opening, a 2 for incomprehensible speech, and a 6 for moving on demand. DIF: Cognitive Level: Application TOP: Glasgow coma scale MSC: NCLEX: Physiological Integrity
REF: 1871 OBJ: 10 KEY: Nursing Process Step: Assessment
17. What is the nurse aware of when assessing a person with a craniocerebral injury? a. Most injuries of this type are irreversible. b. Open injuries are always more serious than closed injuries. c. Signs and symptoms may not occur until several days after the trauma. d. Trauma to the frontal lobe is more significant than to any other area.
ANS: C
If a patient who has been conscious for several days after head injury loses consciousness or develops neurologic signs and symptoms, a subdural hematoma should be suspected. DIF: Cognitive Level: Analysis REF: 1882 TOP: Trauma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 19
18. The nurse is caring for a home health patient who had a spinal cord injury at C5 3 years
ago. The nurse bases the plan of care on the knowledge that the patient will be able to: a. feed self with setup and adaptive equipment. b. transfer self to wheelchair. c. stand erect with full leg braces. d. sit with good balance. ANS: A
A cord injury at C5 allows for ability to drive an electric wheelchair with mobile hand supports and feed self with adaptive equipment. DIF: Cognitive Level: Analysis TOP: Spinal cord injury MSC: NCLEX: Physiological Integrity
REF: 1920 OBJ: 30 KEY: Nursing Process Step: Assessment
19. A frantic family member is distressed about the flaccid paralysis of her son following a
spinal cord injury several hours ago. What does the nurse know about this condition? a. It is an ominous indicator of permanent paralysis. b. It is possibly a temporary condition and will clear. c. It degenerates into a spastic paralysis. d. It will progress up the cord to cause seizures. ANS: B
A period of flaccid paralysis following a cord injury is called areflexia, or spinal shock, and may be temporary. DIF: Cognitive Level: Application REF: 1919 TOP: Trauma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 20
20. A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a
headache. The nurse notes a flushing of the neck and “goose flesh.” What should be the primary nursing intervention based on these assessments? a. Place patient in flat position and check temperature. b. Administer oxygen and check oxygen saturation. c. Place on side and check for leg swelling. d. Sit upright and check blood pressure. ANS: D
These are indicators of autonomic dysreflexia or hyperreflexia. It is a medical emergency. The patient should be placed in an upright position to decrease blood pressure and the blood pressure should be checked. Assessments for impaction, full bladder, or a urine infection can help to evaluate this condition.
DIF: Cognitive Level: Analysis REF: 1921 TOP: Dysreflexia KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
OBJ: 20
21. The nurse is aware that the characteristic gait of the person with Parkinson disease is a
propulsive gait, which causes the patient to: a. stagger and need support of a walker. b. shuffle with arms flexed. c. fall over to one wide when walking. d. take small steps balanced on the toes. ANS: B
The propulsive gait causes the patient to shuffle with his arms flexed and with a loss of postural reflexes. DIF: Cognitive Level: Comprehension TOP: Parkinsonism MSC: NCLEX: Physiological Integrity
REF: 1894 OBJ: 21 KEY: Nursing Process Step: Assessment
22. What does the nurse know about the stroke patient who has expressive aphasia? a. Has difficulty comprehending spoken and written communication. b. Cannot make any vocal sounds. c. Has total loss and comprehension of language. d. Can understand the spoken word, but cannot speak. ANS: D
The patient with expressive aphasia has difficulty articulating words but can understand the written and spoken word. DIF: Cognitive Level: Application REF: 1906-1907 TOP: Aphasia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 16
23. The nurse is aware that the drug t-PA (Activase), a tissue plasminogen activator, must be
given in hours of the onset of symptoms to have maximum benefit. a. 3 hours b. 4 hours c. 6 hours d. 8 hours ANS: A
t-PA must be given within 3 hours of the onset of symptoms to be beneficial. DIF: Cognitive Level: Application REF: 1905 TOP: t-PA KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 14
24. An 83-year-old patient has had a stroke. He is right handed and has a history of
hypertension and “little” strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse should approach him: a. from the right side. b. from the left side.
c. from the center. d. from either side. ANS: B
Another perceptual problem is hemianopia, which is characterized by defective vision or blindness in half of the visual field. If the patient has hemianopia, which is common, the patient should be approached from the nonparalyzed side for care. DIF: Cognitive Level: Analysis REF: 1873 OBJ: 13 TOP: Hemianopia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. The newly admitted patient to the emergency room after a motorcycle accident has
serosanguineous drainage coming from the nose. What is the most appropriate nursing response to this assessment? a. Cleanse nose with a soft cotton-tipped swab. b. Gently suction the nasal cavity. c. Gently wipe nose with absorbent gauze. d. Ask patient to blow his nose. ANS: C
The patient’s ear and nose are checked carefully for signs of blood and serous drainage, which indicate that the meninges are torn and spinal fluid is escaping. No attempt should be made to clean out the orifice or to blow the nose. The drainage can be wiped away. The drainage can be tested for the presence of glucose, which would confirm that the fluid is spinal fluid and not mucus. DIF: Cognitive Level: Application REF: 1918 OBJ: 20 TOP: Trauma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. How would the nurse instruct a patient with Parkinson disease to improve activity level? a. To use a soft mattress to relax the spine. b. To walk with a shuffling gait to avoid tripping. c. To walk with hands clasped behind back to help balance. d. To sit in hard chair with arms for posture control. ANS: C
The patient with Parkinson disease can improve the activity level by sleeping on a firm mattress without a pillow to prevent spinal curvature, hold hands clasped behind to keep better balance, and keep the arms from hanging stiffly at the side. Walk with a lifting of the feet to avoid tripping and “freezing.” DIF: Cognitive Level: Application TOP: Parkinson disease MSC: NCLEX: Physiological Integrity
REF: 1898 OBJ: 21 KEY: Nursing Process Step: Planning
27. What is the basic problem that prompts most of the early signs of Alzheimer’s disease? a. Changes in mood b. Misplacing things c. Memory loss that disrupts daily life d. Problems with words in speaking
ANS: C
Memory loss that disrupts daily life is the basic problem that prompts most of the early signs of AD. DIF: Cognitive Level: Application REF: 1899 OBJ: 15 TOP: Alzheimer’s disease KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 28. A patient is in which stage of Alzheimer’s disease when she demonstrates “sundowning”? a. Early stage b. Second stage c. Third stage d. Final stage ANS: B
“Sundowning” is seen in the AD patient in the second stage of the disease. DIF: Cognitive Level: Knowledge TOP: Alzheimer’s disease MSC: NCLEX: Physiological Integrity
REF: 1899 OBJ: 15 KEY: Nursing Process Step: Assessment
29. Why are the drugs neostigmine (Prostigmin) and pyridostigmine (Mestinon) helpful to the
person with myasthenia gravis? a. Improves speech. b. Improves visual disturbances. c. Reduces pain. d. Promotes nerve impulse transmission. ANS: D
Prostigmine and Mestinon improve the nerve impulses and alleviate the symptoms. DIF: Cognitive Level: Knowledge TOP: Myasthenia gravis MSC: NCLEX: Physiological Integrity
REF: 1897 | 1902 OBJ: 21 KEY: Nursing Process Step: Implementation
30. What should the nurse do when the child arrives on the floor with the diagnosis of
bacterial meningitis? a. Arrange for humidified oxygen per mask. b. Place the child in respiratory isolation. c. Inquire about drug allergy. d. Hold NPO until orders arrive. ANS: B
Persons with bacterial meningitis are placed in respiratory isolation until the pathogen can no longer be cultured, usually 24 hours. DIF: Cognitive Level: Comprehension REF: 1913 OBJ: 18 TOP: Bacterial meningitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 31. What is the purpose of a “drug holiday” in the treatment of Parkinson disease? a. Change all drugs.
b. Allow the natural dopamine levels to rise. c. Restart drugs at a lower dosage with favorable results. d. Reduce the extrapyramidal symptoms. ANS: C
A “drug holiday” is a period when all drugs are withdrawn from the person with Parkinson disease. The drugs are then restarted at a lower dose with favorable results. DIF: Cognitive Level: Analysis TOP: Drug holiday MSC: NCLEX: Physiological Integrity
REF: 1895 OBJ: 21 KEY: Nursing Process Step: N/A
32. What is the first sign of Bell’s palsy? a. Inability to wrinkle forehead and pucker lips on affected side b. Sudden pain in nostril on affected side c. Excessive salivation on the affected side d. Excessive mucus running from nostril on affected side ANS: A
Unilateral weakness of the facial muscles usually occurs, resulting in a flaccidity of the affected side of the face with inability to wrinkle the forehead, close the eyelid, pucker the lips, smile, frown, whistle, or retract the mouth on that side. The face appears asymmetric. DIF: Cognitive Level: Comprehension REF: 1911 TOP: Bell’s palsy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 17
33. Following a myelogram the nurse should include in the postprocedure care assessment for: a. elevation of blood pressure. b. urine retention. c. sensation in lower extremities. d. slurred speech. ANS: C
Postmyelogram care includes the assessment to ensure there is no leakage of CSF, sensation and strength of the lower extremities, or headache. To avoid a headache, the patient should be flat for a few hours. DIF: Cognitive Level: Analysis REF: 1876 TOP: Myelogram KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 11
34. Why is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized
immediately? a. The infection needs to be treated with IV antibiotics to prevent paralysis. b. The brain may swell quickly causing seizures. c. The disease can rapidly progress into respiratory failure. d. IV hydration is needed to prevent possible fatal hypotension. ANS: C
Hospitalization is necessary for GBS patients because the disease progresses very quickly and respiratory failure may occur.
DIF: Cognitive Level: Analysis TOP: Guillain-Barre MSC: NCLEX: Physiological Integrity
REF: 1902 OBJ: 18 KEY: Nursing Process Step: Assessment
35. The nurse explains that the two divisions of the autonomic nervous system work to
maintain homeostasis. Which is the first autonomic event? a. Parasympathetic nervous system dominates b. Extremely stressful or frightening event c. Blood pressure, heart rate, and adrenaline output decrease d. Sympathetic nervous system dominates e. Heart rate and blood pressure rise, secretion of adrenaline ANS: B
In the event of a frightening event, the sympathetic nervous system dominates and increases the blood pressure, heart rate, and adrenaline output in the “fight or flight” mechanism. The body is calmed by the parasympathetic nervous system dominating and reducing the heart rate, blood pressure, and adrenaline output. DIF: Cognitive Level: Analysis TOP: Autonomic nervous system MSC: NCLEX: Physiological Integrity
REF: 1869 OBJ: 1 KEY: Nursing Process Step: Implementation
MULTIPLE RESPONSE 1. Which foods should the person who suffers from migraine headaches avoid? (Select all
that apply.) a. Yogurt b. Caffeine c. Beef d. Pears e. Marinated foods f. Milk ANS: A, B, E
Some foods may cause or worsen headaches. Foods that may provoke headaches include vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork. DIF: Cognitive Level: Analysis REF: 1877 TOP: Headaches KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: N/A
2. What are the three signs of Cushing response? (Select all that apply.) a. Increased pulse rate b. Increased blood pressure c. Widened pulse pressure d. Bradycardia e. Increased systolic blood pressure f. Uncontrolled thermoregulation
ANS: C, D, E
A widened pulse pressure, increased systolic blood pressure, and bradycardia are together called Cushing response. It is considered an important diagnostic sign of late-stage brain herniation. DIF: Cognitive Level: Analysis TOP: Increased intracranial pressure MSC: NCLEX: Physiological Integrity
REF: 1881 OBJ: 19 KEY: Nursing Process Step: Assessment
3. Which of the following techniques are necessary for safely feeding a hemiplegic patient?
(Select all that apply.) a. Mixing liquids and solid foods together b. Taking the patient’s dentures out to prevent choking c. Checking the affected side of mouth for food accumulation d. Offering small bites of food e. Elevating the patient to no more than 30 degrees f. Adding a thickening agent to liquids ANS: C, D, F
Important nursing measures include avoiding foods that cause choking, checking the affected side of the mouth for accumulation of food and resultant poor hygiene, not mixing liquids and solid foods, and encouraging the patient to take small bites. DIF: Cognitive Level: Application REF: 1885 TOP: Hemiplegia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
OBJ: 18
4. What is the reticular activating system (RAS) essential to? (Select all that apply.) a. Concentration b. Wakefulness c. Speech d. Attention e. Memory f. Introspection ANS: A, B, D, F
The RAS, located on the brainstem, is essential to wakefulness, attention, concentration, and introspection. DIF: Cognitive Level: Analysis TOP: Reticular activating system MSC: NCLEX: Physiological Integrity
REF: 1881 OBJ: 1 KEY: Nursing Process Step: Planning
5. What are the effects of normal aging on the nervous system? (Select all that apply.) a. Small vessel occlusion b. Loss of neurons c. Calcification of cerebrum d. Reduction of cerebral blood flow e. Lipofuscin f. Decrease in oxygen use ANS: B, D, E, F
As the person ages, normal age-related changes occur such as loss of neurons, reduction of cerebral blood flow, appearance of lipofuscin, a decrease in oxygen use and brain metabolism, and a decline in velocity of nerve impulses. DIF: Cognitive Level: Application TOP: Age-related changes MSC: NCLEX: Physiological Integrity
REF: 1894 OBJ: 6 KEY: Nursing Process Step: Implementation
COMPLETION
is/are responsible for the transmission of impulses between synapses.
1. ANS:
Neurotransmitters Neurotransmitters (acetylcholine, norepinephrine, dopamine, and serotonin) function to conduct transmission between the synapses. DIF: Cognitive Level: Knowledge TOP: Neurotransmitters MSC: NCLEX: Physiological Integrity
REF: 1865 OBJ: 1 KEY: Nursing Process Step: N/A
2. A
is a diagnostic procedure used to identify lesions by observing the flow of radiopaque dye through the subarachnoid space. ANS:
myelogram Preparation for this procedure is the same as for lumbar puncture. DIF: Cognitive Level: Comprehension TOP: Diagnostic tests MSC: NCLEX: Physiological Integrity
REF: 1875 OBJ: 11 KEY: Nursing Process Step: Planning
3. The nurse explains that the triad of signs of Parkinson disease is:
, rigidity, and
bradykinesia. ANS:
tremor Tremor, rigidity, and bradykinesia are the triad that make up the signs of Parkinson disease. DIF: Cognitive Level: Comprehension TOP: Parkinson disease MSC: NCLEX: Physiological Integrity
REF: 1894 OBJ: 21 KEY: Nursing Process Step: Assessment
4. Involuntary rhythmic movement of the eyes, with oscillations that may be horizontal,
vertical, or mixed movements, is called ANS:
.
nystagmus Nystagmus is a rhythmic movement of the eyes, which may be horizontal, vertical, or mixed in directional movement. The eye movement cannot be controlled by the patient. DIF: Cognitive Level: Knowledge TOP: Anatomy and physiology MSC: NCLEX: Physiological Integrity
REF: 1891 OBJ: 9 KEY: Nursing Process Step: Assessment
5. The waxy substance that covers the neuron fibers and increases the rate of transmission of
impulses is the
.
ANS:
myelin Myelin is the waxy substance that covers the neuron fibers (axons and dendrites) and increases the rate of transmission of impulses. DIF: Cognitive Level: Knowledge REF: 1865 TOP: Myelin KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 2
Chapter 55: Care of the Patient with an Immune Disorder Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. Which of the following is an example of immunocompetence? a. A child that is immune to measles because of an inoculation b. A person who has seasonal allergies every fall c. When the symptoms of a common cold disappear in 1 day d. A neonate having a natural immunity from maternal antibodies ANS: C
Immunocompetence is demonstrated by the immune system responding appropriately to a foreign stimulus and the body’s integrity is maintained as with cold symptoms that resolve with residual illness. DIF: Cognitive Level: Application TOP: Immunocompetence MSC: NCLEX: Physiological Integrity
REF: 1928 OBJ: 1 KEY: Nursing Process Step: Implementation
2. An anxious patient enters the emergency room with angioedema of the lips and tongue,
dyspnea, urticaria, and wheezing after having eaten a peanut butter sandwich. What should be the nurse’s first intervention? a. Apply cool compresses to urticaria. b. Provide oxygen per nonrebreathing mask. c. Cover patient with a warm blanket. d. Prepare for venipuncture for the delivery of IV medication. ANS: B
Provision of oxygen is the initial primary intervention. Anaphylaxis may advance very rapidly and the patient may have to be intubated. Covering the patient with a warm blanket is not wrong, but not an initial intervention. DIF: Cognitive Level: Application TOP: Anaphylactic reaction MSC: NCLEX: Physiological Integrity
REF: 1937 OBJ: 6 KEY: Nursing Process Step: Implementation
3. What is the etiology of autoimmune diseases based on? a. Reaction to a “superantigen” b. Immune system producing no antibodies at all c. T cells destroying B cells d. B and T cells producing autoantibodies ANS: D
Autoimmune disorders are failures of the tolerance to “self.” B and T cells produce autoantibodies that can cause pathophysiologic tissue damage. Autoimmune disorders may be described as an immune attack on the self and result from the failure to distinguish “self” protein from “foreign” protein. DIF: Cognitive Level: Application TOP: Autoimmune disorders
REF: 1940 OBJ: 1 KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity 4. A patient is admitted with a secondary immunodeficiency from chemotherapy. The
nursing plan of care should include provisions for: a. infection control. b. supporting self-care. c. nutritional education. d. maintaining high fluid intake. ANS: A
Immune deficient persons are at risk for infection and need to be protected aggressively for contagion. DIF: Cognitive Level: Application REF: 1933 OBJ: 10 TOP: Immunodeficiency diseases KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 5. The nurse takes into consideration that when the antigen and antibody react, the
complement system is activated which: a. toughens the cell wall. b. generates more T cells. c. attracts phagocytes. d. makes the antigen resistant. ANS: C
The complement system is a group of plasma proteins that are dormant until there is an antigen-antibody interaction. The proteins destroy the cell membrane and attract phagocytes. DIF: Cognitive Level: Application TOP: Complement system MSC: NCLEX: Physiological Integrity
REF: 1929 OBJ: 3 KEY: Nursing Process Step: Implementation
6. How does normal aging change the immune system? a. Depresses bone marrow. b. T cells become hyperactive. c. B cells show deficiencies in activity. d. Increase in the size of the thymus. ANS: C
Normal aging causes deficiencies in both B and T cell activation, but the bone marrow is essentially uncompromised. The thymus decreases in size. DIF: Cognitive Level: Analysis TOP: Age-related changes MSC: NCLEX: Physiological Integrity
REF: 1932 OBJ: N/A KEY: Nursing Process Step: Planning
7. What would the nurse recommend for a 94-year-old home health patient with deteriorated
cell-mediated immunity? a. Avoiding the influenza vaccine b. Getting pneumonia vaccine c. Having skin tests for all antigens
d. Taking large doses of -carotene ANS: B
As the older adult loses some of the cell-mediated immunity, especially against pneumonia and influenza, it is recommended that they acquire the immunization. DIF: Cognitive Level: Application TOP: Age-related changes MSC: NCLEX: Physiological Integrity
REF: 1930 OBJ: 3 KEY: Nursing Process Step: Implementation
8. A patient who works in a plant nursery and has suffered an allergic reaction to a bee sting
is stabilized and prepared for discharge from the clinic. During discussion of prevention and management of further allergic reactions, the nurse identifies a need for additional teaching based on which comment? a. “I need to think about a change in my occupation.” b. “I will learn to administer epinephrine so that I will be prepared if I am stung again.” c. “I should wear a Medic-Alert bracelet indicating my allergy to insect stings.” d. “I will need to take maintenance doses of corticosteroids to prevent reactions to further stings.” ANS: D
The nurse’s responsibilities in patient education are as follows: Teach the patient preparation and administration of epinephrine subcutaneously. There is no need for the patient to take maintenance doses of corticosteroids because this was a short, rapid reaction. DIF: Cognitive Level: Application REF: 1938 OBJ: 5 TOP: Allergic reaction KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance 9. What is the substance released by the T cells that stimulates the lymphocytes to attack an
inflammation? a. Lymphokine b. Epinephrine c. B cells d. Histamine ANS: A
Lymphokines help attract macrophages to the site of the inflammation. DIF: Cognitive Level: Comprehension TOP: Allergic reaction MSC: NCLEX: Physiological Integrity
REF: 1932 OBJ: 3 KEY: Nursing Process Step: N/A
10. Immediately after the nurse administers an intradermal injection of a suspected antigen
during allergy testing, the patient complains of itching at the site, weakness, and dizziness. Which action by the nurse is most appropriate initially? a. Elevate the arm above the shoulder. b. Administer subcutaneous epinephrine. c. Apply a warm compress to area. d. Apply a local antiinflammatory cream to the site.
ANS: B
Injection of subcutaneous epinephrine should be given at the first sign of allergy. DIF: Cognitive Level: Analysis TOP: Anaphylactic reaction treatment MSC: NCLEX: Physiological Integrity 11.
REF: 1934 | 1936 OBJ: 7 KEY: Nursing Process Step: Implementation
Which person is most at risk for a hypersensitivity reaction? a. 26 year old receiving his second desensitization injection b. 35 year old starting back on birth control tablets c. The 52 year old started on a new series of Pyridium for cystitis d. The 84 year old receiving penicillin for an annually recurring respiratory infection ANS: D
The 84 year old with the deteriorated immune system is a prime candidate for a delayed hypersensitivity reaction. DIF: Cognitive Level: Analysis TOP: Delayed hypersensitivity MSC: NCLEX: Physiological Integrity
REF: 1939 OBJ: 5 KEY: Nursing Process Step: Assessment
12. The nurse recommends to the busy mother of three that the antihistamine fexofenadine
(Allegra) would be more beneficial than diphenhydramine (Benadryl) because Allegra: a. is inexpensive. b. contains a stimulant for an energy boost. c. does not dry out the mucous membranes. d. does not induce drowsiness. ANS: D
Allegra does not induce drowsiness as does Benadryl. DIF: Cognitive Level: Comprehension TOP: Antihistamines MSC: NCLEX: Physiological Integrity
REF: 1936 OBJ: N/A KEY: Nursing Process Step: Implementation
13. The patient who had an asthma-like reaction to a desensitization shot was medicated with
a subcutaneous injection of epinephrine. What effect should the nurse assure the anxious patient this will have? a. Cause vasodilation. b. Produce bronchodilation. c. Cause productive coughing. d. Reduction of pulse rate. ANS: B
The drug epinephrine is given in the case of anaphylaxis because it is a quick-acting drug that produces bronchodilation and vasoconstriction, which relieves respiratory distress. The drug can be ordered to be repeated every 20 minutes. The patient may experience an increase in heart rate. DIF: Cognitive Level: Knowledge REF: 1937 OBJ: 3 TOP: Anaphylaxis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
14. Health care facilities have reduced the incidence of serious latex reactions by: a. having local and injectable corticosteroids on hand for employees. b. desensitizing staff who are allergic. c. supplying extra hand washing stations in the halls. d. using only powder-free gloves. ANS: D
Powder inside gloves can become aerosolized and cause inhalant reactions. DIF: Cognitive Level: Comprehension REF: 1938 OBJ: 8 TOP: Latex allergic reaction KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment 15. What should the nurse include to assess for in the plan of care for a patient undergoing
plasmapheresis? a. Hypotension b. Hypersensitivity c. Urticaria d. Flank pain ANS: A
Hypotension occurs during plasmapheresis because of transient volume changes in the blood. DIF: Cognitive Level: Application TOP: Plasmapheresis MSC: NCLEX: Physiological Integrity
REF: 1940-1941 OBJ: 12 KEY: Nursing Process Step: Planning
16. A patient is undergoing immunotherapy on a perennial basis. With this form of treatment,
what should the patient receive? a. Larger doses each week b. Higher concentrations each week c. Increased amounts and concentrations in 6-week cycles d. The same amount and concentration each visit ANS: C
Perennial therapy is most widely accepted, because it allows for a higher cumulative dose, which produces a better effect. Perennial therapy usually begins with 0.05 mL of 1:10,000 dilution and increases to 0.5 mL in a 6-week period. DIF: Cognitive Level: Comprehension TOP: Immunotherapy MSC: NCLEX: Physiological Integrity
REF: 1933 OBJ: N/A KEY: Nursing Process Step: Planning
17. What is the term for transplantation of tissue between members of the same species? a. Allograft b. Autograft c. Isograft d. Homograft ANS: A
The allograft is the transplantation of tissues between members of the same species, such as a graft for full-thickness burns. DIF: Cognitive Level: Analysis REF: 1939 OBJ: N/A TOP: Allograft KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. In which patient should the nurse be most concerned about immunodeficiency disorder? a. The patient taking desensitization injections (immunotherapy) b. The patient on long-term radiation therapy for cancer c. The overweight patient d. The patient recently diagnosed with lupus erythematosus ANS: B
Radiation destroys lymphocytes and depletes the stem cells. Prolonged radiation depresses the bone marrow. DIF: Cognitive Level: Analysis TOP: Immunosuppression MSC: NCLEX: Physiological Integrity
REF: 1940 OBJ: N/A KEY: Nursing Process Step: Planning
19. What is the purpose of plasmapheresis in the treatment of rheumatoid arthritis? a. To add corticosteroids to relieve pain. b. To remove pathologic substances present in the plasma. c. To remove waste products such as urea and albumin. d. To add antinuclear antibodies. ANS: B
Plasmapheresis is the removal of plasma-containing components causing or thought to cause disease. DIF: Cognitive Level: Comprehension TOP: Plasmapheresis MSC: NCLEX: Physiological Integrity
REF: 1940-1941 OBJ: 12 KEY: Nursing Process Step: Planning
20. The nurse explains that when the patient received tetanus antitoxin with the antibodies in
it, the patient received a a. active natural b. passive natural c. active artificial d. passive artificial
type of immunity.
ANS: D
When a person receives an inoculation of antibodies from another source, as with tetanus antitoxin, it is considered a passive artificial immunity. DIF: Cognitive Level: Application REF: 1930 OBJ: 2 TOP: Immunity KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. Because the older adult has decreased production of saliva and gastric secretions, they are
at risk for:
a. b. c. d.
mouth ulcers. fissures in corners of the mouth. gastrointestinal infections. bloating.
ANS: C
Deficient saliva and gastric secretions make the older adult prone to gastrointestinal infections. DIF: Cognitive Level: Analysis TOP: Age-related changes MSC: NCLEX: Physiological Integrity
REF: 1933 OBJ: N/A KEY: Nursing Process Step: Planning
22. What is the major negative effect of cell-mediated immunity? a. Depression of bone marrow b. Rejection of transplanted tissue c. Activation of the T cells d. Stimulation of the B cells ANS: B
Cell-mediated immunity has the negative effect of rejection of transplanted tissue. Activation of T cells and stimulation of B cells are the positive basis of the cell-mediated immunity. DIF: Cognitive Level: Analysis TOP: Hypersensitivity MSC: NCLEX: Physiological Integrity
REF: 1931 OBJ: 3 KEY: Nursing Process Step: Implementation
23. What is B-cell proliferation dependent on? a. Presence of NK (natural killer) cells b. Complement system c. Antigen stimulation d. Lymphokines ANS: C
Antigen stimulation is the sole focus of B-cell proliferation. DIF: Cognitive Level: Knowledge TOP: B-cell proliferation MSC: NCLEX: Physiological Integrity
REF: 1931 OBJ: 3 KEY: Nursing Process Step: Implementation
24. What time frame must blood be transfused within once it has been removed from
refrigeration? a. 2 hours b. 4 hours c. 6 hours d. 3 hours ANS: B
Blood must be administered within 4 hours after removal from refrigeration, and blood components within 6 hours of removal.
DIF: Cognitive Level: Application REF: 1938 OBJ: 9 TOP: Blood products KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 25. The LPN/LVN has arrived at the patient’s bedside with a unit of packed cells to be
connected to an IV that is infusing. When the RN arrives, what is the first thing the nurses must do? a. Check to ensure that the donor and recipient numbers match according to policy. b. Request the patient to sign the card on the packed cells. c. Immediately administer the packed cells. d. Check the patient’s ID bracelet and then administer the packed cells. ANS: A
Donor and recipient numbers are specific and must be thoroughly checked and the patient identified with an armband. DIF: Cognitive Level: Analysis REF: 1938 OBJ: 9 TOP: Blood transfusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 26. The nurse arrives at the bedside of a patient who has had a unit of packed cells infusing in
his right arm for 35 minutes. He is complaining of chills, itching, and shortness of breath. What should be the nurse’s initial action? a. Cover with a warm blanket. b. Take the patient’s temperature. c. Elevate the head of the bed. d. Stop the transfusion and continue with saline. ANS: D
Moderate reactions, resulting in fever, chills, urticaria, and wheezing, occur after the first 30 minutes of administration. In the event of a moderate reaction, stop the transfusion, continue with saline, and notify the health care provider. Elevation of the head, taking vital signs, and covering with a warm blanket are not wrong, but are not of primary importance. DIF: Cognitive Level: Analysis TOP: Blood transfusion MSC: NCLEX: Physiological Integrity
REF: 1938 OBJ: 9 KEY: Nursing Process Step: Implementation
27. Which symptom would be classified as a mild transfusion reaction? a. Orthopnea b. Tachycardia c. Hypotension d. Wheezing ANS: A
Mild transfusion reaction signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, cough, and orthopnea. DIF: Cognitive Level: Knowledge TOP: Blood transfusion MSC: NCLEX: Physiological Integrity
REF: 1938 OBJ: 9 KEY: Nursing Process Step: Assessment
28. What should the nurse do because of the increasing strength of the dose in the injections
for immunotherapy? a. Observe the patient for at least 20 minutes after administration. b. Take the vital signs every 10 minutes for an hour. c. Have the patient lie down quietly for an hour. d. Place a warm compress on the area to speed its absorption. ANS: A
The patient should be observed for 20 minutes after the increased dose of the allergen. If anaphylaxis is going to occur, it will do so within that time frame. DIF: Cognitive Level: Application TOP: Anaphylaxis reaction MSC: NCLEX: Physiological Integrity
REF: 1934 OBJ: 6 KEY: Nursing Process Step: Assessment
29. The nurse outlines for a patient who has asthma attacks from pollen that the process from
exposure to symptoms follows a systematic sequence. What is the last physiologic responses of an allergic asthma attack? a. Release of histamine b. Edema c. Vasodilation d. Activation of mast cells e. Bronchospasm f. Exposure to pollen ANS: E
The mast cells in the lungs are activated by the exposure to pollen. Histamine is released causing vasodilation, edema, and bronchospasm for the asthmatic. DIF: Cognitive Level: Analysis TOP: Sequence of allergic response MSC: NCLEX: Physiological Integrity
REF: 1935 OBJ: 5 KEY: Nursing Process Step: Implementation
30. What is the third step in the sequence of a plasmapheresis procedure? a. Removal of whole blood in one arm b. Circulation of blood through cell separator c. Remainder of plasma returned through vein in opposite arm d. Separation of plasma and its cellular components e. Replacement of plasma with lactated Ringer f. Removal of undesirable components ANS: D
The whole blood is drawn out of one arm; circulated through a cell separator; plasma is separated with its cellular components; the undesirable components are removed; the remainder of plasma is returned through a vein in the opposite arm; and the lost plasma is replaced with lactated Ringer, normal saline, frozen plasma, or albumin. DIF: Cognitive Level: Analysis TOP: Process of plasmapheresis MSC: NCLEX: Physiological Integrity
REF: 1941 OBJ: 12 KEY: Nursing Process Step: N/A
MULTIPLE RESPONSE 1. If a nurse is sensitive to latex gloves, what potential food sensitivities might the nurse
develop? (Select all that apply.) a. Peanuts b. Avocados c. Milk d. Bananas e. Tomatoes f. Potatoes ANS: B, D, E, F
A person sensitive to latex may also be sensitive to certain foods, including avocados, kiwi, guava, bananas, water chestnuts, hazelnuts, tomatoes, potatoes, peaches, grapes, and apricots. DIF: Cognitive Level: Application TOP: Latex allergy MSC: NCLEX: Physiological Integrity
REF: 1938 OBJ: 8 KEY: Nursing Process Step: Assessment
2. Which of the following provide the body with innate immunity? (Select all that apply.) a. Skin and mucous membranes b. Lungs c. Heart d. Tears and saliva e. Natural intestinal and vaginal flora f. Stomach acid ANS: A, D, E, F
The innate immune system is composed of the skin and mucous membranes, cilia, stomach acid, tears, saliva, sebaceous glands, and secretions and flora of the intestine and vagina. These organs, tissues, and secretions provide biochemical and physical barriers to disease. DIF: Cognitive Level: Analysis TOP: Natural immunity MSC: NCLEX: Physiological Integrity
REF: 1929 OBJ: 2 KEY: Nursing Process Step: Assessment
3. Which of the following are diseases which result from one’s own immune system
attacking the body? (Select all that apply.) a. Lupus erythematosus b. Glomerulonephritis c. Polio d. Rheumatoid arthritis e. Thrombocytopenic purpura f. Osteoarthritis ANS: A, B, D, E
Autoimmune diseases such as systemic lupus erythematosus, glomerulonephritis, myasthenia gravis, thrombocytopenic purpura, rheumatoid arthritis, and Guillain-Barré syndrome are treated with plasmapheresis. DIF: Cognitive Level: Application
REF: 1940
OBJ: 11
TOP: Autoimmune disease MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step: Assessment
4. The nurse outlines the functions of the immune system as those actions which: (Select all
that apply.) a. prevent the hemorrhage. b. protect the body’s internal environment. c. maintain the hemoglobin level. d. maintain the homeostasis by removing damaged cells. e. destruct the growth of abnormal cells. ANS: B, D, E
The three main functions of the immune system are to protect the body’s internal environment by destroying antigens and pathogens, maintenance of homeostasis by removing damaged cells, and the destruction of abnormal growth in the body. DIF: Cognitive Level: Application TOP: Purpose of immune system MSC: NCLEX: Physiological Integrity
REF: 1928 OBJ: N/A KEY: Nursing Process Step: Implementation
5. To provide examples of an active acquired immunity, the nurse uses the example of a
person who has acquired immunity from measles because that person has had: (Select all that apply.) a. chickenpox and mumps. b. measles. c. an extremely healthy immune system. d. an inoculation against measles. e. maternal antibodies against measles. ANS: B, D
Active or acquired or adaptive immunity occurs from having had disease or having had an immunization against that specific disease. DIF: Cognitive Level: Application TOP: Acquired immunity MSC: NCLEX: Physiological Integrity
REF: 1930 OBJ: 2 KEY: Nursing Process Step: Implementation
6. What is humoral immunity based on? (Select all that apply.) a. Production of antibodies by B cells b. T cells are activated by an antigen c. The body’s response to an antigen d. Sensitized T cells destroy the antigen e. Helper T cells activate phagocytosis ANS: A, C, E
Both types of immunity are in response to an antigen, In the humoral response, helper T cells activate phagocytosis and the production of antibodies by the B cells. B cells are the main player in humoral response. DIF: Cognitive Level: Analysis TOP: Humoral immunity MSC: NCLEX: Physiological Integrity
REF: 1931 OBJ: 3 KEY: Nursing Process Step: Implementation
COMPLETION 1. The nurse stresses that when a person produces his own antibodies against a specific
antigen, that process of immunity is
immunity
ANS:
active acquired When a person’s immune system produces specific antibodies against an antigen, that process is an active acquired immunity. DIF: Cognitive Level: Knowledge TOP: Active immunity MSC: NCLEX: Physiological Integrity
REF: 1930 | 1931 OBJ: 2 KEY: Nursing Process Step: Implementation
2. A type IV latex allergy is characterized by
.
ANS:
contact dermatitis Type IV latex allergy is that of a contact dermatitis. DIF: Cognitive Level: Knowledge TOP: Latex allergy MSC: NCLEX: Physiological Integrity
REF: 1938 OBJ: 8 KEY: Nursing Process Step: N/A
3. The process of immunity through a controlled exposure to an attenuated organism to
stimulate the production of antibodies is
.
ANS:
immunization The process of immunity through a controlled exposure to an attenuated organism to stimulate the production of antibodies is immunization. DIF: Cognitive Level: Comprehension TOP: Immunizations MSC: NCLEX: Physiological Integrity
REF: 1933 OBJ: 2 KEY: Nursing Process Step: N/A
4. A transfusion using blood from one’s own blood is a(n)
transfusion, which
is the best defense against a transfusion reaction. ANS:
autologous An autologous transfusion uses blood from one’s own body. DIF: Cognitive Level: Knowledge REF: 1939 OBJ: 9 TOP: Autologous transfusion KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance
5. The transfer of tissue between genetically identical individual (twins) is a(n) ANS:
isograft An isograft is the transfer of tissue between genetically identical individual (twins). DIF: Cognitive Level: Knowledge REF: 1939 TOP: Isograft KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: N/A
.
Chapter 56: Care of the Patient with HIV/AIDS Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. When assigned to a newly admitted patient with AIDS, the nurse says, “I’m pregnant. It is
not safe for me or my baby if I am assigned to his case.” Which is the most appropriate response by the charge nurse? a. “This patient would not be a risk for your baby if you use standard precautions and avoid direct contact with blood or body fluids.” b. “You should ask for a transfer to another unit because contact with this patient would put you and your baby at risk for AIDS.” c. “Wear a mask, gown, and gloves every time you go into his room and use disposable trays, plates, and utensils to serve his meals.” d. “We should recommend that this patient be transferred to an isolation unit.” ANS: A
HIV is transmitted from human to human through infected blood, semen, rectal secretions, cervicovaginal secretions, and breast milk. The use of Standard Precautions by all staff members for all patients all the time simplifies this issue. DIF: Cognitive Level: Application REF: 1947 OBJ: 6 TOP: Transmission of AIDS KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 2. The anxious male patient is fearful that he has been exposed to a person with an HIV
infection. He states he does not want to go to a laboratory for the ELISA tests because he does not want to be identified. What would be the nurse’s most helpful response? a. “There really is not an option, you will need to get the Western blot test first.” b. “There is an FDA-approved home test called OraQuick.” c. “The rapid test Reveal can identify all the HIV strains.” d. “You can be tested anonymously for ELISA. If you are seronegative, your concerns are over.” ANS: B
The OraQuick is a home OTC test approved by the FDA. One seronegative on the ELISA is not evidence because seroconversion may not have taken place. The Western blot test follows if the ELISA is positive. DIF: Cognitive Level: Application REF: 1974 OBJ: 6 TOP: HIV testing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The patient, age 21, has been treated for chlamydia and has a history of recurrent herpes.
What should the nurse counsel this patient about? a. Sexual history, risk reduction measures, and testing for HIV b. Getting an appointment at a family planning clinic c. Testing for HIV and what the test results mean d. Abstinence and a monogamous relationship
ANS: A
Chlamydia is considered a sexually transmitted disease (STD). As such it requires further testing and a sexual history to advise the sexual partners. DIF: Cognitive Level: Analysis REF: 1946 OBJ: 6 TOP: Risk for infection KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 4. A patient has just been diagnosed as HIV-positive. He asks the nurse, “Does this mean I
have AIDS?” Which response would be most informative? a. “Most people get AIDS within 3 to 12 weeks after they are infected with HIV.” b. “Don’t worry. You may never get AIDS if you eat properly, exercise, and get plenty of rest.” c. “It varies with every individual, but the average time is 8 to 10 years from the time a person is infected, and some go much longer.” d. “You can expect to develop signs and symptoms of AIDS within 6 months.” ANS: C
Typical progress of HIV includes a period of relative clinical latency, occurring immediately after the primary infection, which can last for several years. Long-term nonprogressors remain symptom-free for 8 to10 years. DIF: Cognitive Level: Analysis TOP: Progression of disease MSC: NCLEX: Physiological Integrity
REF: 1944 OBJ: 4 KEY: Nursing Process Step: Implementation
5. Which of the following is a CDC criterion for the progression of HIV infection to AIDS? a. Increase in viral load b. Decreased ratio of CD8 to CD4 c. Increase in white blood cells d. Increased reactivity to skin tests ANS: A
AIDS is the end stage of an HIV infection. The CDC has developed criteria for the diagnosis of AIDS, which are: increase in viral load even with pharmacologic interventions, increase in the ratio of CD8 to CD4, decline in the WBCs, and a decreased reactivity to skin tests. DIF: Cognitive Level: Analysis TOP: AIDS diagnostic criteria MSC: NCLEX: Physiological Integrity
REF: 1947 OBJ: 7 KEY: Nursing Process Step: Implementation
6. What should the nurse look for when reviewing a patient’s chart to determine whether she
has progressed from HIV disease to AIDS? a. CD4+ count below 500, chronic fatigue, night sweats b. HIV-positive test result, CD4+ count below 200, history of opportunistic disease c. Weight loss, persistent generalized lymphadenopathy, chronic diarrhea d. Fever, chills, CD4+ count below 200 ANS: B
Patients who have progressed from HIV disease to AIDS will have the condition in which the CD4+ cell count drops to less than 200 cells/mm3 and have a history of opportunistic diseases. DIF: Cognitive Level: Comprehension TOP: Progression of disease MSC: NCLEX: Physiological Integrity
REF: 1944 OBJ: 9 KEY: Nursing Process Step: Assessment
7. A male patient is advised to receive HIV antibody testing because of his multiple sexual
partners and injectable drug use. What should the nurse inform the patient to ensure understanding? a. The blood is tested with the highly sensitive test called the Western blot. b. The blood is tested with an ELISA; if positive, it is tested again with an ELISA, followed by a Western blot if the second ELISA is positive. c. A series of HIV tests is performed to confirm if the patient has AIDS. d. If the HIV tests are seronegative, the patient can be assured that he is not infected. ANS: B
The individual’s blood is tested with ELISA or enzyme immunoassay (ELA), antibody tests that detect the presence of HIV antibodies. If the ELA is positive for HIV, then the same blood is tested a second time. If the second ELA is positive, a more specific confirming test such as the Western blot is done. Blood that is reactive or positive in all three steps is reported to be HIV-positive. A seronegative is not an assurance that the individual is free of infection since seroconversion may not have yet occurred. DIF: Cognitive Level: Application REF: 1973 OBJ: 9 TOP: Diagnostic procedures KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 8. A 28-year-old married attorney with one child is in the first trimester of her second
pregnancy. The patient states that she is at no risk for HIV, so she would not need to be counseled about testing for HIV. Which is the most appropriate response? a. “She’s a professional woman in a monogamous relationship. She obviously is not at risk.” b. “Women are not at great risk. The greatest risk is with gay men.” c. “The fastest growing segment of the population with AIDS is women and children. We need to assess her risks.” d. “We need to review her chart to determine if her first child was infected.” ANS: C
Increases in AIDS cases in women and heterosexuals and a slowing of cases in the men who have sex with men (MSM) category are a direct reflection of early educational efforts directed at the MSM population, who were believed to be the only population at risk. Women need to be assessed for different manifestations of HIV infection. It is the current recommendation for voluntary HIV testing for all pregnant women. DIF: Cognitive Level: Application REF: 1946 OBJ: 6 TOP: Risk for infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
9. A young gay patient being treated for his third sexually transmitted disease does not see
why he should use condoms, because “they don’t work.” Which is the most appropriate response? a. “Condoms may not provide 100% protection, but when used correctly and consistently with every act of sexual intercourse they reduce your risk of getting infected with HIV or other sexually transmitted diseases.” b. “You are correct. Condoms don’t always work, so your best protection is to limit your number of partners.” c. “Condoms do not provide 100% protection, so you should always discuss with your sexual partners their HIV status or ask if they have any STD.” d. “Condoms do not provide 100% protection, but when used with a spermicide you can be assured of complete protection against HIV and other STDs.” ANS: A
Risk-reducing sexual activities decrease the risk of contact with HIV through the use of barriers. The most commonly used barrier is the male condom. Although not 100% effective, when used correctly and consistently, male condoms are very effective in the prevention of HIV transmission. DIF: Cognitive Level: Analysis REF: 1973 | 1975 OBJ: 5 TOP: Transmission of disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 10. A 21-year-old male who has been an IV heroin user has been experiencing fever, weight
loss, and diarrhea and has been diagnosed as having AIDS. Currently, he has a low-grade fever, severe diarrhea, and a productive cough. He is admitted with Pneumocystis jiroveci. What should the nurse do when caring for the patient? a. Use a gown, mask, and gloves when assisting the patient with his bath. b. Wear a gown when assisting the patient to use the bedpan. c. Use a gown, mask, and gloves to administer oral medications. d. Use a mask when taking the patient’s temperature. ANS: A
The use of Standard Precautions and body substance isolation has been shown not only to reduce the risk of bloodborne pathogens, but also to reduce the risk of transmission of other disease between the patient and the health care worker. DIF: Cognitive Level: Application REF: 1977 OBJ: 16 TOP: Transmission of disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 11. The nurse should instruct the patient who is diagnosed with AIDS to report signs of
Kaposi’s sarcoma, which include: a. reddish-purple skin lesions. b. open, bleeding skin lesions. c. blood-tinged sputum. d. watery diarrhea. ANS: A
Kaposi’s sarcoma is a rare cancer of the skin and mucous membranes characterized by blue, red, or purple raised lesions seen mainly in Mediterranean men. Kaposi’s sarcoma: firm, flat, raised or nodular, hyperpigmented, multicentric lesions on the skin, and mucous membranes. DIF: Cognitive Level: Application REF: 1943 OBJ: 8 TOP: Kaposi sarcoma KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. A patient states that he feels terrific, but a blood test shows that he is HIV-positive. It is
important for the nurse to discuss with him that HIV may remain dormant for several years. What is true of the patient during this time? a. He is not dangerous to anyone. b. He experiences minor symptoms only. c. He experiences decreased immunity. d. He is contagious. ANS: D
A prolonged period in which HIV is not readily detectable in the blood follows within a few weeks or months of the initial infection. This titer, or viral load, falls dramatically as the immune system responds and controls the HIV infection, and it may last 10 to 12 years. During this period, there are few clinical symptoms of HIV infection, although an individual is still capable of transmitting HIV to others. DIF: Cognitive Level: Comprehension TOP: Progression of disease MSC: NCLEX: Physiological Integrity
REF: 1977 OBJ: 15 KEY: Nursing Process Step: Implementation
13. To be diagnosed as having AIDS, the patient must be HIV-positive, have a compromised
immune system without known immune system disease or recent organ transplant, and present with which of the following? a. Opportunistic infection b. A positive ELISA or Western blot test c. Weight loss, fever, and generalized lymphedema d. CD4+ lymphocyte count less than 200 mm3 ANS: D
The 1993 expanded case definition of AIDS includes all HIV-infected people who have CD4+, T-lymphocyte counts of less than 200 cells/mm3; this includes all people who have one or more of these three clinical conditions: pulmonary tuberculosis, recurrent pneumonia, or invasive cervical cancer, and it retains the 23 clinical conditions listed in the 1987 AIDS case definition. DIF: Cognitive Level: Analysis TOP: Definition of AIDS disease MSC: NCLEX: Physiological Integrity
REF: 1959 | 1974 OBJ: 2 KEY: Nursing Process Step: Assessment
14. Why should interventions such as promotion of nutrition, exercise, and stress reduction be
undertaken by the nurse for patients who have HIV infection? a. They will promote a feeling of well-being in the patient. b. They will improve immune function.
c. They will prevent transmission of the virus to others. d. They will increase the patient’s strength and ability to care for himself or herself. ANS: B
HIV disease progression may be delayed by promoting a healthy immune system. Useful interventions for HIV-infected patients include the following: nutritional changes that maintain lean body mass, regular exercise, and stress reduction. DIF: Cognitive Level: Analysis REF: 1966 OBJ: 15 TOP: Immune function improvement KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 15. A male patient is concerned about telling others he has HIV infection. What should the
nurse stress when discussing his concerns? a. Care providers and sexual partners should be told about his diagnosis. b. There is no reason to hide his disease. c. Secrecy is a poor idea because it will lower his self-esteem. d. His diagnosis will be obvious to most people with whom he will come into contact. ANS: A
Nurses have a responsibility to assess each patient’s risk for HIV infection and counsel those at risk about HIV testing and the behaviors that put them at risk, and about how to reduce or eliminate those risks. The diagnosis needs to be carefully protected and shared only with caregivers who need to know for the purpose of assessment and treatment. DIF: Cognitive Level: Application REF: 1946 | 1962 OBJ: 13 TOP: Coping KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 16. The HIV patient asks the nurse about what to expect in terms of disease progression. The
nurse tells this patient that although the disease can vary greatly among individuals, the usual pattern of progression includes: a. viremia, clinical latency, opportunistic diseases, and death. b. asymptomatic phase, clinical latency, ARC, and AIDS. c. acute retroviral syndrome, early infection, early symptomatic disease, and AIDS. d. transitional viral syndrome, inactive disease, early symptomatic infection, and opportunistic diseases. ANS: C
The progression from HIV to AIDS includes initial exposure, primary HIV infection, asymptomatic HIV infection, early HIV disease, and AIDS. DIF: Cognitive Level: Analysis TOP: Progression of disease MSC: NCLEX: Physiological Integrity
REF: 1944 | 1954 OBJ: 4 KEY: Nursing Process Step: Implementation
17. While teaching community groups about AIDS, what should the nurse indicate as the most
common method of transmission of the HIV? a. Sexual contact with an HIV-infected partner b. Perinatal transmission c. Exposure to contaminated blood d. Nonsexual exposure to saliva and tears
ANS: A
Modes of transmission have remained constant throughout the course of the HIV pandemic. It is also important for health care providers to remember that transmission of HIV occurs through sexual practices, not sexual preferences. Worldwide, sexual intercourse is by far the most common mode of HIV transmission. DIF: Cognitive Level: Application REF: 1947 | 1976 OBJ: 7 TOP: Transmission of disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 18. What do the activated monocytes and macrophages produce in the presence of an
inflammatory process? a. Reduction of red cells b. Increase in WBCs c. Neopterin d. Increase in T-helper cells increase natural killer (NK) cells ANS: C
Neopterin is produced in the presence of an inflammatory reaction and is increased in HIV disease. DIF: Cognitive Level: Comprehension REF: 1953 | 1956 TOP: Neopterin KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
OBJ: 5
19. For most people who are HIV-positive, marker antibodies are usually present 10 to 12
weeks after exposure. What is the development of these antibodies called? a. Immunocompetence b. Seroconversion c. Opportunistic infection d. Immunodeficiency ANS: B
Seroconversion is the development of antibodies from HIV, which takes place approximately 5 days to 3 months after exposure, generally within 2 to 4 weeks. Although the conversion has taken place, the patient is not yet immunodeficient. DIF: Cognitive Level: Analysis REF: 1956 OBJ: 10 TOP: Progression of disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 20. What should the nurse emphasize when counseling an anxious HIV-positive mother about
the care of her HIV-positive infant? a. The baby will develop AIDS and refer her to a local AIDS support group. The baby will remain HIV-positive for the rest of its life. b. Although infants of HIV-infected mothers may test positive for HIV antibodies, not all infants are infected with the virus. c. She has not yet developed AIDS, and that it is possible the baby will not develop AIDS for many years. d. If the infant is started on zidovudine (AZT) within the first month after delivery, AIDS can be prevented.
ANS: B
The decline in pediatric AIDS incidence is associated with the increased compliance with universal counseling and testing of pregnant women and the use of antiretroviral therapy (ART) by HIV-infected pregnant women and their newborn infants. Infants born to HIV-infected mothers will have positive HIV antibody results as long as 15 to 18 months after birth. This is caused by maternal antibodies that cross the placenta during gestation and remain in the infant’s circulatory system. DIF: Cognitive Level: Analysis TOP: Transmission of disease MSC: NCLEX: Psychosocial Integrity
REF: 1947 OBJ: 5 KEY: Nursing Process Step: Planning
21. Why are snacks high in potassium, such as bananas and apricot nectar, recommended? a. Electrolytes are lost through diaphoresis. b. Sodium is lost through frequent diarrhea. c. Potassium will support weight gain. d. Potassium helps fight infection. ANS: C
HIV disease progression may be delayed by promoting a healthy immune system. Nutritional changes that maintain lean body mass, increase weight, and ensure appropriate levels of vitamins and micronutrients are helpful. Eat potassium-rich foods, such as bananas and apricot nectar. DIF: Cognitive Level: Analysis REF: 1959 OBJ: 15 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The depressed patient with AIDS says, “I don’t understand why I am going to be getting
doses of testosterone. What good will that do me now?” What should the nurse keep in mind about testosterone when responding? a. It can lower viral load. b. It can lighten depression. c. It can increase lean body mass. d. It can increase appetite. ANS: C
Testosterone can increase body mass and lean weight. DIF: Cognitive Level: Application REF: 1968 | 1971 OBJ: 16 TOP: Transmission of disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 23. After what period would the home health nurse make a mental health appointment for a
patient with an HIV infection after assessing a diminished ability to attend to daily functioning? a. 1 week b. 2 weeks c. 3 weeks d. 1 month
ANS: B
Patients with HIV infection have a great deal of anxiety and guilt, which may interfere with the daily functions of maintaining relationships and making decisions. When this apathy is assessed for a period of 2 weeks, the nurse should refer the patient for a mental health consult. DIF: Cognitive Level: Analysis REF: 1957 TOP: Coping KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
OBJ: 13
24. The HIV-infected patient who has just seroconverted says he just cannot take all those
confusing, expensive antiretroviral (ART) medications. He says he still feels fine, anyway. What should the nurse keep in mind when counseling this patient? a. Resumption of the ART later in the disease is just as effective. b. Adherence to the ART protocol is essential to the success of the treatment. c. Cessation of the ART may prevent the emergence of a resistant strain of HIV. d. Once ART is initiated, it cannot be restarted in the same patient. ANS: B
Compliance and adherence to the ART protocol is essential to its success. Cessation of the medication may stimulate the emergence of a resistant strain of HIV. ART can be restarted, but the optimum time to start is soon after seroconversion. DIF: Cognitive Level: Application TOP: Adherence to ART MSC: NCLEX: Physiological Integrity
REF: 1958 OBJ: 5 KEY: Nursing Process Step: Assessment
25. Which of the following statements regarding antiretroviral medication is NOT true? a. Recycling drugs previously taken can sometimes improve viral suppression. b. Certain combinations of antiretroviral drugs may reverse the resistance to a single
drug. c. Scientists stress that while medication cocktails can be minimally effective,
administration of a single strong antiretroviral medication is the most effective regimen. d. Some therapies exist that can reduce the quantity of circulating virus in the blood, even rendering the levels of virus in the blood undetectable. ANS: C
Scientists have found that the most effective medication regimen is the use of cocktails. This regimen makes it much more difficult for the virus to develop medication resistance, and may slow progression from asymptomatic or mildly symptomatic HIV infection to a more advanced disease. DIF: Cognitive Level: Analysis TOP: Antiretroviral therapy (ART) MSC: NCLEX: Physiological Integrity
REF: 1959 OBJ: 15 KEY: Nursing Process Step: Implementation
26. The historical progress of the HIV infection began to be tracked in 1979. Which is the first
historical event in sequence of its discovery?) a. Infection in heterosexual men and women b. Infection in hemophiliacs
c. Infection in injection drug users d. Increased incidence of Kaposi carcinoma in young homosexual men e. Increased incidence of P. jiroveci (previously PCP) ANS: E
The history of the incidence of HIV infection was slow in being recognized. The first observation was an increase in incidence of P. jiroveci, followed by increasing incidence of Kaposi carcinoma in the homosexual population. The infection began to be seen in injection drug users, hemophiliacs, then into the heterosexual population. DIF: Cognitive Level: Application REF: 1943 TOP: History of incidence of HIV infection N/A MSC: NCLEX: Health Promotion and Maintenance
OBJ: 1 | 12 KEY: Nursing Process Step:
MULTIPLE RESPONSE 1. Which of the following are early signs and symptoms of an HIV infection? (Select all that
apply.) a. Dry mouth b. Weight loss c. Sore throat d. Vaginal dryness e. Nausea f. Dyspnea ANS: B, C, F
Signs and symptoms of HIV infection include weight loss, sore throat, and dyspnea. DIF: Cognitive Level: Knowledge TOP: HIV infection MSC: NCLEX: Physiological Integrity
REF: 1952 OBJ: 8 KEY: Nursing Process Step: Assessment
2. Which of the following are methods in which children with AIDS could have contracted
their disease? (Select all that apply.) a. During intrauterine life with an HIV-positive mother b. During the birth process of an HIV-positive mother c. From other children who are HIV-positive d. From receiving a transfusion contaminated with the HIV e. From breast-feeding by an HIV-positive mother ANS: A, B, D, E
In the United States, transfusion of infected blood and blood products and transplantation of infected tissues account for 1% of the total adult and adolescent AIDS cases and 2% of the total pediatric AIDS cases. HIV infection can be transmitted from a mother to her infant during pregnancy, at the time of delivery, or after birth, through breast-feeding. In the United States, it is estimated that approximately 25% of infected mothers will transmit HIV to their infants, with approximately 50% to 70% of the transmissions occurring late in utero or intrapartum. In the United States, among children who are less than 13 years old and have AIDS, 93% were infected at birth.
DIF: Cognitive Level: Comprehension TOP: Transmission of disease MSC: NCLEX: Physiological Integrity
REF: 1949 OBJ: 5 KEY: Nursing Process Step: Assessment
3. The home health nurse designing a teaching plan for a person with HIV disease that would
support weight gain would include information pertaining to: (Select all that apply.) a. limiting fluid intake. b. eating high-protein/high-calorie diet. c. drinking nutritional supplements (Boost, Sustacal, etc.). d. eating several small meals during the day. e. providing referrals to dietitians. f. resisting weight training. ANS: B, C, D, E, F
Increase protein, calorie, and fat intake. Offer nutritional supplements. Eat several small meals per day instead of three large meals. Provide for referrals. Weigh the patient daily. Weight training maintains muscle tone and improves appetite. DIF: Cognitive Level: Comprehension REF: 1969 OBJ: 15 TOP: Weight loss KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Which foods would a nurse recommend for a person with debilitating diarrhea because of
HIV infection? (Select all that apply.) a. Bananas b. Ensure c. Fresh broccoli d. Cooked fruits and vegetables e. Red meat f. Apricot nectar ANS: A, D, F
Avoid dairy products, red meat, margarine, butter, eggs, dried beans, peas, and raw fruits and vegetables. Cooked or canned fruits and vegetables will provide needed vitamins. Eat potassium-rich foods, such as bananas and apricot nectar. Discontinue foods, nutritional supplements, and medications that may make diarrhea worse (Ensure, antacids, stool softeners). Avoid gas-producing foods. Serve warm, not hot, foods. Plan small, frequent meals. Drink plenty of fluids between meals. DIF: Cognitive Level: Analysis REF: 1970 OBJ: 15 TOP: Weight loss KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. How does the HIV-2 virus compare to the HIV-1 virus? (Select all that apply.) a. It has lower mortality risks in the older adult. b. It is less virulent. c. It results in the HIV-infected person to suffer from immunodeficiency issues more
slowly. d. It predisposes the HIV-infected person to be a long-term nonprogressor. e. It develops high viral loads. ANS: A, B, C, D
Persons who are infected with the HIV-2 develop problems with immunodeficiency more slowly, and the virus is less virulent than HIV-1. These persons also tend to be identified as long-term nonprogressors. DIF: Cognitive Level: Application REF: 1945 TOP: HIV-2 KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
OBJ: 7
6. Which of the following are examples of the AIDS wasting syndrome in a patient with an
HIV infection? (Select all that apply.) a. Episodes of vomiting for 20 days b. Appearance of Kaposi sarcoma c. Loss of 10% of body mass d. Marked hair loss e. Episodes of diarrhea for 30 days f. Episodes of hypotension ANS: C, E
The AIDS wasting syndrome is due to disturbances in metabolism involving lean body mass. The wasting syndrome is signaled by 10% loss of body weight, 30 days of diarrhea, weakness, and fever. The person who has the wasting syndrome is considered to have AIDS. DIF: Cognitive Level: Analysis TOP: Wasting syndrome MSC: NCLEX: Physiological Integrity
REF: 1968 OBJ: 4 KEY: Nursing Process Step: Assessment
COMPLETION 1.
is a type of sexual option classified as “no risk” for a person to become infected with the HIV. ANS:
Abstinence Abstinence is refraining from sexual contact in which there is exchange of semen, vaginal secretions, or blood. DIF: Cognitive Level: Knowledge REF: 1974 OBJ: 5 TOP: HIV infection prevention KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. An organism that can cross from an animal species to humans is a(n)
organism. ANS:
zoonotic A zoonotic organism is an organism that can cross from an animal species to humans. DIF: Cognitive Level: Knowledge
REF: 1944
OBJ: 1
TOP: Zoonotic KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 3. The nurse explains that an enzyme
transcriptase allows the RNA of the retrovirus to be changed to DNA and incorporated into the host’s genetic material. ANS:
reverse Reverse transcriptase allows the RNA of the retrovirus to be changed to DNA and incorporated into the host’s genetic material. DIF: Cognitive Level: Application TOP: Reverse transcriptase MSC: NCLEX: Physiological Integrity
REF: 1950 OBJ: 7 KEY: Nursing Process Step: Implementation
4. The term that describes an immunosuppressed patient’s inability to react to a skin test is
. ANS:
anergic Anergic is the term that describes an immunosuppressed patient’s ability to react to a skin test. DIF: Cognitive Level: Knowledge REF: 1955 TOP: Anergia KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity
OBJ: 2
5. The combination of efforts of the medical team, pharmacist, nutritionist, social workers,
and clergy is the necessary patients with HIV infection.
approach to the complex needs of the
ANS:
multidisciplinary The use of many disciplines in a combined approach to a complex medical problem is multidisciplinary. DIF: Cognitive Level: Knowledge REF: 1965 OBJ: 11 TOP: Multidisciplinary KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment
Chapter 57: Care of the Patient with Cancer Cooper: Adult Health Nursing, 8th Edition MULTIPLE CHOICE 1. A patient has developed stomatitis from chemotherapy. What should the appropriate
intervention for this condition include? a. Instruction in the following of a liquid diet b. Using a commercial mouthwash after each meal c. Cleaning teeth with a cotton swab dipped in hydrogen peroxide d. Using a soft toothbrush ANS: D
The use of a soft toothbrush to clean the teeth and rinsing with normal saline or soda will prevent added discomfort and bleeding. DIF: Cognitive Level: Comprehension REF: 1998 OBJ: 13 TOP: Stomatitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. Which of the following men should be highest priority for referral for a prostate-specific
antigen (PSA)? a. 43-year-old Hispanic man b. 45-year-old African American man c. 49-year-old Korean man d. 50-year-old Native American man ANS: B
African American men are a high-risk population for prostate cancer. Asian Americans and Native Americans have a relatively low incidence of prostate cancer. DIF: Cognitive Level: Analysis REF: 1983 TOP: PSA testing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
OBJ: 3
3. A patient, age 56, has been advised that his prostate-specific antigen (PSA) level is
elevated. The health care provider then performed a digital rectal examination (DRE). What should the next definitive diagnostic test be? a. CA-125 test b. Transrectal ultrasound c. Needle biopsy of the prostate d. MRI ANS: B
Men over the age of 50 should be advised to have a prostate-specific antigen (PSA) test and rectal examination once a year. Two other screening methods—DRE and transrectal ultrasonography (TRUS)—are used alone and in combination in the early detection of prostate cancer. DIF: Cognitive Level: Analysis TOP: Prostate cancer
REF: 1987 OBJ: 11 KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity 4. How would the nurse explain to the patient who is taking cyclophosphamide (Cytoxan), an
alkylating agent, about how the medication works? a. It inhibits DNA and RNA synthesis. b. It interferes with DNA replication. c. It damages the cell in S phase of replication. d. It alters the hormonal environment that promotes cancer growth. ANS: B
Most chemotherapeutic agents work by interfering with the cell’s ability to multiply or reproduce. Cytoxan interferes with DNA replication. DIF: Cognitive Level: Analysis TOP: Chemotherapy MSC: NCLEX: Physiological Integrity
REF: 1997 OBJ: 13 KEY: Nursing Process Step: Implementation
5. After an elevation of his PSA, the patient has blood drawn for a CA-19-9. When he asks
the nurses the purpose of this new test, what is the most appropriate response? a. It tests for hepatobiliary cancer. b. It tests for colorectal cancer. c. It tests for bladder cancer. d. It tests for lung cancer. ANS: A
The CA-19-9 is a tumor marker for tumors in the hepatobiliary system. DIF: Cognitive Level: Comprehension REF: 1991 OBJ: 11 TOP: CA-19-9 KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. A patient, age 39, receiving chemotherapy for treatment of her cancer has a white blood
cell count of 1600/mm3. This finding requires nursing interventions to provide which of the following? a. Adequate fluid intake b. Protection from falls c. Protection against infection d. Frequent small nutritious snacks ANS: C
The nurse needs to protect the patient against pathogens, monitor the patient for signs of infections, and respond aggressively if an infection occurs. DIF: Cognitive Level: Analysis REF: 1997 TOP: Leukopenia KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment
OBJ: 13
7. What should the home health nurse advise the patient who found a lump in her breast a
week ago during breast self-examination? a. Arrange for an examination by her health care provider. b. Wait until her next ovulatory cycle and check the lump again. c. Postpone appointment until the lump enlarges.
d. Apply warm, moist compresses. ANS: A
Nurses should teach to all patients, both men and women, that any identifiable problem should be brought to the attention of a health care provider. DIF: Cognitive Level: Analysis TOP: Self-examination MSC: NCLEX: Physiological Integrity
REF: 1986 OBJ: 3 KEY: Nursing Process Step: Implementation
8. How many minutes of daily exercise does the American Cancer Society recommend as a
prevention of cancer? a. 10 minutes b. 15 minutes c. 20 minutes d. 30 minutes ANS: C
The ACS recommends 150 minutes of moderate exercise weekly, which comes to around 20 minutes a day. DIF: Cognitive Level: Application TOP: ACS recommendations MSC: NCLEX: Physiological Integrity
REF: 1987 OBJ: 13 KEY: Nursing Process Step: Implementation
9. Using the TNM staging classification system, what does a tumor staged as T4N3M2
mean? a. No evidence of primary tumor, lymph node involvement, or distant metastasis b. Carcinoma in situ, regional lymph node involvement, and metastasis to one site c. Enlarging tumor, increasing lymph node involvement, and distant metastasis d. Enlarging tumor, no lymph node involvement, or distant metastasis ANS: C
TNM cancer staging classification system T4N3M2 means progressive increase in tumor size and involvement, increasing involvement of regional lymph nodes, and distant metastasis present. DIF: Cognitive Level: Analysis TOP: Cancer staging MSC: NCLEX: Physiological Integrity
REF: 1989 OBJ: 10 KEY: Nursing Process Step: Assessment
10. A home health patient undergoing radiation therapy says, “I feel so useless. I have no
energy, no appetite, and I fall asleep whenever I sit down.” What is the nurse’s most therapeutic response? a. “Fatigue is part of your illness. Taking several long naps in the daytime is helpful.” b. “Fatigue is an unfortunate side effect of radiation. It will improve when you finish treatment.” c. “You really shouldn’t be fatigued. Let me make an appointment with your health care provider to get this checked out.” d. “Don’t worry about it. You probably deserve the rest!” ANS: B
Fatigue is a side effect of radiation. Patients should be reassured that energy levels will improve when treatment is finished. DIF: Cognitive Level: Application TOP: Radiation fatigue MSC: NCLEX: Physiological Integrity
REF: 1999 OBJ: 13 KEY: Nursing Process Step: Implementation
11. The nurse instructs a patient who has been smoking for 5 years about the warning signs of
cancer. The nurse tells him that one of cancer’s eight warning signals include: a. nagging cough or hoarseness. b. a sore that does not heal rapidly. c. gallbladder disease. d. hematopoietic changes. ANS: A
Cancer’s eight warning signals include nagging cough or hoarseness. DIF: Cognitive Level: Application REF: 1986 OBJ: 6 TOP: Warning signs of cancer KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. Which of the following is a meal that would represent foods that help prevent cancer? a. Broiled steak, baked potato, whole wheat roll, soy milk b. Baked ham, rice and gravy, apples stewed in butter, whole milk c. Fried pork chops, candied sweet potatoes, white rolls and butter, iced tea d. Broiled chicken, cabbage with onion and garlic, and soy milk ANS: D
Green and yellow vegetables, cruciferous vegetables, whole grain and soy products are all examples of foods that prevent cancer. Reducing the consumption of processed meats and red meat are additional diet-related prevention steps. DIF: Cognitive Level: Knowledge REF: 1987 OBJ: 3 TOP: Cancer prevention KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 13. There is a risk of nausea and vomiting from chemotherapy and targeted therapy. Which of
the following sets of drugs used for cancer treatment represent a high risk in this regard? a. Butyrophenones, phenothiazines, metoclopramide b. Methotrexate, 5-fluorouracil, doxorubicin c. Carmustine (BiCNU), Cisplatin (Platinol), Dacarbazine (DTIC-Dome) d. It does not matter. Chemotherapy provided to all patients will definitely trigger CINV. ANS: C
Carmustine (BiCNU), Cisplatin (Platinol), and Dacarbazine (DTIC-Dome) nearly always cause nausea and vomiting. Butyrophenones, phenothiazines, and metoclopramide are dopamine receptor antagonists (antiemetics) used to prevent and treat CINV. Methotrexate, 5-fluorouracil, and doxorubicin are chemotherapeutic drugs most frequently associated with the development of stomatis. DIF: Cognitive Level: Analysis
REF: 1997
OBJ: 13
TOP: Medications KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 14. What happens during the process of immunosurveillance? a. T cells recognizing and destroying the abnormal cell b. White blood cells (WBC) destroying the abnormal cell c. Excretion of histamine to interfere with the replication of the abnormal cell d. B cells attaching to abnormal cell ANS: A
The T cells are responsible for immunosurveillance by recognizing an abnormal cell and destroying it. DIF: Cognitive Level: Analysis TOP: Immunosurveillance MSC: NCLEX: Physiological Integrity
REF: 1988 OBJ: 8 KEY: Nursing Process Step: Implementation
15. The nurse caring for a patient who is being treated for cancer of the cervix by a radioactive
implant discovers that the applicator with the radioactive material has become dislodged and is lying in the bed between the patient’s legs. What should the nurse do? a. Use long-handled forceps grasp the applicator and wrap it in a towel. b. Help the patient to a chair and cover the applicator with a rubber sheet. c. Reassure the patient by staying at the bedside and call for help. d. Notify the charge nurse. ANS: D
The applicator should not be touched. Reassure the patient and go to report the incident to the charge nurse. DIF: Cognitive Level: Analysis REF: 1996 OBJ: 13 TOP: Internal radiation therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 16. Which of the following people should avoid visiting a patient being treated with internal
radiation therapy? a. A 78 year old using a walker b. An 18-year-old woman c. A woman pregnant in the third trimester d. A 24-year-old nursing mother ANS: C
Persons under the age of 18 and persons who are pregnant should not be allowed to visit a patient with internal radiation. DIF: Cognitive Level: Comprehension REF: 2004 OBJ: 13 TOP: Psychological supportKEY: Nursing Process Step: Diagnosis MSC: NCLEX: Safe, Effective Care Environment 17. A patient, age 63, has terminal cancer of the liver and is cared for by his wife at home. His
abdominal pain has become increasingly severe, and he now says it is intense most of the time. The nurse recognizes that teaching regarding pain management has been effective based on which measure implemented by this patient?
a. Limiting the use of opiate analgesics to prevent addiction b. Using analgesics only when the pain becomes more than he can tolerate c. Taking analgesics around the clock on a regular schedule, using additional doses
for breakthrough pain d. Resigning himself to the fact that pain is an inevitable consequence of cancer ANS: C
Fixed dosage schedules with adequate doses for pain relief provide more constant blood levels and predictable pain relief. DIF: Cognitive Level: Analysis TOP: Pain management MSC: NCLEX: Physiological Integrity
REF: 2001 OBJ: 16 KEY: Nursing Process Step: Evaluation
18. A female patient, age 59, has lost 10 lb in the first 3 weeks of her chemotherapy and does
not eat because nothing tastes good. What would be the appropriate patient problem for the plan of care? a. Ineffective health maintenance, related to lack of knowledge of nutritional requirements during radiation therapy b. Risk for infection, related to poor nutrition c. Imbalanced nutrition: less than body requirements, related to anorexia d. Ineffective therapeutic regimen management, related to refusal to eat ANS: C
Patient problem includes imbalanced nutrition: less than body requirements, related to anorexia from changes in taste and smell. DIF: Cognitive Level: Analysis TOP: Chemotherapy MSC: NCLEX: Physiological Integrity
REF: 1995 OBJ: 13 KEY: Nursing Process Step: Diagnosis
19. What measures would the home health nurse, designing nursing interventions for a patient
receiving external radiation treatments for a malignancy, recommend to protect the patient’s skin? a. Applying warm compresses to damaged skin b. Encouraging patient to apply fragrant lotion to skin c. Patting the skin dry after the bath d. Exposing skin to sun for 10 minutes a day ANS: C
Patting the skin dry rather than rubbing is less damaging to the skin. Lotions, sun exposure, and applications of heat or cold are not beneficial. DIF: Cognitive Level: Application TOP: External radiation therapy MSC: NCLEX: Physiological Integrity
REF: 1996 OBJ: 13 KEY: Nursing Process Step: Implementation
20. Which statement is most appropriate for a nurse to tell a patient before insertion of the
radioactive implant? a. “Nurses will always be available, but they will spend only short periods of time at your bedside.” b. “Personal cleanliness is essential, so you will be given a complete bed bath each
day.” c. “Your diet will be changed to a high-fiber diet to encourage daily bowel movements.” d. “Your bed linens will be completely changed each day to minimize radioactive contamination.” ANS: A
Generally, it is recommended that the nurse spend no more than 10 minutes at a time in the room of a patient with an implant. Baths and linen changes are not given daily. A low-residue diet is the norm to minimize peristalsis and bowel movements that might dislodge the implant. DIF: Cognitive Level: Analysis REF: 1996 OBJ: 13 TOP: Internal radiation therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 21. A male patient is undergoing external radiation therapy on an outpatient basis for
treatment of Hodgkin disease. After 2 weeks of treatment, he tells the nurse that he is so tired he can hardly get out of bed in the morning. Which is an appropriate goal? a. Take two rest periods during the day. b. Ambulate in the hall four times a day. c. Select two activities for distraction. d. Investigate a consultation with a psychiatrist for treatment of depression. ANS: A
The person undergoing radiation therapy should be assured that lethargy and fatigue are not uncommon during treatment, and that frequent rest periods are helpful. Periods of rest are very beneficial. DIF: Cognitive Level: Analysis TOP: External radiation therapy MSC: NCLEX: Physiological Integrity
REF: 1996 OBJ: 13 KEY: Nursing Process Step: Planning
22. The patient receiving radiation therapy complains of the conspicuous markings on the
skin. What can the nurse explain about these markings? a. They are residues of the treatment and can be washed off. b. They are caused by radiation and will fade in time. c. They are indicators of the amount of radiation the patient is receiving. d. They are gridlines for treatment and should be left on. ANS: D
When external radiation is planned, the specific area on the body is marked to indicate the part at which external radiation will be directed. These markings must not be washed off. DIF: Cognitive Level: Application TOP: External radiation therapy MSC: NCLEX: Physiological Integrity
REF: 1995 OBJ: 13 KEY: Nursing Process Step: Implementation
23. Nursing interventions for the patient problem of imbalanced nutrition: less than body
requirements would include all these except: a. provide adequate, easily digestible, soft, bland foods. b. give small, frequent, highly nutritional meals.
c. allow extra time to eat. d. offer three regular meals of highly nutritious foods. ANS: D
A patient problem of imbalanced nutrition: less than body requirements will require the nurse to give small, frequent, highly nutritional meals; to allow extra time to eat; and to provide adequate, easily digestible, soft, bland foods. DIF: Cognitive Level: Application REF: 1998 OBJ: N/A TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. A patient who has malignant cancer secondary to a high-grade lymphoma has been
admitted with muscle weakness, tetany, paresthesia, and convulsion. The nurse notices the patient is being treated for tumor lysis syndrome (TLS) and initial treatment has not been successful. What should the nurse tell the family is the next step in treatment? a. Whole blood transfusion b. A bone marrow biopsy c. Immediate radiation treatment d. Dialysis ANS: D
A nursing intervention for TLS is to prepare the patient and family for dialysis if other measures are not effective. DIF: Cognitive Level: Analysis TOP: Tumor lysis syndrome MSC: NCLEX: Physiological Integrity
REF: 2002 OBJ: 15 KEY: Nursing Process Step: Implementation
25. Which of the following are thrombocytopenic precautions? a. Requesting an order for aspirin for discomfort b. Trimming toenails close c. Using an electric razor d. Vigorous tooth cleaning ANS: C
The patient should be taught to use an electric shaver. Thrombocytopenia is a reduction in the number of circulating platelets, due to the depression of the bone marrow. When the platelet count is less than 20,000/mm3, spontaneous bleeding can occur. DIF: Cognitive Level: Analysis TOP: Thrombocytopenia MSC: NCLEX: Physiological Integrity
REF: 1999 OBJ: 25 KEY: Nursing Process Step: Planning
26. The nurse explains to a 43-year-old patient with a benign tumor in her right breast that a
benign tumor differs from a malignant tumor in that benign tumors: a. do not cause damage to adjacent tissue. b. are simply an overgrowth of normal cells. c. do not spread to other tissues and organs. d. frequently recur in the same site. ANS: C
A benign tumor differs from a malignant tumor because benign tumors are not recurrent or progressive and are nonmalignant. DIF: Cognitive Level: Knowledge TOP: Benign tumor MSC: NCLEX: Physiological Integrity
REF: 1988 OBJ: 8 KEY: Nursing Process Step: Implementation
27. Why is seeking medical attention when any cancer warning signs occur frequently
delayed? a. Difficulty accessing a health care provider or getting a referral consult. b. Lack of knowledge of the warning signs of cancer. c. Fear of the possible diagnosis of cancer and hoping signs will go away. d. Self-examination being complex and difficult to perform. ANS: C
Seeking medical attention when any warning signs occur is frequently delayed because people fear the possible diagnosis of cancer and hope the signs and symptoms will just go away. DIF: Cognitive Level: Analysis TOP: Cancer identification MSC: NCLEX: Physiological Integrity
REF: 2007 OBJ: N/A KEY: Nursing Process Step: Assessment
28. The nurse knows which of the following to be characteristics of malignant tumors? a. Smooth, well defined; movable when palpated b. Resembles parent tissue; rarely fatal c. Rate of growth varies; rarely contained within a capsule d. Remains localized; slow growth ANS: C
Malignant tumors are rarely contained within a capsule and their rate of growth varies; little resemblance to parent tissue; fatal without treatment; irregular and immobile when palpated. DIF: Cognitive Level: Knowledge TOP: Cancer identification MSC: NCLEX: Physiological Integrity
REF: 1988 OBJ: 7 KEY: Nursing Process Step: Assessment
29. The difference between an excisional biopsy and an incisional biopsy is that an excisional
biopsy involves the: a. use of a needle to obtain fluid samples. b. removal of the entire lesion. c. taking a “bite” from the lesion for study. d. shaving of the superficial layers of the lesion. ANS: B
An excisional biopsy involves the excision of the entire lesion. DIF: Cognitive Level: Knowledge TOP: Cancer identification MSC: NCLEX: Physiological Integrity
REF: 1990 OBJ: 12 KEY: Nursing Process Step: Implementation
30. What is the function of organizations like The Lost Chord Club, Reach for Recovery, and I
Can Cope? a. Arrange for transportation to a clinic. b. Provide a small amount of financial support to patients. c. Send volunteers to speak with a person facing a lifestyle change. d. Arrange for reduced drug costs. ANS: C
Support groups like The Lost Chord Club, Reach for Recovery, and I Can Cope are available to send volunteers to talk with persons facing lifestyle changes because of cancer. DIF: Cognitive Level: Application REF: 1995 OBJ: N/A TOP: Cancer KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 31. Which of the following characteristics is common in malignant tumors? a. Usually contained within a capsule. b. Divide and multiply in the same manner as normal cells. c. Proliferate and respond to treatment. d. Progress and destroy surrounding tissues while spreading to distant parts of the
body. ANS: D
Malignant tumors destroy surrounding tissues and may spread to distant parts of the body causing a secondary tumor to grow in that area. Malignant cells divide and multiply but not in the same manner as normal parent cells and are rarely contained within a capsule. DIF: Cognitive Level: Knowledge REF: 1988 OBJ: 7 TOP: Tumor classification KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Which of the following are nursing interventions for the patient problem of imbalanced
nutrition: less than body requirements? (Select all that apply.) a. Provide adequate, easily digestible, soft, bland foods. b. Give small, frequent, highly nutritional meals. c. Allow extra time to eat. d. Offer three regular meals of highly nutritious foods. ANS: A, B, C
A patient problem of imbalanced nutrition: less than body requirements will require the nurse to give small, frequent, highly nutritional meals; to allow extra time to eat; and to provide adequate, easily digestible, soft, bland foods. DIF: Cognitive Level: Application REF: 2001 OBJ: N/A TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
2. Select the foods that are recommended for prevention of colorectal cancer in men. (Select
all that apply.) a. Oranges b. Ham c. Skinless chicken d. Asparagus e. Cheddar cheese f. Squash ANS: A, C, F
Eating plenty of fruits, vegetables, and whole grain foods and limiting intake of high-fat foods will help prevent cancer. DIF: Cognitive Level: Comprehension REF: 1987 OBJ: 3 TOP: Cancer preventing foods KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. The nurse is aware that American men and women have which of the following three sites
for cancer in common? (Select all that apply.) a. Lung b. Brain c. Colon d. Liver e. Rectum f. Thyroid ANS: A, C, E
The three common cancer sites that American men and women share are cancer of the lung, colon, and rectum. DIF: Cognitive Level: Comprehension REF: 1981 OBJ: 2 TOP: Common cancer sites KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 4. Which of the following are risk factors for cancer? (Select all that apply.) a. Ethnicity b. Environmental irritants c. Alcoholism d. Hereditary factors e. Excessive exercise f. Exposure to ultraviolet light ANS: B, C, D, F
Cancer risk factors include smoking and the use of smokeless tobacco, environmental irritants, alcoholism, hereditary factors, and dietary habits. DIF: Cognitive Level: Knowledge REF: 1984 OBJ: 4 TOP: Cancer risk factors KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. What would the nurse encourage the patient to look for during self-testicular testing?
(Select all that apply.)
a. b. c. d. e. f.
Smooth consistency of testicle Stomachache Breast enlargement Heavy feeling in the scrotum Enlarged blood vessels in scrotum Hematuria
ANS: B, C, D
Signs and symptoms of a scrotal tumor include an ache in the groin or stomach, feeling of heaviness in the scrotum, and breast enlargement. DIF: Cognitive Level: Application REF: 1984 OBJ: 3 TOP: Testicular examination KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. What are the signs and symptoms of prostatic enlargement? (Select all that apply.) a. Rotten egg odor to urine b. Hematuria c. Swollen scrotum d. Difficulty starting urine flow e. Strong flow of urine ANS: B, D
Indicators of prostatic hypertrophy are hematuria, difficulty starting urine flow, and weak urine stream. DIF: Cognitive Level: Application REF: 1993 OBJ: 3 TOP: Prostatic hypertrophy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 7. How do cancer cells differ from normal cells? (Select all that apply.) a. They replicate in an organized manner. b. They have larger nuclei. c. They have an irregular shape. d. They have a different number of chromosomes. e. They have a different mitosis process. ANS: B, C, D, E
Cancer cells are disorderly in replication, have larger nuclei, an irregular shape, a different number of chromosomes, and a different process of mitosis. DIF: Cognitive Level: Analysis REF: 1997 OBJ: 7 TOP: Cancer cells KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. The term
cancer cell. ANS:
carcinogenesis
refers to the process by which a normal cell is transformed into a
Carcinogenesis is the process by which a normal cell is transformed into a cancer cell. DIF: Cognitive Level: Knowledge TOP: Development of cancer MSC: NCLEX: Physiological Integrity
REF: 1983 OBJ: 3 KEY: Nursing Process Step: Assessment
2. Men over age 50 should consider an annual
test and rectal examination.
ANS:
PSA (prostate-specific antigen) PSA, prostate-specific antigen PSA prostate-specific antigen Men over age 50 should consult with their health care provider to consider the benefits of having a prostate-specific antigen (PSA) test and rectal examination once a year. DIF: Cognitive Level: Knowledge REF: 1991 OBJ: 3 TOP: Cancer prevention KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. The American Cancer Society recommends a clinical breast examination by a health care
professional for women between the age of 20 and 39 years every
years.
ANS:
3 three Women between the ages of 20 and 39 should have a clinical breast examination by health care professionals every 3 years. DIF: Cognitive Level: Knowledge REF: 1985 OBJ: 3 TOP: Breast cancer KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. A
test screens for occult blood in the stool.
ANS:
guaiac The guaiac test is a screening test for occult blood in the stool. DIF: Cognitive Level: Knowledge REF: 1985 TOP: Guaiac test KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance
OBJ: 1
5. The nurse remarks that the American Cancer Society (ACS) reports that cancer is the
leading cause of death in the United States. ANS:
second 2nd The ACS reports that cancer is the second leading cause of death in the United States. DIF: Cognitive Level: Knowledge REF: 1982 OBJ: 1 TOP: Incidence of cancer KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
Chapter 58: Professional Roles and Leadership Cooper: Foundations of Nursing, 8th Edition MULTIPLE CHOICE 1. What is the correct term for a concise, one- or two-page summary of educational and work
experience, activities and honors, and concrete skills and interests? a. Introduction b. Review c. Résumé d. Composite ANS: C
A résumé is a one- or two-page summary of the applicant’s education and experience. DIF: Cognitive Level: Knowledge TOP: New graduate MSC: NCLEX: N/A
REF: 2011 OBJ: 1 KEY: Nursing Process Step: N/A
2. An employee failed to perform the duties listed in the employment contract. What is the
term for this failure? a. Lawsuit b. Termination c. Breach of contract d. Reprimand ANS: C
Failure by the nurse or employer to perform contractual duties is known as a breach of contract. A breach of contract may result in a reprimand, termination, or lawsuit. DIF: Cognitive Level: Knowledge TOP: New graduate MSC: NCLEX: N/A
REF: 2013 OBJ: 2 KEY: Nursing Process Step: N/A
3. What is the best way to resolve most disagreements? a. Agreement b. Argument c. Communication d. Withdrawing ANS: C
Most problems can best be resolved by communication at the most basic level. DIF: Cognitive Level: Comprehension TOP: New graduate MSC: NCLEX: N/A 4. What is another term for promotion? a. Reward b. Advancement c. Lift
REF: 2015 OBJ: 13 KEY: Nursing Process Step: N/A
d. Bubble ANS: B
Advancement may result from additional preparation or additional experience. It may be gained by learning the position more thoroughly and by assuming new and greater responsibilities. DIF: Cognitive Level: Knowledge TOP: New graduate MSC: NCLEX: N/A
REF: 2015-2016 OBJ: 12 KEY: Nursing Process Step: N/A
5. When a résumé reflects too many job changes, the employer may question it. How long
should an employee remain at the first place of employment? a. 6 months b. 3 months c. 1 year d. 2 years ANS: C
Resigning from a position properly is another skill that the LPN/LVN will need to have. Employers will sometimes question a résumé that reflects frequent job changes; therefore, it is best to remain at the first place of employment at least 1 year. DIF: Cognitive Level: Comprehension TOP: New graduate MSC: NCLEX: N/A
REF: 2016 OBJ: 1 KEY: Nursing Process Step: N/A
6. Technical and scientific changes have resulted in a multiplicity and complexity of
functions placed on nurses, and sometimes job descriptions have not been rewritten. What is true of the role of the LPN/LVN? a. It is constantly enlarging. b. It is constantly changing. c. It is constantly improving. d. It is constantly growing. ANS: B
The role of the LPN/LVN is constantly changing. DIF: Cognitive Level: Comprehension TOP: New graduate MSC: NCLEX: N/A
REF: 2016 OBJ: 6 KEY: Nursing Process Step: N/A
7. Which organization specifically supports and meets the needs of the LVN/LPN? a. NAPNES b. NLN c. ANA d. NCLEX ANS: A
National Association for Practical Nurse Education and Service (NAPNES) is the professional organization that is specifically for LVN/LPNs. The National League for Nursing (NLN) and the American Nurses Association (ANA) are not specific to the LPN. The National Council Licensure Exam (NCLEX) is the test that is taken for licensure. DIF: Cognitive Level: Comprehension TOP: New graduate MSC: NCLEX: N/A
REF: 2017 OBJ: 5 KEY: Nursing Process Step: N/A
8. A nurse may practice in another state if he or she has passed the NCLEX-PN examination
in the nurse’s own state and meets the other state’s educational requirements. What is the process of transferring licensure from one state to another called? a. Auxiliary b. Co-licensure c. Endorsement d. Qualified licensure ANS: C
This licensure transfer from one state to another is called endorsement. DIF: Cognitive Level: Knowledge REF: 2020 TOP: Licensure KEY: Nursing Process Step: N/A
OBJ: 10 MSC: NCLEX: N/A
9. What is the name of the licensing law that defines the title and regulations governing the
practice of nursing and states the requirements for licensure? a. State practice act b. Nurse regulation act c. Nurse practice act d. Legislative act ANS: C
The nurse practice act defines the title and regulations governing the practice of nursing. DIF: Cognitive Level: Comprehension REF: 2021 TOP: Licensure KEY: Nursing Process Step: N/A
OBJ: 9 MSC: NCLEX: N/A
10. What is the term for the commission of an act that a prudent nurse should not have done,
or the omission of an act a prudent nurse should have done, that results in injury or harm to another person? a. Malpractice b. Negligence c. Neglect d. Disregard ANS: B
To qualify as negligence, it must be proved that a prudent member of the profession would have acted differently. DIF: Cognitive Level: Knowledge REF: 2021 TOP: Negligence KEY: Nursing Process Step: N/A
OBJ: 10 MSC: NCLEX: N/A
11. In what setting can the LPN/LVN’s management and leadership skills be developed best?
a. b. c. d.
Acute care hospital Rehabilitation hospital Trauma center Long-term care facility
ANS: D
Management and leadership skills of the LPN/LVN can best be developed in long-term care settings with RN supervision. DIF: Cognitive Level: Comprehension TOP: New graduate MSC: NCLEX: N/A
REF: 2023 OBJ: 12 KEY: Nursing Process Step: N/A
12. Which setting provides greater nurse autonomy and continuity of care and is less costly for
insurance companies? a. Hospice b. Hospitals c. Home health d. Long-term care ANS: C
The advantages of home health are greater nurse autonomy and continuity of care, as well as less cost to insurance. DIF: Cognitive Level: Comprehension TOP: New graduate MSC: NCLEX: N/A
REF: 2023 OBJ: 12 KEY: Nursing Process Step: N/A
13. Which employment setting would likely involve a daytime schedule with weekends off,
and would focus on prevention and patient teaching? a. Long-term care b. Health care provider’s office c. Hospice setting d. Adult day care ANS: B
Health care provider offices typically involve a daytime schedule with most weekends off. The setting focuses on prevention and includes opportunities for patient teaching. DIF: Cognitive Level: Comprehension TOP: New graduate MSC: NCLEX: N/A
REF: 2022 OBJ: 12 KEY: Nursing Process Step: N/A
14. Which health care employment setting would provide the nurse a very good salary, the
opportunity to refuse to take an assignment, and more flexibility in the personal schedule but with an uncertainty of work availability? a. Temporary agency b. Long-term care center c. Outpatient clinic d. Adult day care center ANS: A
In a temporary agency, the salary is good, and an LPN/LVN has the right to refuse assignments. However, one disadvantage is the uncertainty of work availability. DIF: Cognitive Level: Application TOP: New graduate MSC: NCLEX: N/A
REF: 2024 OBJ: 12 KEY: Nursing Process Step: N/A
15. In what employment setting does the nurse give total care to one patient; is totally
independent; provides care in the home, hospital, or other facility; is paid directly by the patient; and is legally responsible for his or her own actions? a. Home health nursing b. Private duty nursing c. Patient care nursing d. Agency care nursing ANS: B
The private duty nurse gives total care to one patient and is paid directly by the patient or responsible party. The nurse is legally responsible for his or her own actions. DIF: Cognitive Level: Application TOP: New graduate MSC: NCLEX: N/A
REF: 2024-2025 OBJ: 12 KEY: Nursing Process Step: N/A
16. A new graduate who has achieved the goal of getting others to do something that is
believed necessary has demonstrated what skill? a. Management b. Leadership c. Influence d. Control ANS: B
Leadership is the art of getting others to want to do something that is perceived as necessary. DIF: Cognitive Level: Application TOP: New graduate MSC: NCLEX: N/A
REF: 2025 OBJ: 13 KEY: Nursing Process Step: N/A
17. What type of leadership involves a leader who displays little trust or confidence in
employees and therefore makes all the decisions? a. Democratic b. Laissez-faire c. Autocratic d. Authoritative ANS: C
The autocratic leader displays little trust in employees, and therefore makes all decisions. DIF: Cognitive Level: Comprehension REF: 2026 TOP: Leadership KEY: Nursing Process Step: N/A
OBJ: 14 MSC: NCLEX: N/A
18. What type of leadership uses four different styles—directing, coaching, supporting, and
delegating? a. Autocratic b. Situational c. Democratic d. Authoritative ANS: B
Situational leadership identifies four typical styles for leaders. DIF: Cognitive Level: Comprehension REF: 2027 TOP: Leadership KEY: Nursing Process Step: N/A
OBJ: 14 MSC: NCLEX: N/A
19. What is the physical, emotional, and spiritual exhaustion that can occur among caregivers? a. Excessiveness b. Burnout c. Fatigue d. Weariness ANS: B
Physical, emotional, and spiritual exhaustion among caregivers is sometimes called burnout. DIF: Cognitive Level: Comprehension REF: 2032 TOP: Burnout KEY: Nursing Process Step: N/A
OBJ: 22 MSC: NCLEX: N/A
20. Why is it important for new graduates to purchase their own malpractice insurance rather
than depend on an institutional policy? a. A private policy will not cover them unless they are on their primary job. b. A private policy will carry personal liability coverage. c. A private policy will protect them against all lawsuits. d. A private policy will protect them from losing their license. ANS: B
The new graduate should purchase private malpractice insurance in addition to that of the institution to ensure that there is personal liability coverage. The private policy will cover the new graduate at any nursing job in which they are employed. No malpractice insurance policy can guarantee that there will not be any lawsuit or loss of license. DIF: Cognitive Level: Application TOP: Malpractice insuranceKEY: MSC: NCLEX: N/A
REF: 2031-2032 OBJ: 21 Nursing Process Step: N/A
MULTIPLE RESPONSE 1. What are considered duties of a team leader? (Select all that apply.) a. Receiving reports on assigned patients b. Making patient assignments for team members c. Assessing all assigned patients d. Administering medications to all patients e. Conferring with team members
ANS: A, B, C, E
Receiving reports on assigned patients, making patient assignments, assessing all assigned patients, and conferring with team members are duties of the team leader. Assisting team members with medication administration is a duty of the team leader, not actually administering the medications to all the patients. DIF: Cognitive Level: Comprehension TOP: Team leading MSC: NCLEX: N/A
REF: 2027 OBJ: 15 KEY: Nursing Process Step: N/A
2. Which actions would best aid the new nurse in coping with working the night shift? (Select
all that apply.) a. Eat large meals during the night to stay awake. b. Use dark shades to block out light when sleeping. c. Obtain a prescription for sedatives to aid sleep. d. Wear sunglasses on the drive home from work. e. Go directly to bed when arriving home from work. ANS: B, D
Dark shades or room darkening blinds will block the sunshine and allow for darkness when sleeping during the daytime hours. Wear sunglasses on the drive home from work to reduce the melatonin-reducing effect of sunshine. It is best to eat light, balanced meals during the night. Sedatives and alcohol should not be used as an aid to sleep. Allow time to unwind after work before going to bed, and try to follow the same routine daily. DIF: Cognitive Level: Application REF: 2015 TOP: Night shift KEY: Nursing Process Step: N/A
OBJ: 3 MSC: NCLEX: N/A
3. A nursing instructor is preparing her class for the NCLEX-PN examination. Which
statements by the students indicate understanding of the testing process? (Select all that apply.) a. “It will be a computerized adaptive test.” b. “I will have a maximum of 265 questions.” c. “The maximum time allowed for testing is 5 hours.” d. “The minimum number of questions on the test is 60.” e. “My state board of nursing must approve my application to test.” ANS: A, C, E
The NCLEX-PN examination is a computerized adaptive test. The minimum number of questions for the PN examination is 85, and the maximum number of questions is 205. The maximum time allowed for the test is 5 hours. The state board of nursing must approve the applicant for testing before the authorization to test is issued. DIF: Cognitive Level: Application TOP: NCLEX exam MSC: NCLEX: N/A
REF: 2019 OBJ: 7 KEY: Nursing Process Step: N/A
4. Which questions should the nurse consider before delegating care to another team
member? (Select all that apply.) a. Is this the right task? b. Is this the right time?
c. Is this the right person? d. Is this the right supervision? e. Is this the right circumstance? ANS: A, C, D, E
The five rights of delegation are right task, right circumstance, right person, right direction, and right supervision. Right time is not included in the five rights of delegation. DIF: Cognitive Level: Comprehension REF: 2027 TOP: Delegation KEY: Nursing Process Step: N/A
OBJ: 16 MSC: NCLEX: N/A
5. What data are necessary to compile an effective end-of-shift report? (Select all that apply.) a. Patient’s mental status b. Status of lung sounds c. All pertinent nursing care d. The patient’s favorite TV shows e. Visitors the patient had during the shift ANS: A, B, C
The patient’s mental status, status of lung sounds, and pertinent nursing care performed during the shift should all be included in an end-of-shift report. The patient’s favorite TV shows and visitors that the patient had during the shift would not normally be included in the end-of-shift report. DIF: Cognitive Level: Application TOP: End-of-shift report MSC: NCLEX: N/A
REF: 2031 OBJ: 20 KEY: Nursing Process Step: N/A
6. A manager is concerned that one of the nurses on the unit is experiencing burnout. Which
symptoms would support the concerns? (Select all that apply.) a. Fatigue b. Forgetfulness c. Increased energy d. Negative outlook e. Changes in eating habits ANS: A, B, D, E
Symptoms of burnout include fatigue, forgetfulness, decreased energy, negative outlook, and changes in eating habits. DIF: Cognitive Level: Comprehension REF: 2032 TOP: Burnout KEY: Nursing Process Step: N/A
OBJ: 22 MSC: NCLEX: N/A
COMPLETION 1. After ANS:
transcribing
each order in a list of orders, the nurse should check off the order.
The nurse should check off each order as it is transcribed to ensure that each order is implemented. DIF: Cognitive Level: Application REF: 2029 OBJ: 19 TOP: Orders KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 2. The experienced nurse who assists a novice to learn the skills of the profession is called
a(n)
.
ANS:
mentor The nurse who guides a novice in the skills of the profession is called a mentor. DIF: Cognitive Level: Comprehension REF: 2021 TOP: Mentoring KEY: Nursing Process Step: N/A
OBJ: 11 MSC: NCLEX: N/A
Cooper FAAHN 8e Chapter 1 Pretest
1. Primitive people believed that a person became ill when an evil spirit entered the a) mind b) spirit c) body d) house
.
2. Florence Nightingale’s plan focused on which concepts? a) Sanitation, recordkeeping, hygiene, and nutrition b) Documentation, assessment, planning, and teaching c) Cleanliness, grammar, recordkeeping, and leadership d) Education, bathing, care of wounds, health, and safety 3. How did World War I and World War II influence nursing? a) They increased focus on service to the patient. b) They offered nurse’s aide certification. c) They offered a career in the military. d) They pressured states to mandate requirements for nurses. 4. What is the difference between approved nursing programs and accredited nursing programs? a) There is no difference. b) Approved programs meet minimum state requirements, whereas accredited programs are reviewed by a professional organization with higher standards than the state. c) The accredited program requires the maximum state requirements, whereas the approved program requires the state’s minimum requirements. d) The approved programs are less expensive than the accredited programs. 5. The phrase holistic health care system indicates that this system’s focus is on the a) disease process of the patient b) patient’s perceived needs c) patient’s financial deficits d) comprehensive care of the patient
.
6. What are Maslow’s five categories of basic human needs? a) Nutrition, safety, love, confidence, and talents b) Security, nutrition, family, self-esteem, and performance c) Physiologic, safety and security, love and belonging, self-esteem, and self-actualization d) Safety and security, self-actualization, education, family, and employment 7. Which is included in the Patient’s Bill of Rights? a) The patient has the right to refuse treatment and be informed of the medical consequences. b) The patient has the right to choose the nurse who is caring for him/her in the hospital. c) The patient has the right to discuss his/her health care provider’s practice with other providers to determine the provider’s ethics. d) The patient has the right to influence his/her roommate’s care while in the hospital. 8. Which falls within the LPN/LVN’s roles and responsibilities? a) Supervise nurse’s aides, registered nurses, and respiratory technicians b) Practice under a physician’s license c) Obtain and maintain current licensure and practice within the scope of practice d) Medically diagnose patients who are admitted to the hospital
1
Cooper FAAHN 8e Chapter 1 Pretest
9. A care plan is a document that outlines the . a) disease process of the patient b) health care provider’s strategy in caring for a patient c) methods used to meet the patient’s needs by the health care team d) general strategy of the unit in which the patient is admitted 10. The term health means . a) condition of physical, mental, and social well-being, and absence of disease b) without disease c) without disease, illness, or physical pain d) without worry or physical difficulties
Chapter Pretest Answers 1. 2. 3. 4. 5.
c a d b d
6. c 7. a 8. c 9. c 10. a
2
Cooper FAAHN 8e Chapter 2 Pretest 1. The difference between criminal law and civil law is that criminal law’s focus is law’s focus is . a) battery; marital divorce b) public offenses; a person’s rights c) a person’s rights; public offenses d) on those who have a criminal history; those offenses that occur in health care 2. A nurse-patient relationship is a a) political b) plutonic c) conservative d) legal
1
and civil
relationship.
3. A nurse is caring for a diabetic patient whose serum glucose level is 520 mg/dL prior to lunch. Insulin sliding scale coverage has been ordered by the health care provider with instructions to call her for any glucose level over 400 mg/dL. The nurse does not call the provider and goes to lunch. The patient develops ketoacidosis and is not stable. This nurse is liable for . a) commission b) malpractice c) breach of confidentiality d) battery 4. A patient is admitted to the surgery center for an endoscopic procedure. The nurse has a consent form for the endoscopic procedure that the patient is required to sign if he/she wishes to have the procedure. The patient states that the surgeon has discussed the procedure and the possible risks associated with the procedure. The nurse explains the procedure to the patient, along with the preprocedure and postprocedure care. This type of consent is an consent. a) endoscopic b) operative c) informed d) administrative 5. This bill was developed in 1972 by the American Hospital Association to promote the public’s understanding of their rights and responsibilities in health care. What is this bill called? a) Medical Bill of Rights b) Hospital Association Bill of Rights c) Patient’s Bill of Rights d) Consumers of Health Care Bill of Rights 6. Which is an ethical principle? a) Compassion b) Autonomy c) Bias d) Merit 7. The National Federation of Licensed Practical/Vocational Nurses’ Code of Ethics was developed to: a) assist LPN/LVNs in managing a crisis with a patient. b) assist LPN/LVNs in passing the NCLEX board examination. c) provide knowledge for the LPN/LVN about the scope of practice. d) provide legal counsel for the LPN/LVN. 8. PAS stands for: a) patient-assisted systems. b) practitioner-assisted suicide. c) patient-assisted suctioning. d) paralegal association of systems.
Cooper FAAHN 8e Chapter 2 Pretest
9. This legal document contains a patient’s wishes regarding such matters as “do not resuscitate.” This document is referred to as a(n) . a) advance directive b) minimal directive c) living will d) health care will 10. When caring for a patient with whom a nurse has a personal conflict, the nurse may a) refuse to care for the patient b) call the health care provider and release the patient c) abandon the patient d) request that the patient not be assigned to him/her Chapter Pretest Answers 1. 2. 3. 4. 5.
b d b c b
6. b 7. c 8. b 9. a 10. d
.
2
Cooper FAAHN 8e Chapter 3 Pretest 1. Patients’ charts are audited for which reasons? a) Observations, nursing diagnoses, and outcomes b) Quality of care, peer review, and quality assurance c) Standards of care, outcome, and services rendered d) Quality improvement, quality of care, and data collection 2. The section of the patient’s chart that contains observations, care given, and patient’s responses is: a) demographic data. b) physician’s progress notes. c) nurse’s notes. d) diagnostic reports. 3. One of the following is not a basic rule for charting? a) Write only what you observe, not opinions. b) Use direct quotes when appropriate. c) Write legibly. d) Mark through the error several times so it is not legible. 4. A Kardex or Rand system is a: a) card system that contains demographic information. b) card system that contains the patient’s medications and allergies. c) card system that contains patient orders and care needs. d) system that contains diagnostic reports. 5. An incident report is a form required for: a) any event that is not consistent with routine patient care. b) any event that is consistent with routine patient care. c) any services rendered for quality assurance purposes. d) notification that a patient’s chart is to be audited. 6. What is a clinical pathway? a) A schedule the health care provider assigns to the patient on a daily basis b) Another term for the hospital daily routine c) A plan in which many health care professionals schedule interventions to promote patient progress d) A schedule the patient develops every day with the nurse 7. Home health care nurses spend 50% of their time documenting in the patient record. Why do they spend so much time charting? a) They have to document the environment and family dynamics. b) They have to document precisely to receive reimbursement from Medicare and insurance. c) They have to document the collaboration among all nurses and other health care professionals. d) They have to document their time and travel. 8. Why are computers considered a benefit to documentation? a) Efficiency and legibility b) Ability to gain access to the Internet c) Ability to email providers instead of calling d) Save costs, such as paper 9. What are some security issues regarding the computerized documentation system? a) Legibility b) Ability to navigate the system c) Possible electrocution d) Confidentiality of information
1
Cooper FAAHN 8e Chapter 3 Pretest
10. Which agency regulates long-term care facilities? a) FDA b) USDA c) Department of Health d) Department of Health and Human Services
Chapter Pretest Answers 1. 2. 3. 4. 5.
b c d c a
6. c 7. b 8. a 9. d 10. c
2
Cooper FAAHN 8e Chapter 4 Pretest
1. Which is not a requirement for communication? a) Sender b) Receiver c) Narrator d) Two-way communication 2. Which is a form of nonverbal communication? a) Eye contact b) Jargon c) Connotation d) One-way communication 3. Assertive communication is a form of communication in which the: a) nurse takes into account the feelings and needs of the patient. b) nurse interacts with another in an overpowering and forceful manner. c) nurse’s personal rights are sacrificed at the expense of feeling resentful toward the patient. d) nurse and the patient are interrupting each other while the other is speaking. 4. Listening is a form of which type of communication? a) Assertive b) Aggressive c) Closed d) Nonverbal 5. The term paraphrasing means restating a: a) phrase to elicit clarification of what was communicated. b) phrase in one’s own terms to verify what was communicated. c) phrase in the exact words the sender used. d) partial phrase to hurry the sender’s communication techniques to save time. 6. Which physiologic factor might hinder communication? a) Grief b) Environment c) Pain d) Culture 7. In regard to personal space, which zone is considered an intimate zone? a) 12 feet or more b) 0-18 inches c) 4-12 feet d) 2-4 feet 8. Which type of aphasia indicates the patient is not able to recognize or interpret the message being received? a) Expressive aphasia b) Nonverbal aphasia c) Receptive aphasia d) Verbal aphasia 9. How might a nurse communicate with a patient who is on a ventilator? a) Facial expression b) Talking to the patient c) Ignoring the patient d) Utilizing a communication board 10. When caring for an unresponsive patient, the nurse should:
1
Cooper FAAHN 8e Chapter 4 Pretest
a) ignore the patient while providing care. b) talk to the patient and explain every procedure or activity that is to take place. c) speak to the patient using medical jargon while providing care to the patient. d) provide loud, audible stimuli while caring for the patient. Chapter Pretest Answers 1. c 2. a 3. a 4. d 5. b
6. c 7. b 8. c 9. d 10. d
2
Cooper FAAHN 8e Chapter 5 Pretest
1
1. Which process is the framework for the practice of nursing? a) Outcomes process b) Management process c) Nursing process d) Assessment process 2. The assessment process is best described as one in which the nurse a) orients the patient to the environment and ensures safety b) collects information and analyzes data c) collects data and reports it to the health care provider d) collects subjective data and reports it to the charge nurse
.
3. The nurse is admitting a patient who is confused and lethargic at times. The patient’s family is at the bedside. The nurse obtains information from the family regarding the patient. This type of data is considered: a) objective. b) subjective. c) primary. d) secondary. 4. Components of the patient problem statement consist of: a) signs and symptoms, cause, and defining characteristics. b) medical label, risk factors, and characteristics. c) nursing interventions, evaluation, and defining characteristics. d) label, definition of the problem, and outcome. 5. A “possible” patient problem statement is utilized when: a) there is no other option. b) a problem is feasible. c) a problem arises and there is a possibility of complications. d) there are no problems or complications, but a risk is noted. 6. Patient problem statements are ranked in order of priority of the patient’s health and safety issues. Which problem statement would be the highest priority? a) insufficient knowledge of disease process b) impaired breathing related to shortness of breath c) impaired skin integrity related to immobility d) impaired coping mechanisms related to medical diagnosis 7. Nursing interventions are: a) broad, general statements. b) steps to complete the evaluation process. c) actions selected or prescribed by the nurse to achieve the desired patient outcome. d) part of the patient problem statement. 8. Clinical pathways are a time frame. a) concise b) collaborative c) measured d) multidisciplinary
plan that schedules clinical interventions over an anticipated
9. During the evaluation phase, the nurse should make one of three judgments regarding the desired outcome. These judgments regarding the outcome are: a) managed, timely, or accurate. b) accurate, concise, or patient-centered.
Cooper FAAHN 8e Chapter 5 Pretest
c) achieved, not achieved, or partially achieved. d) reasonable, timely, or achieved. 10. Case management is the assignment of a health care provider to a patient so the care of that patient is overseen by one individual. This individual typically is a(n): a) nurse. b) physician. c) insurance agent. d) nurse practitioner.
Chapter Pretest Answers 1. 2. 3. 4. 5.
c b d a b
6. b 7. c 8. d 9. c 10. a
2
Cooper FAAHN 8e Chapter 6 Pretest
1. What does transcultural nursing mean? a) Translating different cultural practices into nursing practice b) Understanding various cultural practices and applying them to nursing care c) Understanding cultural practices d) Traveling to other countries to provide nursing care 2. What is ethnocentrism? a) Belonging to one ethnic group b) Believing a person’s cultural practices and beliefs should be the standard c) Educating others about one ethnic group d) Educating other health care professionals about various ethnic groups 3. When communicating, in what culture does silence indicate respect? a) French b) Native American c) Russian d) Asian 4. Some Asian and Native American cultures believe eye contact indicates: a) rudeness. b) interest. c) shyness. d) honesty. 5. Which culture views time as “elastic,” indicating time is flexible? a) European b) Asian c) Hispanic d) Filipino 6. A patriarchal culture believes in which social structure? a) Decisions are made based on a democratic process. b) The female of the household makes the decisions. c) The male of the household makes the decisions. d) The eldest of the household makes the decisions. 7. Our Western culture believes in which type of health practice? a) Folk medicine b) Biomedical medicine c) Holistic medicine d) Spiritual medicine 8. Chinese-American health beliefs focus on which type of medicine? a) Holistic b) Folk c) Biomedical d) Spiritual 9. The holiday Ramadan is practiced by members of what religion? a) Chinese b) European c) Buddhist d) Muslim 10. Fasting during which religious holiday is a practice of the Jewish faith? a) Lent
1
Cooper FAAHN 8e Chapter 6 Pretest
b) Yom Kippur c) Kwanzaa d) Ramadan
Chapter Pretest Answers 1. 2. 3. 4. 5.
b b d a c
6. c 7. b 8. a 9. d 10. b
2
Cooper FAAHN 8e Chapter 7 Pretest
1. What does infection control mean? a) Control of infection within the community b) Control of infection within a facility c) Monitoring infection within the facility and the community d) Limiting infection within a specified area 2. What is medical asepsis? a) Removing organisms within a medical facility b) Eliminating organisms utilizing medical disinfectants c) Eliminating the growth and spread of pathogenic organisms utilizing clean technique d) Eliminating pathogens within a medical clinic 3. The nurse explains that a mode of transmission for a particular disease is a vector. The patient asks, “What is a vector?” She explains a vector is a(n): a) single-celled organism. b) organism that has flagella. c) living carrier. d) inanimate object. 4. What is the difference between a localized infection and a systemic infection? a) The local infection is within a community, and a systemic infection is in more than one community. b) A local infection is confined to a particular area of the body, and a systemic infection is throughout the body. c) A localized infection is within a particular body system, and a systemic infection affects more than one body system. d) A localized infection causes minimal complications, and a systemic infection has many complications. 5. The infection control nurse is explaining to certified nurse’s aides that health care–associated infection means: a) an infection that infects a society. b) an infection that inhabits a facility. c) normal flora within medical facilities. d) an acquired infection while in a medical facility within 12 hours after admission. 6. How are health care–associated infections typically spread? a) By fomites b) By vectors c) Through direct contact with health care personnel d) From contaminated foods served within a health care facility 7. When is the double bagging procedure utilized? a) Whenever a patient is placed in isolation b) When it is impossible to keep the outer surface of a bag free from contamination c) When linen is grossly contaminated with body fluids d) Each time linen is changed in a patient’s room 8. Which of the following is on the second tier of the CDC’s isolation guidelines? a) Airborne, droplet, and contact precautions b) Standard precautions c) Standard precautions and double bagging d) Sterile technique 9. What portion of a sterile drape is considered nonsterile? a) 2 cm of the border
1
Cooper FAAHN 8e Chapter 7 Pretest
b) 1-inch border c) None, the entire drape is sterile d) The portion touched when opening the drape 10. What is lipping? a) Kissing another person b) Placing a sterile drape around a container c) Pouring a small amount of a sterile solution that is discarded before pouring for a sterile procedure d) Adding a sterile adapter to a solution to avoid spilling
Chapter Pretest Answers 1. 2. 3. 4. 5.
b c c b d
6. c 7. b 8. a 9. b 10. c
2
Cooper FAAHN 8e Chapter 8 Pretest 1. Which profession has the highest workers’ compensation claims? a) Iron workers b) Certified nurse’s aides c) Farmers d) Nurses 2. Which system must be protected to minimize injury to the nurse and patient? a) Respiratory b) Musculoskeletal c) Cardiovascular d) Gastrointestinal 3. The patient states the doctor informed her that her cervical spine is out of alignment. This means the cervical spine: a) is straight. b) must be manipulated. c) is not in line with the thoracic vertebrae. d) is normal. 4. The term supine indicates a position in which the patient is lying on the: a) back. b) side. c) stomach. d) side with knees flexed. 5. Semi-Fowler’s position is a position in which the head of the bed is: a) elevated at a 90-degree angle. b) flat. c) slightly lower than the foot of the bed. d) elevated at a 30-degree angle. 6. The prone position is lying on one’s: a) back. b) side. c) stomach. d) side with knees flexed. 7. What does passive ROM mean? a) A nurse or other person performs exercises to a patient’s extremities. b) The patient moves extremities minimally without exertion. c) The patient moves extremities in an extreme manner. d) The patient does not perform exercises to his/her extremities. 8. Before assisting a patient to ambulate to the bathroom, the nurse should first assess: a) the patient’s footwear. b) that the bed alarm has been disarmed. c) the patient’s ability to assist with ambulation. d) that assistive devices are within the patient’s reach. 9. The use of a lift (draw) sheet prevents which type of injury to the patient? a) Shearing b) Fracture c) Ulcerations d) Laceration 10. The nurse must assess neurovascular function, also called CMS assessment. CMS stands for:
1
Cooper FAAHN 8e Chapter 8 Pretest
a) constant movement and sensation. b) contained movement of systems. c) circulation, movement, and sensation. d) circulation, movement, and saturation.
Chapter Pretest Answers 1. 2. 3. 4. 5.
d b c a d
6. c 7. a 8. c 9. a 10. c
2
Cooper FAAHN 8e Chapter 9 Pretest
1. Which is not a factor affecting personal hygiene? a) Social practices b) Cultural variables c) Knowledge d) Product preferences 2.
What room temperature is good for a patient’s hospital room? a) 78° to 80° F b) 65° to 70° F c) 68° to 74° F d) 68° to 80° F
3. A sitz bath cleanses which area? a) Perineal and rectal areas b) Axillae c) Labia folds d) Femoral areas 4. Which is a type of substance used for a medicated bath? a) Betadine b) Saline c) Oatmeal d) Oil 5. Which condition contraindicates a massage? a) Infection b) Pulmonary embolism c) Asthma d) Ileus 6. Which type of patient is prone to develop a pressure sore? a) Asthmatic patient who is up ad lib b) COPD patient who requires assistance to the bathroom c) Chronic renal failure patient who requires assistance getting out of bed d) Confused female with a diagnosis of pneumonia who is lethargic and unable to utilize the call light for assistance 7. Which skin integrity problem can occur when improperly lifting or pulling a patient up in bed? a) Rubbing b) Shearing c) Friction d) Abrasion 8. Which type of physician should be consulted for a diabetic patient with thick, long, yellow toenails? a) Surgeon b) Family-practice physician c) Podiatrist d) Pediatrician 9. Which type of perineal care should be performed at least twice a day? a) Rectal b) Vaginal c) Urinary catheter care d) Uncircumcised care 10. When cleansing this area, the nurse should use clear, clean water only.
1
Cooper FAAHN 8e Chapter 9 Pretest
a) Eyes b) Urinary meatus c) Rectal meatus d) Nares
Chapter Pretest Answers 1. 2. 3. 4. 5.
d c a c b
6. c 7. c 8. c 9. c 10. a
2
Cooper FAAHN 8e Chapter 10 Pretest
1. What is the most common problem that nurses need to address to ensure the safety of their patients? a) Call light not in reach of the patient b) Percentage of falls in the facility c) Patients who are violent d) Side rails not in the upright position 2. What are some safety considerations a nurse should contemplate when caring for an older adult? a) They are old and frail. b) They are bitter and take a lot of medications. c) Their visual acuity is not good, and their reflexes are slow. d) They are concerned about their finances and what this hospitalization will cost them. 3. What type of problem is a major concern for older adults? (Select all that apply.) a) Driving b) Hospitalizations c) Accidental poisoning d) Loneliness 4. What national organization provides guidelines to protect health care workers in their environment? a) National Institutes of Health b) National Alliance for Health Care Providers c) National League of Nurses d) Occupational Safety and Health Administration 5. What type of sensitivity is often seen in the health care environment? a) Allergic reactions to disinfecting chemicals b) Reactions to airborne diseases c) Latex allergies d) Vinyl allergies 6. What does “SRD” stand for? a) Safety Restraining Device b) Safety Reminder Device c) Secure Restraint Detector d) Sentry Radiation Detector 7. What does “RACE” stand for? a) Reaction Accordingly to a Care Environment b) Remove, Accelerant, Contain, and Eliminate c) Rescue, Alarm, Confine, Extinguish d) Rescue, Alert, Contain, and Eliminate 8. Why should a hospital have a disaster plan? a) To be prepared in times of an emergent community situation with the possibility of a large number of casualties b) To be familiar with possible emergent situations that could affect a community c) To eliminate factors that could cause a community disaster d) To fulfill federal guidelines that pertain to hospitals 9. What does universal carry mean? a) How to remove a patient from the bed to the floor b) How to carry a patient as if he/she were an infant c) How to carry two patients at one time d) How to evacuate several patients in a short amount of time
1
Cooper FAAHN 8e Chapter 10 Pretest
10. What needs to be removed from a fire extinguisher before it can be activated? a) The nozzle b) The handle c) The inspection tag d) The pin
Chapter Pretest Answers 1. 2. 3. 4. 5.
b c a, b, c, d d c
6. b 7. c 8. a 9. a 10. d
2
Cooper FAAHN 8e Chapter 11 Pretest
1. Empathy means: a) treating others with respect. b) involving others in the patient’s care. c) understanding and sharing feelings another is experiencing. d) expressing feelings with another. 2. What actions by the nurse might ease a patient’s anxiety? a) The nurse ignores the patient’s feelings and places the patient in a private room. b) The nurse hurries with her admission assessment so the patient might have some time alone. c) The nurse is kind, empathetic, warm, and patient and treats the patient with respect. d) The nurse calls the patient’s family to calm the patient. 3. What is a telephone admission? a) A phone conversation with a patient who is receiving home health care b) A phone conversation to obtain information prior to hospitalization and provide the patient with information prior to admission c) A phone conversation with the patient’s insurer to obtain preauthorization for admission to the hospital d) A phone conversation with a health care provider to obtain orders prior to the patient’s admission 4. What information is not required by emergency department admissions for a patient who was brought in for treatment? a) Date of birth b) Insurance company c) Mother’s maiden name d) Health care provider’s name 5. What should a nurse do with a patient’s money and jewelry if a family member is not present? a) Place them in the hospital safe. b) Place them in the patient’s bedside table drawer. c) Place them in the patient’s closet with the rest of the patient’s clothing. d) Place them in a secure area in the nurse’s station. 6. When is the discharge planning process initiated? a) Once a discharge order has been obtained from the health care provider b) Once the patient is ready to leave the hospital c) Once the insurance company has given a discharge date d) Upon admission to the hospital 7. What is transitional care? a) A discharge planning approach in which the specialists assist with the discharge process and are available to the patient after discharge b) A discharge planning process in which a patient is transitioned through various areas within a facility to ensure the patient’s ability to care for self at home c) Describes the emotional process a patient experiences prior to discharge d) A term utilized by discharge planners to describe certain insurance criteria to indicate the progress a patient is making toward discharge 8. What is a discharge planner’s role in the hospital environment? a) Discharge patients throughout the hospital b) Transfer patients to various facilities within the community c) Assist and coordinate the discharge planning needs of patients d) Assess needs of patients and inform home health care agencies of potential clients 9. What disciplines might be involved in the discharge planning process?
1
Cooper FAAHN 8e Chapter 11 Pretest
a) Physician, psychiatrist, and nurse practitioner b) Dietitian, social worker, and home health care nurse c) Chaplain, nurse’s aide, and respiratory therapist d) Radiology technician, pharmacist, and nurse’s aide 10. What does AMA mean? a) Against the menial actions b) Against medical advice c) Against medical associations d) Against autocratic medical associations
Chapter Pretest Answers 1. 2. 3. 4. 5.
c c b c a
6. d 7. a 8. c 9. b 10. b
2
Cooper FAAHN 8e Chapter 12 Pretest
1. Why is it important to obtain vital signs? a) It is usual nursing practice. b) Vital signs may indicate problems. c) It is required by law. d) Vital signs may indicate the general mood of a patient. 2. What factors can affect a person’s temperature? a) Age and income level b) Lifestyle practices c) Gender d) Environment 3. What is the difference between core temperature and surface temperature? a) Core temperature indicates the temperature of deep tissues, and surface temperature indicates temperature of the skin. b) Core temperature is the temperature of the rectum, and surface temperature is the axillary temperature. c) Core temperature is the temperature of the earth’s core, and surface temperature is ground temperature. d) Core temperature refers to a rectal temperature, and surface temperature is an oral temperature. 4. Why is an oral temperature not obtained in a comatose patient? a) It is not accurate because the patient is hypothermic. b) The comatose patient breathes through the mouth. c) The patient is unable to assist with holding the thermometer. d) An axillary temperature is more accurate. 5. What tool does the nurse utilize to obtain an apical heart rate? a) Thermometer b) Dinamapp c) Stethoscope d) Doppler 6. What part of the stethoscope is utilized to assess lung sounds? a) Bell b) Diaphragm c) Tubing d) Binaurals 7. A dysrhythmia is a(n): a) artery that is occluded. b) vein that is occluded. c) abnormal lung sound. d) abnormal heart rate. 8. When assessing respirations, the nurse should assess: a) rate, depth, rhythm, and quality. b) depth, efficiency, and rate. c) strength, rate, and temperature. d) rate, pulse oximetry, and effort. 9. Apnea means: a) regular respiratory rate. b) shallow breathing. c) lack of respirations.
1
Cooper FAAHN 8e Chapter 12 Pretest
d) rapid respirations. 10. Which blood pressure reading is most indicative of hypertension? a) BP 140/80 b) BP 140/90 c) BP 142/76 d) BP 128/76
Chapter Pretest Answers 1. 2. 3. 4. 5.
b d a c c
6. b 7. d 8. a 9. c 10. b
2
Cooper FAAHN 8e Chapter 13 Pretest
1
1. When obtaining information from a patient, the nurse inquires about signs and symptoms the patient has encountered. A rash would be considered a . a) symptom b) physical abnormality c) sign d) subjective data 2. How is a medical assessment different from a nursing physical assessment? a) The medical assessment is performed by a physician and focuses on the disease process and physical signs and symptoms. The nursing assessment is holistic in its approach, including signs and symptoms. b) The medical assessment focuses on the disease process, whereas the nursing assessment focuses on the nursing process. c) The medical assessment focuses on lab values and physical examination, whereas the nursing assessment focuses on the physical examination. d) The medical assessment focuses on the physical examination, whereas the nursing assessment focuses on the subjective data. 3. Upon initial contact with a patient, which is needed to establish a therapeutic nurse-patient relationship? a) Avoid eye contact and hurry through the assessment. b) Maintain eye contact, introduce yourself, allow questions, and maintain confidence and professionalism. c) Maintain eye contact, ask closed questions, perform a quick interview, and avoid answering questions until the interview is completed. d) Minimize eye contact, interview quickly, and leave the room so the patient can visit or contact family. 4. During the initial step in the nursing health history, the nurse would verify which data gathered by the admitting office to verify accuracy? a) Allergies b) Past hospitalizations c) Lifestyle habits d) Biographic data 5. Chief complaint refers to: a) issues that have caused unhappiness. b) the reason for seeking health care. c) issues that have cost the patient a considerable amount of money. d) issues with the health care system. 6. The purpose of the nurse’s physical assessment of a patient is to determine: a) the patient’s state of health. b) abnormalities and ask the patient to consult his/her physician. c) minor ailments and recommend methods to cure these ailments. d) the health needs and recommend health care professionals to meet those needs. 7. When performing a nursing physical assessment, the nurse’s approach should include assessing: a) the skin, and proceeding through the other body systems. b) the body in an anterior-to-posterior approach. c) the neurologic status, then the body in a head-to-toe approach, focusing on the body systems. d) the head and the lower extremities, proceeding to the body systems that pertain to signs and symptoms about which the patient has voiced complaints. 8. Which physical areas of the body are appropriate for assessing skin turgor? a) Top of the feet and cervical area
Cooper FAAHN 8e Chapter 13 Pretest
b) Posterior thigh and wrist c) Back of the hand and sternum d) Frontal area and posterior thorax 9. When assessing the abdomen, which is not an assessment that is performed by the nurse? a) Deep palpation of masses b) Light palpation of four quadrants c) Auscultation for bowel sounds d) Inspection for lesions 10. Which is an adventitious lung sound? a) Clear and breezy b) Swishing c) Coughing d) Rhonchi
Chapter Pretest Answers 1. c 2. a 3. b 4. d 5. b
6. a 7. c 8. c 9. a 10. d
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Cooper FAAHN 8e Chapter 14 Pretest
1
1. What is the normal range of PaO2 for an older adult? a) 65-75 mm Hg b) 50-60 mm Hg c) 100-120 mm Hg d) 80-100 mm Hg 2. What should the nurse monitor for signs of skin breakdown during oxygen delivery via nasal cannula? a) top of the ears b) bridge of the nose c) oral cavity d) eyelid crease 3. The decreased amount of oxygen content in tissue and cells resulting from respiratory insufficiency is called: a) anoxia. b) cyanosis. c) hypercapnia. d) hypoxia. 4. Nasopharyngeal suctioning is designed to remove what from the upper respiratory tract? a) Acidosis b) Bronchi c) Accumulated secretions d) Cyanosis 5. An artificial opening made by a surgical incision into the trachea is called a(n): a) endotracheal suctioning. b) tracheostomy. c) bronchial suctioning. d) cannula. 6. It is especially dangerous to cause a spark in a room where which gas is being used? a) Carbon dioxide b) Helium c) Oxygen d) Nitrogen 7. If a patient is receiving oxygen via face mask, the nurse should evaluate the skin every: a) 2-4 hours. b) 6-8 hours. c) 15 minutes. d) 2-4 days. 8. An endotracheal tube is used to: a) administer parenteral nutrition. b) provide a patent airway. c) remove a respiratory obstruction. d) enable the patient to speak. 9. Which piece of equipment should the nurse use to perform oropharyngeal suctioning? a) T-tube b) Venturi mask c) Nasal cannula d) Yankauer 10. What is the correct suction catheter size for use on an infant? a) 10- to 12-Fr
Cooper FAAHN 8e Chapter 14 Pretest
b) 12- to 14-Fr c) 6- to 8-Fr d) 4- to 6-Fr
Chapter Pretest Answers 1. 2. 3. 4. 5.
d a d c b
6. c 7. a 8. b 9. d 10. c
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Cooper FAAHN 8e Chapter 15 Pretest
1. A coudé catheter is used for which type of patient who has urinary retention? a) A male patient who has had general anesthesia b) A male patient with a history of prostate enlargement c) A female patient with swollen labia d) A male patient with hypospadias 2. Unlicensed assistive personnel may generally perform which task? a) First-time urinary catheterization b) Performing catheter irrigation c) Obtaining urinary specimen from a catheter d) Catheterization of patients with urethral trauma 3. One action that may assist a patient to regain bladder control is to: a) teach her Kegel exercises. b) ambulate her regularly. c) use absorbent panty liners to prevent wetness. d) restrict fluids to 1000 mL per day. 4. Self-catheterization in the home requires: a) sterile technique. b) clean technique. c) surgical asepsis. d) hygienic technique. 5. Older adults undergoing bladder retraining require a fluid intake of at least a) 1000 b) 3500 c) 2000 d) 500
mL/day.
6. Urine leakage when a person coughs, laughs, or lifts something heavy is called: a) urge incontinence. b) pressure incontinence. c) social incontinence. d) stress incontinence. 7. Dumping syndrome is caused by: a) too-rapid infusion of highly concentrated feedings. b) obstruction of the NG tube. c) excessive intake of water. d) an adverse reaction to antibiotic medications. 8. When irrigating an NG tube, the patient should be placed in which position? a) Sims b) semi-Fowler’s c) Trendelenburg d) side-lying 9. The presence of air or gas in the intestinal tract is called: a) peristalsis. b) defecation. c) ostomy. d) flatus. 10. The surgical creation of an opening in the distal part of the small intestine to allow the passage of fecal material is called a(n): a) urostomy.
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Cooper FAAHN 8e Chapter 15 Pretest
b) colostomy. c) ileostomy. d) enema.
Chapter Pretest Answers 1. 2. 3. 4. 5.
b c a b c
6. d 7. a 8. b 9. d 10. c
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Cooper FAAHN 8e Chapter 16 Pretest
1. This law has been enacted in several states to protect health professionals from legal liability in the event of providing emergency first aid. This law is the: a) Commonwealth law. b) Emergency Medical Act. c) Good Samaritan law. d) Malpractice Amnesty Act. 2. Which organization requires that hospitals have an emergency plan for treating patients contaminated with radioactive substances? a) World Health Organization (WHO) b) Occupational Safety and Health Administration (OSHA) c) Centers for Disease Control (CDC) d) American Red Cross 3. The heart and lungs have stopped functioning in which type of death? a) Biologic death b) Brain death c) Physical demise d) Clinical death 4. After 10 minutes of CPR, a) brain death b) clinical death c) cellular death d) pulmonary distress
occurs.
5. Which maneuver could be performed on a conscious adult who is choking? a) Spock’s maneuver b) Abdominal thrusts c) Valsalva’s maneuver d) Piaget’s maneuver 6. What type of pressure is applied to the artery located above the wound? a) Direct pressure b) Sustained pressure c) Indirect pressure d) Superior pressure 7. What could cause a nosebleed (epistaxis)? a) High altitude b) Hypertension c) High humidity d) Tylenol 8. What nursing intervention is beneficial for a patient with epistaxis? a) Application of steady pressure to both nostrils b) Application of petroleum jelly in the nares c) Application of heat d) Extending the patient’s head 9. If the nurse suspects an ingestion poisoning, whom should the nurse call? a) Emergency department b) Primary care provider c) Poison control center d) Local police department
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Cooper FAAHN 8e Chapter 16 Pretest 10. Hypothermia can result when an individual’s body temperature falls below a) 95 b) 90 c) 96 d) 88 Chapter Pretest Answers 1. 2. 3. 4. 5.
c b d a b
6. c 7. b 8. d 9. c 10. a
° F.
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Cooper FAAHN 8e Chapter 17 Pretest
1. One grain equals how many milligrams? a) 15 mg b) 30 mg c) 60 mg d) 25 mg 2. 30 grams is equivalent to how many ounces? a) 15 oz b) 2 oz c) 0.3 oz d) 1 oz 3. 1000 meters is equal to how many kilometers? a) 0.5 km b) 1 km c) 5 km d) 10 km 4. What is the pharmacology phase in which the drug moves through the body and reaches the site for which it is intended? a) Pharmaceutical phase b) Pharmacokinetic phase c) Pharmacodynamic phase d) Pharmacosynthetic phase 5. Which factor can affect the patient’s response to medication? a) Gender b) Race c) Type of medication d) Age 6. Which is a controlled substance? a) Tylenol b) Vicodin c) Ibuprofen d) Ambien 7. Which is not one of the “six rights” of medication administration? a) Right medication b) Right time c) Right dose d) Right instruction 8. Which is the slowest but safest route to administer medications? a) Intramuscular b) Intravascular c) Oral d) Self-administered 9. Which medication is administered rectally? a) Ampule b) Suppository c) Ointment d) Transdermal 10. The health care provider orders a medication to be administered by the buccal route. This route is:
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Cooper FAAHN 8e Chapter 17 Pretest
a) between the cheek and teeth. b) under the tongue. c) inhalation by the nostrils. d) per the rectum.
Chapter Pretest Answers 1. 2. 3. 4. 5.
c b d d b
6. b 7. d 8. c 9. b 10. a
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Cooper FAAHN 8e Chapter 18 Pretest
1.
What is a normal percentage of water for an adult’s body? a) 70% b) 60% c) 80% d) 20%
2. What is plasma? a) The amount of blood volume b) The amount of urine processed by the nephrons c) The liquid portion of the blood d) The amount of circulating blood cells 3. How does fluid leave the body? a) Through urine and stool b) By kidneys, lungs, skin, and GI tract c) Via the GI tract and kidneys d) By the lungs and the kidneys 4. Which process is the movement of water from an area of lower concentration to an area of higher concentration? a) Osmosis b) Diffusion c) Filtration d) Hydrostatic pressure 5. Which process requires energy? a) Passive osmosis b) Active filtration c) Active transport d) Passive diffusion 6. What does hyponatremia mean? a) Too little sodium b) Too much sodium c) Adequate amounts of potassium d) Too little potassium 7. What can occur when a patient is hypocalcemic? a) Blood loss b) Tetany c) Drowsiness d) Renal calculi 8. A pregnant female should increase which nutrient in her diet? a) Potassium b) Sodium c) Chloride d) Phosphorus 9. What type of IV fluid is compatible with blood? a) D5W b) LR c) D51/2 NS d) NS 10. An autologous blood transfusion is the infusion of:
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Cooper FAAHN 8e Chapter 18 Pretest
a) platelets. b) RBCs. c) WBCs. d) a patient’s own blood.
Chapter Pretest Answers 1. 2. 3. 4. 5.
b c b a c
6. a 7. b 8. d 9. d 10. d
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Cooper FAAHN 8e Chapter 19 Pretest
1. What are essential nutrients? a) They are nutrients that provide energy. b) They are nutrients that the body cannot make. c) They are nutrients required for growth. d) They are nutrients found in fruits and vegetables. 2. What is a monosaccharide? a) Starch b) Protein c) Simple sugar d) Simple saturated fat 3. Once stores are full, further excess is converted to adipose tissue. a) fat b) carbohydrate c) glycogen d) sucrose 4. Which type of fats increases a person’s cholesterol levels? a) Polyunsaturated fats b) Saturated fats c) Unsaturated fats d) Trans fats 5. Dietary cholesterol is highest in which types of meat? a) Poultry b) Beef c) Fish d) Organ 6. Which is a byproduct of protein metabolism? a) Nitrogen b) Phosphorus c) Calcium d) Potassium 7. A person who is on a vegan diet lacks which vitamin? a) B6 b) C c) D d) B12 8. What is needed to assist in the digestion of fats? a) Insulin b) Bile c) Gastric acids d) Nitrogen 9. Which is a fat-soluble vitamin? a) C b) B6 c) A d) B12 10. Pernicious anemia is a lack of which vitamin? a) B6
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Cooper FAAHN 8e Chapter 19 Pretest
b) C c) B12 d) D Chapter Pretest Answers 1. 2. 3. 4. 5.
b c c b d
6. a 7. d 8. b 9. c 10. c
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Cooper FAAHN 8e Chapter 20 Pretest
1. What does complementary therapy mean? a) Complementary programs provided by a health care facility b) Therapies used in addition to conventional treatments c) Therapies that include additional costs during hospitalization d) Therapies that a physician’s assistant provides 2. What does alternative therapy mean? a) Alternative options offered by a physician b) Alternative therapies offered by a psychologist c) The primary treatment instead of conventional medicine d) Alternative options in addition to conventional medicine 3. Why should the nurse maintain a nonjudgmental attitude in obtaining a health history when admitting a patient to the hospital? So the nurse can: a) learn more about the different therapies. b) learn about therapies offered in the surrounding community. c) inform the patient of quackery within the community. d) obtain information regarding all therapies the patient is currently receiving. 4. What is herbal therapy? a) Medicine developed by an herbalist. b) A derivative from the whole plant used to treat illness and maintain health. c) Derived from plants and given to those who have no other treatment options. d) A pharmaceutical filler sold over the counter. 5. How do herbs differ from pharmaceuticals? a) The only difference is herbs are not regulated as pharmaceuticals are. b) The difference is herbs utilize the whole plant, whereas pharmaceuticals utilize only a portion of the plant. c) There is no difference. d) The pharmaceuticals are more expensive and available only by a prescription, whereas the herbs can be purchased over the counter. 6. What is the difference between acupressure and acupuncture? a) Acupressure applies pressure to certain body points, whereas acupuncture applies a needle to these points. b) Acupressure and acupuncture are the same. c) Acupressure is performed by a lay person, whereas acupuncture must be performed by a physician. d) Acupressure is pressure applied to the head and neck, whereas acupuncture is applied to the extremities. 7. A chiropractic doctor cannot: a) manipulate joints. b) prescribe medicine. c) prescribe holistic treatments. d) manipulate the cervical spine. 8. What are the four main benefits of reflexology? a) Relieves stress, prevents illness, increases warmth, and promotes digestion b) Invokes coolness, enhances brain cells, increases metabolism, and limits stress c) Removes stress, enhances circulation, normalizes metabolism, and complements other healing modalities d) Relieves fasciae, promotes health, relieves stress, and increases libido 9. What is the benefit of imagery?
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Cooper FAAHN 8e Chapter 20 Pretest
a) Focus on a specific image b) Evoke physical changes in the body c) Relax the mind d) Promote endorphins 10. What is animal-assisted therapy? a) Health care providers caring for animals b) Animals utilized to assist patients reach their goals c) Animals used to carry items and open doors for those patients who need assistance d) Animals utilized to provide love to patients
Chapter Pretest Answers 1. 2. 3. 4. 5.
b c d b b
6. a 7. b 8. c 9. b 10. b
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Cooper FAAHN 8e Chapter 21 Pretest
1. What is one of the greatest challenges for nurses today? a) Promoting rest b) Providing comfort c) Recognizing discomfort signals d) Providing alternative pain management therapies 2. How would you describe acute pain? a) Lasting longer than 6 months b) Causing sleep disturbances and depression c) Intense and of short duration d) Continuous and intense 3. Which statement is a portion of the gate control theory? a) Pain is intermittent. b) Pain is easily evaluated and controlled. c) The brain is unable to process pain while interpreting other stimuli. d) The brain interprets pain and sends bombarding signals to the localized area. 4. What is considered the fifth vital sign? a) Pulse oximetry b) Skin assessment c) Fall assessment d) Pain assessment 5. Which organization established standards for health care providers regarding pain assessment and management? a) OSHA b) AAPR c) The Joint Commission d) DMV 6. What type of data is considered subjective? a) “My pain begins here and extends to here.” b) The patient is very irritable. c) The patient’s heart rate is 120. d) The patient’s fists are clenched. 7. Which is considered a noninvasive pain relief technique? a) Guided imagery b) Warm blankets c) Tightening wrinkled bed linen d) Acupuncture 8. Which medication is considered an opioid? a) Tylenol b) Ibuprofen c) Demerol d) Anaprox 9. Which route is considered the preferred route to manage chronic pain? a) Subcutaneous b) IM c) IV d) Oral 10. Which is a physiologic sign of sleep deprivation?
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Cooper FAAHN 8e Chapter 21 Pretest
a) Decreased reasoning and judgment b) Mood swings c) Fatigue d) Hyperexcitability
Chapter Pretest Answers 1. 2. 3. 4. 5.
b c c d c
6. a 7. a 8. c 9. d 10. a
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Cooper FAAHN 8e Chapter 22 Pretest
1. What does primary intention mean? a) The first stage of the healing process b) A surgical wound c) A puncture wound d) An infection of a surgical wound 2. Rest and activity are important to the healing process because they cause: a) exhaustion, which promotes deep sleep. b) increased calorie consumption. c) increased circulation and oxygenation of the wound, which promotes healing. d) early mobilization and release from the hospital. 3. How often should a nurse inspect a postoperative surgical wound within the first 24 hours? a) Every hour b) Every shift c) Every 15 minutes d) Every 2-4 hours 4.
How much fluid should the patient consume during the postoperative period? a) 1200-1500 mL b) 2000-2400 mL c) None, the patient should remain NPO d) 200-800 mL
5. A gauze dressing permits: a) air to reach the wound. b) oxygen to reach the wound. c) nothing to reach the wound. d) bacteria to reach the wound. 6. The primary purpose of a wet-to-dry dressing is to: a) increase moisture. b) remove debris. c) improve circulation. d) eliminate bacteria. 7. What does dehiscence mean? a) The wound is healing properly. b) The wound is draining purulent drainage. c) The layers of the wound have separated. d) The wound is infected. 8. Why are staples used to adhere an incision? They are: a) flexible. b) strong and quick to use. c) made of stainless steel. d) less expensive than sutures. 9. What is serous drainage? a) Bloody drainage b) Purulent drainage c) Colored drainage d) Watery drainage 10. What should the nurse assess and document regarding drainage? a) Inflammation, infection, and temperature
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Cooper FAAHN 8e Chapter 22 Pretest
b) Inflammation, drainage systems, and dressing changes c) Color, odor, consistency, and amount d) Amount and color
Chapter Pretest Answers 1. b 2. c 3. d 4. b 5. a
6. b 7. c 8. d 9. b 10. c
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Cooper FAAHN 8e Chapter 23 Pretest
1. What is informed consent? a) The patient legally consents to an invasive procedure knowing all the risks and possible complications. b) The patient consents to all procedures while admitted to the hospital. c) The patient consents to only those procedures performed by the attending physician. d) The patient consents to procedures in which he/she is informed of the risks. 2. Why is it important for the nurse to be able to assess lab values? a) The nurse needs to be able to inform the patient of lab results. b) The nurse must inform the physician of abnormal labs. c) The nurse must be able to assess the patient’s condition based on the lab values. d) The nurse does not assess lab values; this is the physician’s responsibility. 3. What is the nurse’s responsibility after a specimen has been collected? a) Label the specimen and give it to the secretary. b) Label the specimen. c) Label the specimen, ensure the delivery to the lab, and assess the results. d) Label the specimen; determine and diagnose the results. 4. What precautions should the nurse take when obtaining a specimen? a) Standard precautions b) Minimal precautions c) Universal precautions d) Facility procedures regarding the specimen collected 5. What is the function of a 24-hour urine specimen? a) Informs the physician of adrenal function b) Indicates the function of the patient’s bladder c) Indicates the function of the urinary system d) Indicates renal function and urinary output 6. Which stool specimen should be taken to the lab immediately after collection? a) Culture and sensitivity b) Bleeding c) Parasites d) Bacteria 7. What does occult mean when testing a stool specimen? a) Presence of bacteria b) Blood that cannot be seen c) Parasites d) Fat 8. Which time of the day is best for obtaining a sputum specimen? a) Evening b) Afternoon c) Morning d) Bedtime 9. The patient’s recommended medication, based on the type of bacteria identified, is determined by what lab method? a) Culture b) Sensitivity c) Sterility d) Bacteria
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Cooper FAAHN 8e Chapter 23 Pretest
10. A culture and sensitivity are ordered to determine the: a) organism. b) organism and what antibiotic is effective against the organism. c) bacteria. d) types of cells in the culture.
Chapter Pretest Answers 1. 2. 3. 4. 5.
a b c a d
6. c 7. b 8. c 9. b 10. b
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Cooper FAAHN 8e Chapter 24 Pretest 1. What is Erikson’s stage of development for the infant? a) Intimacy versus despair b) Trust versus mistrust c) Mistrust versus intimacy d) Shame versus doubt 2. What is Piaget’s cognitive stage for the infant? a) Operational b) Preoperational c) Identity versus doubt d) Sensorimotor 3. The stage of infancy is from: a) 4 weeks to 15 months. b) birth to 2 years of age. c) birth to 1 year of age. d) 1 to 3 years of age. 4. A nuclear family is one consisting of: a) homosexual partners. b) extended family members. c) nonrelated family members. d) a married man and woman and their children. 5. A matriarchal family pattern is: a) the female assumes primary dominance. b) the male assumes primary dominance. c) both male and female share dominance. d) the children assume dominance. 6. Adolescents are considered to be in which stage according to Piaget? a) Preoperational b) Operational c) Formal operational d) Latent operational 7. What does parallel play mean? a) Children interact when playing. b) Children play beside each other. c) Children take toys from each other when playing. d) Children ignore each other when playing. 8. According to Piaget, school-age children should be in which stage of development? a) Sensorimotor b) Operational c) Industrial d) Concrete operational 9. During adolescence, the issue of safety in regard to a) nutrition b) accidents c) school d) playing 10. What is a form of discrimination against older adults? a) Autoimmunity
is important.
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Cooper FAAHN 8e Chapter 24 Pretest
b) Ageism c) Free radical d) Disengagement
Chapter Pretest Answers 1. b 2. d 3. c 4. d 5. a
6. c 7. b 8. d 9. b 10. b
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Cooper FAAHN 8e Chapter 25 Pretest
1. Loss is best described as: a) a process of mourning. b) a portion of oneself becoming no longer available. c) preparing oneself for the demise of a family member. d) a reaction serving to overcome a personal event. 2. The difference between grief and bereavement is: a) grief is a response to a loss, and bereavement is a depressed response to death. b) grief is a response to death, and bereavement is a response to an anticipated loss. c) bereavement is the response to loss, and grief is the response to a terminal loss. d) bereavement is the anticipated reaction to loss, and grief is the response to an actual loss. 3. What is bereavement overload? a) When a family is unable to overcome its grief b) When a family does not grieve c) When someone has experienced multiple losses and is not processing them d) When a nurse has ignored her feelings toward the loss of a patient 4. Thanatology is the study of: a) dying and death. b) death. c) the grieving process. d) the bereavement process. 5. Why is it important for the nurse to perform an assessment of the five aspects of human functioning? a) To provide care to other nurses caring for the dying patient b) To provide resources to the family of the dying patient c) To provide adequate care to the patient and family who are experiencing death d) To provide postmortem care to the deceased patient 6. Euthanasia means: a) permitting the death of a patient. b) deliberately ending a patient’s life. c) withholding resuscitation measures. d) permitting suicide. 7. Passive euthanasia means: a) permitting suicide. b) deliberately ending a patient’s life. c) resuscitating a patient utilizing respiratory measures only. d) withholding resuscitative measures. 8. A living will is a written document: a) that contains the patient’s wishes. b) that contains do not resuscitate orders. c) that contains the family’s wishes. d) with the patient’s life and medical history. 9. A person given durable power of attorney is someone who: a) cares for the dying person. b) is a lawyer for the patient. c) is an agent who makes health care decisions for a patient. d) is an agent who manages a person’s finances. 10. Which organs can be harvested for organ donation? a) Bladder, eyes, and adrenal glands
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Cooper FAAHN 8e Chapter 25 Pretest
b) Pituitary glands, eyes, and heart c) Spleen, gallbladder, pancreas d) Kidney, pancreas, liver, and heart
Chapter Pretest Answers 1. b 2. a 3. c 4. a 5. c
6. b 7. d 8. a 9. c 10. d
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Cooper FAAHN 8e Chapter 26 Pretest
1. What occurs when the sperm fuses with the ovum? a) Implantation b) Mitosis c) Meiosis d) Fertilization 2. What does zygote mean? a) Ovum b) Sperm c) Fertilized ovum d) Embryo 3. Which type of pregnancy is considered a serious problem? a) Uterine b) Ectopic c) Zygotic d) Embryonic 4. The a) placenta b) uterus c) chorionic villi d) fetal membrane
produces hormones that assist in maintaining the pregnancy.
5. What contains two arteries and one vein? a) Fetal membrane b) Placenta c) Umbilical cord d) Uterine endometrium 6. What procedure can diagnose fetal sex, maturity, health, and genetic defects? a) Ultrasound b) Alpha-fetoprotein c) Amniocentesis d) Nonstress test 7. What maternal cycle begins after the delivery of the placenta? a) Intrapartal period b) Postpartal period c) Antepartal period d) Perinatal period 8. Which is a presumptive sign of pregnancy? a) Amenorrhea b) Dehydration c) Weight gain d) Vaginal bleeding 9. What should be avoided during pregnancy? a) Exercise b) Work c) Sexual intercourse d) Smoking 10. What is called the mask of pregnancy? a) Hyperemesis gravidarum
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Cooper FAAHN 8e Chapter 26 Pretest
b) Pica c) Chloasma d) Hirsutism
Chapter Pretest Answers 1. d 2. c 3. b 4. a 5. c
6. c 7. b 8. a 9. d 10. c
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Cooper FAAHN 8e Chapter 27 Pretest
1. A woman who is pregnant informs her friends that the fetus has dropped. The medical term for this is: a) quickening. b) outflow. c) fetal positioning. d) lightening. 2. A “bloody show” indicates the: a) pregnant female has lost her mucus plug. b) pregnant female is experiencing vaginal bleeding. c) fetus is experiencing distress. d) uterus has ruptured. 3. Which is an indication of false labor? a) Contractions are regular. b) There is no effacement or dilation of the cervix. c) The contractions are strong during ambulation. d) The contractions do not stop. 4. The changes in the fetal skull during delivery are called: a) fusion. b) effusion. c) molding. d) conversion. 5. After a patient’s membranes have ruptured, what should the nurse assess? a) Cervix b) Fundus c) Vagina d) Fetal heart rate 6. The placenta is delivered in which stage of labor? a) First b) Second c) Third d) Fourth 7. A low Apgar score indicates: a) serious problems. b) inadequate blood flow. c) no problems. d) increased muscle tone. 8. Which may interfere with the progress of labor? a) The father b) Constipation c) Full bladder d) Full stomach 9. What is usually a major concern of the patient who is in labor? a) Elimination b) Pain c) Flatus d) Nausea 10. What cultural situation requires assistance from another?
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Cooper FAAHN 8e Chapter 27 Pretest
a) Pica b) Non–English-speaking patient c) Muslim tradition d) The family has requested the placenta
Chapter Pretest Answers 1. 2. 3. 4. 5.
d a b d c
6. c 7. a 8. c 9. b 10. b
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Cooper FAAHN 8e Chapter 28 Pretest
1. Which hormone causes the uterus to contract? a) Estrogen b) Progesterone c) Prolactin d) Oxytocin 2. Within 12 hours after delivery, what rises to the umbilicus? a) Linea nigra b) Linea albicans c) Fundus d) Bladder 3. The term for vaginal discharge after delivery is a) menses b) lochia c) exudate d) serosanguineous
.
4. What can affect the level of the fundus? a) Constipation b) Full bladder c) Urgency to urinate d) Urinary tract infection 5. If a woman has not gained a lot of weight during her pregnancy, when might she return to her prepregnancy weight? a) 8-10 weeks b) 10-12 weeks c) 6-8 weeks d) 4-5 weeks 6. What helps to reduce discomfort and promote healing of the perineum? a) Urinary catheter b) Heating pad c) Heat lamp d) Sitz bath 7. Which is a normal finding for 2 days postpartum? a) Hypertension b) Temperature 100.4° F or higher c) Temperature 98° F or lower d) Respiratory rate of 30 8. What can increase when the postpartum mother is at home and exerting herself? a) Lochia b) Urination c) Defecation d) Temperature 9. What will help with engorgement? a) Ambulation b) Hot shower c) Well-fitting bra d) Slippers 10. Which position is best when assessing the postpartum woman’s perineum?
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Cooper FAAHN 8e Chapter 28 Pretest
a) Lithotomy b) Lateral c) Supine d) Prone
Chapter Pretest Answers 1. 2. 3. 4. 5.
b c b b c
6. d 7. b 8. a 9. b 10. c
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Cooper FAAHN 8e Chapter 29 Pretest 1. The nurse is expecting a patient from the provider’s office with a diagnosis of hyperemesis gravidarum. What is this? a) Increased emesis caused by a viral illness b) Increased emesis during pregnancy c) Increased blood pressure due to increased pregnancy weight d) Increased abdominal girth 2. Which is a classification used for twins? a) Heterozygote b) Trizygote c) Monozygote d) Histizygote 3. Which is a pregnancy in which there is no fetus, only tissue? a) Multigravida b) Ectopic pregnancy c) Hydatidiform mole d) Didactical foramen 4. A complication of pregnancy that is treated by surgery is a) hyperemesis gravidarum b) DIC c) PIH d) ectopic pregnancy
.
5. A surgical D & C would be required for a patient who has experienced a(n): a) incompetent cervix. b) ectopic pregnancy. c) cerclage. d) spontaneous abortion. 6. A pregnant woman should not expose herself to which animal-related household chore? a) Disposing of dog feces in the yard b) Changing the cat’s litter box c) Cleaning the hamster’s cage d) Cleaning the aquarium 7. Which nursing intervention helps minimize postpartum hemorrhage? a) Urinary I & O b) Fundal massage c) Early ambulation d) Forcing fluids 8. What should be monitored routinely for a patient with PIH? a) Blood pressure b) Urine output each prenatal visit c) Hemoglobin d) Temperature 9. Patients with PIH should weigh themselves daily to determine a) fetal weight b) fetal age c) possible fluid retention d) pregnancy weight gain
.
10. A pregnant female with a history of mitral valve prolapse might complain of which symptom?
1
Cooper FAAHN 8e Chapter 29 Pretest
a) Palpitations b) Hunger c) Nocturia d) Polydipsia
Chapter Pretest Answers 1. 2. 3. 4. 5.
b c c d d
6. b 7. b 8. a 9. c 10. a
2
Cooper FAAHN 8e Chapter 30 Pretest 1. Which factor has contributed to children’s obesity? a) Eating fruits and vegetables b) Watching several hours of television c) Participating in recreational sports d) Household chores 2. Research has shown that this has helped decrease substance abuse among adolescents. a) Police in high schools b) Recreational activities geared towards adolescents c) Increased communication regarding substance abuse between parents and adolescents d) Decreased parental influence regarding adolescent activities 3. Which environmental hazard has contributed to increased heart and lung disease? a) Secondhand smoke b) Cigarette smoking c) Use of chewing tobacco d) Fluorocarbons 4. What provides 100% protection from STDs? a) Spermicidal b) Birth control pills c) Prophylactic use of penicillin d) Abstinence 5. Which population is at an increased risk of contracting HIV? a) Middle-aged adults b) Adolescents c) Young adults d) Young males 6. Which is a target for adolescents regarding Healthy People 2020? a) Reduce relapse from eating disorders b) Reduce relapse from drug abuse c) Reduce sexually transmitted diseases d) Reduce mortality 7. Which preventable type of childhood injury has happened for decades? a) Automobile accidents b) Firearm injuries c) Carbon monoxide poisonings d) Bottle mouth 8. Which stage of life occurs when this age group is “trying to fit in”? a) Young adults b) Adolescents c) Middle-aged men d) Young parents 9. What can occur when children go to bed with a bottle that contains carbohydrates? a) Gingivitis b) Oral lesions c) Chancre sores d) Bottle mouth 10. What is a barrier to immunizations? a) Lack of insurance
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Cooper FAAHN 8e Chapter 30 Pretest
b) Lack of Medicaid coverage c) Misunderstandings and communication d) Lack of primary care physicians
Chapter Pretest Answers 1. b 2. c 3. a 4. d 5. c
6. a 7. b 8. b 9. d 10. a
2
Cooper FAAHN 8e Chapter 31 Pretest
1. The pediatric nurse must be a) adequate b) honest c) bold d) accommodating
if he/she is to gain the trust of the pediatric patient.
2. What must be measured supine until age 2? a) Weight b) Skin thickness c) Blood pressure d) Length 3. Which vital sign could vary greatly in the pediatric patient? a) Blood pressure b) Heart rate c) Respirations d) Temperature 4. Which vital sign should be counted for a full minute? a) Blood pressure b) Heart rate c) Respirations d) Temperature 5. Accommodation and refraction are present by what age? a) Toddler b) Preschool c) 6 years old d) Adolescence 6. What could be used to soften cerumen? a) Water b) Soap c) K-Y jelly d) Mineral oil 7. Which growth factor has the biggest influence on the child’s development? a) Nutrition b) Metabolism c) Sleep d) Communication 8. The newborn communicates by: a) babbling. b) crying. c) cooing. d) screaming. 9. For the infant, new foods should be introduced a) 1 day b) 1 month c) 1 week d) 2 weeks 10. What should never be used inside the ear canal? a) Tissue
at a time.
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Cooper FAAHN 8e Chapter 31 Pretest
b) Washcloth c) Syringe d) Cotton-tipped applicator
Chapter Pretest Answers 1. 2. 3. 4. 5.
b d b b c
6. d 7. a 8. b 9. c 10. d
2
Cooper FAAHN 8e Chapter 32 Pretest
1. Which cardiovascular disorder causes a decreased pulmonary flow? a) Patent ductus arteriosus b) Ventricular septal defect c) Tetralogy of Fallot d) Atrial septal defect 2. Which disorder causes a platelet count to fall to 20,000/mm3. a) Aplastic anemia b) Idiopathic thrombocytopenia purpura c) Sickle cell anemia d) Hemophilia 3. Which disease affects the lymphatic system? a) Leukemia b) Hodgkin’s disease c) HIV d) Hemophilia 4. Respiratory distress syndrome occurs most often in: a) male infants. b) low birth weight infants. c) triplets. d) twins. 5. Pediatricians recommend infants be laid in which position when sleeping? a) Prone b) On pillows c) Lithotomy d) Supine 6. Which condition causes thick mucus production? a) Cystic fibrosis b) Asthma c) Pneumonia d) Tuberculosis 7. Parents require teaching to prevent aspiration with which disorder? a) Cystic fibrosis b) Cleft palate c) Asthma d) GERD 8. Which was formerly called mental retardation? a) Mental impairment b) Cognitive impairment c) Mentally challenged d) Cognitively challenged 9. Which cognitive impairment is due to an extra chromosome? a) Autism b) Gaur syndrome c) Down syndrome d) Disintegrative disorder 10. Which cognitive disorder relates to brain function in which there are severe behavioral and intellectual deficits?
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Cooper FAAHN 8e Chapter 32 Pretest
a) Down syndrome b) Autism c) Attention deficit/hyperactivity disorder d) Sheehan’s syndrome 11. The nurse is often the first person or contact for a child who has experienced a) Maltreatment b) Somatization c) Pallor d) Phobias
.
12. In caring for a child with autism, which therapeutic intervention should occur? a) Care from professionals who have advanced training b) Care from pediatric resident physicians c) Care from a pediatric nurse practitioner d) Care from a pediatrician with an interest in autism 13. Which disorder affects primarily adolescents? a) Depression b) Attention deficit/hyperactivity disorder c) Bipolar disorder d) Anorexia 14. A trusting and supportive relationship is critical for a patient diagnosed with which disorder? a) Depression b) Cognitive disorder c) Psychogenic disorder d) Somatic disorder 15. Which is an important nursing intervention when caring for an adolescent who is thought to be suicidal? a) Limit visitors b) Frequent therapy sessions c) Direct questions regarding death d) Direct questions regarding the adolescent’s current state of mind
Chapter Pretest Answers 1. 2. 3. 4. 5. 6. 7. 8.
c b b b d a b b
9. c 10. b 11. a 12. a 13. d 14. a 15. c
2
Cooper FAAHN 8e Chapter 33 Pretest
1. Biologic theories explain: a) why cells become old. b) why the body ages. c) why people are living longer. d) how old the planet is. 2. Which element of the integumentary system becomes brittle and thick? a) Hair b) Facial hair c) Nails d) Skin around the elbows 3. The skin is at risk for a) pressure ulcers b) yeast infections c) ecchymosis d) peeling
in the older population.
4. What will help prevent pressure ulcers? a) Frequent urination b) Limiting fluids c) Weight loss d) Turning every 2 hours 5. Which condition may cause the older adult to develop hypertension? a) Decreased peripheral circulation b) Increased peripheral circulation c) Arteriosclerosis d) Cirrhosis 6. Standing in one place for long periods of time causes a) venous stasis b) atherosclerosis c) cirrhosis d) hypertension 7. Which musculoskeletal problem causes the individual to stoop forward? a) Scoliosis b) Kyphosis c) Lordosis d) Psychosis 8. Removal of what helps the individual with pneumonia? a) Secretions b) Saliva c) Urine d) Nasal mucus 9. Which disease is increasing in incidence among older adults? a) Pruritus b) Gastroenteritis c) Type 2 diabetes d) Neuropathy 10. Which condition may lead to weight gain? a) Hyperparathyroidism
.
1
Cooper FAAHN 8e Chapter 33 Pretest
b) Hyperthyroidism c) Hypothyroidism d) Hypertension
Chapter Pretest Answers 1. b 2. c 3. a 4. d 5. c
6. a 7. b 8. a 9. c 10. c
2
Cooper FAAHN 8e Chapter 34 Pretest
1. Whose efforts brought millions of dollars to support the development of mental hospitals? a) Linda Richards b) Dr. Pinel c) Dorothea Dix d) Al Gore 2. Which is not a component of a healthy self-concept? a) Blaming others for one’s actions b) Positive self-image c) Awareness of one’s emotions d) Recognition of a spouse for support 3. Which behavior could be exhibited by the person who is ill? a) Laughing b) Talking c) Praying d) Anger 4. Which effect has been shown to stimulate the immune system? a) Regression b) Denial c) Withdrawal d) Placebo 5. Which nursing intervention could assist the patient in meeting his/her psychosocial needs? a) Patient education b) Medication c) Discussion d) Privacy 6. Positive thinking assists which link? a) Spiritual awakening b) Biophysical c) Psychosocial d) Mind/body 7. Which area of assessment relates to the emotional status of a patient? a) Skin integrity b) General appearance and behavior c) Psychosocial activities d) Body language 8. When a nurse is assessing the severity of the patient’s illness, he/she is assessing: a) mood. b) insight. c) personality. d) affect. 9. Freud’s levels of personality development are: a) ego, personality, and behavior. b) behavior, self-concept, and personality. c) self, personality, and superego. d) id, ego, and superego. 10. Which is a feeling of apprehension? a) Anger
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Cooper FAAHN 8e Chapter 34 Pretest
b) Stress c) Anxiety d) Withdrawal
Chapter Pretest Answers 1. c 2. a 3. d 4. d 5. a
6. d 7. b 8. b 9. d 10. c
2
Cooper FAAHN 8e Chapter 35 Pretest
1. Which psychiatric disorder is characterized by the individual being out of touch with reality? a) Neurosis b) Psychosis c) Dementia d) Delirium 2. A patient who is exhibiting decreased awareness, disorganized thinking, and irrelevant speech is classified as: a) demented. b) psychotic. c) delirious. d) manic. 3. Which nursing intervention would be appropriate for the demented individual? a) Removing sharp objects from the room b) Providing a high-carbohydrate meal c) Varying the routine d) Placing a clock and calendar in view 4. Which disorder’s clinical manifestations are overactivity and a euphoric state? a) Depression b) Dysthymic disorder c) Mania d) Hypomania 5. Bipolar disorder is also known as: a) hypomania. b) manic-depressive. c) depressive, obsessive. d) obsessive-compulsive. 6. Which is a normal response to a threat? a) Withdrawal b) Depression c) Obsession d) Anxiety 7. Which type of anxiety produces feelings of dread that cannot be identified? a) Free-floating anxiety b) Anxiety trait c) Single anxiety d) Generalized anxiety 8. A patient who reacts to an event in an inappropriate way is suffering from: a) posttraumatic stress syndrome. b) obsessive-compulsive disorder. c) agoraphobia. d) panic attacks. 9. Which intervention helps the person who has experienced a traumatic event? a) Deep breathing b) Debriefing after the event c) Aromatherapy d) St. John’s wort 10. Which individual obtains sexual gratification when observing others during intercourse?
1
Cooper FAAHN 8e Chapter 35 Pretest
a) Pedophile b) Sexual sadist c) Masochist d) Voyeur
Chapter Pretest Answers 1. 2. 3. 4. 5.
b c d c b
6. d 7. a 8. a 9. d 10. b
2
Cooper FAAHN 8e Chapter 36 Pretest
1. Which is a trait of an addictive personality? a) Positive self-image b) A sense of security c) A lessened ability to manage stress d) A feeling of managing one’s emotions 2. This is considered a “late stage of dependence.” a) Legal problems b) Mood swings c) Uses to “feel normal” d) Unemployment 3. Which is considered an “early stage of dependence”? a) User is moderately impaired. b) User loses jobs. c) User might be homicidal. d) User misses work. 4. Which is considered a “gateway” drug? a) Marijuana b) Alcohol c) Nicotine d) Caffeine 5. Blood alcohol levels depend on which two factors? a) Amount of alcohol and body size b) Body size and metabolism c) Amount of alcohol and metabolism d) Type of alcohol and time between drinks 6. Which is a sign and symptom of delirium tremens (DTs)? a) Anxiety and hypothermia b) Agitation and panic c) Depression and drowsiness d) Withdrawal and depression 7. Which is not a form of rehabilitation for the alcoholic? a) Admission to a psychiatric hospital b) Group therapy c) Alcoholics Anonymous d) A residential treatment center 8. Which drug is considered a hallucinogen? a) Heroin b) Amphetamine c) Ketamine d) Marijuana 9. Which is not a sign of a chemically impaired nurse? a) Mood swings b) Blackouts c) Rarely wastes controlled substances d) Frequent absences from the nursing unit 10. Who has jurisdiction over assistance programs for chemically impaired nurses? a) Health Professions Bureau
1
Cooper FAAHN 8e Chapter 36 Pretest
b) American Nurses Association c) State board of nursing d) National League of Nurses
Chapter Pretest Answers 1. c 2. d 3. d 4. b 5. a
6. b 7. a 8. c 9. c 10. c
2
Cooper FAAHN 8e Chapter 37 Pretest
1.
Patients over the age of 65 account for a) 25% b) 50% c) 75% d) 100%
of all home health care patients.
2. In 1983, this system of Medicare reimbursement played a major role in the increased need for home health care in the United States. a) Social Security Act b) Balanced Budget Act c) Diagnosis-related groups d) Omnibus Consolidated and Emergency Supplemental Appropriations Act 3. LPN/LVNs comprise 10-20% of the home care workforce and are directly supervised by the: a) registered nurse. b) physical therapist. c) attending physician. d) home health assistant. 4. The speech-language therapist works with the home care patient on tasks, including: a) feeding self. b) swallowing issues. c) relaxation techniques. d) writing skills. 5. Which method of reimbursement is available to individuals who are disabled or low-income? a) Medicaid b) Medicare c) Third party d) HMOs 6. Discharge planning for a patient in the home care setting begins when? a) Upon discharge from the hospital b) Upon admission to the home care agency c) One week after home care has begun d) Immediately prior to discharge from the home health care agency 7. So that the patient can plan accordingly, the nurse tells the home health patient that a skilled nursing visit typically lasts: a) 15-20 minutes. b) 30-45 minutes. c) At least 1 hour. d) 1-2 hours. 8.
The most important benefit of home health care is that: a) it is less expensive than care in a hospital setting. b) insurance is more likely to pay for home care than long-term care. c) nurses are able to practice more autonomously in the home setting. d) it preserves individual independence and integrity and keeps families together.
9. Who sets the rules for governing certification of home health care agencies? a) Medicare b) Medicaid c) The federal government d) Third-party insurance payers
1
Cooper FAAHN 8e Chapter 37 Pretest
10. The goal of restorative care is to assist the patient in: a) returning to the level of functioning prior to the present illness. b) better health and functioning than on admission. c) preserving the current level of functioning. d) learning healthy lifestyle practices in order to minimize effects of the current illness.
Chapter Pretest Answers 1. 2. 3. 4. 5.
b c a b a
6. b 7. b 8. d 9. c 10. a
2
Cooper FAAHN 8e Chapter 38 Pretest
1. Which of these is a benefit of long-term care? a) It offers a place of care for an extended period of time. b) It provides various services and settings for care. c) It provides care for older adults. d) It provides care for anyone who does not meet hospitalization criteria. 2. Most older adults live in which setting? a) Long-term care facilities b) Assisted-living facilities c) Home d) Retirement communities 3. The long-term care facility focuses on what for its residents? a) 24-hour care b) Multidisciplinary approach c) Individualized approach d) Primary nursing care 4. A subacute unit may be located in which environment? a) Retirement community b) Hospital c) Home health care agency d) Assisted-living facility 5. Which agency provides end-of-life services? a) Palliative nursing facilities b) Long-term care facilities c) Oncology nursing facilities d) Hospice 6. Which facility usually requires a lifetime contract? a) Long-term care facility b) Adult daycare c) Continuing care retirement communities (CCRCs) d) Skilled nursing facility 7. Which aspect of assisted living appeals to the older adult? a) Independent living b) Availability of 24-hour services c) Prepared meals d) Transportation 8. Which is not a common disorder upon admission to a long-term care facility? a) Hyperthyroidism b) Cardiovascular disease c) Depression d) Dementia 9. Which condition is difficult to manage in a long-term care facility? a) Cardiovascular disease b) Cerebral vascular accident c) Alzheimer’s disease d) Diabetes 10. A large long-term care facility might have which health care professional on staff? a) Occupational therapist
1
Cooper FAAHN 8e Chapter 38 Pretest
b) Nurse practitioner c) Assistant nursing director d) Physician’s assistant
Chapter Pretest Answers 1. b 2. c 3. c 4. b 5. d
6. c 7. b 8. a 9. c 10. c
2
Cooper FAAHN 8e Chapter 39 Pretest
1. Rehabilitation focuses on improving: a) quantity of life. b) quality of life. c) range of motion. d) illness. 2. An impairment is: a) loss of a limb. b) irreversible damage to a body system. c) loss of an anatomic structure or function. d) irreversible condition resulting from illness. 3. Which is not a cornerstone of rehabilitation? a) Independence b) Functional ability c) Adaptation d) Adoption 4. A multidisciplinary approach has what type of goals? a) Collaborative b) Discipline-specific c) Habilitative d) Functional 5. A rehabilitation nurse must have a broad knowledge of: a) principles of physical therapy. b) principles of occupational therapy. c) medical-surgical conditions. d) cardiovascular conditions. 6. Which type of rehabilitation is very intensive? a) Comprehensive b) Multidisciplinary c) Interdisciplinary d) Family-centered 7. Which process is similar to the nursing process? a) Family-centered rehabilitative process b) Specialized rehabilitative process c) Five-step process d) Habituation process 8. Which is a key element of family-centered care? a) Friends and family b) Collaboration among family and professionals c) Child and family support d) Family networks 9. Which type of rehabilitation focuses on the older adult population? a) Interdisciplinary rehabilitation b) Comprehensive rehabilitation c) Gerontologic rehabilitation d) Home health care rehabilitative services 10. Which condition affects the individual who has had a spinal cord injury? a) Drooling
1
Cooper FAAHN 8e Chapter 39 Pretest
b) Pulmonary embolus c) Heterotopic ossification d) Bladder stones
Chapter Pretest Answers 1. b 2. c 3. d 4. b 5. c
6. a 7. c 8. b 9. c 10. c
2
Cooper FAAHN 8e Chapter 40 Pretest
1. Where did the hospice concept originate? a) Japan b) China c) Europe d) England 2. What is palliative care? a) A curative treatment plan b) Not a cure, but relieves pain and distress c) Pain management d) Nutritional support 3. The hospice patient and family must agree that what will not be provided? a) Pain medications b) Nutrition c) Life-support measures d) Spiritual counseling 4. Which person evaluates the patient’s psychological needs? a) Physician b) RN c) Social worker d) Bereavement counselor 5. Which person assumes responsibility for the hospice program? a) CEO b) Director of nurses c) Nurse d) Medical director 6. Who coordinates the implementation of the plan of care? a) Physician b) RN coordinator c) LPN/LVN d) Social worker 7. Who would provide respite care for the caregiver? a) Hospice aide b) Hospice volunteer c) Hospice LPN/LVN d) Bereavement coordinator 8. Which person assists the patient with his/her fears and uncertainty? a) Bereavement coordinator b) LPN/LVN c) Spiritual coordinator d) Medical director 9. Which type of pain originates from internal organs? a) Visceral pain b) Somatic pain c) Neuropathic pain d) Burning pain 10. Which would not cause nausea? a) Tumor
1
Cooper FAAHN 8e Chapter 40 Pretest
b) Salivation c) Narcotics d) Constipation
Chapter Pretest Answers 1. c 2. b 3. c 4. c 5. d
6. b 7. b 8. c 9. a 10. b
2
Cooper FAAHN 8e Chapter 41 Pretest
1
1. The plane of the body running lengthwise from front to back is known as: a) distal. b) proximal. c) sagittal. d) coronal. 2. The abdominal cavity contains which body organs? a) Stomach, liver, gallbladder, spleen, and appendix b) Stomach, gallbladder, spleen, small intestine, and bladder c) Liver, gallbladder, spleen, colon, and rectum d) Stomach, liver, gallbladder, and pancreas 3.
is the term used to refer to the body when it is in an erect position with the arms at the sides and the palms forward. a) Lateral position b) Anatomical position c) Superficial position d) Coronal position
4. The division of cells acting in unity to carry out a common function is known as: a) a tissue. b) a system. c) cytoplasm. d) an organ. 5. The smallest complete units of matter are called: a) tissues. b) organs. c) molecules. d) atoms. 6. When body cells trap large protein molecules, a process known as occurs. a) phagocytosis b) calcium pumping c) pinocytosis d) mitosis 7. Which statement best describes the processes associated with diffusion? a) The movement of water through a membrane by a force of pressure or gravity b) The passage of water across a permeable membrane c) The movement of fluid from an area of higher concentration to an area of lower concentration d) The movement of solid particles in a fluid from an area of higher concentration to an area of lower concentration 8.
is the movement of water and particles through a membrane by a force from either pressure or gravity. a) Filtration b) Diffusion c) Osmosis d) Active transport
9. The types of primary tissues that make up the body’s organs are: a) epithelial, connective, muscle, and nervous. b) connective, muscle, striated, and nervous. c) muscle, adipose, epithelial, and nervous.
Cooper FAAHN 8e Chapter 41 Pretest
d) nervous, adipose, areolar, and muscular. 10. The three types of muscle tissue in the body are: a) skeletal, cardiac, and visceral. b) skeletal, connective, and visceral. c) cardiac, fibrous, and hematopoietic. d) visceral, fibrous, and hematopoietic.
Answers: 1. 2. 3. 4. 5.
c d b a d
6. c 7. d 8. a 9. a 10. a
2
Cooper FAAHN 8e Chapter 42 Pretest
1
1. During the admission process for a surgery scheduled the next morning, the patient discloses he has been taking St. John’s wort to manage his depression for the past 2 years. When questioned further, he reveals that his health care provider has not been made aware of this regimen. Based upon your knowledge, you: a) are not concerned as St. John’s wort is a safe, natural method to manage depression and there is no potential impact for a patient undergoing surgery. b) immediately notify the health care provider because of the increased bleeding times associated with the use of St. John’s wort. c) notify the health care provider because of concerns relating to potential interactions with other medications that may be prescribed for a surgical patient. d) are not concerned but encourage the patient to discontinue the medication to be “on the safe side.” 2. Which patient is at greater risk for developing complications postoperatively due to interactions among his herbal remedies and the analgesics administered to manage his pain? a) The patient taking ginger for motion sickness b) The patient taking valerian root to manage insomnia c) The patient taking large amounts of feverfew d) The patient taking moderate amounts of St. John’s wort to manage chronic back pain 3. Which ethnic group is known for avoiding eye contact because of the belief that eye contact signals disrespect? a) African Americans b) Native Americans c) Vietnamese Americans d) Southeast Asian Americans 4. When preparing to complete a surgical consent for a patient scheduled to undergo an exploratory surgery, which individual would require a guardian to sign the surgical consent? a) A hearing-impaired patient, age 100 b) A married 22-year-old female c) An intermittently confused 22-year-old male d) A 91-year-old patient who recently suffered a stroke 5. While you are working in the emergency department, a 15-year-old female arrives to the unit. She is badly hurt and might require surgery. Attempts to locate her parents have been futile. After her condition worsens, the health care provider asks you to prepare her for surgery. How should the issues related to the consent for surgery be handled? a) The surgery can take place as this is an emergency. b) The law requires that the surgeon wait until her parents can be notified. c) There are provisions in the law allowing the hospital’s attorney to provide consent for the surgery in the case of an emergency. d) The patient is able to understand the consent and may sign the papers due to the emergent situation. 6. When considering patients at risk for latex allergies, which patient presents the highest risk? a) There is a history of allergy to melons and tomatoes. b) There is a history of allergy to poinsettia plants. c) The patient works at a paper mill. d) The patient has a history of gastrointestinal disorders. 7. When planning perioperative care for a patient who is at high risk for an allergic response to latex exposure, which element must be included in the plan of care? a) Administer intravenous prophylactic steroid treatment. b) Administer intramuscular injection of a prophylactic antiinflammatory medication. c) Use latex-free supplies.
Cooper FAAHN 8e Chapter 42 Pretest
d) Administer intravenous steroids and antihistamines preoperatively. 8. A complication known as a(n) may occur due to the blood slowing, resulting in an accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the wall of the vessel. a) infarct b) thrombus c) embolus d) transient ischemic attack 9. During the preoperative period, the anesthesiologist prescribes Versed 3.5 mg to be administered IM. This medication, when prescribed prior to surgery, serves which important function? a) The medication aids in the reduction of postoperative pain. b) The anticoagulation effects of the medication reduce operative bleeding. c) The bactericidal actions aid in preventing infection. d) The administration of this medication promotes sedation. 10. A 78-year-old patient is concerned about the impact her insulin-dependent diabetes will have on her postoperative recovery experience. She asks about her insulin needs during the first day after surgery. Which fact will the nurse include in the teaching session? a) There should be no change in her body’s postoperative insulin needs. b) Insulin needs are usually reduced due to the body’s stress response. c) Insulin needs will be slightly elevated due to the administration of intravenous fluids. d) Insulin needs will be greatly increased due to the physiological stress of the anesthesia and surgery.
Chapter Pretest Answers 1. 2. 3. 4. 5.
c b d c a
6. b 7. c 8. b 9. d 10. b
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Cooper FAAHN 8e Chapter 43 Pretest 1. A patient presents to the ambulatory care clinic with complaints of an “itchy rash.” When preparing to examine the rash, the nurse should use what type of lighting? a) Fluorescent lighting b) Natural lighting c) Wood’s light d) Penlight 2. A patient of African-American ancestry having brown skin tones is hospitalized. The health care provider makes a diagnosis of anemia. What skin tones can be found during assessment to support this diagnosis? a) Ashen or gray b) Pale pink c) Yellow toned d) Ruddy 3. After suffering from a condition in which chronic pruritus and scratching occurred, which might be an anticipated finding? a) Fissure development b) Scars c) Keloid scarring d) Lichenification 4. Education for the patient who has been prescribed Benadryl should include which instructions? a) Do not operate heavy machinery while taking the medication. b) Avoid exposure to sunlight during the medication therapy. c) This medication can alter liver function. d) Discontinue use if excessive drying and peeling of skin occurs. 5. Drug therapy for the patient experiencing an outbreak of herpes simplex could include: a) Acyclovir. b) Vistaril. c) Atarax. d) Lidex. 6. The primary mode of transmission for herpes simplex is: a) airborne. b) skin-to-skin contact. c) contact with infected personal articles. d) reactivation of a dormant virus. 7. Upon removal of the thick crust associated with impetigo contagiosa, the skin will appear: a) dry and discolored. b) bruised and torn. c) red and smooth. d) moist and draining. 8. During the data collection interview, the patient states she has noticed a grouping of red and swollen areas with yellowed centers on her back. She reports they are painful. Based upon your knowledge you anticipate a diagnosis of: a) herpes zoster. b) carbuncles. c) felons. d) furuncles. 9. A patient diagnosed with tinea pedis is prescribed Burow’s solution soaks. The patient asks how this medication will work. What should be included in the teaching plan?
1
Cooper FAAHN 8e Chapter 43 Pretest
2
a) Burow’s solution has antimicrobial properties. b) This medication will reduce inflammation. c) Soaking in this medication will act as a skin emollient. d) Burow’s solution has astringent characteristics. 10. After experiencing concerns with a growth on her neck, a patient seeks care. During the assessment, you document the growth as a firm, nodular lesion with a crusted top. Based upon your knowledge, you anticipate a diagnosis of: a) malignant melanoma. b) squamous cell carcinoma. c) basal cell carcinoma. d) keloids.
Chapter Pretest Answers 1. 2. 3. 4. 5.
b c d a a
6. b 7. c 8. b 9. d 10. b
Cooper FAAHN 8e Chapter 44 Pretest
1. The relationship between phosphorus and calcium is best described by which statement? a) Calcium and phosphorus share a relationship of equality. Both are present in equal amounts in the bloodstream. b) Calcium and phosphorus share an inverse relationship. Both minerals are elevated in the bloodstream when both are elevated in the body’s skeleton. c) Calcium and phosphorus share a negative relationship. Both minerals are decreased in the bloodstream when they are elevated in the body’s skeleton. d) Calcium and phosphorus share an inverse relationship. When calcium is elevated, phosphorus levels are reduced. 2. Risk factors for the development of osteoporosis include: a) obesity, European ancestry, and a diagnosis of rheumatoid arthritis. b) slender build, European ancestry, and cigarette smoking. c) menopause, African ancestry, and a diagnosis of gout. d) Asian ancestry, slender build, and a diagnosis of gout. 3. Rheumatoid arthritis and osteoarthritis differ in which way? a) Older patients are more frequently affected by rheumatoid arthritis than osteoarthritis. b) Rheumatoid arthritis is associated with obesity, whereas osteoarthritis is associated with patients having a slender build. c) Rheumatoid arthritis is more often treated with surgery than osteoarthritis. d) Rheumatoid arthritis is a systemic disorder, whereas the effects of osteoarthritis are limited to the body’s joints. 4. When assigning a diagnosis of rheumatoid arthritis, which diagnostic test results are present? a) An elevated rheumatoid factor and an elevated red blood cell count b) An absence of anti-IgG antibodies and an elevated red blood cell count c) A reduction in the white blood cell count and a low erythrocyte sedimentation rate d) A reduced red blood cell count and an elevated rheumatoid factor 5. When administering Tolmetin sodium to manage rheumatoid arthritis, which nursing implications apply? (Select all that apply.) a) Monitor blood pressure. b) Give with food or milk. c) Give with an antacid. d) Avoid aspirin and aspirin products while taking this medication. e) Avoid driving during initial phases of therapy. 6. A patient diagnosed with osteoarthritis asks what type of exercise is beneficial to her condition. Based upon your understanding, you encourage: a) swimming. b) a combination of running and walking. c) aerobic dancing. d) stair-climbing. 7. A 65-year-old male patient presents to the clinic. He has complaints of severe pain at night. The assessment reveals a reddened, edematous great toe. Tophi are noted along the rim of the left ear. Based upon your knowledge, you anticipate a diagnosis of: a) rheumatoid arthritis. b) osteoarthritis. c) osteoporosis. d) gout.
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Cooper FAAHN 8e Chapter 44 Pretest
2
8. A 54-year-old male patient has a checkup with the health care provider. He has a 4-year history of osteoarthritis, type 1 diabetes, and hypertension. The only medications he takes on a regular basis are NSAIDs for the management of his arthritis, Lantus to manage the diabetes, and vitamin supplements. Which will be most closely monitored at this appointment given his health history? a) Rheumatoid factor b) Blood cell profile c) Blood glucose d) Heart rate 9. After undergoing an amputation of the lower left leg, the patient complains of discomfort in his left leg and foot. He requests pain medication for the sensation. The nurse’s best course of action will be to: a) medicate the patient for the complaints of pain. b) attempt to distract the patient from the situation. c) explain to the patient the discomfort he is reporting is not possible since his limb is missing. d) contact the health care provider concerning a possible consult with a psychologist. 10. When performing an assessment of a patient’s capillary refill in the extremity that has been casted for a fracture, which findings are normal? a) Return to normal within 5 to 7 seconds b) Return to normal within 2 to 3 seconds c) Sluggish return to normal d) No blanch noted
Chapter Pretest Answers 1. 2. 3. 4. 5.
d b d d b, e
6. a 7. d 8. c 9. a 10. b
Cooper FAAHN 8e Chapter 45 Pretest
1
1. A 56-year-old patient who is undergoing chemotherapy reports to the clinic with thick white patches on her tongue and mucous membranes. The health care provider makes a diagnosis of Candida albicans. Based upon your knowledge, you anticipate the most likely treatment will include: a) amoxicillin 500 mg qid. b) half-strength commercial mouthwash tid. c) nystatin vaginal tablets 100,000 units. d) full-strength hydrogen peroxide rinses qid. 2. A 43-year-old male patient is scheduled to undergo a colonoscopy. In preparation for the examination the teaching provided should include point? a) NPO 4 to 6 hours before the procedure. b) Continue normal dietary intake until the day of the procedure. c) Enemas or cathartics will be administered to reduce the residue in the bowel. d) The week prior to the procedure, the patient will need to begin a soft diet. 3.
is a diagnostic procedure that can also be used to remove polyps and coagulate sources of bleeding. a) Esophagogastroduodenoscopy b) Upper gastrointestinal study c) Bernstein test d) Sigmoidoscopy
4. A 32-year-old female patient presents to the clinic with complaints of heartburn, flatulence, dysphagia, and a sour taste in her mouth. After an examination, you anticipate a diagnosis of: a) carcinoma of the esophagus. b) leukoplakia. c) gastroesophageal reflux disease. d) gastric ulcers. 5. A patient has recently been diagnosed with duodenal ulcers. The health care provider has prescribed Carafate to manage the condition. The patient asks you to explain the purpose of this medication. You understand this medication functions to: a) heal the ulcers by adhering to the proteins in the ulcer base. b) neutralize the acidity of the stomach contents. c) inhibit gastric acid secretion. d) block histamine receptors. 6. A 23-year-old female patient is being treated for gastric ulcers that have occurred as a result of the medications she takes to manage her arthritis. The health care provider has prescribed Cytotec (misoprostol). Based upon your knowledge of this medication, what is a chief nursing implication? a) This medication causes CNS depression, and alcohol ingestion must be avoided. b) Monitor serum electrolytes. c) Monitor liver enzyme levels. d) Ensure the patient is using a reliable form of contraceptive. 7. A patient presents with complaints of hemorrhoids. He reports they have been a source of concern for the past 2 years. His health care provider has decided to perform surgery to treat the problem. Which diagnosis would you expect to see on this patient’s nursing care plan? a) Pain, related to edema b) Disturbed body image, related to loss of normal body appearance c) Imbalanced nutrition: less than body requirements, related to decreased oral intake d) Potential for complications related to reduced hemoglobin 8. A 43-year-old female patient has been diagnosed with peritonitis. Her recent health history includes childbirth via vaginal delivery, dental extraction, and appendicitis. She asks how she could have gotten this illness. Which of the following has placed her at greatest risk?
Cooper FAAHN 8e Chapter 45 Pretest
a) Her age b) Recent childbirth c) Recent dental work d) Recent appendicitis 9. A 73-year-old male patient is being treated for colon cancer. The health care provider will be performing a proctocolectomy. The patient asks what this surgery entails. Based upon your knowledge, you understand this procedure involves: a) removal of the anus, rectum, and colon. b) removal of a portion of the large intestine and anastomosis of the remaining segment. c) surgical formation of an opening of the ileum onto the surface of the abdomen, through which fecal matter is emptied. d) surgical formation of an opening onto the surface of the abdomen for the passage of urinary wastes. 10. A patient scheduled to undergo diagnostic testing of the intestines has been prescribed GoLYTELY. He asks what the medication will accomplish. Based upon your knowledge, you understand this medication will be used to: a) aid in the prevention of infection. b) cleanse the bowel. c) reduce peristalsis. d) increase peristalsis. Chapter Pretest Answers 1. 2. 3. 4. 5.
c c a c a
6. d 7. a 8. d 9. a 10. b
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Cooper FAAHN 8e Chapter 46 Pretest
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1. The patient who is undergoing an oral cholecystography test can expect which medication regimen before the procedure? a) The nurse will administer iodine via piggyback IV just before the procedure. b) The nurse has no medication responsibilities for the test because the medications will be administered by the radiology technician. c) There are no preparatory medications given for this test. d) The patient will begin to take iopanoic acid tablets after the last evening meal. 2. The result of an indirect bilirubin test is 0.2 mg/dL. This indicates: a) a normal indirect bilirubin value. b) an elevation in the indirect bilirubin level. c) a slight decrease in indirect bilirubin level. d) a markedly reduced indirect bilirubin level. 3. A patient presents with complaints of abdominal pain that radiates to the back. Diagnostic tests are ordered to determine if the cause is pancreatitis. Which results support the diagnosis of pancreatitis? a) Reduced serum amylase and lipase b) Leukocytosis, decreased hematocrit, and hypercalcemia c) Leukocytosis, reduced serum amylase and lipase d) Leukocytosis, hypoalbuminemia, and hyperglycemia 4. The patient diagnosed with cirrhosis should be advised to avoid which medication? a) Acetaminophen b) Iron supplements c) Calcium supplements d) Vitamin supplements 5. A patient diagnosed with hepatitis A asks how she could have contracted the disease. She should be advised that: a) this type of hepatitis can be transmitted via food or beverages contaminated with fecal material. b) the cause of this type of hepatitis is unknown. c) hepatitis A can be transmitted via blood transfusions. d) she was probably infected by sexual contact with an infected individual. 6. The mother of a 16-year-old patient asks you about vaccinating her daughter against hepatitis B. Based upon your knowledge, you respond: a) “She is too old to be vaccinated; it should have been done during her early childhood.” b) “She can begin the three-shot series at any age.” c) “She can begin the four-shot series at any age.” d) “Your daughter is not at any risk for becoming infected and should not be vaccinated at this time.” 7. While you are working at the clinic, a patient presents with complaints of nausea and vomiting. She reports experiencing localized right upper quadrant pain. Which condition is associated with these clinical manifestations? a) Pancreatic cancer b) Cholelithiasis c) Hepatitis G d) Pancreatitis 8. A patient who was admitted with biliary pain is requesting an analgesic. He reports morphine has been effective when he was hospitalized for another unrelated health issue. What actions should the nurse take? a) The patient should be advised that morphine is not administered in biliary pain because it can mask important clinical manifestations. b) The health care provider should be advised of the patient’s preference of analgesic.
Cooper FAAHN 8e Chapter 46 Pretest
c) The patient should be advised that morphine is not administered for biliary pain because it can cause further discomfort due to spasms of the sphincter of Oddi. d) Medications to reduce biliary pain are limited due to the risk of addiction. Alternative pain relief therapies should be initiated. 9. The health care provider orders neomycin for a patient diagnosed with cirrhosis. Which statement best explains the rationale for its use? a) Neomycin is used to reduce the ammonia levels and reduce hepatic encephalopathy. b) Neomycin, an antibiotic, is used to prevent infection. c) Neomycin will be used to bind with the bile acids in the GI tract and reduce the levels of bile acids. d) This medication will be used to manage bleeding esophageal varices. 10. Older adults often demonstrate altered responses to medications such as anticonvulsants, psychotropics, and oral anticoagulants. These altered responses can result from the: a) older adult’s reduced vascular elasticity, which reduces the rate of medication metabolism. b) older adult’s reduced cardiovascular functioning, limiting the blood transport of the medications. c) decrease in protein synthesis, altering drug metabolism in the older adult. d) fact that there are fewer liver cells in the older adult, limiting the surface area available to aid in drug metabolism. Chapter Pretest Answers 1. 2. 3. 4. 5.
d a d a a
6. b 7. b 8. c 9. a 10. c
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Cooper FAAHN 8e Chapter 47 Pretest
1. The a) platelets b) erythrocytes c) leukocytes d) neutrophils 2.
1
are the main component of blood.
The normal hemoglobin level in men is: a) 14-18 g/dL. b) 12-16 g/dL. c) 16-18 g/dL. d) 18-20 g/dL.
3. Which of the white blood cells plays a role in allergic reactions? a) Basophils b) Monocytes c) Eosinophils d) Neutrophils 4. When providing care to a patient who has suffered a large burn to the neck and chest, a WBC with differential test is ordered. Which factor would most likely be noted? a) The monocyte level will be elevated. b) The erythrocyte sedimentation rate will be reduced. c) The hemoglobin level will be reduced. d) The neutrophil levels will be elevated. 5. The blood type a) AB b) B c) O d) A
is often referred to as the universal recipient.
6. Which mother will be a candidate for the administration of RhoGAM after the birth of a baby? a) The mother is O positive and the baby is O positive. b) The mother is AB positive and the baby is A positive. c) The mother is A negative the baby is AB negative. d) The mother is A negative and the baby is O positive. 7. When caring for a patient diagnosed with iron deficiency anemia, the nurse’s responsibilities include patient education concerning dietary intake. What foods should be included in the diet? a) Strawberries, cantaloupe, and legumes b) Liver, citrus fruit, and cottage cheese c) Eggs, shellfish, and broccoli d) Whole-grain breads, nuts, and dried fruit 8. A patient is hospitalized with a diagnosis of lymphedema. When developing the plan of care, which of these interventions would be most appropriate? a) Reduced sodium intake b) Antiviral medication therapy c) Intravenous fluid replacement d) Restrictions in dietary protein 9. After the staging process, a patient being treated for Hodgkin’s disease has been identified as being in stage II. Which best describes her level of disease process? a) Diffuse and disseminated involvement of one or more extralymphatic tissues b) Two or more abnormal lymph nodes on the same side of the diaphragm c) Abnormal lymph node regions on both sides of the diaphragm d) Regional extranodal sites located 10. Which statement is correct concerning the administration of oral iron therapy? a) If a dose is missed, do not double the next dose to catch up.
Cooper FAAHN 8e Chapter 47 Pretest
b) Enteric-coated iron is an acceptable option for patients who have difficulty taking pills. c) Patients experiencing gastrointestinal upset when taking iron pills should take the pills accompanied with an antacid preparation. d) When diluting liquid iron preparations, use water, not juice.
Chapter Pretest Answers 1. 2. 3. 4. 5.
b a c c a
6. d 7. d 8. d 9. b 10. a
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Cooper FAAHN 8e Chapter 48 Pretest
1. A patient reports being diagnosed with a murmur. Which phenomenon can be used to explain what might be the cause of this occurrence? a) Inappropriate closure of the ventricular lock b) The entrance of the blood into partially contracted chambers c) Ineffective closure of the valves d) Inadequate levels of blood as it leaves the atria 2. Which of the heart’s chambers is the thickest and most muscular? a) Right atrium b) Right ventricle c) Left atrium d) Left ventricle 3. When preparing the patient for an electrocardiogram, which configuration is correct for electrode placement? a) 6 electrodes on the chest and 4 on the limbs b) 8 electrodes on the chest and 4 on the limbs c) 5 electrodes on the chest and 4 on the limbs d) 6 electrodes on the chest and 6 on the limbs 4. The homocysteine test has been completed on your patient. Which value, if noted, will be within normal limits? a) Less than 3 umol/L b) 8 umol/L c) 23 umol/L d) 25-32 umol/L 5. Which risk factor is considered nonmodifiable? a) Age b) Dietary intake c) Hyperlipidemia d) Sedentary lifestyle 6. After completing a serum assessment of the LDL, which is considered an optimal reading? a) Not in excess of 175 mg/dL b) 150-174 mg/dL c) 125-149 mg/dL d) Below 100 mg/dL 7. A beta-adrenergic blocker has been prescribed to manage a patient diagnosed with persistent sinus tachycardia. Which medication can be anticipated? a) Digoxin (Lanoxin) b) Procainamide (Pronestyl) c) Verapamil (Calan) d) Propranolol (Inderal) 8. You are preparing to administer digoxin. Which assessment will need to be completed prior to administration? a) Assess apical pulse. b) Monitor blood pressure. c) Monitor for sleep disturbances. d) Monitor for visual disturbances. 9. A patient diagnosed with coronary artery disease has questions concerning the best diet for managing her condition. Which diet would be most helpful? a) High protein, low fat
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Cooper FAAHN 8e Chapter 48 Pretest
b) 2 g sodium, low cholesterol, 1500 calories, fluid restriction c) 4 g sodium, restricted potassium, moderate fat, high protein d) Low protein, low fat, high phosphorus 10. A patient diagnosed with elevated LDL plans to make daily dietary changes. Which will be most therapeutic? a) 10-20 g of soluble fiber daily, including foods such as wheat bread and beans b) 20-30 mg of soluble fiber daily, including foods such as bran and broccoli c) 20-30 g of soluble fiber daily, including foods such as bran, beans, and peas d) 10-20 mg of insoluble fiber daily, including foods such as bran, beans, and wheat bread
Chapter Pretest Answers 1. 2. 3. 4. 5.
c d a b a
6. d 7. d 8. a 9. b 10. c
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Cooper FAAHN 8e Chapter 49 Pretest
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1. When performing a thoracentesis, the maximum amount of fluid that can be removed within a 30minute period of time is: a) 1300 mL. b) 1000 mL. c) 2000 mL. d) 1500 mL. 2. While performing an assessment of lung sounds, brief, intermittent, bubbling sounds are heard at the end of inspiration. Based upon your knowledge, you recognize these sounds as: a) a pleural friction rub. b) sibilant wheezes. c) medium crackles. d) coarse crackles. 3. When performing an assessment of the respiratory system, you hear sonorous wheezes. To which cause can these sounds be attributed? a) Caused by mucus or pus in the small airways and alveoli b) Associated with disease in the bronchioles c) Caused by a narrowing in the bronchioles d) Caused by the transportation of air through the tracheobronchial passages 4. When comparing the characteristics of inhaled and exhaled air, which statement is most correct? a) Inhaled air contains about 20% oxygen and exhaled air has only about 10% oxygen. b) Inhaled air contains about 16% oxygen and exhaled air has about 16% oxygen. c) Exhaled air contains about 16% oxygen and 3.5% carbon dioxide. d) Exhaled air contains about 15% oxygen and 10% carbon dioxide. 5. The oxygen, and acids. a) chemoreceptors b) visceral pleura c) parietal pleura d) hyoid
function(s) to assist in the determination or evaluation of carbon dioxide,
6. The health care provider has ordered a sputum specimen from the patient. Which information is accurate regarding obtaining a sputum specimen? a) A hypotonic saline mist can be used to aid in obtaining the specimen. b) Obtain the sputum specimen before initiating antibiotic therapy. c) Collect the specimen after meals. d) The patient should avoid drinking any water 1 hour prior to obtaining the specimen. 7. When caring for a patient who has respiratory acidosis, which statement concerning the mode of compensation by the body is correct? a) Lungs retain CO2 to lower the pH. b) The kidneys will retain increased amounts of HCO3 to increase pH. c) The kidneys will begin to reduce the amounts of stored HCO3 to increase pH. d) The lungs will “blow off” CO2 to raise pH. 8. The most common causative agent of tonsillitis is: a) Haemophilus influenzae. b) staphylococcus. c) group B streptococci. d) group A streptococci.
Cooper FAAHN 8e Chapter 49 Pretest
9. When administering corticosteroids to patient with a chronic respiratory disorder, which information should be included during patient education? a) “Do not discontinue medication abruptly.” b) “You will require routine monitoring of kidney function.” c) “Take the medication on an empty stomach.” d) “You will require routine monitoring of liver function.” 10. Which statement about the cultural and ethnic considerations associated with tuberculosis is correct? a) The incidence of tuberculosis in Caucasians is only slightly higher than that in non-Caucasians. b) In the United States, tuberculosis occurs in urban middle-class and middle-aged citizens. c) The incidence of tuberculosis among immigrants from southeastern Asia and Haiti is similar to those of their home countries. d) There is a low incidence of tuberculosis in foreign-born individuals from Latin America and Africa. Chapter Pretest Answers 1. 2. 3. 4. 5.
a c d c a
6. b 7. b 8. c 9. a 10. c
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Cooper FAAHN 8e Chapter 50 Pretest
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1. The is the functional unit of the kidney. a) nephron b) renal pelvis c) renal pyramid d) renal papilla 2. When ketone bodies are present in the urine, it indicates: a) potential infection or tumors. b) toxicity of the urine related to heavy metal exposure. c) the oxidation of fatty acids. d) probable kidney disease. 3. A patient whose health care provider has ordered a prostate-specific antigen (PSA) test asks you questions about the test. What information will you include in your response? a) The PSA is less accurate than the PAP test, but it is the first line of recommended testing at this time. b) A PSA result lower than 4 ng/mL is associated with the presence of benign prostatic hypertrophy and prostatitis. c) The PSA should be obtained after the provider completes the physical examination. d) Elevated PSA results are associated with the presence of prostate cancer. 4. The collection of a creatinine clearance test involves which action? a) A urine specimen is obtained by using a straight catheter to ensure the specimen is not contaminated. b) A blood specimen is collected after the morning meal the day of the test. c) The urine will be collected over a 24-hour period. d) The collection period begins with the first kept urine specimen. 5. A patient diagnosed with acute renal failure can expect to have which medication prescribed to promote diuresis during the oliguric phase? a) Nalidixic acid b) Osmitrol c) Triamterene d) Furosemide 6. While providing care for a patient who has blood in his urine, which catheter will be most effective? a) Malecot b) Robinson c) Whistle-tip d) Suprapubic 7. Reabsorption of water, glucose, and necessary ions back into the blood takes place in the . a) loop of Henle b) Bowman’s capsule c) distal convoluted tubule d) glomerulus 8. A patient has been diagnosed with cystitis. Which may have contributed to the development of this condition? a) Recent catheterization b) The use of steroids c) Immobility d) Hypertension
Cooper FAAHN 8e Chapter 50 Pretest
9. A patient who has been experiencing urinary difficulty has been diagnosed with benign prostatic hypertrophy. Which statement by the patient indicates the need for further teaching? a) “The health care provider may prescribe medications to manage my condition.” b) “The insertion of a Foley catheter can help relieve my discomfort.” c) “I may need radiation to manage this condition.” d) “Surgery may be indicated to manage this condition.” 10. When providing care for the patient diagnosed with nephritis, which dietary change is indicated? a) Increase protein to promote healing. b) Increase calories to increase energy. c) Increase sodium to replenish blood levels. d) Reduce calcium to assist the kidney’s filtration responsibilities. Chapter Pretest Answers 1. 2. 3. 4. 5.
a c d c b
6. c 7. a 8. a 9. c 10. b
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Cooper FAAHN 8e Chapter 51 Pretest 1. The is known as the “master gland.” a) thyroid gland b) pituitary gland c) parathyroid gland d) adrenal gland 2. When a patient experiences a reduction in blood glucose levels, which hormone is secreted in response? a) Insulin b) Carbohydrates c) Glucagon d) Progesterone 3. The body’s response to stressors is known as “fight or flight.” What part of the body is responsible for this phenomenon? a) Adrenal medulla b) Anterior pituitary gland c) Posterior pituitary gland d) Cerebellum 4. When interpreting the results of the serum thyroxine test, which result is within normal range? a) 1-3.5 ng/dL b) 5-12 mcg/dL c) 65-195 ng/dL d) 0.3-5.4 mcg/mL 5. When providing teaching for the parents of a child diagnosed with dwarfism, which point should be included in the information presented? a) The child will appear older than his peers as a result of the condition. b) A dental consultation will be indicated to assist with the difficulties anticipated as the primary teeth erupt. c) Sexual development will be delayed. d) The child will most likely experience sterility. 6. You are assigned to plan the care for a patient diagnosed with acromegaly. What considerations should be incorporated into the plan? a) To compensate for the increase in body size, the caloric count of the patient should be closely monitored. b) Narcotic analgesics are indicated for the pain experienced. c) Bedrest will be indicated during acute episodes. d) The diet should be soft and easy to chew. 7. The evaluation of urine and serum test results are indicated in the care of a patient suspected of diabetes insipidus. Which result is associated with this condition? a) Urine specific gravity 1.003-1.008 b) Serum sodium 139 mEq/L c) Serum osmolality 280 mOsm/kg d) Urine specific gravity 1.001-1.005 8. Which medication can be associated with the onset of syndrome of inappropriate antidiuretic hormone (SIADH)? a) Opiates b) NSAIDs c) Antibiotics d) Oral contraceptives
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Cooper FAAHN 8e Chapter 51 Pretest
9. Medical management of hyperthyroidism can include: a) methimazole. b) calcium. c) thyroglobulin. d) vitamin D. 10. Insulin with a rapid onset is prescribed. Which insulin listed below will meet the criterion? a) NPH b) Lente c) Lantus d) Humalog Chapter Pretest Answers 1. 2. 3. 4. 5.
b c a b c
6. d 7. d 8. a 9. a 10. d
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Cooper FAAHN 8e Chapter 52 Pretest
1. The American Cancer Society makes which recommendation concerning the use of mammography for women who do not have any remarkable risk factors? a) Mammograms should be done annually beginning at age 35 for all patients. b) Patients should begin to have annual mammograms beginning at age 40. c) Mammography baseline examinations should begin at age 30. d) Mammograms should be performed every 2 years after age 45. 2.
The use of lotions and deodorants has what influence on a mammogram? a) Lotions and deodorants do not impact the accuracy of a mammogram. b) Lotions and deodorants can cause false positive responses on the mammogram’s interpretation. c) Lotion doesn’t influence mammogram readings, but deodorant can cause a false negative interpretation. d) Lotions and deodorants can cause false negative responses on the interpretation of a mammogram.
3. A 35-year-old patient has been diagnosed with a vaginal yeast infection. Based upon your knowledge, what medication might be ordered for treatment? a) Acyclovir b) Danazol c) Premarin d) Metronidazole 4. While reviewing the medical records of a 36-year-old patient, you notice she has been seen at the clinic with complaints of dyspareunia. You recognize this medical terminology refers to: a) painful intercourse. b) painful menstrual cramps. c) an estrogen imbalance. d) the presence of vaginal dryness. 5. A 42-year-old woman presents with complaints of vaginal irritation and dyspareunia. Her health care provider diagnoses her with atrophic vaginitis. She asks how she contracted this disorder. What information should be included in the patient education? a) Reduced estrogen levels have caused vaginal changes, resulting in the symptoms being experienced. b) Excessive douching is associated with the development of this disorder. c) An increase in the normal pH of the vaginal vault has caused the changes being experienced. d) This disorder is associated with sexual contact with an infected partner. 6. A 22-year-old female patient is hospitalized with complaints of a sore throat, headache, nausea, vomiting, and fever. During data collection, you note she has a red macular rash on her hands and feet. What diagnosis do you anticipate for this patient? a) Pelvic inflammatory disease b) Endometriosis c) Systemic bacterial vaginosis d) Toxic shock syndrome 7. During a routine visit to her health care provider, a 23-year-old patient asks how often she should have a breast examination. What information will you provide to the patient? a) “You need to perform a self-breast exam monthly, and your breasts need to be examined annually by your health care provider.” b) “You will need to perform a self-breast exam each month, and your health care provider will examine them every 2 years.” c) “As long as you are examining your breasts at home monthly, there is no need to begin annual provider examinations until you begin to experience menopausal signs and symptoms.” d) “Perform a self-breast exam monthly, and then follow up for a breast exam with your health care provider every 3 years.”
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Cooper FAAHN 8e Chapter 52 Pretest
8. A 32-year-old male patient has been diagnosed with a primary episode of genital herpes. What medication do you anticipate will be prescribed? a) Tetracycline b) Penicillin c) Zovirax d) Rocephin 9. A patient reports to the clinic with complaints of dysuria, pruritus, and a frothy green penile discharge. These clinical manifestations are associated with: a) trichomoniasis. b) herpes simplex. c) gonorrhea. d) syphilis. 10.
refers to the number of births a woman has experienced. a) Gravidity b) Parity c) Metrorrhagia d) Dysmenorrhea
Chapter Pretest Answers 1. 2. 3. 4. 5.
b b d a a
6. d 7. d 8. c 9. a 10. b
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Cooper FAAHN 8e Chapter 53 Pretest
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1. When explaining the physiology of vision, it is important to understand that convergence involves the: a) bending of light rays as they pass through the structures of the eye. b) medial movement of both eyes, allowing light rays from the object to hit the same point on both retinas. c) ability of the eyes to focus on objects at differing distances. d) inability of the aging eye to focus on objects at increasing distances. 2. A young man diagnosed as colorblind has which impairment? a) A dietary deficiency of vitamin A b) The absence of cones c) The absence of rods d) A reduction in aqueous humor 3. The area of the tongue responsible for the sensation of bitter flavors is the: a) posterior portion. b) right side. c) tip of the tongue. d) left side. 4. When caring for a patient having a history of glaucoma, which preprocedural medication will be contraindicated? a) Mydriatic drops b) Miotic drops c) Cycloplegic drops d) Antibiotic ointment 5. A patient has just finished seeing the health care provider concerning an eye disorder. The patient states he has been diagnosed with myopia. Based upon your understanding, which statement is correct? a) There is an inability of the eyes to focus in the same direction. b) The rays of light entering the eye are focusing behind the retina. c) There is an elongation of the eyeball, causing light rays to focus in front of the retina. d) One eye turns inward in the direction of the nose. 6. When assessing a patient who has developed cataracts associated with drug/medication use, which medication will be implicated? a) Chemotherapeutic medication b) Nonsteroidal antiinflammatory medication c) Marijuana d) Corticosteroids 7. A patient presents to the health care provider with complaints of decreasing coordination in voluntary movements. Which diagnostic test can be anticipated? a) Past-point test b) Romberg test c) Rinne test d) Weber test 8. When planning the care of a patient diagnosed with Ménière’s disease, which dietary recommendation will be incorporated? a) Sodium restriction b) Protein restrictions c) Push fluid intake during daytime hours d) Potassium restriction
Cooper FAAHN 8e Chapter 53 Pretest
9. After having surgery to treat a hearing loss, the patient asks when she can resume her normal activities. What information will be included in the patient education? a) “You may wash your hair 48 hours after surgery.” b) “You may return to work in 4-6 weeks.” c) “You can take trips in the car only after 3-4 weeks.” d) “Physical activity will be limited for the first week postoperatively.” 10. When caring for a patient who underwent a stapedectomy, the patient voices concern because he is unable to note any improvement in hearing since the procedure. What information is the best response by the nurse? a) “I will need to contact your health care provider to communicate this setback.” b) “Improvements in hearing will not be noted until after the swelling subsides.” c) “The health care provider will see you tomorrow.” d) “Don’t worry; your hearing will begin to improve tomorrow.” Chapter Pretest Answers 1. 2. 3. 4. 5.
b b a a c
6. d 7. a 8. a 9. d 10. b
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Cooper FAAHN 8e Chapter 54 Pretest
1. The concept of proprioception refers to: a) being perceptually unaware of and inattentive to one side of the body. b) a defect of vision or blindness in half of the visual field. c) the sensation pertaining to spatial position and muscular activity stimuli originating from within the body. d) a numbness in the lower extremities associated with reduced environmental temperatures. 2. While reviewing a cerebrospinal fluid test result, you note that the lab identified reduced glucose and chloride levels. Based upon your knowledge, you anticipate a diagnosis consistent with a: a) bacterial infection. b) viral infection. c) herpes viral infection. d) varicella infection. 3. The a) vagus b) hypoglossal c) acoustic d) olfactory
cranial nerve is responsible for the sense of smell.
4. After performing the Glasgow coma scale test, the patient assessment reveals a score of 13. This score indicates: a) a light comatose state. b) disorientation. c) normal neurologic functioning. d) a deep comatose state. 5. The health care provider of a patient who has suffered a mild CVA has recorded in her notes that the patient is experiencing dysarthria. This refers to which occurrence? a) Poorly articulated speech b) A reduced degree of motor movement abilities c) A complete loss of motor movement abilities d) Inability to swallow 6. A patient is in a coma after a serious motor vehicle accident. He has been diagnosed with a significant neurologic impairment. He is demonstrating decorticate posturing. An assessment of his positioning will reveal: a) flaccid upper extremities accompanying tightened lower muscle extremity tone. b) flexion of the arms, wrists, and fingers with adduction in the upper extremities. c) all four extremities are in rigid extension with hyperpronation of the forearms and plantar extension of the feet. d) all four extremities are in rigid flexion with hyperpronation of the forearms and feet. 7. After a seizure, the patient appears groggy and lethargic. These findings are consistent with which stage of the seizure? a) Postictal period b) Postrecovery period c) Post-aura d) Aura phase 8. A patient who has recently been diagnosed with seizures asks if he will be allowed to drive again. What is the best response to his question? a) “Unfortunately, you will not ever drive again.” b) “Once the seizures are under medical control for a period of time, you might be able to drive.” c) “It is best you do not drive, as the stressors could bring on seizure activity.” d) “Seizure activity should not hinder your driving ability.”
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Cooper FAAHN 8e Chapter 54 Pretest
9. An assessment noting diplopia, vertigo, loss of joint sensation, and nystagmus is consistent with which disorder? a) Multiple sclerosis b) Parkinson’s disease c) Huntington’s disease d) Myasthenia gravis 10. When caring for a patient with a diagnosis of trigeminal neuralgia, an area for concern is: a) respiratory insufficiency. b) avoidance of skin breakdown. c) activation of trigger points. d) muscle wasting.
Chapter Pretest Answers 1. 2. 3. 4. 5.
c d d c a
6. b 7. a 8. b 9. a 10. c
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1.
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is the ability of the immune system to mobilize an antibody in response to an antigen. a) Cellular immunity b) Cell-mediated immunity c) Immunotherapy d) Immunocompetence
2. Which statement concerning innate immunity is correct? a) There are no physical barriers with this subcategory of immunity. b) Innate immunity involves a nonspecific inflammatory response. c) Innate immunity employs T lymphocytes to protect the body. d) Innate immunity utilizes humoral immunity. 3. When describing the manner in which B cells work, which is most correct? B cells: a) are produced in response to antibodies. b) decrease in number as they respond to a potential pathogen. c) are an active part of the innate immune process. d) increase in number as they are called to respond to an antigen. 4.
immunity results from the development and continuing presence of antibodies circulating in the plasma. a) Humoral b) Cell-mediated c) Cellular d) Histamine-based
5. When caring for a patient with a disorder of the immune system, you are asked what is meant by the term antigen. What should be included in your response? a) An antigen is able to protect the body from a pathogen. b) Antigens allow the body to fight off infection. c) Antigens are potential invaders of the body’s immune system. d) Antigens and antibodies are interchangeable terms referring to the body’s ability to defend itself from disease. 6. Which position is most appropriate for a patient being treated for an anaphylactic reaction? a) Sitting upright b) Sitting upright with the legs elevated c) Recumbent with legs elevated d) Recumbent with the legs lowered 7. When an autoimmune disorder occurs, which best explains what has taken place? a) The immune system’s concept of memory has not effectively provided recall about exposure to an antigen. b) The humoral immune system has overreacted in response to environmental stimuli. c) There has been a decrease in T cell production. d) The body has not been able to effectively differentiate its own cells from foreign invaders. 8. A patient who suffered an allergic reaction asks how potential allergens can get into the body and cause the reaction. Which is an accurate statement? a) Most allergens enter the body from cuts and other skin openings. b) The oral cavity is the portal for most environmental allergens. c) The gastrointestinal and respiratory systems are the most common means of entry for allergens. d) The most common route of entry for pathogens involves the ingestion of pathogens.
Cooper FAAHN 8e Chapter 55 Pretest
9. Common allergens that could be associated with anaphylaxis include: a) milk, chocolate, and peanuts. b) walnuts and grapes. c) peanuts, shellfish, and wheat. d) oats, strawberries, and grapes. 10. At the first sign of anaphylaxis, administration of epinephrine is indicated. What dosage is appropriate? a) 0.2-0.5 mL epinephrine IM b) 0.2-0.5 mL epinephrine subcutaneously c) 1.5-2.0 mL epinephrine IV push d) 0.5-1.0 mL epinephrine IM
Chapter Pretest Answers 1. 2. 3. 4. 5.
d b d a c
6. c 7. d 8. d 9. a 10. a
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Cooper FAAHN 8e Chapter 56 Pretest
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1. When reviewing the number of total AIDS cases in people age 55 or older, which statement is most accurate? a) Fewer than 5% of the reported cases of AIDS are people age 55 or older. b) The number of AIDS cases in people older than 55 is greater than that in the population of age 2035 years. c) More than 10% of AIDS cases are reported to be in people age 55 or older. d) Between 5% and 10% of AIDS cases have been reported to be in people age 55 or older. 2. Which population demonstrates the highest rate of HIV seroprevalence? a) Hispanics b) African Americans c) Caucasian Americans d) European immigrants 3. The terminology used to describe HIV- and AIDS-related procedures is important. Which term is most appropriate? a) HIV antibody test b) AIDS test c) AIDS serology examination d) AIDS positive 4. What percentage of HIV-positive individuals are considered rapid progressors? a) Less than 5% b) 5% to 10% c) 10% to 15% d) More than 15% 5. During seroconversion, which characteristic is correct? a) The viral load is low, with a short-term drop in CD4+ cells. b) The viral load is low, with a short-term elevation in CD4+ cells. c) The viral load is extremely high, with a short-term elevation in CD4+ cells. d) The viral load is extremely high, with a short-term drop in CD4+ cells. 6.
refers to the development of antibodies from HIV. a) Asymptomatic immunodeficiency disease b) Seroconversion c) Primary HIV infection d) Retroconversion
7. The initial test used to begin the diagnostic process for HIV infection employs which test? a) Seronegative test b) ELISA test c) Western blot test d) bDNA reaction test 8. When caring for the patient diagnosed with Pneumocystis jirovecii pneumonia, which medication can be anticipated? a) Acyclovir b) Amphotericin B + 5-flucytosine c) Trimethoprim-sulfamethoxazole d) Vancomycin 9. When reviewing the expenses for the care of a person infected with HIV, which is responsible for the largest portion of the health care expenditures? a) Medications b) Hospitalization
Cooper FAAHN 8e Chapter 56 Pretest
c) Health care provider expenses d) Alternative therapies 10. The anticipated lifetime cost of care for the HIV-positive person is: a) $250,000 to $350,000. b) $350,000 to $450,000. c) $450,000 to $550,000. d) Exceeds all of these amounts.
Chapter Pretest Answers 1. 2. 3. 4. 5.
d a a c a
6. b 7. b 8. c 9. a 10. d
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1. When counseling a 16-year-old male about the use of smokeless tobacco, he says that because there is no smoke, he does not need to be concerned about lung cancer. What is the best response from the nurse? a) “You certainly are correct. Smokeless tobacco is safe for your use.” b) “Smokeless tobacco is associated with cancer of the liver and pancreas.” c) “Your risk of mouth, larynx, pharynx, and esophageal cancer will increase with the use of smokeless tobacco.” d) “It is still not clear what cancer risks are increased by the use of smokeless tobacco.” 2.
has been identified as a risk factor for the development of breast, prostate, and ovarian cancers. a) Obesity b) Smoking c) Radiation exposure d) Chlorine
3. A woman of Japanese descent voices concerns about her risk for breast cancer. What should she be told? a) “Breast cancer is common in Japanese women.” b) “There is little breast cancer found in Japanese women.” c) “Your risk of developing breast cancer is higher before menopause.” d) “Breast cancer should not be a concern for you.” 4. When preparing to instruct a group of students about making dietary changes to reduce the incidence of breast cancer, which factor is correct? a) White cheese should be substituted for yellow cheese whenever possible. b) Heavy alcohol intake could increase the risk of breast and uterine cancer. c) The daily diet should include four servings of fruits and vegetables. d) Cauliflower, carrots, and cantaloupe are the best sources of beta-carotene. 5. When considering the impact of dietary intake on the development of cancer, which statement is correct? a) Nearly 70% of cancer-related deaths can be attributed to high-fat and high-fiber diets. b) Diets high in fat and low in fiber can be blamed for nearly one-third of cancer-related deaths. c) Low-protein diets are associated with the development of colon cancers. d) High-protein diets are linked to breast cancer. 6. The teaching care plan for a 23-year-old woman concerning preventive behaviors for the development of cervical cancer should include: a) taking oral contraceptive medications to reduce the development of cervical cancer. b) reporting signs and symptoms of abdominal swelling, vaginal bleeding, and chronic stomach pain. c) avoiding sun exposure between noon and 3 PM. d) employing the use of barrier contraceptives with sexual intercourse. 7. Characteristics associated with benign tumors include: a) a variable rate of growth. b) little resemblance to the parent tissue. c) immobility when palpated. d) resemblance to parent tissue. 8. The term referring to an uncontrolled or abnormal growth of cells is a) metastasis b) proliferation c) neoplasm d) anaplasia
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Cooper FAAHN 8e Chapter 57 Pretest
9. A laboratory test has determined that a 59-year-old male undergoing chemotherapy for lung cancer has a platelet count of 100,000/mm3, hemoglobin of 15 g/dL, and hematocrit of 44%. Which intervention can be anticipated? a) Administration of diphenhydramine b) Avoidance of aspirin or aspirin preparations c) Administration of Epogen d) A transfusion of packed RBCs 10. Tumor lysis syndrome is most likely to occur in which patient? a) A 33-year-old female during her first day of chemotherapy for metastatic breast cancer b) A 55-year-old man diagnosed with basal cell carcinoma of the lips c) A 23-year-old male diagnosed with osteosarcoma who had his last chemotherapy treatment 10 days ago d) A 67-year-old female diagnosed with ovarian cancer who had a recent hysterectomy
Chapter Pretest Answers 1. 2. 3. 4. 5.
c a b a b
6. d 7. d 8. c 9. b 10. a
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Cooper FAAHN 8e Chapter 58 Pretest
1. When preparing a résumé, the appropriate length of the document should be: a) at least two pages. b) one page. c) as long as needed. d) no more than three pages. 2. Questions that cannot be asked during a job interview include: a) job-related criminal convictions. b) future professional goals. c) education. d) criminal arrest or criminal convictions unrelated to the job. 3. When planning to leave a job, it is best that the employee: a) provide a written letter of resignation to the immediate supervisor. b) e-mail the facility outlining plans to leave. c) provide a letter outlining the problems encountered in the job and the plans to leave it. d) call the facility and let them know the plans to terminate employment. 4. NAPNES is an organization whose mission involves which of the following? a) Promotion of an understanding of practical nursing schools and continuing education for the LPN/LVN b) Promotion of the image of the LPN/LVN c) Provision of malpractice, personal liability, and health and accident insurance d) Lobbying on the state and national levels for issues that are of interest and concern to the LPN/LVN 5. An LPN/LVN graduate is preparing to take the NCLEX® examination. Which statement is accurate regarding the number of questions that will be encountered on the examination? a) Each student can expect at least 100 questions. b) The number of questions will vary as each applicant is required to demonstrate a minimum of 85% accuracy. c) Meeting the passing standard varies as will the number of questions to each applicant. d) The minimum number of questions is 75. 6. When scheduling an appointment to complete the NCLEX® examination, an applicant must be provided a testing appointment within of calling the testing center. a) 30 days b) 45 days c) 6 weeks d) 90 days 7. When an LVN/LPN plans to move to another state, what must be done to be allowed to practice in the new state? a) The LPN/LVN must apply to take the examination in the new state. b) The LPN/LVN must have 6 months of work experience to become licensed in a second state. c) The LPN/LVN contacts the state board of nursing in the new state to apply for licensure. d) Successful completion of the NCLEX® examination ensures the LPN/LVN can practice in each of the 50 states. 8. The is responsible for defining the title and regulations governing the practice of nursing. a) NCLEX b) NCSBN c) state legislature d) nurse practice act
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Cooper FAAHN 8e Chapter 58 Pretest
9. The responsibilities of the state board of nursing include which of the following? a) Prosecuting nurses who violate the state’s rules pertaining to nursing care b) Developing the questions used on the NCLEX c) Approving schools of nursing d) Assessing fines to health care facilities for violations of HIPAA 10. The leadership style characterized by a people-centered approach to facilitate completion of goals while focusing on the self-worth of individuals is known as: a) laissez-faire. b) coaching. c) democratic. d) autocratic.
Chapter Pretest Answers 1. 2. 3. 4. 5.
b d a a c
6. a 7. c 8. d 9. c 10. c
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