TEST BANK for Understanding Medical-Surgical Nursing, 6th Edition by Williams. by StudyGuide

TEST BANK

Understanding Medical Surgical Nursing 6th Edition Williams Test Bank Chapter 1. Critical Thinking and the Nursing Process MULTIPLE CHOICE 1. The nurse is caring for a group of patients on a medical-surgical unit. Which patient should the licensed practical nurse/licensed vocational nurse (LPN/LVN) assess first? 1. A patient with a blood glucose of 42 mg/dL 2. A patient who reports a pain level of 2 3. A patient who has just received a diagnosis of cancer 4. A patient who has a respiratory rate of 22 ANS: 1 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs. Pages: 6–7 Heading: Prioritize Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult

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Feedback This patient has a dangerously low blood glucose level and requires immediate intervention. This patient will need to be assessed, but is not as high a priority. According to Maslow, psychosocial needs are not as high of a priority as physiological needs. A respiratory rate of 22 is within normal range.

PTS:

CON: Patient-Centered Care

2. The LPN/LVN enters the room of a patient who is angry and yells, “I asked 5 minutes ago for my pain medication. I’m going to call the CEO of the hospital if you don’t get it for me now.” Which statement by the nurse demonstrates intellectual empathy? 1. “We are short-staffed today, so it will take me longer to meet your needs.” 2. “I am sorry you had to wait, I know you must be in a lot of pain.” 3. “I had another patient who had severe pain, and I had to get to them first.” 4. “I will get you the number for the CEO, but he is aware of how busy we are.” ANS: 2 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 2. Describe attitudes and skills that promote good critical thinking Page: 2 Heading: Intellectual Empathy Integrated Process: Communication and Documentation Client Need: Psychosocial Integrity NURSING TEST BANK

Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate

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Feedback This statement does not consider an individual’s situation. This statement demonstrates intellectual empathy by considering this patient’s situation and will likely alleviate the patient’s anger. This statement does not consider a patient’s situation and does not demonstrate intellectual empathy. This statement addresses the patient’s statement of wanting to call the CEO, but does not demonstrate intellectual empathy by considering the patient’s situation.

PTS:

CON: Communication

3. The nurse is collecting data on a patient. Which data are described as subjective? 1. Respiratory rate of 26 per minute 2. Patient report of shortness of breath 3. Coarse lung sounds bilaterally 4. Cough producing green sputum ANS: 2 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 5. Differentiate between objective and subjective data. Page: 4 Heading: Subjective Data Integrated Process: Communication and Documentation Client Need: Communication and Documentation Cognitive Level: Application (Applying) Concept: Communication Difficulty: Moderate

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Feedback Respiratory rate of 26 per minute is an example of objective data. A patient reporting symptoms to the nurse is an example of subjective data. Coarse lung sounds is an example of objective data. A productive cough is an example of objective data. PTS:

CON: Communication

4. A patient with a newly fractured femur reports a pain level of 8/10 and analgesic medication is not due for another 50 minutes. Which action should the nurse take first? 1. Reposition the patient. 2. Give the medication in 30 minutes. 3. Notify the registered nurse (RN) or physician. 4. Tell the patient it is too early for pain medication. ANS: 3

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Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using the nursing process. Page: 3 Heading: Clinical Judgement Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE—Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback The patient who has a fractured femur is having acute pain. Repositioning a patient with a new fracture is not likely to relieve pain. Giving the medication before the prescribed time is beyond the nurse’s scope of practice. The patient should not have to wait for pain relief, so the LPN should inform the RN or physician so new pain relief orders can be obtained. The nurse needs to do more than expect the patient to wait for pain relief.

PTS:

CON: Patient-Centered Care

5. The nurse is prioritizing care based on Maslow hierarchy of needs. Which need does the nurse identify as having the highest priority? 1. Job-related stress 2. Feeling of loneliness 3. Pain level of 9 on 0-to-10 scale 4. Lack of confidence ANS: 3 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs Page: 7 Heading: Prioritize Care Integrated Process: Caring Client Need: SECE – Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback Job-related stress falls under safety according to Maslow and is addressed after physiological needs. According to Maslow, loneliness is addressed under social needs following physiological and safety. Pain is a physiological need and is the highest priority. Lack of confidence falls under esteem according to Maslow and is addressed following physiological, safety, and social needs.

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PTS:

CON: Patient-Centered Care

6. The nurse is planning care and setting goals for a newly admitted patient. Who should the nurse include when conducting these nursing actions? 1. Patient 2. Nurse manager 3. Hospital chaplain 4. Patient’s health care provider (HCP) ANS: 1 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse is using the nursing process. Page: 6 Heading: Prioritize Care Integrated Process: Communication and Documentation Client Need: SECE—Management of Care Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate

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Feedback Planning care and setting goals is an action performed with the patient. The patient must be in agreement with the plan for it to be successful in meeting the desired outcomes. The nurse manager may or may not be aware of the patient’s care needs. The hospital chaplain may not be aware of the patient’s needs. The focus of nursing care is different from that of the HCP.

PTS:

CON: Communication

7. While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes serosanguineous drainage on the dressing. Which statement should the nurse use to document this finding? 1. “Normal drainage noted.” 2. “Moderate drainage recently noted.” 3. “Scant serosanguineous drainage seen on dressing.” 4. “Pale pink drainage 2 cm by 1 cm noted on dressing.” ANS: 4 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 6. Document subjective and objective data. Page: 5 Heading: Documentation of Data Integrated Process: Communication and Documentation Client Need: PHYS—Physiological Adaptation Cognitive Level: Application [Applying] Concept: Communication

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Difficulty: Moderate

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Feedback These statements are interpretations of the data and use words that have vague meanings, which should be avoided when documenting. These statements are interpretations of the data and use words that have vague meanings, which should be avoided when documenting. These statements are interpretations of the data and use words that have vague meanings, which should be avoided when documenting. Objective data are pieces of factual information obtained through physical assessment and diagnostic tests that are observable or knowable through the five senses. The nurse should document exactly what is seen.

PTS:

CON: Communication

8. The nurse is caring for a patient using the nursing process. Which step should the nurse take first? 1. Implementation 2. Planning 3. Nursing diagnosis 4. Assessment ANS: 4 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using the nursing process. Page: 4 Heading: Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback The steps of the nursing process are data collection/assessment, nursing diagnosis, planning, implementation, and evaluation. The steps of the nursing process are data collection/assessment, nursing diagnosis, planning, implementation, and evaluation. The steps of the nursing process are data collection/assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment, or data collection, is the first step in the nursing process and is used to evaluate a patient’s condition before providing care. The other steps, in order, are nursing diagnosis, planning, implementation, and evaluation.

PTS:

CON: Patient-Centered Care

9. The nurse is administering morphine to a patient reporting a pain level of 8 on a 0-to-10 scale. This describes which step of the nursing process?

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1. 2. 3. 4.

Assessment Nursing diagnosis Implementation Evaluation

ANS: 3 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using the nursing process. Page: 8 Heading: Identify Interventions Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE – Coordination of Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback Administering medication does not describe assessment. Administering medication does not describe nursing diagnosis. Administering medication describes the implementation process, since an action is being taken to help the patient meet a desired outcome. Administering medication does not describe the evaluation phase of the nursing process.

PTS:

CON: Patient-Centered Care

10. The nurse is developing an outcome for a patient with exacerbation of asthma. Which is the most appropriate outcome for this patient? 1. The patient will not experience shortness of breath. 2. The patient will have a respiratory rate of 16 to 20 per minute. 3. The patient will ambulate without reporting shortness of breath. 4. The patient will not require use of an inhaler. ANS: 2 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 3. Describe the thinking that occurs in each step of the nursing process. Page: 8 Heading: Establish Outcomes Integrated Process: Clinical Problem-solving (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback This is a vague outcome and is not measurable. This is a measurable outcome and is not vague. This is a vague outcome and is not measurable.

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This is a vague outcome and is not measurable.

PTS:

CON: Patient-Centered Care

11. The nurse suspects a patient is experiencing adverse effects to a newly prescribed antihypertensive medication. After being informed that the effects are expected, the nurse remains concerned and conducts an Internet search on the patient’s manifestations. Which critical thinking behavior did the nurse implement? 1. Sense of justice 2. Intellectual courage 3. Intellectual empathy 4. Intellectual perseverance ANS: 4 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 2. Describe attitudes and skills that promote critical thinking. Page: 2 Heading: Intellectual Perseverance Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback A sense of justice examines motives when making decisions. Intellectual courage looks at other points of view, even when the nurse does not agree with them. Intellectual empathy understands how another person feels when making decisions. Intellectual perseverance is not giving up.

PTS:

CON: Patient-Centered Care

12. The nurse is identifying outcomes for a patient with fluid volume deficit. Which outcome should the nurse use to guide this patient’s care? 1. Patient’s intake will be measured daily. 2. Patient’s intake will be 3,000 mL daily. 3. Fluids will be at the bedside for the patient. 4. Fluids the patient likes will be at the bedside. ANS: 2 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 3. Describe the thinking that occurs in each step of the nursing process. Page: 7 Heading: Establish Outcomes Integrated Process: Clinical Problem-solving (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying]

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Concept: Patient-Centered Care Difficulty: Moderate Feedback These statements are nursing actions. This outcome provides objective measurable data. These statements are nursing actions. These statements are nursing actions.

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PTS:

CON: Patient-Centered Care

13. The nurse is formulating nursing diagnoses for a patient with chronic obstructive pulmonary disease (COPD). Which diagnosis is of the highest priority? 1. Activity intolerance 2. Impaired gas exchange 3. Risk for injury 4. Deficient knowledge ANS: 2 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs. Page: 6 Heading: Prioritize Care Integrated Process: Clinical Problem-solving (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

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Feedback Although activity intolerance is a nursing diagnosis for a patient with COPD, it is not the highest priority. Impaired gas exchange is the highest priority according to Maslow. A risk for diagnosis is not a priority because the patient is only at risk for the problem, it is not an actual problem as of yet. According to Maslow, deficient knowledge is not a priority.

PTS:

CON: Patient-Centered Care

14. An RN delegates a patient care assignment to the LPN/LVN. Which phase of the nursing process should the LPN/LVN perform independently? 1. Assessment 2. Planning care 3. Implementation 4. Nursing diagnosis ANS: 3 Chapter: Chapter 1 Critical Thinking and the Nursing Process

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Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using the nursing process. Page: 22 Heading: Role of the Licensed Practical Nurse/Licensed Vocational Nurse Integrated Process: Clinical Problem-Solving (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback The LPN/LVN assists the RN with collecting data, formulating nursing diagnoses, and in determining outcomes and planning care to meet patient needs. The LPN/LVN assists the RN with collecting data, formulating nursing diagnoses, and in determining outcomes and planning care to meet patient needs. The LPN/LVN independently provides direct patient care. The LPN/LVN assists the RN with collecting data, formulating nursing diagnoses, and in determining outcomes and planning care to meet patient needs.

PTS:

CON: Patient-Centered Care

15. The LPN/LVN is reviewing a care plan for a patient who underwent abdominal surgery 2 hours ago and has a priority nursing diagnosis of acute pain. Which intervention should the nurse implement first? 1. Teach the patient how to splint the abdomen when coughing. 2. Assist the patient with early ambulation. 3. Encourage the patient to increase fluid intake. 4. Administer hydromorphone (Dilaudid) per order as needed for pain. ANS: 4 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs. Page: 6 Heading: Prioritize Care Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult

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Feedback Splinting is important, but if the patient is in pain, he or she will not likely retain information. Early ambulation is important, but does not address the diagnosis of acute pain. The patient may need to increase fluid intake, but this is not a priority

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intervention. The patient has a nursing diagnosis of acute pain; this intervention should be implemented first.

PTS:

CON: Patient-Centered Care

16. Which critical thinking trait is demonstrated when the LPN/LVN is unsure of how to perform a dressing change and asks the RN for assistance? 1. Intellectual courage 2. Intellectual integrity 3. Intellectual humility 4. Intellectual empathy ANS: 3 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 2. Describe attitudes and skills that promote good critical thinking. Page: 2 Heading: Intellectual Humility Integrated Process: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Comprehension (Understanding) Concept: Communication Difficulty: Moderate

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Feedback Intellectual courage allows the nurse to look at other points of view even if he or she does not agree. Intellectual integrity is holding oneself to the same level of standards one expects others to meet. The LPN/LVN is demonstrating intellectual humility, which is having the ability to ask for assistance when he or she is unsure. Intellectual empathy allows the nurse to put himself or herself in the patient’s shoes.

PTS:

CON: Communication

17. During morning report, the LPN/LPN is assigned a group of patients. Which patient should the LPN/LPN see first? 1. A patient scheduled for magnetic resonance imaging (MRI) due to back pain 2. A patient reporting constipation and stomach cramps 3. A 2-day postsurgical patient reporting pain at a level of 6 4. A patient with pneumonia who is short of breath and anxious ANS: 4 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs. Page: 3 Heading: Prioritize Care

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Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

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Feedback The patient’s problems of pain, constipation, and scheduled tests are all important but are not immediately life threatening. The patient’s problems of pain, constipation, and scheduled tests are all important but are not immediately life threatening. The patient’s problems of pain, constipation, and scheduled tests are all important but are not immediately life threatening. Using Maslow hierarchy of needs and considering which patient problems are life threatening, shortness of breath is most important.

PTS:

CON: Patient-Centered Care

18. The LPN/LVN asks a patient who received 2 mg of Morphine IV 30 minutes ago to rate his or her pain. This describes which step of the nursing process? 1. Assessment 2. Planning 3. Implementation 4. Evaluation ANS: 4 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 3. Describe the thinking that occurs in each step of the nursing process. Page: 8 Heading: Evaluation of Outcomes Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback The assessment process would be conducted prior to administering the Morphine. This does not describe the planning phase of the nursing process. The implementation phase of the nursing process is the administration of Morphine. Asking the patient if the Morphine was effective by asking him or her to rate the pain describes the evaluation phase of the nursing process.

PTS:

CON: Patient-Centered Care

19. The LPN/LVN is assisting the RN in planning interventions for a patient. Which is an example of a collaborative action?

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1. 2. 3. 4.

Administering a medication Giving a back rub Assessing a patient Teaching relaxation techniques

ANS: 1 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 3. Describe the thinking that occurs in each step of the nursing process. Page: 6 Heading: Nursing Diagnosis Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback Administering a medication requires an order from the HCP, which makes this a collaborative action. Giving a back rub is an independent nursing action. Assessing a patient is an example of an independent nursing action. Teaching relaxation techniques is an example of an independent nursing action.

PTS:

CON: Patient-Centered Care

20. The LPN/LVN is reviewing nursing diagnoses for a patient. Which diagnosis should the nurse report to the RN as incorrect? 1. Risk for injury 2. Heart failure 3. Ineffective gas exchange 4. Activity intolerance ANS: 2 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using the nursing process. Page: 6 Heading: Nursing Diagnosis Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback Risk for injury is a nursing diagnosis and does not require correction. Heart failure is a medical diagnosis and requires correction. Ineffective gas exchange is a nursing diagnosis and does not require correction. Activity intolerance is a nursing diagnosis and does not require correction.

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PTS:

CON: Patient-Centered Care

21. The LPN/LVN is caring for a group of patients. Which patient should the nurse assess first? 1. A patient with an oxygen saturation level of 96% on room air 2. A patient who has a blood pressure of 208/114 mm Hg 3. A patient who reports a pain level of 7 on a scale of 0 to 10 4. A patient with a temperature of 100.2°F ANS: 2 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs. Page: 7 Heading: Prioritize Care Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Difficult

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Feedback An oxygen saturation of 96% is not too concerning. This is not the highest priority. A blood pressure of 208/114 mm Hg is very high and should be addressed immediately. This patient should be seen first. This patient is in pain and should be seen, but is not as high of a priority as the patient with hypertension. This patient has a low-grade temperature, which is not a priority.

PTS:

CON: Patient-Centered Care

22. The LPN/LVN is caring for a patient who begins to exhibit shortness of breath and chest pain. Which action should the nurse take first? 1. Administer medication as ordered. 2. Notify the RN. 3. Document the findings in the chart. 4. Reposition the patient. ANS: 2 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs. Page: 3 Heading: Prioritize Care Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care

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Difficulty: Difficult

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Feedback The nurse will likely need to administer medication, but should first notify the RN of the patient’s condition. The LPN/LVN should notify the RN immediately of the change in the patient’s status. The nurse will document the findings in the chart, but should first notify the RN. Repositioning the patient may not help in this situation; the LPN/LVN should first notify the RN.

PTS:

CON: Patient-Centered Care

23. While teaching how to apply a topical medication the patient begins to vomit. Which action should the nurse take to meet the patient’s human needs? 1. Provide a clean gown before resuming the teaching. 2. Position an emesis basin for patient use while teaching. 3. Administer medication prescribed for nausea and vomiting. 4. Wait for the vomiting to stop and begin the teaching session again. ANS: 3 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs. Page: 7 Heading: Prioritize Care Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback These actions do not take the patient’s physiological needs into consideration. The patient will not be able to achieve a higher level of the hierarchy before basic physiological needs are met. These actions do not take the patient’s physiological needs into consideration. The patient will not be able to achieve a higher level of the hierarchy before basic physiological needs are met. Basic physiological needs must be met first. Since the patient is vomiting, the nurse should provide the medication that is prescribed for nausea and vomiting. These actions do not take the patient’s physiological needs into consideration. The patient will not be able to achieve a higher level of the hierarchy before basic physiological needs are met.

PTS:

CON: Patient-Centered Care

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24. A nurse approaches a person in a restaurant who appears to be experiencing respiratory distress. Which action should the nurse perform first? 1. Diagnose the problem. 2. Assist the person to lie down. 3. Gather data from other people. 4. Collect data about the person’s condition. ANS: 4 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 3. Describe the thinking that occurs in each step of the nursing process. Page: 7 Heading: Subjective Data Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

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Feedback Diagnosing the problem would occur after collecting data. Assisting the person to lie down is implementing an action to address the problem. The nurse can collect data from other people if necessary. The first step in the nursing process is to collect data, and the patient should come first.

PTS:

CON: Patient-Centered Care

25. The nurse is reviewing nursing diagnoses. Which is an example of a correctly written nursing diagnosis? 1. Acute pain related to tissue trauma as evidenced by facial grimacing and rating pain at a level of 9 on a 0-to-10 scale 2. Pain related to appendicitis as evidenced by moaning and guarding 3. Acute pain related to guarding abdomen and rating pain at a level of 9 on a 0-to-10 scale 4. Pain as evidenced by status postsurgical procedure ANS: 1 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 3. Describe the thinking that occurs in each step of the nursing process. Page: 6 Heading: Nursing Diagnosis Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback

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This is a well-written three-part nursing diagnosis that includes the etiology and signs and symptoms. This is a medical diagnosis, not a nursing diagnosis. This nursing diagnosis is missing correct etiology. This is a medical diagnosis and is also missing correct signs and symptoms.

PTS:

CON: Patient-Centered Care

26. After identifying nursing diagnoses the nurse plans outcomes for a patient with gastroesophageal reflux disease. Which outcome should the nurse use to evaluate this patient’s care? 1. The patient will have less heartburn. 2. The patient will sleep through the night. 3. The patient’s esophageal burning will resolve 30 minutes after taking oral antacids. 4. The patient will state that burning only occurs when eating foods high in acid content. ANS: 3 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 3. Describe the thinking that occurs in each step of the nursing process. Page: 8 Heading: Nursing Diagnosis Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

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Feedback Outcomes should not be vague or open to interpretation, and should use subjective words such as normal, large, small, or moderate. Sleeping through the night may or may not be associated with the patient’s problem. Outcomes should be measurable, realistic for the patient, and have an appropriate time frame for achievement. Stating that the burning only occurs with eating foods high in acid content is a patient statement that could be used for subjective data collection.

PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 1. After collecting data, the nurse identifies diagnoses to guide the patient’s care. Which diagnoses did the nurse document correctly? (Select all that apply.) 1. Diabetes 2. Acute pain 3. Pancreatitis

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4. Activity intolerance 5. Impaired physical mobility ANS: 2, 4, 5 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 3. Describe the thinking that occurs in each step of the nursing process. Page: 8 Heading: Nursing Diagnosis Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback Diabetes and pancreatitis are medical diagnoses. Acute pain, activity intolerance, and impaired physical mobility are nursing diagnoses. Diabetes and pancreatitis are medical diagnoses. Acute pain, activity intolerance, and impaired physical mobility are nursing diagnoses. Acute pain, activity intolerance, and impaired physical mobility are nursing diagnoses. 1

CON: Patient-Centered Care

2. A patient with a family history of diabetes is experiencing high blood glucose levels, confusion, an unsteady gait, and dehydration. Which nursing diagnoses should the nurse identify as appropriate for this patient’s care? (Select all that apply.) 1. Diabetes 2. Dehydration 3. Risk for falls 4. Hyperglycemia 5. Deficient fluid volume ANS: 3, 5 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 3. Describe the thinking that occurs in each step of the nursing process. Page: 6 Heading: Nursing Diagnosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

Feedback Diabetes, dehydration, and hyperglycemia are medical problems. The nurse assists with medical diagnoses; however, the nurse does not diagnose and

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3. 4.

PTS:

treat medical problems. Diabetes, dehydration, and hyperglycemia are medical problems. The nurse assists with medical diagnoses; however, the nurse does not diagnose and treat medical problems. Deficient fluid volume and risk for falls are nursing diagnoses related to the patient’s symptoms and condition. Diabetes, dehydration, and hyperglycemia are medical problems. The nurse assists with medical diagnoses; however, the nurse does not diagnose and treat medical problems. Deficient fluid volume and risk for falls are nursing diagnoses related to the patient’s symptoms and condition. 1

CON: Patient-Centered Care

3. The nurse identifies the diagnosis potential for ineffective gas exchange as appropriate for a patient with pneumonia. Which independent nursing actions should the nurse plan for this problem? (Select all that apply.) 1. Apply oxygen 2 liters per nasal cannula. 2. Turn and reposition in bed every 2 hours. 3. Coach to deep-breathe and cough every hour. 4. Administer intramuscular antibiotic medication. 5. Encourage to drink 240 mL of fluid every 2 hours. ANS: 2, 3, 5 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 3. Describe the thinking that occurs in each step of the nursing process. Page: 6 Heading: Nursing Diagnosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback Interventions that need an HCP’s order include administering oxygen and medication. These are collaborative interventions. Independent nursing actions are those that can be implemented without an HCP’s order. Independent nursing actions are those that can be implemented without an HCP’s order. Interventions that need an HCP’s order include administering oxygen and medication. These are collaborative interventions. Independent nursing actions are those that can be implemented without an HCP’s order. 1

CON: Patient-Centered Care

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4. The nurse is planning outcomes for a patient with acute pain who is exhibiting tachypnea and hypertension. Which outcomes should be included in the patient’s care? 1. Patient will rate pain at a level of 2 on a 0-to-10 scale 30 minutes after receiving Morphine. 2. Patient will ambulate without pain. 3. Patient will not exhibit signs or symptoms of pain. 4. Patient will maintain respiratory rate between 16 and 20. 5. Patient’s blood pressure will remain within normal limits. ANS: 1, 4 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 3. Describe the thinking that occurs in each step of the nursing process. Page: 6 Heading: Establish Outcomes Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback This is a measurable and specific outcome. This is not a measurable outcome and is too vague. This is not a measurable outcome and is vague. This is a measurable and specific outcome. This outcome is not specific and is not measurable. The nurse should define normal limits. 1

CON: Patient-Centered Care

ORDERED RESPONSE 1. The nurse is caring for a group of patients. Place in order the patients the nurse should see from highest to lowest priority (1 to 5). 1. A patient who underwent abdominal surgery yesterday and reports a pain level of 5 on a 0-to-10 scale 2. A patient with deep vein thrombosis (DVT) who reports shortness of breath 3. A patient awaiting education from the diabetes educator 4. A patient with eczema who reports itching 5. A patient who reports nausea after chemotherapy ANS: 2, 1, 5, 4, 3 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs. Page: 6 Heading: Prioritize Care Integrated Process: Clinical Problem-solving Process (Nursing Process)

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Client Need: SECE: Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback The patient in pain is a priority, but should be seen after the patient with shortness of breath. The patient with DVT exhibiting shortness of breath could have a pulmonary embolism and should be seen first. A patient waiting for diabetes education is not a priority and can be seen last in this group of patients. Itching is a symptom of eczema and is a priority, but not as high a priority as shortness of breath, pain, or nausea. This patient can be seen fourth. Nausea is a priority, but this patient can be seen after the patient with shortness of breath and pain. 1

CON: Patient-Centered Care

2. The nurse is caring for a patient recovering from a stroke. Place in the order of the nursing process the observations or actions provided while caring for this patient. 1. Hand grasp absent left hand 2. Alteration in cerebral perfusion 3. Flexed left thumb and index finger 4. Coached to squeeze rubber ball placed in left hand 5. Self-feed using left hand ANS: 1, 2, 5, 4, 3 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 3. Describe the thinking that occurs in each step of the nursing process. Page: 4 Heading: NURSING PROCESS Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback Assessed data is the absence of a left-hand grasp. The nursing diagnosis that is associated with the absence of a hand grasp is alteration in cerebral perfusion. The patient flexing the left thumb and index finger evaluates the success of the intervention of squeezing a rubber ball in the left hand. Coaching to squeeze a rubber ball in the left hand is an intervention to improve left hand function. The goal of nursing care is for the patient to self-feed using the left hand.

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PTS:

CON: Patient-Centered Care

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Chapter 2. Evidence-Based Practice MULTIPLE CHOICE 1. The nurse working in a radiation oncology department wants to reduce the incidence of skin breakdown in patients who receive beam radiation. Which question should the nurse use to guide a literature search about this topic? 1. How often do patients with beam radiation experience skin breakdown? 2. Why do patients who get radiation beam therapy have skin breakdown? 3. What nursing interventions minimize the occurrence of skin breakdown in patients receiving beam radiation? 4. How does our rate of skin breakdown in patients receiving beam radiation compare to other institutions in the city? ANS: 3 Chapter: Chapter 2 Evidence-Based Practice Objective: 4. Describe the EBP process. Page: 10 Heading: Step 1: Ask the Burning Question Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS: Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Moderate

1 2 3

Feedback The frequency of skin breakdown and why patients develop skin breakdown does not help identify ways to prevent skin breakdown. The frequency of skin breakdown and why patients develop skin breakdown does not help identify ways to prevent skin breakdown. Asking a burning clinical question is the first step in the evidence-based practice (EBP) process. It is important to include related factors in the question and to focus on nursing interventions and care. In this situation, the nurse should focus on nursing care that may reduce the occurrence of skin breakdown for the specific patient population of interest. Information on statistics from other organizations will not help the nurse identify ways to prevent skin breakdown.

PTS:

CON: Evidence-Based Practice

2. A licensed practical nurse (LPN) working on the pediatric floor is interested in improving patient outcomes for children with asthma. Which clinical question would best guide the nurse’s next steps? 1. How many patients with asthma have a pet dog or cat? 2. What is the monthly admission rate of patients with asthma to the unit? 3. What patient education materials are available to address effective management of asthma in pediatric patients? 4. How has the occurrence rate of asthma in children under the age of 5 changed

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since the hospital instituted a no smoking policy for the hospital grounds? ANS: 3 Chapter: Chapter 2 Evidence-Based Practice Objective: 4. Describe the EBP process. Page: 11 Heading: Step 1: Ask the Burning Question Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Moderate

Feedback Information about pets, admission rates of patients with asthma, and asthma occurrence since the implementation of a no smoking policy will not help improve patient outcomes for children with asthma. Information about pets, admission rates of patients with asthma, an asthma occurrence since the implementation of a no smoking policy will not help improve patient outcomes for children with asthma. Asking a burning clinical question is the first step in the EBP process. It is important to include related factors in the question and to focus on nursing interventions and care. For this scenario, the nurse would focus on nursing care that affects patient outcomes for the specific patient population of interest. Patient education is a critical component of nursing care. Information about pets, admission rates of patients with asthma, and asthma occurrence since the implementation of a no smoking policy will not help improve patient outcomes for children with asthma.

PTS:

CON: Evidence-Based Practice

3. The nurse is preparing to give oral care to a patient receiving tube feedings. Which approach should the nurse use to provide care that is based on EBP? 1. Use a soft toothbrush and toothpaste to brush the teeth. 2. Have the patient use swish-and-swallow Nystatin twice a day. 3. Increase oral suctioning to every 2 hours using toothette suction devices. 4. Use mouthwash and toothettes to swab the teeth and mouth three times a day. ANS: 1 Chapter: Chapter 2 Evidence-Based Practice Objective: 3. Explain how to identify nursing evidence that should be put into practice. Page: 12 Heading: Step 3: Think Critically Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS: Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Moderate

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1 2 3 4

Feedback Evidence-based information shows the use of toothbrushes for oral care is much more effective than foam swabs in removing plaque from the teeth. Swish-and-swallow Nystatin is a medication that treats oral thrush and is not routinely used to provide oral care. Oral suctioning is not an approach to provide oral care. Toothettes are not an effective mechanism for providing oral care.

PTS:

CON: Evidence-Based Practice

4. The nurse is reviewing four articles for research and notes the evidence presented in one article is weaker than the others. Which level of research is the nurse most likely reviewing? 1. Level I 2. Level II 3. Level III 4. Level IV ANS: 4 Chapter: Chapter 2 Evidence-Based Practice Objective: 3. Explain how to identify nursing evidence that should be put into practice. Page: 11 Heading: Identifying Nursing Evidence Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordination of Care Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Easy

1 2 3 4

Feedback The rating scale used to level the quality of evidence ranges form level I (strongest) to level IV (weakest). The rating scale used to level the quality of evidence ranges form level I (strongest) to level IV (weakest). The rating scale used to level the quality of evidence ranges form level I (strongest) to level IV (weakest). The rating scale used to level the quality of evidence ranges form level I (strongest) to level IV (weakest).

PTS:

CON: Evidence-Based Practice

5. The nurse working on an oncology unit wants to know if it is best practice to clean a central line in a circular motion or a back-and-forth motion. What action should the nurse take first? 1. Ask the physicians what they think is best. 2. Ask the patient what their preference is. 3. Develop a research question to guide a literature search. 4. Continue performing the procedure per hospital policy. ANS: 3 Chapter: Chapter 2 Evidence-Based Practice

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Objective: 4. Describe the EBP process. Page: 11 Heading: Step 1: Ask the Burning Question Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Moderate

1 2 3 4

Feedback Physicians do not determine best practice. The patient’s preference may not be reflective of what is best practice. The nurse should formulate a question to guide a literature search to determine the best practice for cleaning a central line. The nurse should not take no action—the current practice may not be the best practice.

PTS:

CON: Evidence-Based Practice

6. A group of nurses conducted a pilot study about implementing a team to turn patients every hour to prevent skin breakdown. The results proved the intervention to be a success. What step should the nurses take next to implement the turn team hospital wide? 1. Educate individuals in the facility about implementing the change hospital wide. 2. Collect evidence to support implementation of a turn team. 3. Plan a pilot study to determine if implementing a turn team will reduce skin breakdown. 4. Propose the change to a policy and procedure committee. ANS: 1 Chapter: Chapter 2 Evidence-Based Practice Objective: 4. Describe the EBP process. Page: 13 Heading: Step 5: Make It Happen Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS: Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Moderate

2 3 4

Feedback Since turning a patient is an independent nursing intervention, a literature review has been conducted, and a pilot study has been implemented where results have been proved to be successful, the next step is to educate other nurses in the facility about how to implement the turn team. A literature review has already been done. A pilot study has already been conducted. Since turning patients is an independent nursing intervention, it is not required to go to a committee for policy and procedure change.

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PTS:

CON: Evidence-Based Practice

7. A nursing student asks the registered nurse (RN) preceptor why EBP is important. How should the nurse respond to the student? 1. “EBP makes nursing more professional.” 2. “EBP helps ensure we can demand more pay.” 3. “EBP helps validate the difference nurses really make.” 4. “EBP guides nursing decisions to optimize effective care.” ANS: 4 Chapter: Chapter 2 Evidence-Based Practice Objective: 2. Discuss why EBP should be used. Page: 11 Heading: Reasons For Using EBP Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Moderate

1 2 3 4

Feedback EBP is not used to support professionalism in nursing or as a mechanism to increase nurses’ salaries. EBP is not used to support professionalism in nursing or as a mechanism to increase nurses’ salaries. EBP is not used to validate the importance of nursing care. Evidence-based nursing practice is much more than just evaluating research studies to determine what results to apply to nursing practice. Evidence-based nursing practice is a systematic process that utilizes current evidence to make decisions about the care of patients, including evaluation of quality and applicability of existing research, patient preferences, costs, clinical expertise, and clinical settings.

PTS:

CON: Evidence-Based Practice

8. The nurse is reviewing a proposal for changing the type of needleless systems currently used to administer IV medications in the hospital. Which part of the proposal most effectively supports the proposed change? 1. A pilot study is planned. 2. Two cases of staff injury related to needle sticks have occurred in the past 3 years. 3. A single randomized clinical trial is cited as evidence to support the new policy. 4. The supporting evidence includes research conducted at an outpatient hematology center. ANS: 1 Chapter: Chapter 2 Evidence-Based Practice Objective: 5. List the six steps of EBP. Page: 12 Heading: Step 4: Measure Outcomes Before and After Change

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Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Difficult

1 2 3 4

Feedback A small pilot study is typically done before an institute-wide change is made. This would not be a statistically significant number to support the need for change. More evidence or evidence of a higher level would better support the proposed change. It is important to consider the context in which the evidence will be used, and research involving a population similar to that of the nurse’s institution is helpful.

PTS:

CON: Evidence-Based Practice

9. The nurse is planning a Quality and Safety Education for Nurses (QSEN) project to focus on informatics. Which would the nurse include in this project? 1. Collecting data on repeat admissions 2. Implementing a medication barcode system 3. Collaborating with a pharmacist about medication reconciliation 4. Including the patient in a care plan meeting ANS: 2 Chapter: Chapter 2 Evidence-Based Practice Objective: 8. Describe how the Quality and Safety Education for Nurses (QSEN) project can promote safe patient care. Page: 12 Heading: Quality and Safety Education for Nurses Project Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordination of Care Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Moderate

1 2 3 4

Feedback Collecting data on repeat admissions is an example of quality improvement. Implementing a medication barcode system is an example of informatics. Collaborating with a pharmacist about medication reconciliation is an example of teamwork and collaboration. Including a patient in a care plan meeting demonstrates patient-centered care.

PTS:

CON: Evidence-Based Practice

10. The nurse is teaching a group of students about implementing EBP to control pain. Which statement best describes understanding of evidence? 1. “I saw a commercial for pain medication that works well.”

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2. “The patient has chronic pain and will need more medication.” 3. “We could give this patient Morphine every 4 hours. It works for the other patient.” 4. “There are studies that prove nonpharmacological methods can relieve pain.” ANS: 4 Chapter: Chapter 2 Evidence-Based Practice Objective: 1. Define evidence-based practice (EBP) and evidence-informed practice. Page: 12 Heading: Reasons For Using EBP Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Moderate

1 2 3 4

Feedback Watching a commercial does not demonstrate an understanding of evidence. Not all patients who experience chronic pain need more medication; this statement does not demonstrate an understanding of evidence. Just because a drug regimen works for one patient does not mean it will work for another. This statement does not demonstrate evidence. Basing care on studies demonstrates an understanding of evidence.

PTS:

CON: Evidence-Based Practice

11. A licensed practical nurse/licensed vocational nurse (LPN/LVN) is preparing to insert an indwelling urinary catheter. The policy states to test the balloon before inserting the catheter, although evidence supports not testing the balloon. Which action should the nurse take? 1. Continue to test the balloon per hospital policy. 2. Refuse to insert the catheter until policy is changed. 3. Conduct a literature search and present the literature to the policy committee. 4. Begin the practice of not testing the balloon when inserting urinary catheters. ANS: 3 Chapter: Chapter 2 Evidence-Based Practice Objective: 4. Describe the EBP process. Page: 12 Heading: Step 2: Search for and Collect the Most Relevant and Best Evidence Available Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Safety and Infection Control Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Difficult

1 2

Feedback The nurse is not practicing using evidence if he or she does nothing and continues to follow policy. The patient needs an indwelling urinary catheter, so refusing to complete the

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procedure is not beneficial to the patient. The nurse should review the literature and present the literature to the policy review committee for an update to the current policy. The nurse still needs to follow policy and should first present information to the policy committee.

PTS:

CON: Evidence-Based Practice

12. The nurse is providing diabetic education to a patient with a low literacy level. Which statement best promotes health literacy? 1. “You will frequently rotate sites when administering insulin.” 2. “You will need to self-administer insulin subcutaneously.” 3. “If you experience hypoglycemia, consume 15 grams of carbohydrates.” 4. “You will need to call your doctor if your blood sugar is over 300.” ANS: 4 Chapter: Chapter 2 Evidence-Based Practice Objective: 7. Explain health literacy. Page: 14 Heading: Health Literacy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Moderate

1 2 3 4

Feedback This statement has big words and may not be understood by a patient with low health literacy. This statement has medical terminology that may not be understood by a patient with low health literacy. This statement has medical terminology that may not be understood by a patient with low health literacy. This statement uses smaller words, avoids medical jargon, and is most likely to be understood by a patient with low health literacy.

PTS:

CON: Evidence-Based Practice

13. The nurse wants to conduct a pilot study on frequency of readmission for patients with heart failure. Which question should the nurse use to guide a literature review? 1. “What can nurses do to improve hospital readmission rates for patients with heart failure?” 2. “What causes patients with heart failure to have repeat admissions?” 3. “Why do patients with heart failure have a high incidence of readmission?” 4. “How often are patients with heart failure readmitted?” ANS: 4 Chapter: Chapter 2 Evidence-Based Practice Objective: 4. Describe the EBP process.

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Page: 14 Heading: Step 1: Ask the Burning Question Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Moderate

2 3 4

Feedback The nurse is wanting to look at frequency of readmission rates for patients with heart failure. Asking what nurses can do to improve rates of readmission does not relate to frequency of readmission. A question asking about the cause of readmission rates for patients with heart failure does not relate to frequency of readmissions. A question asking why patients have a high incidence of readmission does not relate to frequency of readmissions. A question asking how often patients with heart failure are readmitted is an appropriate question.

PTS:

CON: Evidence-Based Practice

14. While reviewing a patient care assignment with an unlicensed assistive personnel (UAP), the nurse explains the reason for turning and repositioning a patient every 2 hours. Why did the nursing include this information? 1. Ensures that evidence-based care is provided 2. Guarantees that the patient will receive morning care 3. Helps a UAP focus on the action being performed 4. Helps a UAP with time management of tasks to complete ANS: 1 Chapter: Chapter 2 Evidence-Based Practice Objective: 2. Discuss why EBP should be used. Page: 14 Heading: Reasons For Using EBP Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Evidence-Based Practice Difficulty: Moderate

Feedback Evidence-based care should be given at all times, if possible, and in all settings where nursing care is given. A way to ensure that evidence-based care is provided is to explain why the care should be given at the time the care is delegated. Explaining the reason for the care is not done to guarantee that the patient will receive morning care, help the UAP focus on actions, or help with time management. Explaining the reason for the care is not done to guarantee that the patient will

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receive morning care, help the UAP focus on actions, or help with time management. Explaining the reason for the care is not done to guarantee that the patient will receive morning care, help the UAP focus on actions, or help with time management.

PTS:

CON: Evidence-Based Practice

15. A low health literacy level can lead to which outcome? 1. Improved self-esteem 2. Poor health outcome 3. Low health care cost 4. Decrease in hospitalizations ANS: 2 Chapter: Chapter 2 Evidence-Based Practice Objective: 7. Explain health literacy. Page: 14 Heading: Health Literacy Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Communication Difficulty: Moderate

1 2 3 4

Feedback The patient will experience a decrease in self-esteem, not an increase. Poor health outcomes are common in patients with low health literacy. A patient with low health literacy will experience an increase in health care cost. A patient with low health literacy will experience an increase in hospitalizations.

PTS:

CON: Communication

16. The nurse is working on ensuring all care plans are individualized to meet each patient’s specific needs. This focuses on which area of QSEN? 1. Evidence-Based Practice 2. Safety 3. Patient-Centered Care 4. Informatics ANS: 3 Chapter: Chapter 2 Evidence-Based Practice Objective: 8. Describe how the Quality and Safety Education for Nurses (QSEN) project can promote safe patient care. Page: 14 Heading: Quality and Safety Education for Nurses Project Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Moderate

1 2 3 4

Feedback Evidence-based practice is not specific to providing individualized patient care. Safety is not specific to providing individualized patient care. Patient-centered care is ensuring the care plan is individualized to meet the patient’s needs and schedules rather than those of the institution or caregiver. Informatics is not specific to providing individualized patient care.

PTS:

CON: Evidence-Based Practice

MULTIPLE RESPONSE 1. The nurse works in a clinic where many of the patients did not attend school beyond elementary level. What interventions can the nurse implement to promote health literacy for this particular group? (Select all that apply.) 1. Ask an interpreter to explain the material. 2. Provide easy-to-understand written materials. 3. Use video or computer for learning purposes. 4. Encourage the patient to attend speech therapy. 5. Provide brochures with pictured instructions. ANS: 2, 3, 5 Chapter: Chapter 2 Evidence-Based Practice Objective: 7. Explain health literacy. Page: 14 Heading: HEALTH LITERACY Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Communication Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback The patients read at a low level; an interpreter will not resolve this issue. Providing easy-to-understand written materials will promote health literacy. Use of a video or computer to provide teaching is a technique to promote health literacy. Speech therapy is not a method used to promote health literacy. Providing brochures with pictures may be effective since the patients may read at a low level. 1

CON: Communication

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2. The nurse is working with a committee to determine EBP approaches for patient care. Which steps will the committee members include when determining EBP? (Select all that apply.) 1. Evaluate the change. 2. Measure the outcome. 3. Ask the nursing experts. 4. Manipulate current practice. 5. Search for the best available evidence. ANS: 1, 2, 5 Chapter: Chapter 2 Evidence-Based Practice Objective: 5. List the six steps of EBP. Page: 14 Heading: The EBP Process Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback The steps in the EBP process are Ask, Search, Think, Measure, Make It Happen, and Evaluate. An acronym to remember these steps is ASKMME. The steps in the EBP process are Ask, Search, Think, Measure, Make It Happen, and Evaluate. An acronym to remember these steps is ASKMME. Asking nursing experts and manipulating current practice are not steps in the EBP process. Asking nursing experts and manipulating current practice are not steps in the EBP process. The steps in the EBP process are Ask, Search, Think, Measure, Make It Happen, and Evaluate. An acronym to remember these steps is ASKMME. 1

CON: Evidence-Based Practice

3. The nurse is implementing the QSEN focus of patient-centered care. Which nursing actions support this focus? (Select all that apply.) 1. Individualize interventions. 2. Schedule interventions to meet the patient’s needs. 3. Evaluate interventions for applicability to the patient. 4. Scan prescribed medications using the bar-coding system. 5. Document responses to treatment in the electronic medical record. ANS: 1, 2, 3 Chapter: Chapter 2 Evidence-Based Practice Objective: 8. Describe how the Quality and Safety Education for Nurses project can promote safe patient care. Page: 14 Heading: Quality and Safety Education for Nurses Project Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: SECE: Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Evidence-Based Practice Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback When collaborating on the development of nursing care plans, it is important to individualize interventions to provide patient-centered care. As nursing interventions are performed, they should meet the patient’s preferred schedules. Nurses should always evaluate each suggested intervention to see if it fits the patient. Scanning medication using a bar-coding system and documenting in the electronic medical record are actions that support the focus of informatics. Scanning medication using a bar-coding system and documenting in the electronic medical record are actions that support the focus of informatics. 1

CON: Evidence-Based Practice

ORDERED RESPONSE 1. List in order the six steps of EBP using 1 through 6. Search for and collect relevant evidence. Think critically. Ask the burning question. Make it happen. Evaluate the practice change. Measure outcomes before and after change. ANS: 2, 3, 1, 5, 6, 4 Chapter: Chapter 2: Evidence-Based Practice Objective: 5. List the six steps of EBP. Page: 11 Heading: The EBP Process Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Evidence-Based Practice Difficulty: Moderate Feedback: Step 1: Ask the burning question: What do you want to know? Step 2: Search for and collect relevant and best evidence available. Step 3: Think critically: Appraise the evidence you find for validity, relevance to the situation, and applicability. Step 4: Measure outcomes before and after change. Step 5: Make it happen: Implement the desired change. Step 6: Evaluate the practice change to determine if it made a significant difference. PTS:

CON: Evidence-Based Practice

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Chapter 3. Issues in Nursing Practice MULTIPLE CHOICE 1. The nurse is caring for a patient newly admitted and notes a stage III pressure ulcer. For the hospital to receive payment for services rendered for this patient, which action must the nurse take? 1. Notify the patient’s insurance of the pressure ulcer. 2. Document the ulcer and interventions provided. 3. Be careful not to mention the ulcer in documentation. 4. Tell the patient his care will not be covered by insurance. ANS: 2 Chapter: Chapter 3 Issues in Nursing Practice Objective: 3. Explain the significance of hospital-acquired conditions. Page: 19 Heading: Hospital-Acquired Conditions and Present-on-Admission Reporting Integrated Process: Communication and Documentation Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Communication Difficulty: Moderate

1 2

3 4

Feedback The nurse does not need to notify the patient’s insurance of the pressure ulcer; documentation will be reviewed to determine coverage. The nurse should carefully document the ulcer upon admission, so the patient’s health insurance can verify the patient came to the hospital with the ulcer and what you did to prevent further skin breakdown. The nurse should not falsify documentation. The nurse does not know if the patient’s care will be covered and should not mention this to the patient.

PTS:

CON: Communication

2. The nurse is caring for a patient who begins to exhibit difficulty swallowing. Which discipline will the nurse likely include in the patient’s care? 1. Occupational therapist 2. Respiratory therapist 3. Social worker 4. Speech pathologist ANS: 4 Chapter: Chapter 3 Issues in Nursing Practice Objective: 5. Discuss the licensed practical nurse/licensed vocational nurse’s role in leadership and delegation. Page: 20 Heading: Collaborative Care

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Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Legal Moderate

1 2 3 4

Feedback An occupational therapist assists in restoring self-care, work, and leisure skills that have been diminished as a result of developmental deficits or injury. A respiratory therapist works with patients who have respiratory problems. A social worker treats patients and their families with psychosocial issues. A speech therapist provides direct clinical services to those with communication or swallowing problems.

PTS:

CON: Legal

3. The nurse suspects a patient is a victim of human trafficking. Which characteristic supports this suspicion? 1. The individual has a man with her who answers all questions for her and will not leave the room. 2. The patient is talkative and makes eye contact. 3. The patient is calm and answers questions. 4. The patient tells the nurse she is stressed because she owns a chain of restaurants. ANS: 1 Chapter: Chapter 3 Issues in Nursing Practice Objective: 11. Describe human trafficking indicators to report. Page: 28 Heading: Human Trafficking and the Nurse’s Role Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Legal Difficulty: Moderate

1 2 3 4

Feedback An individual may be a victim of human trafficking when someone with her appears to be in control and will not leave the patient alone. A patient who is talkative and makes eye contact is likely not a victim of human trafficking. Victims of human trafficking are more likely to be anxious and depressed. The fact that the patient owns a chain of restaurants and is stressed from running the restaurants indicates she is not controlled by anyone.

PTS:

CON: Legal

4. The nurse is caring for a famous actor. The press approaches the nurse leaving work and asks about the actor. What is the most appropriate response by the nurse? 1. “I will ask the actor to call you and give you an update.” 2. “The actor has severe pneumonia and will be placed on a ventilator.”

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3. “I cannot release any information due to patient confidentiality.” 4. “All I can say is the actor is a patient here and he is stable.” ANS: 3 Chapter: Chapter 3 Issues in Nursing Practice Objective: 12. Describe the Health Insurance Portability and Accountability Act of 1996. Page: 29 Heading: Health Insurance Portability and Accountability Act (HIPAA) Integrated Process: Communication and Documentation Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Legal Difficulty: Moderate Feedback The nurse cannot confirm the actor is a patient in the hospital. The nurse cannot provide any information about the patient. This is a correct response when asked to share patient information. The nurse cannot confirm the actor is in the hospital.

1 2 3 4

PTS:

CON: Legal

5. A nurse manager has to make a decision about scheduling and asks the nurses on the unit before making a decision. This demonstrates which style of leadership? 1. Autocratic 2. Democratic 3. Laissez-faire 4. Coaching ANS: 2 Chapter: Chapter 3 Issues in Nursing Practice Objective: 4. Describe four leadership styles. Page: 21 Heading: Democratic (Participative) Leadership Integrated Process: Communication and Documentation Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Communication Difficulty: Moderate

1 2 3 4

Feedback An autocratic leader does not ask for the input of others. A democratic leader allows decisions to be made within the group and shares responsibility with the group. A laissez-faire leader delegates decision making. A coaching leader works with others to develop problem-solving skills and helps employees feel valued and respected.

PTS:

CON: Communication

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6. Which task is most appropriate for the licensed practical nurse/licensed vocational nurse (LPN/LVN) to delegate to the unlicensed assistive personnel (UAP)? 1. Changing the dressing of a patient who had abdominal surgery 2. Ambulating a patient who just underwent knee surgery 3. Assessment of a newly admitted patient 4. Feeding a patient who needs assistance with eating ANS: 4 Chapter: Chapter 3 Issues in Nursing Practice Objective: 5. Discuss the licensed practice nurse/licensed vocational nurse’s role in leadership and delegation. Page: 22 Heading: Leadership and Delegation for the LPN/LVN Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Collaboration Difficulty: Difficult

1 2 3 4

Feedback Changing the dressing of a postoperative patient is not within the UAP scope of practice. Although a UAP may ambulate patients, a patient who just underwent knee surgery should be ambulated by the registered nurse (RN). Assessment is not in the scope of practice of a UAP. UAP may feed a patient who requires assistance eating.

PTS:

CON: Collaboration

7. The nurse notices a colleague place a hydrocodone tablet in their pocket prior to leaving the hospital. Which action should the nurse take? 1. Confront the coworker about what the nurse saw. 2. Ask an RN what to do. 3. Notify the nurse manager of the unit. 4. Call the police and report the incident. ANS: 3 Chapter: Chapter 3 Issues in Nursing Practice Objective: 6. Describe the importance of ethics in health care. Page: 24 Heading: Ethics and Values Integrated Process: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application (Application) Concept: Legal Difficulty: Moderate Feedback

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1 2 3 4

The nurse should not confront the coworker about what he saw. The nurse does not need to ask the RN’s opinion but should go directly to the nurse manager. The nurse should first report the incident to the nurse manager. This may be an incident handled by the board of nursing, not the police. The nurse should first report the incident to the nurse manager. This may be an incident handled by the board of nursing, not the police.

PTS:

CON: Legal

8. The nurse is caring for a patient receiving morphine who states the morphine is no longer working. The nurse notifies the health care provider and requests that an increase in dosage or a different medication be given. Which of these is the nurse demonstrating? 1. Advocacy 2. Paternalism 3. Confidentiality 4. Veracity ANS: 1 Chapter: Chapter 3 Issues in Nursing Practice Objective: 6. Describe the importance of ethics in health care. Page: 22 Heading: Ethical Principles Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Ethics Difficulty: Moderate

1 2 3 4

Feedback The nurse is demonstrating advocacy by ensuring the patient is free of pain. Paternalism occurs when patients are prevented from making autonomous decisions. Confidentiality is maintaining a patient’s privacy. Veracity is telling the truth.

PTS:

CON: Ethics

9. The nurse is caring for a patient with liver failure who is unconscious. The patient’s girlfriend of 12 years has been making health care decisions. The patient is still legally married, and his wife whom he has not seen in 20 years shows up and wants to take over in making medical decisions. Which action should the nurse take? 1. Provide care according to the girlfriend’s wishes. 2. Ask the charge nurse to assign another nurse to care for the patient. 3. Ask for an ethics committee consult. 4. Ignore both parties and provide care based on the nurse’s own values. ANS: 3 Chapter: Chapter 3 Issues in Nursing Practice

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Objective: 6. Describe the importance of ethics in health care. Page: 25 Heading: Building Blocks of Ethics Integrated Process: Caring Client Need: SECE—Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Ethics Difficulty: Difficult

1 2 3

Feedback The nurse cannot provide care based on one person’s wishes who may not have a legal right to make those decisions. Asking the charge nurse to assign another nurse to care for the patient does not address the issue. An ethics committee consult would be appropriate in addressing the issue of the two parties, even though the estranged wife still has a legal right to make decisions. The nurse needs to respect decisions made by the person with the legal right to make those decisions.

PTS:

CON: Ethics

10. Which action by the nurse demonstrates adherence to the Health Insurance Portability and Accountability Act (HIPAA)? 1. Taking a photo of a patient for Instagram 2. Logging out of a computer after documenting patient care 3. Discussing a patient’s status with a friend 4. Posting details about the patient without using the name on Facebook ANS: 2 Chapter: Chapter 3 Issues in Nursing Practice Objective: 12. Describe the Health Insurance Portability and Accountability Act of 1996. Page: 25 Heading: Social Media and Protecting Privacy Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Legal Difficulty: Moderate

1 2 3 4

Feedback Taking a picture of the patient violates HIPAA. Logging off a computer after documenting protects patient privacy. Discussing a patient’s status with a friend is a violation of HIPAA. Posting details on Facebook, even if it does not include the patient’s name, is a violation of HIPAA.

PTS:

CON: Legal

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11. An LPN/LVN delegates oral care to a UAP. The patient never receives the oral care. Who is held accountable? 1. The nurse manager 2. The charge nurse 3. The UAP 4. The LPN/LVN ANS: 4 Chapter: Chapter 3 Issues in Nursing Practice Objective: 5. Discuss the licensed practical nurse/licensed vocational nurse’s role in leadership and delegation. Page: 28 Heading: Leadership and Delegation for the LPN/LVN Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Legal Difficulty: Moderate

1 2 3 4

Feedback The nurse manager is not held accountable for the care delegated. The charge nurse is not held accountable for the care delegated. Although the UAP should have completed the care, the individual who delegated the care is held responsible. The LPN/LVN is held accountable for delegating the care.

PTS:

CON: Legal

12. During a patient care conference, the health care providers (HCPs) are reviewing potential outcomes based on individual interventions. Which bioethical theory is being demonstrated during this care conference? 1. Religion 2. Deontology 3. Theological 4. Utilitarianism ANS: 4 Chapter: Chapter 3 Issues in Nursing Practice Objective: 6. Describe the importance of ethics in health care. Page: 27 Heading: Ethical Theories Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Ethics Difficulty: Moderate

Feedback Religious teachings are key concepts for ethical decision making for some

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2 3 4

individuals. Deontology requires actions not to be judged only in terms of their consequences. Theological perspectives include the many religious traditions represented in our culture. In utilitarian theory, actions are judged by their consequences, so outcomes are the most important elements to consider in ethical decision making.

PTS:

CON: Ethics

13. The nurse is assessing an unresponsive older adult who lives with her daughter and notes multiple pressure ulcers and bruises all over. Which action by the nurse is most appropriate? 1. Call the daughter and tell her if the abuse doesn’t stop you will call the police. 2. Notify the authorities of suspected abuse. 3. Contact a nursing home to see if she will accept the patient. 4. Do not get involved in a suspected abuse case. ANS: 2 Chapter: Chapter 3 Issues in Nursing Practice Objective: 10. Explain mandatory reporting for health care professionals. Page: 28 Heading: Mandatory Reporting Integrated Process: Communication and Documentation Client Need: SECE— Coordinated Care Cognitive Level: Application (Applying) Concept: Legal Difficulty: Moderate

1 2 3 4

Feedback The nurse should not threaten the daughter. The nurse has a legal obligation to notify the authorities of suspected abuse. It is not the nurse’s role to contact a nursing home for placement. The nurse has a legal obligation to report suspected abuse. PTS:

CON: Legal

14. The LPN/LVN is contemplating whether delegation is appropriate. Which would help the LPN/LVN make this decision? 1. Patient’s bill of rights 2. Nurse practice act 3. Facility policy and procedure manual 4. Joint Commission guidelines ANS: 2 Chapter: Chapter 3 Issues in Nursing Practice Objective: 5. Discuss the licensed practical nurse/licensed vocational nurse’s role in leadership and delegation. Page: 30 Heading: Leadership and Delegation for the LPN/LVN

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Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Legal Difficulty: Moderate Feedback A patient’s bill of rights does not provide guidance for delegation. The nurse practice act will provide guidelines for delegation. A policy and procedure manual does not provide guidance on delegation. Joint Commission guidelines do not provide guidance for delegation.

1 2 3 4

PTS:

CON: Legal

15. The nurse is caring for a patient with end-stage renal failure who wishes to stop dialysis treatment. Which response by the nurse is best? 1. “You will die if you do not continue dialysis.” 2. “I respect your decision and will let your doctor know.” 3. “You need to consider your family when making your decision.” 4. “I think you should continue dialysis for a few more weeks.” ANS: 2 Chapter: Chapter 3 Issues in Nursing Practice Objective: 6. Describe the importance of ethics in health care. Page: 30 Heading: Ethical Principles Integrated Process: Caring Client Need: SECE—Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Ethics Difficulty: Difficult

1 2 3 4

Feedback The nurse should respect the patient’s decision even though he may not agree with it. This statement indicates the nurse is respecting the patient’s decision. The nurse should not attempt to make the patient feel guilty about his decision. The nurse should respect the patient’s opinion; this statement is attempting to coerce the patient into continuing treatment.

PTS:

CON: Ethics

16. Before leaving a patient’s room, the nurse says that pain medication will be provided within 15 minutes. The nurse returns in 10 minutes with the pain medication. Which ethical principle did the nurse demonstrate? 1. Justice 2. Fidelity 3. Veracity 4. Beneficence

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ANS: 2 Chapter: Chapter 3 Issues in Nursing Practice Objective: 6. Describe the importance of ethics in health care. Page: 25 Heading: Nonmaleficence Integrated Process: Caring Client Need: SECE: Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Ethics Difficulty: Moderate

1 2

3 4

Feedback Justice is based on fairness and equality. Fidelity is the obligation to be faithful to commitments made to self and others. In health care, fidelity includes faithfulness or loyalty to agreements and responsibilities accepted as part of the practice of nursing. It also means not promising a patient something that one cannot deliver or cannot control. Veracity is to tell the truth and not intentionally deceive or mislead patients. Beneficence means actions taken and treatments provided will benefit a person and promote welfare.

PTS:

CON: Ethics

17. The nursing staff is meeting to discuss a patient’s desire for all life support measures, even though the patient has end-stage renal disease. Once a list of all possible actions is generated, what should the staff do next? 1. List the stakeholders. 2. Determine the best action. 3. Gather important information. 4. Identify positive and negative consequences. ANS: 4 Chapter: Chapter 3 Issues in Nursing Practice Objective: 6. Describe the importance of ethics in health care. Page: 25 Heading: Ethics and Values Integrated Process: Caring Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Legal Difficulty: Moderate

1 2 3 4

Feedback Identifying the stakeholders occurs earlier in the process. Determining the best action occurs after each action is analyzed for positive and negative consequences. Gathering important information occurs earlier in the process. After developing a list of all possible actions, identify the positive and negative

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consequences for each. PTS:

CON: Legal

18. A patient with malnutrition refuses to ingest animal protein products, because it is against religious teachings. What should the nurse do to support this patient’s beliefs while ensuring the patient’s health status? 1. Explain the animal protein is the best source of nutrition for the patient’s needs at this time. 2. Talk with a dietitian about sources of non-animal–based protein to include in the patient’s diet. 3. Suggest to the physician that the patient is going against medical advice and should be discharged. 4. Schedule the organization’s clergy to meet with the patient to discuss interpretation of religious teachings. ANS: 2 Chapter: Chapter 3 Issues in Nursing Practice Objective: 6. Describe the importance of ethics in health care. Page: 30 Heading: Nonmaleficence Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

1 2

3 4

Feedback There are other sources of protein beside animal-based products. Religious teachings are key concepts of ethical decision making for some people, and many consider these teachings a divine source of values and morals. One of the difficulties with religious traditions is that it is not simply the official church teaching that is involved, but the individual member’s interpretation of that teaching. Assessment of the importance of this dimension of the patient’s life is important in an ethical analysis. Since the patient will not consume animal-based protein, the nurse should support the patient’s needs by discussing alternative sources of protein with the dietitian. The patient is not going against medical advice in this situation. This would be challenging the patient to defend personal interpretation of religious teachings.

PTS:

CON: Patient-Centered Care

19. The nurse is informed of several victims of gang violence being brought by ambulance to the emergency department. Which injury should the nurse prepare to report to the authorities? 1. Fractures 2. Abrasions 3. Lacerations

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4. Gunshot wounds ANS: 4 Chapter: Chapter 3 Issues in Nursing Practice Objective: 10. Explain mandatory reporting for health care professionals. Page: 28 Heading: Mandatory Reporting Integrated Process: Caring Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Legal Difficulty: Moderate

1 2 3 4

Feedback There are no regulations about the mandatory reporting of fractures, abrasions, and lacerations. There are no regulations about the mandatory reporting of fractures, abrasions, and lacerations. There are no regulations about the mandatory reporting of fractures, abrasions, and lacerations. Maintaining confidentiality of personal health information is an expectation when providing patient care unless it compromises mandatory reporting such as the reporting of gunshot wounds.

PTS:

CON: Legal

20. A health care administrator is reviewing material submitted to the legislature on tort reform. What should the administrator explain to nurse leaders about this legislation? 1. Limits organizational liability for damages 2. Requires continuing education for all caregivers 3. Expects all staff to have read organizational policies before completing procedures 4. Expects all staff to have malpractice or liability insurance ANS: 1 Chapter: Chapter 3 Issues in Nursing Practice Objective: 14. Discuss how to provide quality care and limit liability. Page: 30 Heading: Limitation of Liability Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Legal Difficulty: Moderate

1 2

Feedback Tort reform legislation is directed at limiting liability for health care professionals and institutions. Having liability insurance, reading policies, and continuing education can help reduce a nurse’s liability, but are not part of legislative reform.

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Having liability insurance, reading policies, and continuing education can help reduce a nurse’s liability, but are not part of legislative reform. Having liability insurance, reading policies, and continuing education can help reduce a nurse’s liability, but are not part of legislative reform.

PTS:

CON: Legal

MULTIPLE RESPONSE 1. Which of the following must be reported to the state board of nursing? (Select all that apply.) 1. Address changes 2. Number of individuals in household 3. Location of employment 4. Conviction occurring in any state 5. Student loan debt ANS: 1, 4 Chapter: Chapter 3 Issues in Nursing Practice Objective: 10. Explain mandatory reporting for health care professionals. Page: 30 Heading: Required Licensure Reporting Integrated Process: Communication and Documentation Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Legal Difficulty: Moderate

2. 3. 4.

5. PTS:

Feedback Address changes must be reported to your state licensing board to ensure you can always be contacted. Failure to do so is a violation of state law and can result in missing important communications. The number of individuals living in your household does not need to be reported to the state licensing board. Employment location does not need to be reported to the state licensing board. Convictions for misdemeanors or felonies must be reported regardless of where they occurred. If not reported, you can be sanctioned for the conviction as well as for not reporting. Student loan debt does not need to be reported to the state licensing board. 1

CON: Legal

2. The nurse is preparing to delegate a task to the UAP. Which actions should the nurse take in compliance with the National Council of State Boards of Nursing’s (NCSBN) rights of delegation? (Select all that apply.) 1. Right day 2. Right place

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3. 4. 5. 6.

Right person Right supervision Right circumstances Right communication

ANS: 2, 3, 4, 5, 6 Chapter: Chapter 3 Issues in Nursing Practice Objective: 5. Discuss the licensed practical nurse/licensed vocational nurse’s role in leadership and delegation. Page: 23 Heading: Leadership and Delegation for the LPN/LVN Integrated Process: Caring Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Legal Difficulty: Difficult

1. 2. 3. 4. 5. 6.

PTS:

Feedback The right day is not an identified right to follow when delegating. The NCSBN identifies the five rights of delegation as the right task, person, circumstances, supervision, and communication. The NCSBN identifies the five rights of delegation as the right task, person, circumstances, supervision, and communication. The NCSBN identifies the five rights of delegation as the right task, person, circumstances, supervision, and communication. The NCSBN identifies the five rights of delegation as the right task, person, circumstances, supervision, and communication. The NCSBN identifies the five rights of delegation as the right task, person, circumstances, supervision, and communication. 1

CON: Legal

3. A nurse is working on a medical unit in a hospital undergoing a Joint Commission review. The investigator asks the nurse to explain “never events.” What examples should the nurse use to explain these kinds of events? (Select all that apply.) 1. Surgery on the wrong body part 2. Paralyzed leg after falling from a bed 3. Death from falling out of bed 4. Having to restart an IV infusion 5. Canceling surgery because blood work is not safe ANS: 1, 2, 3 Chapter: Chapter 3 Issues in Nursing Practice Objective: 2. Describe safe health care practices. Page: 28 Heading: Safe Practice Integrated Process: Caring Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying)

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Concept: Legal Difficulty: Moderate

4. 5.

PTS:

Feedback The Joint Commission considers “never events” to be sentinel events. Examples of these events include surgery on the wrong body part, loss of body function from a fall, or a death after a fall. The Joint Commission considers “never events” to be sentinel events. Examples of these events include surgery on the wrong body part, loss of body function from a fall, or a death after a fall. The Joint Commission considers “never events” to be sentinel events. Examples of these events include surgery on the wrong body part, loss of body function from a fall, or a death after a fall. Having to restart an IV infusion and canceling surgery are not considered sentinel events. Having to restart an IV infusion and canceling surgery are not considered sentinel events. 1

CON: Legal

4. The LPN is working in a senior center and is approached by a participant who asks the nurse, “Can you help me understand my Medicare benefits?” What should the nurse include in a response to this patient? (Select all that apply.) 1. “Medicare is a payment system for the working poor.” 2. “Medicare Part B covers outpatient services and has a monthly cost.” 3. “Medicare is a federally funded program for individuals 65 and over.” 4. “Prescription drug coverage for those with Medicare is available.” 5. “Medicare Part A covers inpatient hospital care and is free to those who qualify for Social Security.” ANS: 2, 3, 4, 5 Chapter: Chapter 3 Issues in Nursing Practice Objective: 1. Identify factors influencing changes in the health care delivery system. Page: 30 Heading: Medicare and Diagnosis-Related Groups Integrated Process: Caring Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Legal Difficulty: Difficult

1. 2.

Feedback Medicare is not a payment system for the working poor. This best describes Medicaid. Medicare is run by the U.S. government and currently covers all individuals age 65 and over. Several Medicare plan options are offered: Original Medicare, Medicare Health Plans, Medigap policies, and prescription drug coverage for everyone with Medicare. There are two parts of coverage in the original Medicare plan. Part A covers inpatient hospital care, skilled nursing

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PTS:

facilities, hospice services, and some home care. There is no premium or deductible for Part 1. Part B is medical insurance that covers physician costs, outpatient services, some home care, supplies, and other things not covered by Part 1. Some preventive services may also be covered. A monthly premium and yearly deductible are paid in exchange for Part B coverage. Medicare Part D is prescription drug coverage. Medicare is run by the U.S. government and currently covers all individuals age 65 and over. Several Medicare plan options are offered: Original Medicare, Medicare Health Plans, Medigap policies, and prescription drug coverage for everyone with Medicare. There are two parts of coverage in the original Medicare plan. Part A covers inpatient hospital care, skilled nursing facilities, hospice services, and some home care. There is no premium or deductible for Part 1. Part B is medical insurance that covers physician costs, outpatient services, some home care, supplies, and other things not covered by Part 1. Some preventive services may also be covered. A monthly premium and yearly deductible are paid in exchange for Part B coverage. Medicare Part D is prescription drug coverage. Medicare is run by the U.S. government and currently covers all individuals age 65 and over. Several Medicare plan options are offered: Original Medicare, Medicare Health Plans, Medigap policies, and prescription drug coverage for everyone with Medicare. There are two parts of coverage in the original Medicare plan. Part A covers inpatient hospital care, skilled nursing facilities, hospice services, and some home care. There is no premium or deductible for Part 1. Part B is medical insurance that covers physician costs, outpatient services, some home care, supplies, and other things not covered by Part 1. Some preventive services may also be covered. A monthly premium and yearly deductible are paid in exchange for Part B coverage. Medicare Part D is prescription drug coverage. Medicare is run by the U.S. government and currently covers all individuals age 65 and over. Several Medicare plan options are offered: Original Medicare, Medicare Health Plans, Medigap policies, and prescription drug coverage for everyone with Medicare. There are two parts of coverage in the original Medicare plan. Part A covers inpatient hospital care, skilled nursing facilities, hospice services, and some home care. There is no premium or deductible for Part 1. Part B is medical insurance that covers physician costs, outpatient services, some home care, supplies, and other things not covered by Part 1. Some preventive services may also be covered. A monthly premium and yearly deductible are paid in exchange for Part B coverage. Medicare Part D is prescription drug coverage. 1

CON: Legal

5. The nurse is planning to prepare medications for assigned patients. Which actions should the nurse take to ensure a safe environment while preparing the medications? (Select all that apply.) 1. Find a laboratory value for a physician as requested. 2. Place a “no interruption sign” on the door of the medication room. 3. Answer a patient’s call light after checking the medication administration record. 4. Listen to information provided by the charge nurse about a newly admitted patient.

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5. Ask coworkers to provide you with time to concentrate while preparing medication. ANS: 2, 5 Chapter: Chapter 3 Issues in Nursing Practice Objective: 2. Describe safe health care practices. Pages: 30–31 Heading: Safe Practices Integrated Process: Caring Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Legal Difficulty: Moderate

PTS:

Feedback Finding laboratory values, answering a call light, and listening to the charge nurse provide information are all distractions that could lead to medication errors. Efforts to reduce medication errors include identifying “no interruption” zones and asking coworkers for time to concentrate while preparing medications. Finding laboratory values, answering a call-light, and listening to the charge nurse provide information are all distractions that could lead to medication errors. Finding laboratory values, answering a call-light, and listening to the charge nurse provide information are all distractions that could lead to medication errors. Efforts to reduce medication errors include identifying “no interruption” zones and asking coworkers for time to concentrate while preparing medications. 1

CON: Legal

ORDERED RESPONSE 1. Place in order, from 1 to 5, the five major components in the management process. 1. Coordinating 2. Organizing 3. Planning 4. Controlling 5. Directing ANS: 3, 2, 5, 1, 4 Chapter: Chapter 3 Issues in Nursing Practice Objective: 5. Discuss the licensed practical nurse/licensed vocational nurse’s role in leadership and delegation. Page: 21 Heading: Management Functions

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Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Leadership and Management Difficulty: Difficult Feedback: The first step in the management process is planning. Organizing is the second step followed by directing. Coordinating is the fourth step and controlling is the final step. PTS:

CON: Leadership and Management

2. Place in order, from 1 to 8, the steps to process an ethical dilemma. 1. Determine the best action with the strongest ethical support. 2. Gather and verify the information. 3. Implement the action. 4. Examine possible actions and the consequences of each action. 5. Identify the ethical dilemma. 6. Determine the ethical foundation for each action. 7. Identify the stakeholders and their values. 8. Evaluate the outcome. ANS: 5, 7, 2, 4, 6, 1, 3, 8 Chapter: Chapter 3 Issues in Nursing Practice Objective: 8. List the steps in the ethical decision-making model. Page: 27 Heading: Ethical Decision Making Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Ethics Difficulty: Difficult Feedback: Ethical decision making is an informed, logical problem-solving process. The steps assist in approaching a problem in an organized and systematic manner: identify the ethical dilemma, identify the stakeholders and their values, gather and verify the information, examine possible actions and the consequences of each action, determine the ethical foundation for each action, determine the best action with the strongest ethical support, implement the action, and evaluate the outcome. PTS:

CON: Ethics

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Chapter 4. Cultural Influences on Nursing Care MULTIPLE CHOICE 1. The nurse is preparing to teach a patient of the Asian culture to perform postoperative dressing changes at home after discharge. Which statement made by the nurse indicates cultural competence? 1. “Tell me how you feel about your surgery.” 2. “Asian people are smart, so this should be easy for you to understand.” 3. “American surgeons are highly qualified; I’m sure you will heal quickly.” 4. “Will you tell me about any traditional healing practices that you would like to use?” ANS: 4 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 2. List examples of cultural characteristics, values, beliefs, and practices. Page: 35 Heading: Concepts Related to Culture Integrated Process: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Culture Difficulty: Moderate Feedback 1 This is an assessment designed to elicit the patient’s emotional reaction to the surgery. This may be an important part of adult learning, but it is not the best option to represent cultural competence. 2 This statement represents a stereotype—an opinion or belief about a group of people that is ascribed to an individual. 3 This statement exemplifies ethnocentrism or the tendency for people to think that their ways of thinking, acting, and believing are the only right, proper, and natural ways. 4 Cultural sensitivity is using language and statements that do not offend another person’s cultural beliefs. Cultural competence includes the skills and knowledge required to provide effective nursing care. The use of traditional healers and healing therapies is common for Asian individuals and assessing the patient’s desire to use such healers or therapies shows the nurse is culturally sensitive and competent to provide care. PTS:

CON: Culture

2. A patient who is a Jehovah’s Witness has severe gastrointestinal bleeding and a dangerously low hemoglobin level. The patient is fully alert and competent and refuses to accept the blood transfusion ordered by the physician. Which action by the nurse is most appropriate? 1. Obtain a court order to give the blood. 2. Administer the blood while the patient is sleeping. 3. Have the patient’s spouse sign the consent to have the blood administered. 4. Ensure the patient understands possible consequences and then respect the

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patient’s wishes. ANS: 4 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 3. Describe attributes of culturally diverse patients and their families and how they affect nursing care. Page: 35 Heading: Health Care Values, Beliefs, and Practices Integrated Process: Caring Client Need: PHYS: Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Spirituality Difficulty: Moderate Feedback 1 Administering the blood without the patient’s knowledge or consent is unethical. 2 Administering the blood without the patient’s knowledge or consent is unethical. 3 Administering the blood without the patient’s knowledge or consent is unethical. 4 Patients’ beliefs should be respected, even when their decisions go against medical advice. The patient needs to understand the consequences of the decision. PTS:

CON: Spirituality

3. The nurse is caring for a patient from Germany who does not speak or understand English. Which action best facilitates communication? 1. Ask the patient’s daughter to interpret. 2. Speak clearly, facing the patient. 3. Use an interpreter to translate. 4. Use hand signs to communicate. ANS: 3 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 3. List examples of cultural characteristics, values, beliefs, and practices. Page: 36 Heading: Nursing Assessment and Strategies Integrated Process: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Communication Difficulty: Moderate Feedback 1 The daughter may unintentionally or intentionally edit or alter important information; this also violates HIPAA. 2 If the patient does not understand English, speaking clearly facing the patient will not make him or her understand the nurse. 3 An interpreter is the best practice for communication with a non-English

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speaking patient. Although some communication may take place through hand signs, the best method of communicating important information to the patient is through an interpreter.

PTS:

CON: Communication

4. A male nurse is receiving a new admission who is a female Muslim patient. Which action should the nurse take? 1. Tell the patient the unit is short-staffed and she has no choice but to have a male nurse. 2. Ask the female nurse to perform the assessment but continue to care for this patient. 3. The nurse should do nothing. Female Muslim patients may be cared for by men. 4. Ask a female colleague to take the patient. ANS: 4 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 5. Apply a holistic approach to patient care that respects cultural and spiritual characteristics and attributes. Page: 38 Heading: Choice of Health Care Providers Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Culture Difficulty: Moderate Feedback 1 The male nurse cannot force the patient to allow a male nurse to care for her if it is against her religious or cultural beliefs. 2 A male nurse may not provide any care for a female Muslim patient. 3 A male nurse may not provide any care for a female Muslim patient. 4 It is appropriate to ask a female colleague to assume care for a female Muslim patient. PTS:

CON: Culture

5. The nurse is caring for a European American patient who is Jewish. For which illness should the nurse suggest screening for before becoming pregnant? 1. Sickle cell anemia 2. Tay-Sachs disease 3. Thalassemia 4. Diabetes mellitus ANS: 2 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 4. Identify data you should collect from culturally diverse patients and their families. Page: 38

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Heading: European American (Non-Hispanic White) Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Culture Difficulty: Moderate Feedback 1 African American patients are at high risk for sickle cell anemia. 2 European Americans (Jewish) are at risk for Tay-Sachs. This is a genetic disease that can be passed on to offspring. 3 European Americans (non-Jewish) are at high risk for thalassemia. 4 European Americans (non-Jewish) are at high risk for diabetes mellitus. PTS:

CON: Culture

6. The nurse is caring for a patient who practices Buddhism. Which is true regarding Buddhist beliefs of death? 1. Do not touch the body for 3 to 8 hours after death. 2. The body must not be cremated. 3. Organ donation is not acceptable. 4. The family sits with the deceased for 48 hours after death. ANS: 1 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 5. Apply a holistic approach to patient care that respects cultural and spiritual characteristics and attributes. Page: 39 Heading: Death and Dying and End-of-Life Issues Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Culture Difficulty: Moderate

1 2 3 4

Feedback Patients of the Buddhist faith believe the spirit lingers in the body for 3 to 8 hours after death and the body should not be touched once breathing ceases. Buddhists believe the deceased should be cremated before the next sunrise. Organ donation is not forbidden in the Buddhist faith. Buddhists believe the body should be cremated by the next sunrise.

PTS:

CON: Culture

7. A patient of northern European descent recovering from surgery denies postoperative pain; however, vital signs indicate an elevated pulse and blood pressure. The patient refuses to move in bed. Which nursing action would best ensure comfort and timely discharge? 1. Give the pain medicine as prescribed. 2. Ask the physician to prescribe the analgesics around the clock. 3. Explain that the pain medicine will help prevent complications.

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4. Respect the patient’s denial of pain and do not encourage the pain medicine. ANS: 3 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 3. Describe attributes of culturally diverse patients and their families and how they affect nursing care. Page: 39 Heading: Health Care Values, Beliefs, and Practices Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Culture Difficulty: Moderate Feedback 1 The patient’s wishes must be respected, so giving the medication without the patient’s consent is not appropriate. 2 The patient’s wishes must be respected, so giving the medication without the patient’s consent is not appropriate. 3 Explaining that pain control can help prevent complications allows the patient to make an informed decision. 4 Respecting the patient’s denial of pain and not encouraging the pain medication may not necessarily support the patient’s comfort and allow for appropriate healing of the incision. PTS:

CON: Culture

8. The nurse is assessing a group of patients. Which patient does the nurse identify at highest risk for stroke? 1. A European American female 2. A Hispanic female 3. An African American male 4. An Asian American male ANS: 3 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 3. Describe attributes of culturally diverse patients and their families and how they affect nursing care. Page: 39 Heading: African American (Non-Hispanic Black) Integrated Process: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Culture Difficulty: Moderate Feedback 1 A European American female is not at highest risk for stroke. 2 A Hispanic female is not at highest risk for stroke. 3 An African American male is at highest risk for high blood pressure, obesity, and diabetes, all of which lead to heart disease and stroke.

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An Asian American male is not at highest risk for stroke.

PTS:

CON: Culture

9. The nurse is caring for a patient who values time. Which demonstrates respect for this cultural phenomenon? 1. Include the matriarch of the family in all decisions. 2. Avoid standing closely to the patient. 3. Maintain eye contact with the patient. 4. Ensure 9:00 medications are administered at 9:00, not 9:20. ANS: 4 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 3. Describe attributes of culturally diverse patients and their families and how they affect nursing care. Page: 37 Heading: Time Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Culture Difficulty: Moderate Feedback 1 This describes respect for social organization. 2 This describes respect for space. 3 This describes respect for communication styles. 4 This describes respect for time. PTS:

CON: Culture

10. The nurse is caring for a patient who states she has been consuming therapies and herbal remedies recommended by her healer. Which statement by the nurse is most appropriate? 1. “You cannot take any herbal remedies or therapies while you are receiving treatment here.” 2. “The physician knows what he is doing; I would follow his treatment instead of your healer.” 3. “Please tell me exactly what you are taking so I can make sure they don’t interact with your medications.” 4. “If you would prefer, you can continue to take your herbal remedies and therapies instead of the prescribed treatment.” ANS: 3 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 5. Apply a holistic approach to patient care that respects cultural and spiritual characteristics and attributes. Page: 34 Heading: Health Care Values, Beliefs, and Practices Integrated Process: Caring Client Need: SECE: Safety and Infection Control

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Cognitive Level: Application (Applying) Concept: Culture Difficulty: Moderate Feedback 1 Many therapies prescribed by a healer can be continued as long as interactions are double-checked. 2 Many therapies prescribed by a healer can be continued as long as interactions are double-checked; this statement belittles the patient’s beliefs. 3 Many therapies prescribed by a healer can be continued as long as interactions are double-checked. 4 The nurse should not suggest only remedies prescribed by a healer be taken (instead of those prescribed by a physician). PTS:

CON: Culture

11. The nurse is caring for a Chinese patient who refuses antibiotics for pneumonia. Which can the nurse infer as the reason? 1. The patient has many allergies and is afraid to have a reaction. 2. The patient cannot afford antibiotics. 3. Western medicine is prohibited among the Chinese culture. 4. The patient believes the illness is caused by an imbalance of Yin. ANS: 4 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 5. Apply a holistic approach to patient care that respects cultural and spiritual characteristics and attributes. Page: 34 Heading: Environmental Control Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Culture Difficulty: Moderate Feedback 1 This is not likely a reason for refusing antibiotics. 2 This is not likely a reason for refusing antibiotics. 3 Western medicine is not prohibited in the Chinese culture. 4 The patient likely believes a disturbance of Yin caused the illness and does not believe antibiotics will treat the cause. PTS:

CON: Culture

12. The mother of a 6-year-old Vietnamese child admitted with pneumonia is rubbing a coin on the child’s back. The coin leaves red marks. What should the nurse do about this observation? 1. Report the possibility of child abuse. 2. Do not allow the mother to be alone with her child. 3. Explain to the mother that she cannot do this in the hospital. 4. Add a statement to the care plan that the family practices coining.

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ANS: 4 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 3. Describe attributes of culturally diverse patients and their families and how they affect nursing care. Page: 34 Heading: Health Care Values, Beliefs, and Practices Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Culture Difficulty: Moderate Feedback 1 This is a culturally insensitive response. 2 This is a culturally insensitive response. 3 This is a culturally insensitive response. 4 Individuals from Asian cultures may practice coining. This is an example of a cultural practice that is harmless and may be included in the patient’s care. PTS:

CON: Culture

13. The nurse is caring for a patient who moved to the United States from the Philippines 4 years ago. Which action indicates acculturation? 1. The patient only cooks food from his home country. 2. The patient joins a church whose members are predominately from the Philippines. 3. The patient speaks English instead of Tagalog. 4. The patient wears clothing common to the Philippines. ANS: 3 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 2. List examples of cultural characteristics, values, beliefs, and practices. Page: 35 Heading: Concepts Related to Culture Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Culture Difficulty: Moderate Feedback 1 Continuing to cook food from the home country does not indicate acculturation. 2 Joining a church with members from the patient’s home country does not indicate acculturation. 3 Speaking the language of the new country instead of the old country demonstrates acculturation. 4 Wearing clothing common to the home country does not demonstrate acculturation.

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PTS:

CON: Culture

14. Which topic should the nurse include in a health promotion course for a Pacific Islander? 1. Genetic testing for sickle cell anemia 2. Methods of preventing HIV 3. Home blood pressure monitoring 4. Dietary alternatives for lactose products ANS: 2 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 5. Apply a holistic approach to patient care that respects cultural and spiritual characteristics and attributes. Page: 40 Heading: Native Hawaiian or Other Pacific Islander Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Culture Difficulty: Moderate Feedback 1 Sickle cell anemia is common among African American individuals. 2 Native Hawaiian or other Pacific Islanders are at high risk for HIV/AIDS and should be taught methods of prevention. 3 Pacific Islanders are not at high risk for high blood pressure. 4 Native Hawaiian or Pacific Islanders are not at risk for lactose intolerance. PTS:

CON: Culture

15. Which question should the nurse ask when assessing spirituality? 1. “What religion are you affiliated with?” 2. “Do you believe in God?” 3. “Do you have any spiritual practices of which I need to be aware?” 4. “Is there a priest or pastor you would like for me to contact? ANS: 3 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 4. Identify data you should collect from culturally diverse patients and their families. Page: 35 Heading: Concepts Related to Spirituality Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Spirituality Difficulty: Moderate Feedback 1 This statement assumes the patient practices a religion. 2 It is not relevant to know if the patient believes in God. 3 This statement does not assume the patient is religious but assesses if he or she

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would like you to be aware of any spiritual practices. This statement assumes the patient is religious.

PTS:

CON: Spirituality

16. The nurse is caring for a Hispanic patient and calls a local Catholic priest to come visit with the patient without asking religious preference. Which has the nurse demonstrated? 1. Cultural awareness 2. Ethnocentrism 3. Acculturation 4. Stereotyping ANS: 4 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 1. Define common concepts related to culture and spirituality. Page: 34 Heading: Concepts Related to Culture Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Culture Difficulty: Moderate Feedback 1 Cultural awareness means the nurse understands history and ancestry and an appreciation for a culture’s arts, music, crafts, celebration, foods, and traditional clothing. 2 Ethnocentrism means the nurse thinks his or her culture’s beliefs are the only way to believe. 3 Acculturation is accepting a new culture including his or her own. 4 The nurse is stereotyping the patient; thinking that all Hispanics are Catholic. PTS:

CON: Culture

MULTIPLE RESPONSE 1. The nurse is caring for a patient from Korea who does not speak or understand English. The patient’s 8-year-old son offers to interpret medical information. Which are reasons to be cautious of allowing him to interpret? (Select all that apply.) 1. He may be proficient in medical terminology and understand what is being said. 2. He may not be mature enough to handle information being conveyed. 3. Using the son to interpret violates the patient’s right to privacy. 4. The son may intentionally omit information being conveyed. 5. The son is readily available compared to an interpreter. ANS: 2, 3, 4 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 3. Describe attributes of culturally diverse patients and their families and how they affect nursing care. Page: 35

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Heading: Nursing Assessment and Strategies Integrated Process: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Communication Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback The interpreter should be proficient in medication terminology; this is not a reason to exclude the son from interpreting. The son may not be mature enough to handle information being conveyed, such as a cancer diagnosis. Using the son to interpret does violate a patient’s right to privacy. There may be things the mother doesn’t want her son to know. Using a family member to interpret can cause important information to be intentionally or unintentionally omitted or edited. Having a family member readily available to interpret is a plus, but an official interpreter should be used. 1

CON: Communication

2. A female nurse is providing smoking cessation counseling and education during a community health fair. The nurse should avoid physical closeness, shaking hands, or touching during instruction with which of the following? (Select all that apply.) 1. A 35-year-old man of Asian descent 2. A 45-year-old woman of Arab descent 3. A 28-year-old man of Hispanic descent 4. A 52-year-old woman of African American descent 5. A 41-year-old woman of American Indian descent ANS: 1, 5 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 3. Describe attributes of culturally diverse patients and their families and how they affect nursing care. Page: 40 Heading: Space Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Culture Difficulty: Difficult

2. 3.

Feedback For American Indians/Native Alaskans, touch is not acceptable from strangers. Asians and Pacific Islanders avoid physical closeness and touching. Touch between persons of the same gender is acceptable, and personal space is very close for Arab Americans. Individuals of Hispanic descent value touching and closeness.

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4. 5.

PTS:

African Americans have close personal space and touch frequently, although less with strangers. For American Indians/Native Alaskans, touch is not acceptable from strangers. Asians and Pacific Islanders avoid physical closeness and touching. 1

CON: Culture

3. Which of the following are examples of secondary characteristics of cultural diversity? (Select all that apply.) 1. Race 2. Gender 3. Socioeconomic status 4. Political beliefs 5. Spirituality ANS: 3, 4 Chapter: Chapter 4 Cultural Influences on Nursing Care Objective: 2. List examples of cultural characteristics, values, beliefs, and practices. Page: 35 Heading: Characteristics of Cultural Diversity Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Comprehension (Understanding) Concept: Culture Difficulty: Easy

1. 2. 3. 4. 5. PTS:

Feedback Race is a primary characteristic of cultural diversity. Gender is a primary characteristic of cultural diversity. Socioeconomic status is an example of a secondary characteristic of cultural diversity. Political beliefs are an example of a secondary characteristic of cultural diversity. Spirituality is an example of a primary characteristic of cultural diversity. 1

CON: Culture

4. The nurse is caring for a patient who is Jewish and follows a kosher diet. Which food choices will the nurse identify as appropriate for this patient? (Select all that apply.) 1. Cheese 2. Shrimp 3. Salmon 4. Tuna 5. Pork ANS: 3, 4 Chapter: Chapter 4 Cultural Influences on Nursing Care

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Objective: 5. Apply a holistic approach to patient care that respects cultural and spiritual characteristics and attributes. Page: 39 Heading: Biological Variations Integrated Process: Caring Client Need: PHYS: Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Culture Difficulty: Difficult

1. 2. 3. 4. 5. PTS:

Feedback Cheese must be kosher before eating. Shrimp is forbidden for a kosher diet. Salmon is an acceptable food for a kosher diet. Tuna is an acceptable food for a kosher diet. Pork is forbidden for a kosher diet. 1

CON: Culture

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Chapter 5. Complementary and Alternative Modalities MULTIPLE CHOICE 1. The nurse reviews the evidence of an herb’s effectiveness and notes a rating of a grade 6. Which is an accurate description of this grade? 1. Strong evidence against use 2. Strong evidence for the herb’s use 3. Moderate evidence for the herb’s use 4. No literature found on this herb ANS: 1 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 4. Identify safety issues associated with complementary and alternative modalities. Page: 46 Heading: Herbal Therapy Integrated Process: Caring Client Need: SECE: Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 A grade of F indicates strong evidence against the herb’s use. 2 A grade of A indicates strong research evidence supporting the herb’s use. 3 A grade of C indicates moderate evidence supporting the herb’s use. 4 A grade of F does not indicate no literature was found. PTS:

CON: Safety

2. A patient with migraines tells the nurse she is using a technique to alleviate pain that involves pressure and kneading of the body. The nurse knows the patient is using which technique? 1. Biofeedback 2. Aquatherapy 3. Massage therapy 4. Guided imagery ANS: 3 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 3. Identify how selected modalities are classified. Page: 48 Heading: Massage Therapy Integrated Process: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Health Promotion Difficulty: Moderate

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1 2 3 4

Feedback This does not describe biofeedback. Aquatherapy involves water. The patient is describing massage therapy. This does not describe guided imagery. PTS:

CON: Health Promotion

3. Which statement accurately describes an alternative modality? 1. Alternative modalities are used in addition to a conventional modality. 2. Alternative modalities are not effective. 3. An alternative modality is a therapy used instead of a conventional modality. 4. Only hippies use alternative modalities. ANS: 3 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 1. Explain the difference between complementary and alternative modalities. Page: 43 Heading: Complementary or Alternative: What’s the Difference? Integrated Process: Caring Client Need: Health Promotion Cognitive Level: Comprehension (Understanding) Concept: Health Promotion Difficulty: Moderate Feedback 1 Complementary modalities are used in conjunction with conventional modalities. 2 Alternative modalities can be beneficial. 3 Alternative modalities are used instead of conventional therapies. 4 Many people use alternative modalities. PTS:

CON: Health Promotion

4. The nurse learns that a patient plans to try St. John’s wort for depression. How should the nurse respond to the patient about this herbal remedy? 1. “Some people believe it can be helpful for depression. Because it is an herb, it would be safe to try it.” 2. “Herbs are medicines. You should not try anything without first consulting your primary care provider.” 3. “Herbs can be dangerous. You should avoid taking them while you are on other medications because interactions could occur.” 4. “St. John’s wort has been shown in research to be safe and effective for treating depression. Be sure to follow the package instructions.” ANS: 2 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 4. Identify safety issues associated with complementary and alternative modalities. Page: 47

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Heading: Herbal Therapy Integrated Process: Communication and Documentation Client Need: SECE: Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 Not all herbal remedies are safe for all people. 2 Any herb can be effective for some and dangerous for others, depending on medical history and other prescribed medications. The primary care provider should always be consulted before the patient tries something new. 3 Some herbal preparations are safe to take with prescribed medications. 4 The patient needs to discuss the use of this herbal remedy with the primary care provider before ingesting. PTS:

CON: Safety

5. The nurse is teaching a patient about the practice of chiropractic medicine. Which statement indicates an understanding of the teaching? 1. “The chiropractor can prescribe me some medication for my neck pain.” 2. “The practitioner will insert needles along meridians of qi flows.” 3. “The chiropractor will perform manipulation of the vertebral column.” 4. “The practitioner will lead me through a visualization exercise.” ANS: 3 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 3. Identify how selected modalities are classified. Page: 44 Heading: Chiropractic Medicine Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate Feedback 1 Chiropractors cannot prescribe medications. 2 This describes acupuncture. 3 This is an accurate description of the practice of chiropractic medicine. 4 This describes guided imagery. PTS:

CON: Health Promotion

6. A patient informs the nurse she is taking echinacea. The nurse suspects the patient is attempting to treat which condition? 1. Diabetes 2. Osteoarthritis 3. Anxiety 4. Flu

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ANS: 4 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 3. Identify how selected modalities are classified. Page: 47 Heading: Common Herbs and Their Intended Uses Integrated Process: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate Feedback 1 Ginseng is known to lower blood glucose levels. 2 Capsaicin is used to treat pain associated with osteoarthritis. 3 Chamomile and kava are used to reduce anxiety. 4 Echinacea is used to treat colds and flu. PTS:

CON: Health Promotion

7. The staff development instructor is preparing a presentation on the different types of medicine being used by the patients cared for in the organization. Which definition should the instructor use to describe the allopathic system or philosophy of health care? 1. A system that holds that disease is a result of nerve dysfunction 2. A system that maintains that illness is the result of falling out of balance with nature 3. A method of treating disease with remedies that produce effects different from those caused by the disease 4. A system that uses tiny doses of a substance that create the symptoms of disease in a healthy person to relieve those symptoms in a sick person ANS: 3 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 2. Describe systems of health care that have contributed to the development of new modalities. Page: 44 Heading: Introduction of New Systems Into Traditional Western Health Care Integrated Process: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate Feedback 1 Chiropractic medicine treats nerve dysfunction. 2 Ayurvedic medicine believes that illness results from falling out of balance with nature. 3 Allopathy is a method of treating disease with remedies that produce effects different from those caused by the disease. 4 Homeopathy uses tiny doses of substances that create symptoms. PTS:

CON: Health Promotion

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8. The nurse is assisting a patient to use guided imagery. Which health problem is the patient most likely experiencing? 1. Gallstones 2. Hypertension 3. Hyperthyroidism 4. Diabetes mellitus ANS: 2 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 3. Identify how selected modalities are classified. Page: 47 Heading: Guided Imagery Integrated Process: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate Feedback 1 Gallstones, diabetes, and hyperthyroidism require medical intervention, although guided imagery may help relieve some of the patient’s distress related to these conditions. 2 Guided imagery is often used to alleviate stress and to treat stress-related conditions such as insomnia and high blood pressure. 3 Gallstones, diabetes, and hyperthyroidism require medical intervention, although guided imagery may help relieve some of the patient’s distress related to these conditions. 4 Gallstones, diabetes, and hyperthyroidism require medical intervention, although guided imagery may help relieve some of the patient’s distress related to these conditions. PTS:

CON: Health Promotion

9. The nurse is assisting a patient with aquatherapy. The patient likely has which condition? 1. Arthritis 2. Insomnia 3. AIDS 4. Hypertension ANS: 1 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 3. Identify how selected modalities are classified. Page: 48 Heading: Aquatherapy Integrated Process: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Health Promotion Difficulty: Moderate

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Feedback Aquatherapy is effective for arthritis. Biofeedback is effective for insomnia. Guided imagery is effective for AIDS. Guided imagery is effective for hypertension.

1 2 3 4

PTS:

CON: Health Promotion

10. The nurse is taking a medication history and the patient is reluctant to tell the nurse about a certain herb because it has been banned by the Food and Drug Administration (FDA). The nurse should suspect the patient is taking which herb? 1. Garlic 2. Ginger 3. St. John’s wort 4. Ephedra ANS: 4 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 4. Identify safety issues associated with complementary and alternative modalities. Page: 47 Heading: Common Herbs and Their Intended Uses Integrated Process: Caring Client Need: SECE: Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate

1 2 3 4

Feedback Garlic has not been banned. Ginger has not been banned. St. John’s wort has not been banned. Ephedra was banned in 2004 because of deadly side effects, but patients still obtain it outside of the United States.

PTS:

CON: Safety

11. A patient experiencing symptoms of menopause asks the nurse which herbal remedy can help alleviate the symptoms. Which remedy should the nurse suggest? 1. Feverfew 2. Echinacea 3. Black cohosh 4. Red yeast rice ANS: 3 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 3. Identify how selected modalities are classified. Page: 47 Heading: Common Herbs and Their Intended Uses (Table 5.2)

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Integrated Process: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Difficult Feedback 1 Feverfew has anti-inflammatory properties and may help treat migraines, stimulate appetite, promote menstruation, eliminate worms, and suppress fever. 2 Echinacea has antiviral properties and may be effective for colds, flu, and other infections. 3 Black cohosh may ease symptoms of menstruation. 4 Red yeast rice reduces cholesterol and triglycerides. PTS:

CON: Health Promotion

MULTIPLE RESPONSE 1. The nurse is caring for a patient experiencing poor appetite, nausea, and vomiting from chemotherapy. Which herbs should the nurse suggest the patient use to help with these symptoms? (Select all that apply.) 1. Kava 2. Ginger 3. Ginkgo 4. Feverfew 5. Echinacea ANS: 2, 4 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 5. Identify safety issues associated with complementary and alternative modalities. Page: 47 Heading: Common Herbs and Their Intended Uses (Table 5.2) Integrated Process: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5. PTS:

Feedback Kava is for anxiety or insomnia. Ginger may be effective for nausea and vomiting. Ginkgo may help memory. Feverfew is used to stimulate appetite. Echinacea is an antiviral. 1

CON: Health Promotion

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2. The nurse is reviewing a medication list for a patient about to undergo abdominal surgery. Which would warrant a phone call to the surgeon? (Select all that apply.) 1. Garlic 2. Atenolol 3. Ginkgo 4. Ginseng 5. Insulin ANS: 1, 3, 4 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 4. Identify safety issues associated with complementary and alternative modalities. Page: 47 Heading: Herbal Therapy Integrated Process: Caring Client Need: SECE: Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Difficult

1. 2. 3. 4. 5. PTS:

Feedback Garlic places the patient at risk for bleeding. Atenolol does not place the patient at risk for bleeding. Gingko places the patient at risk for bleeding. Ginseng places the patient at risk for bleeding. Insulin does not place the patient at risk for bleeding. 1

CON: Safety

3. The nurse is teaching a patient about biologically based modalities. Which topics should the nurse include in the teaching? (Select all that apply.) 1. Pet therapy 2. Magnet therapy 3. Hypnosis 4. Herbal medicine 5. Diet therapies ANS: 4, 5 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 1. Explain the difference between complementary and alternative modalities. Page: 44 Heading: Categories and Types of Complementary and Alternative Modalities Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate Feedback

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1. 2. 3. 4. 5. PTS:

Pet therapy is a miscellaneous therapy. Magnet therapy is an energetic modality. Hypnosis is a mind-body modality. Herbal medicine is a biologically based modality. Diet therapies are biologically based modalities. 1

CON: Health Promotion

4. A patient with chronic pain tells the nurse she wants to learn more about body-based modalities. The nurse will teach the patient about which techniques? (Select all that apply.) 1. Guided imagery 2. Acupressure 3. Chiropractic medicine 4. Massage 5. Aquatherapy ANS: 2, 3, 4 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 1. Explain the difference between complementary and alternative modalities. Pages: 47–48 Heading: Categories and Types of Complementary and Alternative Modalities Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5. PTS:

Feedback Guided imagery is a mind-body modality. Acupressure is a body-based modality. Chiropractic medicine is a body-based modality. Massage is a body-based modality. Aquatherapy is a miscellaneous therapy. 1

CON: Health Promotion

5. The nurse is caring for a patient who reports that he practices traditional Chinese medicine. The nurse knows this includes which practices? (Select all that apply.) 1. Acupressure 2. Acupuncture 3. Qi Gong 4. Guided imagery 5. Chiropractic medicine ANS: 1, 2, 3 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 3. Identify how selected modalities are classified. Page: 44 Heading: Traditional Chinese Medicine

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Integrated Process: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5. PTS:

Feedback Acupressure is used in traditional Chinese medicine. Acupuncture is used in traditional Chinese medicine. Qi Gong is used in traditional Chinese medicine. Guided imagery is not a practice used in traditional Chinese medicine. Chiropractic medicine is not a practice used in traditional Chinese medicine 1

CON: Health Promotion

6. The nurse is assisting a patient with using guided imagery to relieve pain. Which instructions should the nurse include? (Select all that apply.) 1. “Picture what this place looks like and how comfortable you feel.” 2. “Feel the sense of deep relaxation and peace of this place.” 3. “The doctor will adjust your spine at this time, take a deep breath.” 4. “I am going to shine this light on you for 2 hours.” 5. “Close your eyes and keep them closed until the exercise is complete.” ANS: 1, 2, 5 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 5. Describe the role of a licensed practical nurse/licensed vocational nurse in assisting a patient with complementary and alternative modalities. Page: 47 Heading: Guided Imagery (Box 5.1) Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5. PTS:

Feedback This describes instruction for guided imagery. This describes instruction for guided imagery. This describes instruction for chiropractic medicine. This describes instruction for light therapy. This describes instruction for guided imagery. 1

CON: Health Promotion

7. The nurse reviews a list of patients scheduled for appointments in a cancer clinic and notes the types of treatments each patient is using. Which patients are using complementary therapy? (Select all that apply.) 1. A 74-year-old with leukemia uses self-hypnosis prior to a bone marrow biopsy. 2. A 17-year-old with sarcoma practices relaxation and imagery during radiation

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therapy. 3. A 66-year-old with lymphoma uses headphones to listen to music during chemotherapy. 4. A 41-year-old with breast cancer chooses to have radiation therapy instead of a mastectomy. 5. A 52-year-old with colon cancer stops chemotherapy and goes to Mexico for shark cartilage therapy. ANS: 1, 2, 3 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 3. Identify how selected modalities are classified. Page: 44 Heading: Categories and Types of Complementary and Alternative Modalities Integrated Process: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Health Promotion Difficulty: Difficult

4. 5. PTS:

Feedback Complementary therapy refers to a therapy used in addition to a conventional therapy. Guided imagery, self-hypnosis, music, and relaxation techniques are all examples of complementary therapy. Complementary therapy refers to a therapy used in addition to a conventional therapy. Guided imagery, self-hypnosis, music, and relaxation techniques are all examples of complementary therapy. Complementary therapy refers to a therapy used in addition to a conventional therapy. Guided imagery, self-hypnosis, music, and relaxation techniques are all examples of complementary therapy. Radiation is a conventional medical treatment option. Shark cartilage in place of chemotherapy is considered alternative therapy. 1

CON: Health Promotion

8. The nurse is educating a patient regarding herbal therapies. Which statements indicate the need for further teaching? (Select all that apply.) 1. “All herbal medications are covered by insurance.” 2. “There is a chance herbal therapies will interact with my prescription drugs.” 3. “Herbal remedies are safer than prescription drugs because they are just food.” 4. “I need to ask my doctor before taking any herbal remedy.” 5. “Herbal medications are safe because they are FDA approved.” ANS: 1, 3, 5 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 4. Identify safety issues associated with complementary and alternative modalities Page: 46 Heading: Herbal Therapy Integrated Process: Teaching/Learning Client Need: SECE: Safety and Infection Control

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Cognitive Level: Application (Applying) Concept: Safety Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback Herbal remedies are not covered by insurance. This is a correct statement; herbal remedies can interact with prescription drugs. Many herbal remedies are safe but have potentially dangerous side effects; they are not any safer than prescription drugs. This is a correct statement; the patient should always ask the health care provider before taking any nonprescription drug. Herbal medications are not FDA approved and are not any safer than herbal medications. 1

CON: Safety

9. The nurse is teaching a class about mind-body modalities. Which topics should the nurse include in the teaching? (Select all that apply.) 1. Acupressure 2. Herbal medicine 3. Reiki 4. Art therapy 5. Yoga ANS: 4, 5 Chapter: Chapter 5. Complementary and Alternative Modalities Objective: 3. Identify how selected modalities are classified. Page: 46 Heading: Categories and Types of Complementary and Alternative Modalities (Table 5-1) Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5. PTS:

Feedback Acupressure is an example of a manipulative and body-based modality. Herbal medicine is an example of a biologically based modality. Reiki is an example of an energetic modality. Art therapy is a type of mind-body modality. Yoga is a type of mind-body modality. 1

CON: Health Promotion

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Chapter 6. Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances MULTIPLE CHOICE 1. The nurse is caring for a patient with dehydration. The patient asks the nurse about the cause. Which does the nurse identify as the most likely cause? 1. Constipation 2. Nausea 3. Kidney failure 4. Profuse diaphoresis ANS: 4 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 3. Predict patients who are at the highest risk for dehydration and fluid excess. Page: 54 Heading: Pathophysiology and Etiology Integrated Process: Caring Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Fluid and Electrolyte Balance Difficulty: Moderate

1 2 3 4

Feedback Diarrhea, not constipation, is a cause of dehydration. Vomiting, not nausea, is a contributing factor to dehydration. Kidney failure is a cause of fluid volume excess. Profuse diaphoresis is a common cause of dehydration. PTS:

CON: Fluid and Electrolyte Balance

2. The nurse is caring for a patient with fluid volume excess. Which medication can the nurse expect to administer? 1. Pamidronate disodium (Aredia) 2. Potassium chloride 3. Furosemide (Lasix) 4. Calcium gluconate ANS: 3 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 5. Describe therapeutic measures for patients with fluid and electrolyte imbalances. Page: 57 Heading: Drug Therapy Integrated Process: Caring Client Need: PHYS—Pharmacological Therapies

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Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 Pamidronate disodium (Aredia) is used to treat hypercalcemia. 2 Potassium chloride is used to treat hypokalemia. 3 Furosemide (Lasix) is a loop diuretic used to remove fluid. 4 Calcium gluconate is used to treat hypocalcemia and hyperkalemia. PTS:

CON: Fluid and Electrolyte Balance

3. The nurse is told to administer IV fluid the same osmolarity as blood. Which fluid can the nurse expect to administer? 1. 0.9% normal saline 2. 0.45% saline (1/2 NS) 3. 10% dextrose in water (D10W) 4. 5% dextrose in 0.9% saline (D5NS) ANS: 1 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 5. Describe therapeutic measures for patients with fluid and electrolyte imbalances. Page: 54 Heading: Osmosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 0.9% normal saline is an isotonic solution (same osmolarity as blood). 2 1/2 NS is a hypotonic solution. 3 D10W is a hypertonic solution. 4 D5NS is a hypertonic solution. PTS:

CON: Fluid and Electrolyte Balance

4. An older adult with gastroenteritis is disoriented and weak and has the following laboratory test results: Hematocrit (Hct) 56% (normal 40%–51%) Blood urea nitrogen (BUN) 32 mg/dL (normal 6–20 mg/dL) Which nursing diagnosis should the nurse select for this patient? 1. Risk for injury 2. Excess fluid volume 3. Deficient fluid volume 4. Impaired skin integrity ANS: 3

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Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 4. Identify data to collect in patients with fluid and electrolyte imbalances. Page: 54 Heading: Diagnostic Tests Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 Impaired skin integrity and risk for injury are possible, but they are not indicated by the data provided. 2 Excess fluid volume would be associated with low BUN and Hct. 3 Elevated BUN and Hct show concentration due to deficient fluid volume. 4 Impaired skin integrity and risk for injury are possible, but they are not indicated by the data provided. PTS:

CON: Fluid and Electrolyte Balance

5. A patient with hypertension is placed on a low-sodium diet. The nurse recognizes that further teaching is necessary if the patient chooses which menu? 1. Pork chop, steamed brown rice, and fruit cocktail 2. Broiled salmon, mashed sweet potato, broccoli, and pumpkin pie 3. Tomato soup, grilled cheese sandwich, salad, and chocolate chip cookie 4. Grilled chicken, boiled potatoes, frozen green beans, and gelatin dessert ANS: 3 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 8. Identify foods that have high sodium, potassium, and calcium contents. Page: 58 Heading: Common Food Sources of Potassium (Table 6.1) Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate Feedback 1 Poultry, fish, fruits, and fresh vegetables have small amounts of sodium. 2 Poultry, fish, fruits, and fresh vegetables have small amounts of sodium. 3 Processed cheeses and canned soups are high in sodium. 4 Poultry, fish, fruits, and fresh vegetables have small amounts of sodium. PTS:

CON: Health Promotion

6. An older adult patient has an IV infusion of 0.45% normal saline infusing at 150 mL/hr. Which assessment finding should cause the nurse to be most concerned? 1. Tenderness at the IV site

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2. Capillary refill is <3 seconds 3. Urine specific gravity is 1.018 4. Newly noted crackles in the lungs ANS: 4 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 3. Predict patients who are at the highest risk for dehydration and fluid excess. Page: 58 Heading: Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 Tenderness at the IV site is concerning but is not the highest priority listed. 2 The values listed for urine specific gravity and capillary refill are normal. 3 The values listed for urine specific gravity and capillary refill are normal. 4 This patient is at risk for fluid volume overload; newly noted crackles are indicative of fluid volume overload. PTS:

CON: Fluid and Electrolyte Balance

7. The nurse is reviewing laboratory results for a group of patients. Which value should be of most concern to the nurse? 1. Sodium level 140 mEq/L 2. Magnesium level 1.0 mEq/L 3. Potassium level 3.5 mEq/L 4. Calcium level 10 mg/dL ANS: 2 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 4. Identify data to collect in patients with fluid and electrolyte imbalances. Page: 66 Heading: Electrolyte Imbalance Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Fluid and Electrolyte Balance Difficulty: Difficult Feedback 1 This level is normal (135–145 mEq/L). 2 Normal magnesium level is 1.5 to 2.5 mEq/L. This is quite low. 3 This level is on the low end of normal (3.5–5 mEq/L). 4 This level is normal (9–11 mg/dL). PTS:

CON: Fluid and Electrolyte Balance

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8. The nurse is caring for a group of patients. Which patient most warrants a phone call to the health care provider (HCP)? 1. A patient with end-stage renal failure and 1+ pitting edema 2. A patient who is crying and wants a visitor 3. A patient with abdominal cramping and hyperactive deep tendon reflexes 4. A patient who just received furosemide (Lasix) for hypervolemia ANS: 3 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 7. Categorize common signs, symptoms, and treatments for sodium, potassium, calcium, and magnesium imbalances. Page: 64 Heading: Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 Patients with kidney failure have signs of hypervolemia. 2 Psychosocial needs do not come first in prioritization. 3 This patient could have hypocalcemia; the HCP should be notified. 4 The patient is being treated for hypervolemia and there is no indication of distress. PTS:

CON: Fluid and Electrolyte Balance

9. The nurse is preparing to administer furosemide (Lasix) to a patient with a potassium level of 2.8 mEq/L. Which action should the nurse take? 1. Administer the medication as ordered. 2. Notify the HCP before administering the dose. 3. Hold the medication and document the potassium level. 4. Give the patient half of the ordered dose. ANS: 1 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 5. Describe therapeutic measures for patients with fluid and electrolyte imbalances. Page: 61 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback

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The nurse should not administer the medication; the potassium level is very low, and Lasix is a potassium-wasting diuretic. The nurse should notify the HCP prior to administering the medication. The nurse should notify the HCP and not hold the medication and document the level; the potassium is low. It is not within the nurse’s scope of practice to half a prescribed dose.

PTS:

CON: Fluid and Electrolyte Balance

10. The nurse is caring for a group of patients. Which patient is at highest risk for hyponatremia? 1. A patient with a nasogastric tube connected to suction 2. A patient with chronic constipation 3. A patient who experienced a saltwater near-drowning 4. A patient with diabetes insipidus ANS: 1 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 2. List the signs and symptoms of common fluid imbalances. Page: 60 Heading: High-Risk Conditions for Hyponatremia (Box 6.3) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 A patient with a nasogastric tube connected to suction is at risk for hyponatremia. 2 A patient with constipation will not experience hyponatremia. 3 A patient who experienced a fresh-water near downing is at high risk for hyponatremia. 4 A patient with diabetes insipidus will have hypernatremia. PTS:

CON: Fluid and Electrolyte Balance

11. A patient develops an irregular heart rate, abdominal cramping, and diarrhea after a thyroidectomy. Which emergency medication should the nurse anticipate being prescribed for this patient? 1. Furosemide (Lasix) 2. Calcium gluconate 3. Potassium chloride 4. Diazepam (Valium) ANS: 2 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances

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Objective: 5. Describe therapeutic measures for patients with fluid and electrolyte imbalances. Page: 63 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This will not raise serum calcium levels. 2 These are initial signs of hypocalcemia, which can occur with accidental removal of the parathyroid glands during thyroidectomy. 3 This will not raise serum calcium levels. 4 This will not raise serum calcium levels. PTS:

CON: Fluid and Electrolyte Balance

12. The nurse is using Chvostek sign to assess for hypocalcemia. Which statement correctly describes this test? 1. Inflate a blood pressure cuff around the upper arm for 4 minutes. 2. Apply pressure over the ulnar and radial arteries. 3. Tap the face just below and in front of the ear. 4. Forcefully dorsiflex the ankle when the knee is in an extended position. ANS: 3 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 5. Describe therapeutic measures for patients with fluid and electrolyte imbalances. Page: 63 Heading: Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate

1 2 3 4

Feedback This describes Trousseau sign. This describes Allen test. This describes Chvostek sign. This describes Homan sign. PTS:

CON: Fluid and Electrolyte Balance

13. The nurse is concerned that an older patient is at risk for dehydration. What reduced function did the nurse assess in this patient? 1. Filtration

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2. Kidney function 3. Sensation of thirst 4. Cardiac contractility ANS: 3 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 3. Predict patients who are at highest risk for dehydration and fluid excess. Page: 54 Heading: Gerontological Issues Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This can potentially increase water retention. 2 This can potentially increase water retention. 3 Reduced sensation of thirst causes patients to take in less water, which can be dangerous in an older patient who has reduced body water. 4 This can potentially increase water retention. PTS:

CON: Fluid and Electrolyte Balance

14. While assessing an older adult patient with fluid excess, the nurse notes the following: T = 98.6°F, P = 92, R = 18, BP = 166/88 mm Hg, bilateral crackles, oxygen saturation = 95%. Which action should the nurse take first? 1. Provide oxygen at 2 L per nasal cannula. 2. Place the patient in a high Fowler position. 3. Provide a urinal and encourage the patient to void. 4. Lay the patient flat in bed to listen to bowel sounds. ANS: 2 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 5. Describe therapeutic measures for patients with fluid and electrolyte imbalances. Page: 57 Heading: Positioning Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept; Fluid and Electrolyte Balance Difficulty: Moderate

1 2

Feedback Oxygen is not necessary at this time, as the pulse oximeter reading is within normal limits. To facilitate ease in breathing, the head of the patient’s bed should be in semi-

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Fowler or high Fowler position. These positions allow greater lung expansion and thus aid respiratory effort. Voiding will not relieve fluid overload in the absence of diuretic therapy. Laying the patient flat in bed may cause dyspnea.

PTS:

CON: Fluid and Electrolyte Balance

15. The nurse reviews the following results for an arterial blood gas (ABG). How does the nurse interpret these results? pH 7.46, PCO2 34, HCO3 26, PaO2 88% 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis ANS: 4 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 10. Compare how arterial blood gases change for each type of acid-base imbalance. Page: 67 Heading: Sources of Acids and Bases Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Acid/Base Balance Difficulty: Difficult Feedback 1 These results do not indicate metabolic acidosis. 2 These results do not indicate respiratory acidosis. 3 These results do not indicate metabolic alkalosis. 4 These blood gas results are indicative of respiratory alkalosis. PTS:

CON: Acid/Base Balance

16. An older patient is admitted for treatment of fluid volume excess. For which serious respiratory complication of fluid volume excess should the nurse assess this patient? 1. Pulmonary edema 2. Pulmonary infarction 3. Pulmonary fibrosis 4. Pulmonary embolism ANS: 1 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 2. Identify signs and symptoms of common fluid imbalances. Page: 57 Heading: Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential

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Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 Acute fluid excess typically results in congestive heart failure. As the fluid builds up in the heart, the heart is not able to properly function as a pump. The fluid then backs up into the lungs, causing a condition known as pulmonary edema. 2 Pulmonary infarction is not related to fluid volume. 3 Pulmonary fibrosis is not related to fluid volume. 4 Pulmonary embolism is not related to fluid volume. PTS:

CON: Fluid and Electrolyte Balance

17. The nurse is caring for a patient who is being treating for fluid volume excess. Which assessment finding indicates that treatment has been effective? 1. Respiratory rate 24/min 2. Output 1,500 mL in 24 hours 3. Blood pressure 132/80 mm Hg 4. Weight loss of 5 lb in 24 hours ANS: 4 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 2. Identify signs and symptoms of common fluid imbalances. Page: 57 Heading: Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 The respiratory rate is slightly elevated, which can be a sign of fluid excess. 2 Output of 1,500 mL may be normal and does not necessarily indicate resolution of fluid excess. 3 The blood pressure may be within the patient’s normal limits. 4 Weight is the most reliable measure of fluid volume. PTS:

CON: Fluid and Electrolyte Balance

18. Which serum pH can the nurse expect to see in a patient with chronic obstructive pulmonary disease (COPD)? 1. 7.30 2. 7.40 3. 7.50 4. 7.60 ANS: 1

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Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 10. Compare how arterial blood gases change for each type of acid-base imbalance. Page: 67 Heading: Acid-Base Imbalances Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Acid/Base Balance Difficulty: Moderate Feedback 1 A pH less than 7.35 is acidotic; a patient with COPD is in respiratory acidosis. 2 This is a normal pH. 3 This pH is alkalotic. 4 This pH is alkalotic. PTS:

CON: Acid/Base Balance

19. The nurse is caring for a patient with arterial blood gas results of: pH 7.18, PCO2 42, HCO3 15, and Pa O2 84%. The patient has a blood glucose level of 845. How should the nurse interpret these results? 1. Respiratory acidosis 2. Metabolic acidosis 3. Respiratory alkalosis 4. Metabolic alkalosis ANS: 2 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 10. Compare how arterial blood gases change for each type of acid-base imbalance. Page: 67 Heading: Acid-Base Imbalances Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Acid/Base Balance Difficulty: Difficult Feedback 1 The patient is not experiencing respiratory acidosis. 2 The pH is acidotic and the HCO3 is low; this patient is experiencing metabolic acidosis. 3 The patient is not experiencing respiratory alkalosis. 4 The patient is not experiencing metabolic alkalosis. PTS:

CON: Acid/Base Balance

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20. A patient with uncontrolled diabetes mellitus develops metabolic acidosis. Which assessment finding indicates that the patient’s compensatory mechanisms are working? 1. Vomiting 2. Excessive thirst 3. Watery diarrhea 4. Deep rapid breathing ANS: 4 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 9. Give examples of common causes for acidosis and alkalosis. Page: 67 Heading: Acid-Base Imbalances Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Acid/Base Balance Difficulty: Moderate Feedback 1 Vomiting causes acid loss and can result in alkalosis. 2 Thirst corrects dehydration, not acidosis. 3 Watery diarrhea can worsen metabolic acidosis. 4 Deep rapid breathing gets rid of carbon dioxide, which leaves less carbon dioxide to combine with water to make carbonic acid in the body. PTS:

CON: Acid/Base Balance

21. A patient having a severe anxiety attack has an arterial blood gas result showing respiratory alkalosis. Which nursing action should the nurse take first? 1. Administer nasal oxygen at 6 L/min. 2. Give the patient a glass of orange juice. 3. Place the patient in high Fowler position. 4. Have the patient rebreathe air from a paper bag. ANS: 4 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 9. Give examples of common causes of acidosis and alkalosis. Page: 67 Heading: Acid-Base Imbalances Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Acid/Base Balance Difficulty: Moderate

1 2

Feedback Oxygen and orange juice will not help. Oxygen and orange juice will not help.

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The Fowler position will increase ventilation and could worsen alkalosis. Rebreathing from a paper bag reduces carbon dioxide loss, which increases carbonic acid in the body, correcting alkalosis.

PTS:

CON: Acid/Base Balance

22. The nurse is caring for a group of patients. Which patient is at highest risk for hypovolemia? 1. A patient with congestive heart failure 2. A patient with end-stage kidney failure 3. A patient who received 6 liters of IV fluid 4. A patient who lost 2 liters of blood during surgery ANS: 4 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 3. Predict patients who are at the highest risk for dehydration and fluid excess. Page: 54 Heading: Pathophysiology and Etiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This patient is at risk for hypervolemia. 2 This patient is at risk for hypervolemia. 3 This patient is at risk for hypervolemia. 4 This patient is at risk for hypovolemia. PTS:

CON: Fluid and Electrolyte Balance

23. The nurse is teaching a patient with a calcium level of 7.8 mg/dL about food choices. Which food choice made by the patient indicates an understanding of the teaching? 1. 1.5 ounces of cheddar cheese 2. 1 large apple 3. 1 small steak 4. 1-ounce potato chips ANS: 1 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 5. Describe therapeutic measures for patients with fluid and electrolyte imbalances. Page: 63 Heading: Food Sources of Calcium (Table 6.3) Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance

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Difficulty: Moderate Feedback 1 Cheese is high in calcium. 2 An apple is not high in calcium. 3 A steak is not high in calcium. 4 Potato chips are not high in calcium. PTS:

CON: Fluid and Electrolyte Balance

24. The nurse is caring for a group of patients. Which patient is at highest risk for developing metabolic alkalosis? 1. A patient with COPD 2. A patient with diabetes 3. A patient with severe anxiety 4. A patient with prolonged vomiting ANS: 4 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 9. Give examples of common causes of acidosis and alkalosis. Page: 68 Heading: Acid-Base Balance Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Acid/Base Balance Difficulty: Difficult

1 2 3 4

Feedback A patient with lung disease is at risk for respiratory acidosis. A patient with diabetes is at risk for metabolic acidosis. A patient with severe anxiety is at risk for respiratory acidosis. A patient with prolonged vomiting is at risk for metabolic alkalosis. PTS:

CON: Acid/Base Balance

MULTIPLE RESPONSE 1. The nurse is teaching a patient about taking oral potassium supplements. Which topics should the nurse cover in the teaching? (Select all that apply.) 1. Take potassium supplements on an empty stomach. 2. Keep appointments for laboratory tests to check potassium level. 3. It is okay to supplement the potassium supplement for a cheaper version. 4. Do not crush extended-release potassium tablets. 5. Nausea, vomiting, and diarrhea are normal side effects of this medication. ANS: 2, 4 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances

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Objective: 6. Identify the education needs of patients with fluid imbalances. Page: 62 Heading: Tips for Taking Oral Potassium Supplements (Box 6.4) Integrated Process: Teaching/Learning Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback Potassium supplements should be taken with a full meal. It is important to have the potassium level monitored while on the medication. Do not supplement a potassium supplement for another. Extended-release potassium tablets such as K-Dur or Slow-K cannot be crushed. Nausea, vomiting, diarrhea, and abdominal cramping should be reported to the HCP. 1

CON: Fluid and Electrolyte Balance

2. The nurse is planning care for a patient with a fluid volume excess and a serum sodium level of 125 mg/dL. Which interventions should the nurse include in this patient’s plan of care? (Select all that apply.) 1. Weigh daily. 2. Monitor strict intake and output. 3. Administer diuretics as prescribed. 4. Implement fluid restriction as prescribed. 5. Administer IV saline as prescribed. ANS: 1, 2, 3, 4 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 5. Describe therapeutic measures for patients with fluid and electrolyte imbalances. Page: 60 Heading: Expected Outcome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate

Feedback For patients who have a fluid excess and a low sodium level, a fluid restriction is often ordered. Diuretics that rid the body of fluid but do not cause sodium loss may also be used. Intake and output are strictly monitored, and the patient is weighed daily. For patients who have a fluid excess and a low sodium level, a fluid

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5. PTS:

restriction is often ordered. Diuretics that rid the body of fluid but do not cause sodium loss may also be used. Intake and output are strictly monitored, and the patient is weighed daily. For patients who have a fluid excess and a low sodium level, a fluid restriction is often ordered. Diuretics that rid the body of fluid but do not cause sodium loss may also be used. Intake and output are strictly monitored, and the patient is weighed daily. For patients who have a fluid excess and a low sodium level, a fluid restriction is often ordered. Diuretics that rid the body of fluid but do not cause sodium loss may also be used. Intake and output are strictly monitored, and the patient is weighed daily. IV saline is indicated if the patient does not have a fluid volume excess. 1

CON: Fluid and Electrolyte Balance

3. During an assessment, the nurse learns that an older patient has been taking twice the prescribed amount of calcium supplements. Which physical assessment findings should the nurse identify as being consistent with this patient’s intake of calcium? (Select all that apply.) 1. Muscle weakness 2. Faint bowel sounds 3. Increased heart rate 4. Elevated blood pressure 5. Dry mucous membranes ANS: 1, 2, 3, 4 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 2. List the signs and symptoms of common fluid imbalances. Page: 65 Heading: Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate

2. 3. 4. 5.

Feedback Acute hypercalcemia is associated with increased heart rate and blood pressure, skeletal muscle weakness, and decreased gastrointestinal (GI) motility. Acute hypercalcemia is associated with increased heart rate and blood pressure, skeletal muscle weakness, and decreased GI motility. Acute hypercalcemia is associated with increased heart rate and blood pressure, skeletal muscle weakness, and decreased GI motility. Acute hypercalcemia is associated with increased heart rate and blood pressure, skeletal muscle weakness, and decreased GI motility. Dry mucous membranes are associated with fluid volume deficit and not hypercalcemia.

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PTS:

CON: Fluid and Electrolyte Balance

4. The nurse is caring for a patient with hypokalemia. Which clinical manifestations can the nurse expect to find upon assessment? (Select all that apply.) 1. Muscle cramping 2. Weak and thready pulse 3. Nausea 4. Diarrhea 5. Hyperactive deep tendon reflexes (DTRs) ANS: 1, 2, 3 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 2. List the signs and symptoms of common fluid imbalances. Page: 63 Heading: Hypokalemia Integrated Process: Caring Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback Muscle cramping is a symptom of hypokalemia. Weak and thready pulse is a clinical manifestation of hypokalemia. Nausea is a clinical manifestation of hypokalemia. Diarrhea is a sign of hyperkalemia, hypocalcemia, and hyponatremia. Hyperactive DTRs are a sign of hypocalcemia.

1. 2. 3. 4. 5. PTS:

CON: Fluid and Electrolyte Balance

ORDERED RESPONSE 1. The nurse is caring for a group of patients. Prioritize from 1 to 4, with one being the highest priority, the order in which the nurse should assess the patients. 1. A 47-year-old patient who reports two loose stools and feels nauseated 2. A 52-year-old patient with fluid volume excess and 2+ pedal edema 3. A 60-year-old patient with a potassium level of 2.6 mEq/L and heart palpitations 4. A 71-year-old patient with a calcium level of 10 mg/dL and negative Trousseau sign ANS: 3, 2, 1, 4 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalance Objective: 7. Categorize common causes, signs, and symptoms, and treatments for sodium, potassium, calcium, and magnesium imbalances. Pages: 63–68

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Heading: Electrolyte Imbalance Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Fluid and Electrolyte Balance Difficulty: Difficult Feedback: The nurse should first assess the patient with the very low potassium level experiencing heart palpitations, because hypokalemia can cause cardiac dysrhythmias (circulation). The second patient the nurse should assess is the patient with fluid volume excess and pitting edema (circulation). The third patient the nurse should assess is the patient reporting loose stools and nausea, followed by the patient with a normal calcium level and negative Trousseau sign. PTS:

CON: Fluid and Electrolyte Balance

COMPLETION 1. A patient with dehydration is prescribed 1 L of 0.9% normal saline intravenously to run over 8 hours. At what rate should the nurse set the infusion pump? Enter the numeral only. ANS: 125 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 5. Describe therapeutic measures for patients with fluid and electrolyte imbalances. Page: 64 Heading: Osmosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback: Divide 1,000 mL by 8 hours to give a rate of 125 mL/hr. PTS:

CON: Fluid and Electrolyte Balance

2. The nurse is preparing to administer furosemide (Lasix) 40 mg intravenously to a patient with heart failure. Available is furosemide (Lasix) 20 mg/mL vials. How many mL will the nurse administer? Enter the numeral only. ANS: 2 Chapter: Chapter 6 Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances Objective: 5. Describe therapeutic measures for patients with fluid and electrolyte imbalances.

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Page: 64 Heading: Drug Therapy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback: The nurse is to administer 40 mg, but only 20 mg/mL is available. Multiply the mL by 2, which gives you a ratio of 40 mg/2 mL. PTS:

CON: Fluid and Electrolyte Balance

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Chapter 7. Nursing Care of Patients Receiving Intravenous Therapy MULTIPLE CHOICE 1. The IV infusion pump for a patient receiving an IV therapy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first? 1. Notify the physician. 2. Check for kinking of the tubing or a closed clamp. 3. Decrease the rate to 10 mL/hr and flush the line with 1 mL of heparin solution. 4. Turn off the IV solution and gently flush the line with 3 mL of saline flush solution. ANS: 2 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 3. Plan nursing interventions to prevent IV therapy complications. Page: 77 Heading: Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 There is no reason to notify the physician. 2 A kink in the tubing or closed clamp is often the reason for occlusion and can be easily remedied. 3 Flushing tubing can dislodge a clot into systemic circulation. 4 Flushing tubing can dislodge a clot into systemic circulation. PTS:

CON: Fluid and Electrolyte Balance

2. The nurse is caring for a patient who is receiving parenteral nutrition (PN). The patient develops increased thirst, blurred vision, and a headache. Which action should the nurse take? 1. Check the patient’s glucose level. 2. Assess blood pressure. 3. Discontinue the PN. 4. Apply oxygen. ANS: 1 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 3. Plan nursing interventions to prevent IV therapy complications. Page: 82 Heading: Parenteral Nutrition Integrated Process: Clinical Problem-Solving Process Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying)

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Concept: Metabolism Difficulty: Moderate Feedback 1 PN causes an elevation in blood glucose; the patient is exhibiting symptoms of hyperglycemia. The nurse should check the blood glucose. 2 PN causes an elevation in blood glucose; the patient is exhibiting symptoms of hyperglycemia. The nurse should check the blood glucose. 3 PN causes an elevation in blood glucose; the patient is exhibiting symptoms of hyperglycemia. The nurse should check the blood glucose. 4 PN causes an elevation in blood glucose; the patient is exhibiting symptoms of hyperglycemia. The nurse should check the blood glucose. PTS:

CON: Metabolism

3. The nurse suspects the patient has developed septicemia as a complication of peripheral IV therapy. Which clinical manifestation supports the nurse’s suspicion? 1. Sharp pain at the site 2. Fever and chills 3. Coolness of skin at the site 4. Resistance during flushing ANS: 2 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 4. Identify common complications associated with IV therapy. Page: 79 Heading: Complications of Peripheral Intravenous Therapy (Table 7.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 This is indicative of phlebitis, infiltration, extravasation, or venous spasm. 2 Fever and chills are signs of septicemia. 3 This is a sign of infiltration or extravasation. 4 This is a sign of venous spasm, infiltration, extravasation, phlebitis, thrombosis, or hematoma. PTS:

CON: Infection

4. For which patient would a port be most beneficial? 1. A patient receiving a dose of piperacillin-tazobactam (Zosyn) 2. A patient being rehydrated with normal saline 3. A patient receiving a blood transfusion for anemia 4. A patient receiving chemotherapy ANS: 4 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 8. Describe types of central venous access devices.

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Page: 80 Heading: Ports Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate

1 2 3 4

Feedback A port is not appropriate for a one-time dose of antibiotic. A port is not appropriate for a patient with dehydration. A port is not appropriate for a blood transfusion. A port is used for long-term therapy, such as chemotherapy. PTS:

CON: Safety

5. Which patient would benefit most from hypodermoclysis? 1. A 5-year-old patient with poor venous access receiving normal saline 2. A 16-year-old patient receiving multiple blood transfusions 3. A 24-year-old patient receiving chemotherapy 4. A 35-year-old patient with poor venous access receiving multiple antibiotic transfusions ANS: 1 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 9. List indications for subcutaneous infusions (hypodermoclysis). Page: 83 Heading: Hypodermoclysis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1 Hypodermoclysis is for pediatric or elderly patients with poor venous access receiving minimal medications. 2 Hypodermoclysis is not appropriate for this patient. 3 Hypodermoclysis is not appropriate for this patient. 4 Hypodermoclysis is not appropriate for this patient. PTS:

CON: Safety

6. Upon entering a patient’s room, the licensed practical nurse (LPN) notes a white precipitate forming in the IV tubing at the site of a piggybacked antibiotic. What should the nurse do first? 1. Stop the infusion. 2. Notify the physician. 3. Call the pharmacy to see whether this is an expected reaction. 4. When the infusion is complete, remove the tubing and send it to the laboratory for

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analysis. ANS: 1 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 4. Identify common complications associated with IV therapy. Page: 77 Heading: Needleless Connectors (Be Safe Box above) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 Solids should never be infused—they could cause an embolism. The infusion should be stopped immediately to prevent this from happening. 2 After the IV is stopped, the pharmacy and physician should be notified. 3 After the IV is stopped, the pharmacy and physician should be notified. 4 Tubing may be sent for analysis according to agency policy. PTS:

CON: Safety

7. The licensed practical nurse/licensed vocational nurse (LPN/LVN) is assessing a patient receiving IV therapy and notes crackles upon auscultation of lung sounds and puffy eyelids. Which action should the nurse take? 1. Notify the registered nurse (RN) immediately. 2. Stop the IV and switch the patient to a different IV solution. 3. Place the patient in semi-Fowler position. 4. Obtain cultures of the IV site. ANS: 3 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 4. Identify common complications associated with IV therapy. Page: 78 Heading: Complications of Peripheral Intravenous Therapy (Table 7.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate

1 2 3 4

Feedback The patient is experiencing fluid volume overload; the nurse should alert the RN immediately. It is not within the nurse’s scope of practice to order a different IV fluid. The nurse should place the patient in high-Fowler position. It is not necessary to obtain cultures of the site; in addition, the nurse cannot obtain cultures without an order.

PTS:

CON: Fluid and Electrolyte Balance

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8. The nurse is preparing to administer IV fluid to a patient using a microdrop set. Which tubing will the nurse select? 1. 10 tt/mL 2. 15 gtt/mL 3. 20 gtt/mL 4. 60 gtt/mL ANS: 4 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 1. Discuss how the practice of IV therapy is regulated. Page: 74 Heading: Calculating Administration Rates Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Comprehension (Understanding) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 This is a macrodrip set. 2 This is a macrodrip set. 3 This is a macrodrip set. 4 This is a microdrip set. PTS:

CON: Fluid and Electrolyte Balance

9. At a monthly staff meeting, the nurse manager announces that all central line insertion and dressing kits will now come bundled with 2% chlorhexidine gluconate (CHG) for site preparation and cleansing. Which evidence best supports this decision? 1. The use of 2% chlorhexidine gluconate reduces hospital costs by 7%. 2. CHG is the preferred prep solution of choice based on scientific evidence. 3. The company that supplies IV and central line catheter equipment has recently changed the product bundling to include 2% CHG. 4. The chief of surgery is interested in performing a direct comparison study examining infection rates associated with long-term access devices as they are related to length of time the catheters are in place. ANS: 2 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 8. Describe types of central venous access devices. Page: 80 Heading: Central Venous Access Devices Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Safety and Infection Control Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This option does not reflect an improvement in patient outcomes.

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2 3 4

Evidence supporting a clinical change in practice should be related to improved patient outcomes and should be based on high-level evidence. This option does not reflect an improvement in patient outcomes. This option does not reflect an improvement in patient outcomes.

PTS:

CON: Patient-Centered Care

10. The nurse mistakenly assesses the blood pressure of the patient on the arm an IV is transfusing. What can this cause? 1. Fluid overload 2. Increase in venous pressure 3. Septicemia 4. Electrolyte imbalance ANS: 2 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 4. Identify common complications associated with IV therapy. Page: 76 Heading: Patency of the Cannula Integrated Process: Clinical Problem-Solving Process (Nursing Judgement) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 Fluid overload is not caused by taking blood pressure on the arm of an IV infusion. 2 An increase in venous pressure can occur as a result of taking the patient’s blood pressure on an arm with an IV infusion. 3 Septicemia is not a result of taking a blood pressure on an arm with an IV infusion. 4 Electrolyte imbalance is not a result of taking a blood pressure on an arm with an IV infusion. PTS:

CON: Fluid and Electrolyte Balance

11. A patient is prescribed to receive two units of packed red blood cells. When preparing for this patient’s infusion of blood, which type of IV solution should the LPN/LVN select? 1. 0.9% normal saline 2. 0.45% normal saline 3. Dextrose 5% and water 4. Dextrose 5% and 0.9% normal saline ANS: 1 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 3. Plan nursing interventions to prevent IV therapy complications. Page: 76 Heading: Sodium Chloride Solutions Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 According to the American Association of Blood Banks, blood component administration sets can be primed only with 0.9% sodium chloride solution. 2 Blood component administration sets are not to be primed with any solution other than 0.9% normal saline. 3 Blood component administration sets are not to be primed with any solution other than 0.9% normal saline. 4 Blood component administration sets are not to be primed with any solution other than 0.9% normal saline. PTS:

CON: Safety

12. The nurse is preparing to start an IV on a newly admitted patient. Which action by the nurse places the patient at risk for infection? 1. The nurse dons gloves before starting the IV. 2. The nurse applies a tourniquet to assess a vein. 3. The nurse cleans the area with an alcohol pad. 4. The nurse blows on the area cleansed with alcohol. ANS: 4 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 3. Plan nursing interventions to prevent IV therapy complications Page: 73 Heading: Expected Outcome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE: Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 This prevents infection. 2 This does not cause infection. 3 This prevents infection. 4 Blowing on an already clean area can contribute to infection. PTS:

CON: Infection

MULTIPLE RESPONSE 1. The nurse is preparing to administer a hypertonic solution to a patient with hypovolemia. Which fluids are considered to be hypertonic? (Select all that apply.) 1. 5% dextrose in 0.9% sodium chloride (D5NS) 2. Albumin 25% 3. 0.45% sodium chloride (1/2NS)

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4. 5% dextrose in water (D5W) 5. 0.9% sodium chloride (NS) ANS: 1, 2 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 6. Differentiate characteristics of isotonic, hypertonic, and hypotonic solutions. Page: 76 Heading: Hypertonic Solutions Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Difficult

1. 2. 3. 4. 5. PTS:

Feedback D5NS is a hypertonic solution. 25% albumin is a hypertonic solution. 1/2 NS is a hypotonic solution. D5W is an isotonic solution. NS is an isotonic solution. 1

CON: Fluid and Electrolyte Balance

2. The nurse is caring for a patient receiving a continuous IV infusion who develops sudden dyspnea, chest pain, and change in mental status. Which interventions should the nurse implement? (Select all that apply.) 1. Notify the health care provider (HCP). 2. Place the patient in high-Fowler position. 3. Administer oxygen as ordered. 4. Monitor vital signs. 5. Culture the IV site. ANS: 1, 3, 4 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 4. Identify common complications associated with IV therapy. Page: 77 Heading: Complications of Peripheral Intravenous Therapy (Table 7.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4.

Feedback The patient is experiencing symptoms of a venous air embolism. The HCP should be notified immediately. The patient should be placed in Trendelenburg position or left side-lying. Oxygen should be administered. Vital signs should be monitored.

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5. PTS:

There is not a reason to culture the IV site. 1

CON: Patient-Centered Care

3. The nurse is caring for a patient receiving a continuous IV infusion who develops sudden dyspnea, chest pain, and change in mental status. Which interventions should the nurse implement? (Select all that apply.) 1. Notify the health care provider (HCP). 2. Place the patient in high-Fowler position. 3. Administer oxygen as ordered. 4. Monitor vital signs. 5. Culture the IV site. ANS: 1, 3, 4 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 4. Identify common complications associated with IV therapy. Page: 77 Heading: Complications of Peripheral Intravenous Therapy (Table 7.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4. 5. PTS:

CON: Patient-Centered Care

4. The nurse is preparing to administer a medication IV push. What should the nurse do prior to administering the medication? (Select all that apply.) 1. Assess the catheter for patency. 2. Look up the rate of the medication. 3. Dilute the medication with normal saline. 4. Change the dressing of the IV site. 5. Assess allergies. 6. Flush the IV with heparin. ANS: 1, 2, 5 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 3. Plan nursing interventions to prevent IV therapy complications. Page: 73 Heading: Needleless Connectors Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate

1. 2. 3. 4. 5. 6.

PTS:

Feedback The nurse must assess the catheter for patency before administering any medication. The nurse must know the rate to administer the medication before administering. Not all medications are compatible with NS and not all medications are required to be diluted. It is not necessary to change the IV site dressing. The nurse must always assess allergies before administering medication. Sodium chloride is recommended to maintain patency of peripheral intermittent devices. 1

CON: Fluid and Electrolyte Balance

COMPLETION 1. A patient is prescribed levofloxacin (Levaquin) 500 mg in 100 mL of normal saline to be infused over 1 hour. At what rate will the nurse set the infusion pump? Enter the numeral only. ANS: 100 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 5. Calculate flow and drip rates for IV solutions. Page: 74 Heading: Calculating Administration Rates Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback: If a volume is to infuse over 1 hour, the rate is the same as the volume (100 = 100). PTS:

CON: Fluid and Electrolyte Balance

2. A patient is prescribed D5W to run over 12 hours using a set delivering 15 gtt/mL. Calculate the drip rate. Round to the nearest whole number. Enter the numeral only. ANS: 21 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy

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Objective: 5. Calculate flow and drip rates for IV solutions. Page: 74 Heading: Calculating Administration Rates Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback: gtt/min = 15 gtt/mL × 1,000 mL/12 hr × 1 hr/60 min = 20.83 mL/hr, which rounds to 21 gtt/min PTS:

CON: Fluid and Electrolyte Balance

3. A patient is prescribed IV fluid of 500 mL of lactated Ringer to infuse over 2 hours. At what rate will the nurse set the infusion pump? Enter the numeral only. ANS: 250 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 5. Calculate flow and drip rates for IV solutions. Page: 74 Heading: Calculating Administration Rates Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS-Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback: mL/hr = 500 mL/2 hr = 250 mL/hr PTS:

CON: Fluid and Electrolyte Balance

4. A patient is prescribed 100 mL of 25% albumin IV to run over 1 hour. The albumin will transfuse using a 60 gtt/mL set. Calculate the drip rate. Round to the nearest whole number. Enter the numeral only. ANS: 100 Chapter: Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy Objective: 5. Calculate flow and drip rates for IV solutions. Page: 74 Heading: Calculating Administration Rates Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate

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Feedback: gtt/min = 60 gtt/mL × 100 mL/1 hr × 1 hr/60 min = 6,000/60 = 100 gtt/mL PTS:

CON: Fluid and Electrolyte Balance

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Chapter 8. Nursing Care of Patients With Infections MULTIPLE CHOICE 1. The nurse is teaching a nursing student about infection. Which is an example of a reservoir of infection? 1. Insect 2. Virus 3. Bacteria 4. Droplets ANS: 1 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 1. List the links in the chain of infection. Page: 87 Heading: Reservoir Integrated Process: Teaching/Learning Client Need: SECE—Safety and Infection Control Cognitive Level: Comprehension (Understanding) Concept: Infection Difficulty: Moderate Feedback 1 An insect, human, water, soil, or medical devices are reservoirs for infection. 2 A virus is a causative agent. 3 Bacteria is a causative agent. 4 Droplets are a portal of exit. PTS:

CON: Infection

2. There are limited amounts of influenza vaccine currently available in the clinic. Which individual should the nurse identify as having the highest priority to receive vaccination at this time? 1. A 15-year-old who plays ice hockey 2. A 26-year-old with three young children 3. A 49-year-old who works in food services 4. An 88-year-old who lives in an apartment for senior citizens ANS: 4 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 2. Explain how to interrupt the routes of transmission for infection. Page: 90 Heading: Infection Control in the Community Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Difficult Feedback

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Although all individuals are encouraged to receive an annual influenza vaccination, the 15-year-old, 26-year-old, and 49-year-old have more competent immune systems. The influenza vaccination can be delayed for these individuals. Although all individuals are encouraged to receive an annual influenza vaccination, the 15-year-old, 26-year-old, and 49-year-old have more competent immune systems. The influenza vaccination can be delayed for these individuals. Although all individuals are encouraged to receive an annual influenza vaccination, the 15-year-old, 26-year-old, and 49-year-old have more competent immune systems. The influenza vaccination can be delayed for these individuals. Factors that increase susceptibility to infection are very young age, old age, malnourishment, being immunocompromised, chronic disease, stress, and invasive procedures.

PTS:

CON: Infection

3. The nurse is caring for a group of patients. Which patient does the nurse identify at highest risk for developing an infection? 1. A 12-year-old child who plays sports and lives with his parents 2. A 24-year-old who works at a bank and lives at home 3. A 45-year-old stay-at-home parent who lives with a friend 4. A 60-year-old who lives in a long-term care facility ANS: 4 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 3. Describe the body’s defense mechanisms to fight infection. Page: 92 Heading: Infection Control in Health Care Agencies Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1 A child is at moderate risk because he or she is around other kids who might be sick, but not at the highest risk. 2 This patient is not at high risk. 3 This patient is not at high risk. 4 This patient is at highest risk because he or she is older and lives in a long-term care facility. PTS:

CON: Infection

4. The nurse is caring for a patient who has a localized infection on the foot caused by a spider bite. Which clinical manifestations can the nurse expect to see? 1. Redness at the site 2. Hypotension 3. Decreased urine output

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4. Tachycardia ANS: 1 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 3. Describe the body’s defense mechanisms to fight infection. Page: 91 Heading: Localized Infection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 Redness at the site is a common sign or symptom of a localized infection. 2 Hypotension is a clinical manifestation of a systemic infection. 3 Decreased urine output is a sign of systemic infection. 4 Tachycardia is a clinical manifestation of a systemic infection. PTS:

CON: Infection

5. A patient asks a nurse to explain the difference between the Ebola virus versus the Zika virus. Which response by the nurse is accurate? 1. “The Zika virus is transmitted by an infected fruit bat.” 2. “The patient could experience long-term joint and vision problems with the Zika virus.” 3. “A patient will be isolated if he or she contracted the Zika virus.” 4. “ELISA testing is used to diagnose the Ebola virus.” ANS: 4 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with an infection. Page: 91 Heading: Ebola and Zika Infections (Table 8.2) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 The Ebola virus is transmitted by an infected fruit bat. 2 The patient with Ebola could experience long-term joint pain and vision problems. 3 The patient will be isolated if he or she contracted the Ebola virus, not Zika. 4 ELISA testing is used to diagnose the Ebola virus. PTS:

CON: Infection

6. A patient develops a hospital-acquired surgical wound infection. Which organism should the nurse recognize as being the most likely cause of this infection? 1. Shigella

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2. Salmonella 3. Campylobacter 4. Staphylococcus aureus ANS: 4 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 3. Describe the body’s defense mechanism to fight infection. Page: 92 Heading: Infection Control in Health Care Agencies Integrated Process: Clinical Problem-Solving Process (Nursing process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 Hospital-acquired surgical wound infections are not commonly caused by shigella, salmonella, or campylobacter. 2 Hospital-acquired surgical wound infections are not commonly caused by shigella, salmonella, or campylobacter. 3 Hospital-acquired surgical wound infections are not commonly caused by shigella, salmonella, or campylobacter. 4 S aureus is the most common pathogen causing hospital-acquired surgical wound infections. PTS:

CON: Infection

7. The nurse is taking a health history for a patient who is ill. The patient states that no one in his family is sick nor has he been around any sick individuals. The nurse suspects the patient likely contracted the illness by indirect transmission. Which is an example of this type of transmission? 1. Picking up a toy a sick child has played with 2. Talking to a sick individual 3. Walking past a person with a cough 4. Standing next to a person who sneezes ANS: 1 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 3. Describe the body’s defense mechanisms to fight infection. Page: 88 Heading: Direct Transmission Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 Picking up a toy a sick individual has touched is an example of indirect transmission. 2 This describes direct transmission.

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3 4

This describes direct transmission. This describes direct transmission.

PTS:

CON: Infection

8. The nurse is reviewing orders for a patient with an infection. Which order should the nurse implement last? 1. Administer the antibiotic. 2. Culture the patient’s wound. 3. Obtain a urine sample. 4. Obtain a sputum sample. ANS: 1 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with an infection. Page: 97 Heading: Nursing Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 All cultures and specimens should be taken before administering an antibiotic, so the results are not altered. 2 All cultures and specimens should be taken before administering an antibiotic, so the results are not altered. 3 All cultures and specimens should be taken before administering an antibiotic, so the results are not altered. 4 All cultures and specimens should be taken before administering an antibiotic, so the results are not altered. PTS:

CON: Infection

9. For which patient would the nurse wash her hands with soap and water instead of using an alcohol-based hand rub? 1. Administering pills to a patient with HIV 2. Cleaning stool off of a patient with Clostridium difficile 3. Taking the temperature of a patient with asthma 4. Opening a cup of milk for a patient with vertigo ANS: 2 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with an infection. Page: 93 Heading: Hand Hygiene Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing)

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Concept: Infection Difficulty: Moderate Feedback 1 Alcohol-based rub is acceptable as long has hands are not visibly soiled. 2 The nurse should use soap and water after cleaning a patient with C difficile. 3 Alcohol-based rub is acceptable as long has hands are not visibly soiled. 4 Alcohol-based rub is acceptable as long has hands are not visibly soiled. PTS:

CON: Infection

10. The nurse is reviewing orders for a newly admitted patient. Which laboratory test can the nurse expect to be ordered for a patient to rule out a systematic infection? 1. Capillary blood glucose (CBG) 2. Complete metabolic panel (CMP) 3. Complete blood count (CBC) 4. Pancreatic enzymes ANS: 3 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with an infection. Page: 104 Heading: Laboratory Assessment Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE-Safety and Infection Control Cognitive Level:—Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 A CBG assesses blood glucose. 2 A CMP assesses electrolytes. 3 A CBC looks at white blood cells (WBCs) to determine if the patient has an infection. 4 Pancreatic enzymes determines if the pancreas is inflamed. PTS:

CON: Infection

11. The nurse is participating in planning care for a patient with mononucleosis. Which action should the nurse recommend to promote recovery? 1. Exercise 2. Rest periods 3. Full liquid diet 4. Fluid restriction ANS: 2 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with an infection. Page: 90 Heading: Standard Precautions and Transmission-Based Precautions Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 Exercise should be guided by the health care provider when the acute phase is over, based on patient tolerance. 2 Symptoms of mononucleosis are treated as needed with supportive care. Fatigue may last for months. Rest is important. 3 Fluids and diet are not restricted. 4 Fluids and diet are not restricted. PTS:

CON: Infection

12. The nurse is caring for a patient who develops red man syndrome. Which medication does the nurse suspect this patient is receiving? 1. Azithromycin (Zithromax) 2. Metronidazole (Flagyl) 3. Vancomycin (Vancocin hydrochloride) 4. Levofloxacin (Levaquin) ANS: 3 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 4. Describe the principles of anti-infective medication administration. Page: 99 Heading: Medications Used to Treat Infections Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1 This medication does not cause red man syndrome. 2 This medication does not cause red man syndrome. 3 This medication can cause red man syndrome. 4 This medication does not cause red man syndrome. PTS:

CON: Infection

13. The nurse is transporting a patient with active tuberculosis (TB) to radiology. Which action should the nurse take? 1. Place a surgical mask on the patient. 2. Be sure the patient is wearing a protective gown. 3. Instruct the patient to wear gloves to radiology. 4. Place a surgical mask on the nurse transporting the patient. ANS: 1 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with an infection.

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Page: 95 Heading: Standard Precautions and Transmission-Based Precautions (Table 8.3) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 The patient should wear a surgical mask for transport to radiology. 2 The patient does not need to wear a protective gown. 3 The patient does not need to wear gloves. 4 The nurse does not require a surgical mask for transport; the nurse uses an N95 respirator when caring for a patient with TB. PTS:

CON: Infection

14. A patient requires care that might cause the splattering of body secretions. Which item should the nurse wear when caring for this patient? 1. Cap 2. Gown 3. Face shield 4. Shoe covers ANS: 3 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with an infection. Page: 95 Heading: Standard Precautions Integrated Process: Clinical Problem-Solving Process Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 A cap, gown, or shoe covers may be worn as needed. 2 A cap, gown, or shoe covers may be worn as needed. 3 Using a mask, eye protection, or face shield for patient care if splashes or sprays of blood or body fluids are likely is the most essential item to wear. 4 A cap, gown, or shoe covers may be worn as needed. PTS:

CON: Infection

15. The nurse has contributed to a staff education program about the principles for the first tier of standard precautions. Which statement by a nursing assistant indicates a correct understanding of the teaching? 1. “All patients are presumed infectious.” 2. “Isolation is not required for most diseases.” 3. “Patients with a known infection are placed in isolation upon admission.” 4. “Patients are not considered infectious until confirmed so by the laboratory.”

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ANS: 1 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with an infection. Page: 95 Heading: Standard Precautions Integrated Process: Teaching/Learning Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 Standard precautions are used in the care of all patients. These precautions require one to assume that all patients are infectious regardless of their diagnosis. Using gloves, gowns, masks, goggles, face shields, and, most important, hand washing helps prevent the spread of infection to health care workers and other patients. 2 Transmission-based precautions are only added as needed, such as isolation. 3 Transmission-based precautions are only added as needed, such as isolation. 4 Transmission-based precautions are only added as needed, such as isolation. PTS:

CON: Infection

16. The nurse is contributing to a staff education program about infection control. What information from the following list should the nurse recommend including about methods that are effective in destroying bacterial spores? 1. Prolonged drying times 2. Prolonged high temperatures 3. Cleansing with soap and water 4. Brief exposure to room temperatures ANS: 2 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 3. Describe the body’s defense mechanisms to fight infection. Page: 87 Heading: Bacteria Integrated Process: Teaching/Learning Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 Prolonged drying times, cleaning with soap and water, or exposure to room temperatures are not effective to eliminate spores. 2 Prolonged exposure to high temperature destroys spores. 3 Prolonged drying times, cleaning with soap and water, or exposure to room temperatures are not effective to eliminate spores. 4 Prolonged drying times, cleaning with soap and water, or exposure to room temperatures are not effective to eliminate spores.

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PTS:

CON: Infection

17. The nurse is caring for a patient with herpes simplex. Which statement related to disease transmission should the nurse include in the patient’s discharge teaching? 1. “Herpes simplex is an airborne disease.” 2. “HEPA filtration is necessary with herpes simplex.” 3. “Herpes simplex is transmitted through direct transmission.” 4. “Vehicle transmission means that particles float through the air.” ANS: 3 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with an infection. Page: 87 Heading: Direct Transmission Integrated Process: Teaching/Learning Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 Measles, chickenpox, and tuberculosis are transmitted by airborne transmission. 2 HEPA filtration is not required because herpes simplex is not an airborne illness. 3 Herpes simplex is transmitted through direct transmission. Illnesses spread by direct transmission may include influenza, impetigo, scabies, conjunctivitis, pediculosis, herpes, C difficile, and all sexually transmitted diseases, including HIV. 4 Vehicle transmission refers to the spread of an infectious organism by contact with a contaminated object. PTS:

CON: Infection

18. The nurse observes a patient being transported through the hall wearing a mask. For which medical diagnosis should the nurse suspect the patient is receiving care? 1. Measles 2. Cellulitis 3. Diphtheria 4. C difficile ANS: 1 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with an infection. Page: 94 Heading: Standard Precautions and Transmission-Based Precautions (Table 8.3) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying)

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Concept: Infection Difficulty: Moderate Feedback 1 A mask must be worn for measles, TB, and varicella (chickenpox, shingles) during patient transport. 2 A mask does not need to be worn for cellulitis, diphtheria, or C difficile. 3 A mask does not need to be worn for cellulitis, diphtheria, or C difficile. 4 A mask does not need to be worn for cellulitis, diphtheria, or C difficile. PTS:

CON: Infection

19. The nurse is caring for a patient who is immunocompromised. Which action should the nurse take to ensure that the patient does not develop a hospital-acquired infection? 1. Restrict oral fluids. 2. Apply lotion to dry skin. 3. Provide alcohol-based mouthwash. 4. Massage back with a skin-drying agent. ANS: 2 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with an infection. Page: 94 Heading: Infection Control in Health Care Agencies Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 Restricting oral fluids could cause the oral mucous membranes to dry, permitting the entry of microorganisms into the body. 2 Intact skin and mucous membranes are the body’s first line of defense against infection. Preventing skin dryness and cracking with lotion keeps the skin intact so organisms do not have an entry point. 3 Alcohol-based mouth washes are drying and could permit the entry of microorganisms into the body. 4 Using a drying agent on the skin could encourage drying and cracking, which could lead to microorganisms entering the body. PTS:

CON: Infection

20. A patient learns that a serum antibody test is positive. What should the nurse explain to the patient about this test result? 1. An active infection is present. 2. It is more accurate than a blood culture. 3. The body has been exposed to an antigen. 4. A specific antibiotic has been identified for the infection. ANS: 3

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Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with an infection. Page: 89 Heading: Laboratory Assessment Integrated Process: Clinical Problem-Solving Process Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 A positive result for this test does not always mean an active infection is present. It can simply mean there has been an exposure to the antigen. 2 This test is not as accurate as a culture. 3 A serum antibody test measures the reaction to a certain antigen. 4 This test does not identify antibiotics appropriate to treat an infection. PTS:

CON: Infection

21. The school nurse is planning to teach a group of school-age children on cough etiquette. What should the nurse emphasize with these students? 1. Sneeze into hands if a tissue is not available. 2. Place used tissues in backpacks or pockets of clothing. 3. Wash hands with soap and water for 20 seconds after blowing the nose. 4. Move 1 foot away from another person when having to sneeze or cough. ANS: 3 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with infection. Page: 92 Heading: Hand Hygiene Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 Sneezing should be into the upper sleeve and not the hands. 2 Used tissues should be placed in the wastebasket. 3 The nurse should instruct the students to wash hands frequently with soap and water for 20 seconds especially after blowing the nose. 4 For droplet precautions, the distance is 3 feet, so the students should be instructed to move at least 3 feet away from another person when sneezing. PTS:

CON: Infection

MULTIPLE RESPONSE

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1. The nurse is caring for a group of patients requiring droplet precautions. Which conditions require these precautions? (Select all that apply.) 1. Influenza 2. Pertussis 3. Measles 4. Mumps 5. HIV 6. TB ANS: 1, 2, 4 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with an infection. Page: 95 Heading: Standard Precautions and Transmission-Based Precautions Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate

1. 2. 3. 4. 5. 6. PTS:

Feedback A patient with influenza requires droplet precautions. A patient with pertussis requires droplet precautions. A patient with measles requires airborne precautions. A patient with mumps requires droplet precautions. A patient with HIV requires standard precautions. A patient with TB requires airborne precautions. 1

CON: Infection

2. The nurse is contributing to a staff education program about infection control. What should the nurse recommend as examples of diseases that are transmitted by direct contact? (Select all that apply.) 1. Malaria 2. Measles 3. Impetigo 4. Influenza 5. Chickenpox 6. Lyme disease ANS: 3, 4 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 3. Describe the body’s defense mechanisms to fight infection. Page: 95 Heading: Direct Transmission Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Infection

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Difficulty: Moderate

1. 2. 3.

5. 6. PTS:

Feedback Diseases spread through vectors include malaria and Lyme disease. Measles and chickenpox are transmitted by airborne transmission. Illnesses spread by direct transmission may include influenza, impetigo, scabies, conjunctivitis, pediculosis, herpes, C difficile, and all sexually transmitted diseases, including HIV. Illnesses spread by direct transmission may include influenza, impetigo, scabies, conjunctivitis, pediculosis, herpes, C difficile, and all sexually transmitted diseases, including HIV. Measles and chickenpox are transmitted by airborne transmission. Diseases spread through vectors include malaria and Lyme disease. 1

CON: Infection

3. A patient is being admitted for treatment of a viral infection. Which diseases should the nurse recognize as being caused by a virus? (Select all that apply.) 1. Measles 2. Shingles 3. Gonorrhea 4. Trichomoniasis 5. Candida albicans 6. Infectious mononucleosis ANS: 1, 2, 6 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 3. Describe the body’s defense mechanisms to fight infection. Page: 95 Heading: Viruses Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate

1. 2. 3. 4. 5. 6.

PTS:

Feedback Shingles (varicella zoster), measles (rubeola), and infectious mononucleosis (Epstein-Barr) are caused by viruses. Shingles (varicella zoster), measles (rubeola), and infectious mononucleosis (Epstein-Barr) are caused by viruses. Gonorrhea (Neisseria gonorrhoeae) is caused by bacteria. Trichomoniasis (Trichomonas vaginalis) is caused by protozoa. C albicans is a fungus. Shingles (varicella zoster), measles (rubeola), and infectious mononucleosis (Epstein-Barr) are caused by viruses. 1

CON: Infection

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4. The nurse is caring for a group of patients. Which patients are at high risk for infection? (Select all that apply.) 1. A patient on the burn unit with third-degree burns 2. A patient with HIV 3. A patient with atrial fibrillation (A-fib) 4. A patient who takes corticosteroids for asthma 5. A patient who just finished a round of chemotherapy 6. A patient with attention deficit-hyperactivity disorder (ADHD) ANS: 1, 2, 4, 5 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with an infection. Page: 89 Heading: Risk Factors for Infection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate

1. 2. 3. 4. 5. 6. PTS:

Feedback A patient with burns is at high risk for infection. A patient with HIV is at high risk for infection. A patient with A-fib is not at high risk for infection. A patient who takes corticosteroids is at high risk for infection. A patient who is receiving chemotherapy is at high risk for infection. A patient with ADHD is not at high risk for infection. 1

CON: Infection

5. The nurse is assisting with the development of an educational program to reduce the incidence of infectious diseases in a community. What topics should the nurse suggest be included in this program? (Select all that apply.) 1. Use of cough etiquette 2. Performance of hand hygiene 3. Safe food handling techniques 4. Use of safety equipment with sports 5. Importance of receiving immunizations ANS: 1, 2, 3, 5 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with an infection. Pages: 92–94 Heading: Direct Transmissions Integrated Process: Clinical Problem-Solving Process Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate

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4. 5.

PTS:

Feedback Educating the public about the importance of hand hygiene, the Center for Disease Control and Prevention’s (CDC) respiratory hygiene/cough etiquette measures, immunization, clean water, safe food handling techniques, and safer sex precautions helps prevent the spread of disease in the community. Educating the public about the importance of hand hygiene, the CDC’s respiratory hygiene/cough etiquette measures, immunization, clean water, safe food handling techniques, and safer sex precautions helps prevent the spread of disease in the community. Educating the public about the importance of hand hygiene, the CDC’s respiratory hygiene/cough etiquette measures, immunization, clean water, safe food handling techniques, and safer sex precautions helps prevent the spread of disease in the community. Use of safety equipment with sports helps prevent accidental injuries. Educating the public about the importance of hand hygiene, the CDC’s respiratory hygiene/cough etiquette measures, immunization, clean water, safe food handling techniques, and safer sex precautions helps prevent the spread of disease in the community. 1

CON: Infection

COMPLETION 1. The nurse is preparing to administer metronidazole (Flagyl) 500 mg in 100 mL of normal saline to run over 1 hour intravenously to a patient with an infection. At what rate will the nurse set the infusion pump? Enter the numeral only. ANS: 100 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 4. Describe principles of anti-infective medication administration. Page: 99 Heading: Medications Used to Treat Infections (Table 8.4) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback: When an IV is transfusing over an hour, the rate is equal to the volume 100 = 100 mL/hr. PTS:

CON: Infection

2. The nurse is preparing to administer fluconazole (Diflucan) 50 mg in 100 mL of normal saline to run over 30 minutes intravenously. At what rate will the nurse set the infusion pump? Enter the numeral only.

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ANS: 200 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 4. Describe the principles of anti-infective medication administration. Page: 101 Heading: Medications Used to Treat Infections (Table 8.4) Integrated Process: Clinical Problem-Solving Process Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback: When you are administering a medication over 30 minutes, you double the volume: 2 × 100 mL/0.5 hr = 200 mL/hr. PTS:

CON: Infection

ORDERED RESPONSE 1. The nurse is teaching a group of nursing students about the chain of infection. Place in order of occurrence, from 1 to 6. 1. Mode of transmission 2. Reservoir 3. Susceptible host 4. Portal of exit 5. Portal of entry 6. Infectious agent ANS: 6, 2, 4, 1, 5, 3 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 4. Describe the principles of anti-infective medication administration. Pages: 85–88 Heading: Medications Used to Treat Infections (Table 8.4) Integrated Process: Clinical Problem-Solving Process Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback: The chain of infection is: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host. PTS:

CON: Infection

2. The nurse is teaching a group of nursing students how to wash their hands correctly. Place in order, from 1 to 5, the correct steps for handwashing. 1. Rub hands together for 20 seconds. 2. Use the paper towel to turn on the faucet.

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3. Rinse hands together with fingertips pointed downward. 4. Dry hands with disposable paper towel. 5. Wet hands with warm water, soap, and lather. ANS: 5, 1, 3, 4, 2 Chapter: Chapter 8. Nursing Care of Patients With Infections Objective: 5. Describe nursing care for a patient with infection. Page: 92 Heading: Hand Hygiene Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback: The student should first wet hands with warm water, soap, and lather. Rub hands together for 30 seconds, then rinse hands together with fingertips pointed downward. Then dry the hands with a paper towel and use that towel to shut off the faucet. PTS:

CON: Infection

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Chapter 9. Nursing Care of Patients in Shock MULTIPLE CHOICE 1. A patient with gastrointestinal bleeding is awake, alert, and oriented and has the following vital sign measurements: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature 98.6°F (37°C). Which finding should the nurse consider as a possible sign of early shock? 1. Respirations 18/min 2. Heart rate 118 beats/min 3. Temperature 98.6°F (37°C) 4. Blood pressure 130/90 mm Hg ANS: 2 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 2. Identify the etiology, signs, and symptoms for each of the four categories of shock. Page: 108 Heading: Metabolic and Hemodynamic Changes in Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 This finding is within normal limits and does not necessarily indicate manifestations of early shock. 2 When blood pressure falls, the body activates the sympathetic nervous system to increase cardiac output by causing the heart to beat faster and stronger. Compensatory responses produce the classic signs and symptoms of the initial stage of shock: tachycardia; tachypnea; restlessness; anxiety; and cool, clammy skin with pallor. 3 This finding is within normal limits and does not necessarily indicate manifestations of early shock. 4 This finding is within normal limits and does not necessarily indicate manifestations of early shock. PTS:

CON: Perfusion

2. The nurse is reviewing orders for a patient in anaphylactic shock. Which medication should the nurse plan to administer first? 1. Dobutamine (Dobutrex) 2. 0.9% normal saline 3. Epinephrine (Adrenalin) 4. Dexamethasone (Decadron) ANS: 3 Chapter: Chapter 9. Nursing Care of Patients in Shock

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Objective: 6. Prioritize care for a patient in shock. Page: 113 Heading: Medications Used for Shock (Table 9.6) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 Dobutrex is given for heart failure and cardiogenic shock. 2 Normal saline may be given, but after epinephrine. 3 Epinephrine is the first drug used to treat anaphylactic shock. 4 Decadron may be given, but epinephrine is the first drug given. PTS:

CON: Perfusion

3. A patient with progressive shock is diaphoretic and confused. The most recent blood pressure measurement was 82/40 mm Hg and a urinary catheter output was 10 mL for 1 hour. IV fluids are infusing at 150 mL/hr. Which action should the nurse take related to the urine output? 1. Encourage oral fluids. 2. Irrigate urinary catheter. 3. Increase IV fluid infusion rate. 4. Check urinary catheter for kinking. ANS: 4 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 5. Plan nursing care for patients in shock. Page: 116 Heading: Metabolic and Hemodynamic Changes in Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 Oral fluids will not help if the system is kinked; also, the patient is confused and so may not be able to take oral fluids safely, and an IV is infusing to hydrate the patient. 2 Catheter irrigation is invasive and breaks the sterile system. 3 An order is needed to increase the IV rate. 4 Collecting data is the first step in critically thinking about a situation. In this case, the urine output is lower than normal, which could be due to several reasons. The initial action of the nurse should be to inspect the urinary catheter system for proper functioning. If the catheter system is inhibiting urine output, then that issue must be addressed to correct the situation. Other interventions will not help if the system is the cause. PTS:

CON: Perfusion

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4. On arrival in the emergency department, a patient who was in a motor vehicle accident is apprehensive, confused, and hypotensive. The patient has tachycardia, oliguria, and cool clammy skin. What should the nurse do first? 1. Cover the patient with warm blankets. 2. Perform a rapid head-to-toe assessment. 3. Obtain the patient’s medical history from family. 4. Reorient the patient to person, place, and time. ANS: 2 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 5. Plan nursing care for patients in shock. Page: 114 Heading: Data Collection Integrated Process: Clinical Problem-Solving Process Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 Covering with blankets can occur after the initial rapid assessment is completed. 2 The priority is to assess the patient in shock quickly, starting with the ABCs: airway, breathing, circulation, and disability. 3 The patient’s medical history can be obtained at a later time. 4 The patient can be reoriented at a later time. PTS:

CON: Perfusion

5. A patient who is hemorrhaging has pale mucous membranes, blood pressure 92/52 mm Hg, pulse 160 beats/minute, and respirations 30/minute. The patient is receiving IV fluids at 150 mL/hour, has a blood transfusion infusing, and is being provided oxygen via a mask. What should the nurse recognize as the most likely cause of the patient’s respiratory rate? 1. Electrolyte imbalances 2. Inadequate tissue perfusion 3. Rapid rate of fluid replacement 4. Reaction to the blood transfusion ANS: 2 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 3. Identify etiology, signs, and symptoms for each of the four categories of shock. Page: 111 Heading: Effect on Organs and Organ Systems Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Integrity Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback

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1 2

3 4

An electrolyte imbalance will not affect the patient’s respiratory rate. When blood pressure falls, the body activates the sympathetic nervous system to increase cardiac output to deliver adequate oxygen to the tissues by causing the heart to beat faster and stronger. Compensatory responses produce the classic signs and symptoms of the initial stage of shock: tachycardia; tachypnea; restlessness; anxiety; and cool, clammy skin with pallor. The fluids should provide the body with needed volume and reduce the rapid respiratory rate. A blood transfusion reaction would have manifestations other than a rapid respiratory rate.

PTS:

CON: Perfusion

6. Despite aggressive treatment, the condition of a patient in shock continues to worsen. Surgical intervention stops the bleeding and the shock stabilizes. Which finding should the nurse act on immediately? 1. The blood pH is 7.36. 2. Bowel sounds are hypoactive. 3. Urinary output is 15 mL/hr. 4. Pupils are equally reactive to light. ANS: 3 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 6. Prioritize care for a patient in shock. Page: 109 Heading: Nursing Care Plan for Patients Experiencing Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 Acidosis is expected with shock, and a pH within normal limits is normal. 2 Bowel sounds typically remain hypoactive after surgery. 3 Because blood is shunted away from the kidneys early in shock to save fluid and provide oxygen to vital organs, the kidneys commonly are injured first. The kidneys can tolerate reduced blood flow for about 1 hour before sustaining permanent damage. Urine output should be monitored for reduction to detect injury. 4 Pupils that are equally reactive to light are normal. PTS:

CON: Perfusion

7. The nurse can expect a patient who lost 2 liters of blood during surgery to experience which type of shock? 1. Cardiogenic 2. Anaphylactic 3. Hypovolemic 4. Obstructive

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ANS: 3 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 1. Explain the pathophysiology of shock and compensatory mechanisms. Page: 109 Heading: Hypovolemic Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 Cardiogenic shock occurs when the heart fails as a pump and decreases cardiac output. Patients at risk for this type of shock include those with heart defects or disease. 2 Anaphylactic shock occurs as a result of a hypersensitivity reaction. 3 This patient is at risk for hypovolemic shock with a blood loss of 40%, or 2 L. 4 Obstructive shock occurs when there is a blockage of blood flow outside the heart. PTS:

CON: Perfusion

8. The nurse is caring for a patient in septic shock. The nurse identifies which as the contributing factor? 1. Blood loss 2. Hypersensitivity reaction 3. Infection 4. Heart failure ANS: 3 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 2. Identify the etiology, signs, and symptoms for each of the four categories of shock. Page: 111 Heading: Septic Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 Blood loss is a contributing factor to hypovolemic shock. 2 Hypersensitivity reaction causes anaphylactic shock. 3 Infection is the cause of septic shock. 4 Heart failure leads to cardiogenic shock. PTS:

CON: Perfusion

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9. The nurse is caring for a group of patients. Which patient is at high risk for developing obstructive shock? 1. A patient with a wound that won’t heal 2. A patient with myocarditis 3. A patient who lost 500 mL of blood during surgery 4. A patient with a tension pneumothorax ANS: 4 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 2. Identify the etiology, signs, and symptoms for each of the four categories of shock. Page: 111 Heading: Obstructive Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 This patient is at risk for septic shock. 2 This patient is at risk for cardiogenic shock. 3 This patient is at risk for hypovolemic shock. 4 This patient is at risk for obstructive shock. PTS:

CON: Perfusion

10. The unlicensed assistive personnel (UAP) reports the following to the nurse. Which patient should the nurse see first based on this information? 1. A patient with a blood pressure of 110/74 mm Hg 2. A patient with respirations of 36 breaths/min 3. A patient with a heart rate of 78 beats/min 4. A patient with a urine output of 120 mL over 3 hours ANS: 2 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 2. Identify the etiology, signs, and symptoms for each of the four categories of shock. Page: 109 Heading: Metabolic and Hemodynamic Changes in Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate

1 2

Feedback This patient has a normal blood pressure. This patient has rapid respirations and may be experiencing signs of shock and should be seen first.

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This patient has a normal heart rate. This patient has normal urine output.

PTS:

CON: Perfusion

11. The nurse is caring for a patient in mild shock. Which medication should the nurse question before providing if ordered for a patient experiencing shock? 1. Benadryl 2. Morphine 3. Dopamine 4. Solu-Medrol ANS: 2 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 5. Plan nursing care for patients in shock. Page: 109 Heading: Effect on Organs and Organ Systems Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 Benadryl, Solu-Medrol, and dopamine are all medications used to treat shock. 2 Decreased afterload occurs from vasodilation that occurs from morphine. Shock is characterized by hypotension, so any drug such as morphine, that decreases blood pressure should be avoided or used cautiously. 3 Benadryl, Solu-Medrol, and dopamine are all medications used to treat shock. 4 Benadryl, Solu-Medrol, and dopamine are all medications used to treat shock. PTS:

CON: Perfusion

12. The nurse knows early in shock, blood is shunted away from the kidneys. How long can the kidneys tolerate reduced blood flow before cells begin to die? 1. 1 hour 2. 2 hours 3. 3 hours 4. 4 hours ANS: 1 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 1. Explain the pathophysiology of shock and compensatory mechanisms. Page: 108 Heading: Effect on Organ and Organ Systems Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Comprehension (Understanding) Concept: Perfusion Difficulty: Moderate

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1 2 3 4

Feedback The kidneys can tolerate reduced blood flow for 1 hour. The kidneys can tolerate reduced blood flow for 1 hour. The kidneys can tolerate reduced blood flow for 1 hour. The kidneys can tolerate reduced blood flow for 1 hour. PTS:

CON: Perfusion

13. Data collection findings for a patient include shortness of breath with crackles in the lung bases, jugular vein distention, daily weight increased by 3 pounds from yesterday, report of chest pain, blood pressure 86/40 mm Hg, pulse 132 beats/minute, and respirations 30/minute. Which order should the nurse question? 1. Electrocardiogram (ECG) STAT 2. 500 mL 0.9% normal saline (NS) over 30 minutes 3. Oxygen 2 L/min via nasal cannula 4. Arterial blood gases (ABGs) STAT and repeat in 1 hour ANS: 2 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 3. Describe therapeutic measures for shock. Page: 110 Heading: Cardiogenic Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 An ECG, ABGs, or oxygen would be appropriate orders. 2 The patient data indicate possible cardiogenic shock. This means that any fluid given may overwhelm the heart, which could lead to death. The nurse should question IV orders for a cardiogenic shock patient. 3 An ECG, ABGs, or oxygen would be appropriate orders. 4 An ECG, ABGs, or oxygen would be appropriate orders. PTS:

CON: Perfusion

14. A patient with a history of a myocardial infarction has chest pain. The patient’s skin color is grayish, blood pressure is 88/70 mm Hg, pulse is 116 beats/minute and irregular, and respirations are 30/minute. Which action should the nurse take? 1. Place the patient supine. 2. Notify the charge nurse. 3. Check the urine specific gravity. 4. Infuse 0.9% NS wide open. ANS: 2 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 6. Prioritize care for a patient in shock. Page: 109

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Heading: Critical Thinking Integrated Process: Clinical Problem-Solving Process Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 The supine position would hinder breathing. 2 The charge nurse can notify the physician, so orders can be received to aid the critically ill patient. 3 Urine specific gravity is used to determine fluid volume status and is not needed for this patient. 4 Increased fluids could overwhelm the heart. PTS:

CON: Perfusion

15. The nurse has been informed a patient suffered injury to the liver caused by ischemia. What can the nurse expect to find? 1. Decreased bilirubin levels 2. Elevated ammonia levels 3. Decreased liver enzymes 4. Increased plasma proteins ANS: 2 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 1. Explain the pathophysiology of shock and compensatory mechanisms. Page: 108 Heading: Effect on Organs and Organ Systems Integrated Process: Clinical Problem-Solving Process Client Need: PHYS—Physiological Adaptations Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 Bilirubin levels will increase. 2 Ammonia levels will increase. 3 Liver enzymes will increase. 4 Plasma proteins will decrease. PTS:

CON: Perfusion

16. A patient asks the nurse what happens during shock. Which response by the nurse is accurate? 1. “The respiratory rate increases to deliver oxygen to the tissues.” 2. “Heart rate decreases to prevent the heart from working hard.” 3. “Epinephrine, cortisol, and glucagon decrease blood glucose levels to decrease cell fuel.” 4. “Renin-angiotensin-aldosterone system leads to vasodilation and loss of sodium.”

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ANS: 1 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 1. Explain the pathophysiology of shock and compensatory mechanisms. Page: 108 Heading: Metabolic and Hemodynamic Changes in Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1 2 3 4

Feedback The respiratory rate increases to deliver oxygen to the tissues. The heart rate increases to increase cardiac output. Epinephrine, cortisol, and glucagon increase blood glucose to increase cell fuel. Renin-angiotensin-aldosterone system leads to vasoconstriction and sodium retention.

PTS:

CON: Perfusion

17. A patient in shock is diagnosed with metabolic acidosis. What should the nurse realize as being the mechanism behind the development of this acid-base imbalance? 1. Excessive aerobic metabolism 2. Excessive anaerobic metabolism 3. Decreased anaerobic metabolism 4. Release of cortisol and glucagon ANS: 2 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 1. Explain the pathophysiology of shock and compensatory mechanisms. Page: 108 Heading: Metabolic and Hemodynamic Changes in Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 Metabolic acidosis will not develop in the presence of aerobic metabolism. 2 Anaerobic metabolism results in the production of lactic acid as an unwanted by-product. Unless the lactic acid can be circulated to the liver and removed from the bloodstream, the blood will become increasingly acidic. 3 Decreased anaerobic metabolism will not cause metabolic acidosis to develop. 4 The release of cortisol and glucagon ensures the body tissues receive fuel because of the shock. PTS:

CON: Perfusion

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18. The nurse is assessing a patient who received 3 liters of normal saline for treatment of shock. Which finding indicates effectiveness of treatment? 1. Cool, clammy skin 2. Decreased urine output 3. Increased blood pressure 4. Increased heart rate ANS: 3 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 7. Identify findings that demonstrate a positive response to therapeutic measures for shock. Page: 116 Heading: Metabolic and Hemodynamic Changes in Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 Cold, clammy skin is indicative of ineffective treatment. 2 Decreased urine output is indicative of ineffective treatment. 3 Increased blood pressure indicates effective treatment. 4 Increased heart rate is indicative of ineffective treatment. PTS:

CON: Perfusion

19. The nurse is caring for a group of patients. Which patient is at high risk for developing sepsis? 1. A 20-year-old marathon runner with allergies 2. A 25-year-old banker with HIV 3. A 30-year-old construction worker with bipolar disorder 4. A 35-year-old teacher with fibromyalgia ANS: 2 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 4. List data to collect when caring for patients with shock. Page: 112 Heading: Septic Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 This patient is not at risk for sepsis. 2 This patient is immunocompromised and is at high risk for sepsis. 3 This patient is not at high risk for sepsis. 4 This patient is not at high risk for sepsis.

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CON: Perfusion

20. The nurse is receiving report on patients assigned for the next shift. Which patient should the nurse observe first? 1. A patient who has a pressure ulcer who is due for a dressing change 2. A patient with diabetes who has a blood sugar level of 85 and is eating lunch 3. A patient with cellulitis who is receiving the first dose of IV antibiotics and who is reporting a feeling of tightness in the throat 4. A patient with sickle cell anemia who is receiving a monthly transfusion of a unit of packed red blood cells who is reporting left knee pain ANS: 3 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 6. Prioritize care for a patient in shock. Page: 111 Heading: Anaphylactic Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 There are no abnormalities occurring that require immediate intervention. 2 There are no abnormalities occurring that require immediate intervention. 3 The patient may be having an allergic reaction and requires immediate attention to intervene as anaphylactic shock may occur. 4 There are no abnormalities occurring that require immediate intervention. PTS:

CON: Perfusion

21. The nurse is caring for an 85-year-old patient with septic shock. What should the nurse keep in mind when repositioning this patient? 1. Change positions slowly. 2. Reduce flow rate of oxygen. 3. Increase flow rate of IV fluids. 4. Place in Trendelenburg position. ANS: 1 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 5. Plan nursing care for patients in shock. Page: 111 Heading: Gerontological Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback

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For the geriatric patient, positions should be changed slowly. Age-related losses of cardiovascular reflexes can result in hypotension. The oxygen and IV flow rates cannot be changed without a health care provider’s order. The oxygen and IV flow rates cannot be changed without a health care provider’s order. Trendelenburg position is not indicated for this health problem.

PTS:

CON: Perfusion

22. A patient in shock is found unresponsive. The nurse knows that immediate cardiopulmonary resuscitation is required because brain cells begin to die if deprived of oxygen for how many minutes? 1. 1 2. 2 3. 4 4. 8 ANS: 3 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 1. Explain the pathophysiology of shock and compensatory mechanisms. Page: 107 Heading: Effect on Organs and Organ Systems Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 Brain cells do not begin to die until 4 minutes have passed without oxygen and glucose. 2 Brain cells do not begin to die until 4 minutes have passed without oxygen and glucose. 3 If the brain is deprived of circulation for more than 4 minutes, brain cells die from a lack of oxygen and glucose. As a result, prolonged shock can result in brain death. 4 Brain cells are dying if deprived of oxygen and glucose for 8 minutes. PTS:

CON: Perfusion

MULTIPLE RESPONSE 1. The nurse is assisting in the care of a patient with early signs and symptoms of shock. Which diagnostic tests should the nurse expect to be prescribed for this patient? (Select all that apply.) 1. Urinalysis 2. Chest x-ray 3. ABG

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4. CBC 5. Electroencephalogram (EEG) 6. Blood type and crossmatch ANS: 1, 2, 3, 4, 6 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 6. Prioritize care for a patient in shock. Page: 112 Heading: Assessment of the Patient in Shock (Table 9.4) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1. 2. 3. 4. 5. 6.

PTS:

Feedback CBC, chest x-ray, blood typing and crossmatch, ABGs, and urinalysis are diagnostic tests done in the assessment of shock. CBC, chest x-ray, blood typing and crossmatch, ABGs, and urinalysis are diagnostic tests done in the assessment of shock. CBC, chest x-ray, blood typing and crossmatch, ABGs, and urinalysis are diagnostic tests done in the assessment of shock. CBC, chest x-ray, blood typing and crossmatch, ABGs, and urinalysis are diagnostic tests done in the assessment of shock. EEG would not be done. CBC, chest x-ray, blood typing and crossmatch, ABGs, and urinalysis are diagnostic tests done in the assessment of shock. 1

CON: Perfusion

2. The nurse is caring for a patient with stroke. Which does the nurse identify as complications of this condition? (Select all that apply.) 1. Acute respiratory distress syndrome (ARDS) 2. Cancer 3. Diabetes 4. Disseminated intravascular coagulation (DIC) 5. Multiple organ dysfunction syndrome (MODS) ANS: 1, 4, 5 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 2. Identify the etiology, signs, and symptoms for each of the four categories of shock. Page: 111 Heading: Complications From Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

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1. 2. 3. 4. 5. PTS:

Feedback ARDS is a complication of shock. Cancer is not a complication of shock. Diabetes is not a complication of shock. DIC is a complication of shock. MODS is a complication of shock. 1

CON: Perfusion

3. A patient is developing anaphylactic shock. What should the nurse expect to observe in this patient? (Select all that apply.) 1. Polyuria 2. Urticaria 3. Bronchospasm 4. Muscle cramps 5. Laryngeal edema ANS: 2, 3, 5 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 2. Identify the etiology, signs, and symptoms for each of the four categories of shock. Page: 111 Heading: Anaphylactic Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback Decreased urine rather than increased urination would be seen in a patient in shock. Anaphylactic shock symptoms include urticaria, pruritus, wheezing, laryngeal edema, angioedema, and severe bronchospasm. Anaphylactic shock symptoms include urticaria, pruritus, wheezing, laryngeal edema, angioedema, and severe bronchospasm. Muscle cramps are not associated with anaphylactic shock. Anaphylactic shock symptoms include urticaria, pruritus, wheezing, laryngeal edema, angioedema, and severe bronchospasm. 1

CON: Perfusion

4. The nurse is caring for a group of patients. Which patients are at highest risk for developing cardiogenic shock? (Select all that apply.) 1. A patient with myocarditis 2. A patient with cardiomyopathy 3. A patient with A-fib 4. A patient with an allergy to bees 5. A patient who has heatstroke

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ANS: 1, 2, 3 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 2. Identify the etiology, sign, and symptoms for each of the four categories of shock. Page: 111 Heading: Cardiogenic Shock Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Difficult

1. 2. 3. 4. 5. PTS:

Feedback This patient is at high risk for cardiogenic shock. This patient is at high risk for cardiogenic shock. This patient is at high risk for cardiogenic shock. This patient is at risk for anaphylactic shock. This patient is at risk for hypovolemic shock. 1

CON: Perfusion

ORDERED RESPONSE 1. A patient in shock is being transported to the nearest emergency department. Upon arrival, in which order should the nurse provide care? Place the actions in the order that they should be performed from 1 to 6. 1. Ensure breathing. 2. Secure an airway. 3. Assess level of consciousness. 4. Prepare for x-rays and other tests. 5. Apply pressure to bleeding wounds. 6. Monitor heart rate and blood pressure. ANS: 2, 1, 6, 5, 3, 4 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 6. Prioritize care for a patient in shock. Page: 114 Heading: Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Difficult

Feedback The order of interventions and testing is guided by the stability of the patient. The order for interventions should be securing an airway, ensure breathing, monitor

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PTS:

heart rate and blood pressure, apply pressure to bleeding wounds, assess level of consciousness, and prepare for x-rays and other diagnostic tests. The order of interventions and testing is guided by the stability of the patient. The order for interventions should be securing an airway, ensure breathing, monitor heart rate and blood pressure, apply pressure to bleeding wounds, assess level of consciousness, and prepare for x-rays and other diagnostic tests. The order of interventions and testing is guided by the stability of the patient. The order for interventions should be securing an airway, ensure breathing, monitor heart rate and blood pressure, apply pressure to bleeding wounds, assess level of consciousness, and prepare for x-rays and other diagnostic tests. The order of interventions and testing is guided by the stability of the patient. The order for interventions should be securing an airway, ensure breathing, monitor heart rate and blood pressure, apply pressure to bleeding wounds, assess level of consciousness, and prepare for x-rays and other diagnostic tests. The order of interventions and testing is guided by the stability of the patient. The order for interventions should be securing an airway, ensure breathing, monitor heart rate and blood pressure, apply pressure to bleeding wounds, assess level of consciousness, and prepare for x-rays and other diagnostic tests. The order of interventions and testing is guided by the stability of the patient. The order for interventions should be securing an airway, ensure breathing, monitor heart rate and blood pressure, apply pressure to bleeding wounds, assess level of consciousness, and prepare for x-rays and other diagnostic tests. 1

CON: Perfusion

COMPLETION 1. The nurse is teaching a patient how to administer epinephrine 0.5 mg intramuscularly. The available dose is 0.5 mg/0.5 mL. How many mL will the patient be taught to administer? Enter the numeral only. ANS: 0.5 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 5. Plan nursing care for patients in shock. Page: 113 Heading: Medications Used for Shock (Table 9.6) Integrated Process: Teaching/Learning Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback: mL = 0.5 mL PTS:

CON: Perfusion

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2. A patient who weighs 84 kg is prescribed dobutamine (Dobutrex) 0.5 mcg/kg. How many mcg will this patient receive? Enter the numeral only. ANS: 42 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 5. Plan nursing care for patients in shock. Page: 113 Heading: Medications Used for Shock (Table 9.6) Integrated Process: Teaching/Learning Client Need: PHYS-Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback: Multiply 84 by 0.5, which equals 42 mcg. PTS:

CON: Perfusion

3. The nurse is preparing to administer 1 liter of 0.9% NS over 2 hours intravenously to a patient experiencing shock. At what rate will the nurse set the infusion pump? Enter the numeral only. ANS: 500 Chapter: Chapter 9. Nursing Care of Patients in Shock Objective: 5. Plan nursing care for patients in shock. Page: 113 Heading: Medications Used for Shock (Table 9.6) Integrated Process: Teaching/Learning Client Need: PHYS-Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback: mL/hr = 1,000 mL/2 hrs = 500 mL/hr PTS:

CON: Perfusion

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Chapter 10. Nursing Care of Patients in Pain MULTIPLE CHOICE 1. A patient has been on opioids for 3 months to control pain caused by injuries from a motor vehicle crash. The patient asks about the risk of withdrawal symptoms when the drugs are no longer needed. How should the nurse respond to the patient? 1. “Ask your doctor for a sedative to get you through the worst of the withdrawal symptoms.” 2. “As long as you taper the drug dose down slowly, you should not experience withdrawal symptoms.” 3. “You would have to be on these drugs much longer than 3 months to have problems with withdrawal.” 4. “You were using the drugs for legitimate pain, so you will not have to go through withdrawal when you stop them.” ANS: 2 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 3. Differentiate among addiction, physical dependence, and tolerance. Page: 121 Heading: Opioid Addiction Integrated Process: Communication and Documentation Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate Feedback 1 Sedatives are not usually necessary and may be addictive. 2 After 3 months of use, some withdrawal symptoms are likely; these can be minimized or eliminated by slowly tapering the dose. 3 The nurse has no way of knowing the patient’s potential response to withdrawing from the medication. 4 The reason for the medication is not important. PTS:

CON: Comfort

2. The nurse is caring for a patient with lung cancer who has been receiving morphine for 2 weeks and reports the medication is no longer effective. Which is the patient likely experiencing? 1. Physical dependence 2. Tolerance 3. Addition 4. Pseudoaddiction ANS: 2 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 3. Differentiate among addiction, physical dependence, and tolerance. Page: 123

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Heading: Opioid Addiction Integrated Process: Caring Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate Feedback 1 Physical dependence is a normal physiological response that most people experience after a week or more of continued opioid use. If the drug is discontinued abruptly, the patient may experience withdrawal symptoms. 2 Tolerance is when a drug becomes less effective; therefore, a larger dose is required to provide the same level of pain relief. 3 Addiction is a disease of the brain that causes the compulsive pursuit of a substance to obtain reward or relief from craving. 4 Pseudoaddiction resembles psychological dependence, such as drug-seeking behaviors in an attempt to get pain needs met. This occurs when doses are too low or too far spaced out. PTS:

CON: Comfort

3. A patient with chronic pain is on a sustained-release opioid that is ordered every 12 hours. After 6 hours, the patient complains of increasing pain. Which intervention by the nurse is appropriate? 1. Obtain an order for an immediate-release opioid for breakthrough pain. 2. Teach the patient a relaxation technique to use until the next dose is due. 3. Assess the patient’s vital signs and administer the next dose of opioid early. 4. Explain to the patient that the medication being administered lasts for 12 hours. ANS: 1 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 7. Describe the three classes of analgesics and their uses. Page: 124 Heading: Opioid Analgesics Integrated Process: Caring Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate Feedback 1 Breakthrough pain is treated with immediate-release agents. 2 A relaxation exercise might help for a short period of time but not for 6 hours. 3 Giving the next dose early does not follow physician’s orders and will only help one time. The patient needs an order for future use also. 4 It is unethical to not treat the patient’s pain. PTS:

CON: Comfort

4. The nurse is preparing to provide an opioid medication for a patient’s postoperative pain. Which action should the nurse take first?

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1. 2. 3. 4.

Determine the respiratory rate. Observe the patient’s skin color. Take the patient’s oral temperature. Ask the patient when he last ate something.

ANS: 1 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 6. Perform a basic pain assessment. Page: 126 Heading: Opioid Analgesics Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate Feedback 1 Opioids are respiratory depressants, and respiratory function is a priority. 2 Skin color, temperature, and oral intake may be helpful, but they are not the most important when providing this medication. 3 Skin color, temperature, and oral intake may be helpful, but they are not the most important when providing this medication. 4 Skin color, temperature, and oral intake may be helpful, but they are not the most important when providing this medication. PTS:

CON: Comfort

5. A patient with peripheral neuropathy states, “I don't know why the doctor put me on an antidepressant. I am not depressed!” Which response by the nurse is best? 1. “Depression is often a factor in pain. Treating the depression helps treat the pain.” 2. “Maybe you are more depressed than you realize. Would you like to talk about it?” 3. “Antidepressants are sometimes used to treat nerve pain such as you are experiencing.” 4. “Why don’t you try it for a while, and if you don’t feel better, you can ask your doctor if you can stop it?” ANS: 3 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 8. Describe commonly used pain medication treatment modalities and their appropriate use. Page: 124 Heading: Analgesic Adjuvants Integrated Process: Teaching/Learning Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate Feedback 1 Depression is not necessarily a factor in neuropathy. 2 Depression is not necessarily a factor in neuropathy.

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Certain antidepressants have been shown to relieve pain related to neuropathy. Antidepressants may take several weeks to be effective, so they should not be stopped prematurely.

PTS:

CON: Comfort

6. A patient receiving large doses of opioids is lethargic and difficult to arouse, with a respiratory rate of 6 per minute and constricted pupils. Which medication should the nurse anticipate being prescribed? 1. Naloxone (Narcan) 2. Furosemide (Lasix) 3. Diazepam (Valium) 4. Flumazenil (Romazicon) ANS: 1 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 7. Describe the three classes of analgesics and their uses. Page: 128 Heading: Opioid Antagonists Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate

1 2 3 4

Feedback The patient is exhibiting signs of opioid overdose. Narcan is an opioid antagonist. Lasix is a diuretic. Valium is a benzodiazepine that could further depress the patient’s level of consciousness. Romazicon is the antidote to benzodiazepine overdose.

PTS:

CON: Comfort

7. A physician writes an order to give a saline injection to a patient who has been requesting frequent meperidine (Demerol) shots. Which initial response by the licensed practical nurse (LPN) is best? 1. Tell the patient that the physician has ordered a placebo. 2. Administer the saline and carefully document the patient’s response. 3. Tell the patient that a pain shot is being administered, without revealing exactly what it is. 4. Tell the physician about feeling uncomfortable administering saline if the patient thinks it is Demerol. ANS: 4 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 9. Recognize appropriate use of nonpharmacological pain management techniques.

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Page: 128 Heading: Placebos Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate

1 2 3 4

Feedback Use of placebos is unethical and inappropriate unless the patient has given written consent. The use of placebos is a denial of the patient’s report of pain. The use of placebos is a denial of the patient’s report of pain. If a placebo is ordered for a patient, discuss concerns with the physician and nurse supervisor.

PTS:

CON: Comfort

8. A patient with chronic back pain has a new order for a fentanyl (Duragesic) patch. As the nurse applies the patch, the patient states, “I’m really glad to get that patch on. I am really hurting bad.” Which response by the nurse is correct? 1. “You should feel some relief of your pain within about half an hour.” 2. “The patch may take a while to work. Would you like a pain shot in the meantime?” 3. “Other analgesics can’t be given while the patch is on, so try to bear it until it takes effect.” 4. “Because it is absorbed right through the skin, you will feel relief within minutes after I apply this patch.” ANS: 2 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 7. Describe the three classes of analgesics and their uses. Page: 128 Heading: Opioid Analgesics Integrated Process: Communication and Documentation Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate

1 2

3 4

Feedback Pain will not be relieved within minutes or half of an hour. It may take up to 3 days for a patch to provide an effective level of pain relief, and the patient may require an immediate-release form of pain medication until that time. It is appropriate to administer a short-acting agent while waiting for the patch to take effect. Other pain medications can be provided while the patch is in place. Pain will not be relieved within minutes or half of an hour.

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CON: Comfort

9. The nurse enters a room just as a patient’s daughter pushes the button of his IV patientcontrolled analgesia (PCA) pump. Which response by the nurse is appropriate? 1. “Thanks for helping out your dad. Is he too weak to push the button?” 2. “If you need to push the button for your dad, first be sure his respiratory rate is higher than 10.” 3. “It is dangerous for anyone but your dad to push the button. Remind him to push it himself if he needs it.” 4. “It is against hospital policy for anyone but the patient to push the button. If I see you pushing it again, I will have to call the supervisor.” ANS: 3 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 8. Identify commonly used pain medication treatment modalities and their appropriate use. Page: 129 Heading: Patient-Controlled Analgesia Integrated Process: Communication and Documentation Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate

1 2 3

Feedback The safety of IV PCA is affected if someone other than the patient administers the dose. The safety of IV PCA is affected if someone other than the patient administers the dose. No one should push the button except the patient. PCA is safe if it is controlled by the patient and appropriately monitored. Family members can help by reminding their loved one to use the PCA if they think the person is in pain. Admonishing the daughter is unnecessary—she needs to be educated, not scolded.

PTS:

CON: Comfort

10. The nurse is performing a pain assessment on a newly admitted patient. Which question best assesses the severity of pain? 1. “Can you tell me when the pain began?” 2. “Is there anything that makes the pain better or worse?” 3. “Can you point to where the pain is located?” 4. “Can you please rate your pain on a scale of 0 to 10?” ANS: 4 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 6. Perform a basic pain assessment. Page: 133 Heading: What’s Up Guide for Pain Assessment (Table 10.4)

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Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate

1 2 3 4

Feedback Asking the patient when the pain started assesses timing. Asking the patient what makes the pain better or worse assesses aggravating and alleviating factors. Asking the patient where the pain is located assesses location. Asking the patient to rate the pain assesses severity.

PTS:

CON: Comfort

11. A patient who has just returned from abdominal surgery states, “I learned relaxation exercises, so I won’t need any drugs.” Which statement about relaxation therapy should the nurse use to guide care for this patient? 1. Relaxation therapy works much the same as a placebo. 2. Relaxation therapy is not useful for postoperative patients or for severe pain. 3. Relaxation therapy is an excellent adjunct treatment for pain when used with analgesics. 4. Effective use of relaxation therapy can eliminate the need for analgesics postoperatively. ANS: 3 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 9. Recognize appropriate use of nonpharmacological pain management techniques. Page: 131 Heading: Nonpharmacological Therapies Integrated Process: Teaching/Learning Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate

1 2 3 4

Feedback Relaxation therapy does not work the same as a placebo. It can help the patient feel more in control. Relaxation is an adjunct treatment for any type of pain but should not be expected to replace pain medication. The use of relaxation cannot eliminate the need for analgesics after surgery.

PTS:

CON: Comfort

12. The nurse is having difficulty assessing the pain of a mentally impaired patient who has an approximate functional level of a 4-year-old child. Which method should the nurse use to determine the patient’s pain level?

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1. 2. 3. 4.

Use the FACES scale. Ask, “Are you hurting?” Observe the patient’s facial expression. Explain to the patient how to use a 0-to-10 pain scale, with 0 being no pain and 10 being the worst possible pain.

ANS: 1 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 6. Perform a basic pain assessment. Page: 135 Heading: Pain Assessment Tools Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate

1 2 3 4

Feedback The FACES scale was developed for use in children and would be appropriate for someone functioning at a 4-year-old level. Facial expression and the response to “Are you hurting?” may be helpful, but they are not as objective as using a research-validated scale. Facial expression and the response to “Are you hurting?” may be helpful, but they are not as objective as using a research-validated scale. The 0-to-10 scale is too complex for a 4-year-old.

PTS:

CON: Comfort

13. The nurse is caring for a group of patients. Which patient is experiencing chronic pain? 1. A patient who underwent heart surgery 2 days ago 2. A patient who fractured a tibia in a motorcycle accident 3. A patient who fell off a ladder 6 months ago and injured his back 4. A patient who sprained her wrist yesterday rollerblading ANS: 3 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 1. Describe current definitions of pain. Page: 121 Heading: Definitions of Pain Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Comfort Difficulty: Moderate

1 2 3

Feedback This patient is experiencing acute pain. This patient is experiencing acute pain. This patient is experiencing chronic pain.

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This patient is experiencing acute pain.

PTS:

CON: Comfort

14. The nurse is caring for a patient who is receiving morphine via PCA. Which finding would be of most concern to the nurse? 1. Blood pressure 114/72 mm Hg 2. Pulse 76 beats/min 3. Respirations 10 breaths/min 4. Report of level 3 pain on 0-to-10 scale ANS: 3 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 6. Perform a basic pain assessment. Page: 129 Heading: Opioid Antagonists (BE Safe! Box) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Comfort Difficulty: Moderate

1 2 3 4

Feedback This blood pressure is normal. This heart rate is normal. The respiratory rate is very low and should concern the nurse. The patient should not experience pain with the PCA; the respiratory rate is most concerning at this time.

PTS:

CON: Comfort

15. A patient reports that she has been having bloody stools for the past month. Which medication can the nurse expect to note on the medication history? 1. Gabapentin (Neurontin) 2. Duloxetine (Cymbalta) 3. Naproxen (Aleve) 4. Fentanyl (Duragesic) ANS: 3 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 6. Perform a basic pain assessment. Page: 125 Heading: Analgesic and Adjuvant Agents (Table 10.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Comfort Difficulty: Moderate

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1 2 3 4

Feedback This medication does not cause bleeding or bruising. This medication does not cause bleeding or bruising. Naproxen (Aleve) can cause bleeding (bruising). This medication does not cause bleeding or bruising. PTS:

CON: Comfort

16. The nurse is reviewing orders for a patient with diabetic neuropathy. Which medication should the nurse expect to administer? 1. Carbamazepine (Tegretol) 2. Midazolam (Versed) 3. Oxycodone (OxyContin) 4. Celecoxib (Celebrex) ANS: 1 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 7. Describe the three classes of analgesics and their uses. Page: 127 Heading: Analgesic and Adjuvant Agents (Table 10.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Comfort Difficulty: Moderate

1 2 3 4

Feedback This medication is used to treat neuropathic pain. Versed is used to treat anxiety or muscle spasms associated with pain. This medication is used to alter perception of pain (treat pain). This medication is used to reduce pain and inflammation. PTS:

CON: Comfort

17. The nurse is caring for a patient who underwent an amputation of the left arm. The patient reports level 9 pain on a 0-to-10 scale. Which action should the nurse take? 1. Encourage the patient to use only nonpharmacological therapies. 2. Administer normal saline and tell the patient it is morphine. 3. Remind the patient there is nothing there to “hurt.” 4. Administer 4 mg of morphine intravenously as prescribed. ANS: 4 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 5. Differentiate between nociceptive and neuropathic pain. Page: 137 Heading: Pain Transmission: Nociceptive or Neuropathic Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying)

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Concept: Comfort Difficulty: Moderate

1 2 3 4

Feedback The patient is experiencing a high amount of pain and just underwent surgery; pharmacological pain relief is appropriate. It is unethical to administer saline and tell the patient it is morphine. The patient feels the pain (phantom limb pain) and the nurse should treat it. The nurse should administer pharmacological pain relief to treat the patient’s report of pain at level 9 on a 0-to-10 scale.

PTS:

CON: Comfort

18. The nurse is caring for a patient who was in a motor vehicle accident and has multiple fractures. The patient reports level 9 pain on a 0-to-10 scale. Which route should the nurse use to administer the medication for quickest relief of pain? 1. Oral 2. Rectal 3. Intramuscular (IM) 4. IV ANS: 4 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 8. Identify commonly used pain medication treatment modalities and their appropriate use. Page: 131 Heading: Routes for Analgesic Administration (Table 10.3) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Comfort Difficulty: Moderate

1 2 3 4

Feedback Oral does not have a quick onset. Rectal does not have a rapid onset. IM has a rapid onset, but slower than IV. IV has the quickest onset of action. PTS:

CON: Comfort

19. The nurse is caring for a patient with metastatic cancer. The patient is receiving 4 mg of morphine intravenously every 6 hours as needed and 5 mg hydrocodone/acetaminophen (Lortab) every 6 hours orally as needed for breakthrough pain. The patient reports the medication is effective, but the medication wears off before the dose is due. The nurse notifies the health care provider. Which order should the nurse anticipate? 1. Changing the morphine to a different opioid 2. Changing medications to an around-the-clock schedule 3. Adding an additional medication

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4. Increasing the dose of the current medication ANS: 2 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 8. Identify commonly used pain medication treatment modalities and their appropriate use. Page: 131 Heading: Scheduling Options Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Comfort Difficulty: Moderate

1 2 3 4

Feedback The patient reports the medication is effective, but wears off. An around-the-clock schedule is effective for a patient who experiences predictable pain. The patient reports the medication is effective, but wears off. The patient reports the medication is effective, but wears off.

PTS:

CON: Comfort

20. The nurse is caring for a group of patients. Which patient is experiencing acute pain? 1. A patient who has experienced back pain for 2 years 2. A patient with a diagnosis of pancreatitis 3. A patient who experienced a knee injury in high school 12 years ago 4. A patient diagnosed with osteoarthritis last year ANS: 2 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 1. Describe the current definitions of pain. Page: 121 Heading: Definitions of Pain Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Comfort Difficulty: Moderate

1 2 3 4

Feedback This describes chronic pain. This describes acute pain. This describes chronic pain. This describes chronic pain. PTS:

CON: Comfort

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21. A patient taking hydromorphone for cancer pain is experiencing constipation. What should the nurse teach to help this patient? 1. Take a mild laxative. 2. How to self-administer a Fleet enema. 3. Slowly decrease the dose of hydromorphone. 4. Eat a high-fiber diet and increase fluid intake. ANS: 4 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 8. Identify commonly used pain medication treatment modalities and their appropriate use. Page: 127 Heading: Patient Education Integrated Process: Teaching/Learning Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate

1 2 3 4

Feedback Laxatives and enemas treat constipation after it becomes a problem. Laxatives and enemas treat constipation after it becomes a problem. It is inappropriate to encourage a patient with cancer pain to decrease analgesia because pain will recur. A high-fiber diet and fluids are the first line of defense because they help prevent constipation.

PTS:

CON: Comfort

22. The nurse is reviewing orders for a patient and notes an order for extra-strength Tylenol 2 tablets (1,000 mg) every 4 hours around the clock. What action should the nurse take? 1. Seek clarification from the health care provider. 2. Administer the medication as prescribed. 3. Give the patient half of the ordered dose. 4. Administer regular acetaminophen (325 mg) every 4 hours around the clock. ANS: 1 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 8. Identify commonly used pain medication treatment modalities and their appropriate use. Page: 126 Heading: Analgesic and Adjuvant Agents Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate Feedback

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1 2 3 4

The nurse should seek clarification because this dose exceeds the maximum safe dose for Tylenol. This dose exceeds the maximum daily dose. It is not within the nurse’s scope of practice to change a dose. It is not within the nurse’s scope of practice to change a medication.

PTS:

CON: Comfort

23. A patient with a gastrostomy tube is prescribed a sustained-released opioid medication. What should the nurse do when preparing to provide this medication to the patient? 1. Provide the medication orally for the patient to swallow. 2. Crush the medication and administer it through the tube. 3. Dissolve the medication in water and administer it through the tube. 4. Ask the physician to prescribe the medication as an elixir for tube administration. ANS: 4 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 8. Identify commonly used pain medication treatment modalities and their appropriate use. Page: 126 Heading: Opioid Analgesics (Be Safe! Box) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate

1 2

3 4

Feedback The patient has a gastrostomy tube for a reason. Oral intake is probably compromised. This patient is unable to take oral medications. A controlled- or time-release tablet should never be crushed. Because the tablet is designed to deliver a dose of medication over time, crushing it could deliver the entire dose at once, resulting in overdose. Dissolving the medication in water and administering it through the tube could cause an overdose. The nurse should ask the physician to prescribe the medication as an elixir for tube administration because a time-release tablet should never be crushed.

PTS:

CON: Comfort

24. The nurse is caring for a group of patients. Which patient should the nurse see first? 1. A patient who underwent an appendectomy 2 hours ago reporting level 8 pain on a 0-to-10 scale 2. A patient who underwent a knee replacement 3 days ago reporting level 2 pain on a 0-to-10 scale 3. A patient with chronic back pain reporting level 8 pain on a 0-to-10 scale 4. A patient with a sprained ankle reporting level 5 pain on a 0-to-10 scale ANS: 1

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Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 6. Perform a basic pain assessment. Page: 124 Heading: Definitions of Pain Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Comfort Difficulty: Moderate

1 2 3 4

Feedback This patient should be seen first; he is postoperative (acute) and has a high level of reported pain. This patient has acute pain, but is reporting a low level of pain. This patient reports a high level of pain, but she is experiencing chronic pain and should be seen after the patient with acute level 8 pain. This patient is experiencing acute pain, but a moderate level.

PTS:

CON: Comfort

MULTIPLE RESPONSE 1. The nurse is reviewing medications prescribed for a patient experiencing pain. Which medications should the nurse realize are being used as adjuvant agents for this patient’s pain? (Select all that apply.) 1. Steroids 2. Antibiotics 3. Cylclooxygenase-2 (COX-2) inhibitors 4. Anticonvulsants 5. Benzodiazepines 6. Tricyclic antidepressants ANS: 1, 4, 5, 6 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 8. Identify commonly used pain medication treatments modalities and their appropriate use. Page: 124 Heading: Analgesic and Adjuvant Agents (Table 10.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Difficult

Feedback Steroids reduce inflammation. Tricyclic antidepressants help treat neuropathic pain. Benzodiazepines help relieve anxiety and muscle spasms. Anticonvulsants are used to relieve sharp or cutting pain related to peripheral

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2. 3. 4.

PTS:

nerve syndromes. Antibiotics treat infection, not pain COX-2 inhibitors are NSAIDs, not adjuvants. Steroids reduce inflammation. Tricyclic antidepressants help treat neuropathic pain. Benzodiazepines help relieve anxiety and muscle spasms. Anticonvulsants are used to relieve sharp or cutting pain related to peripheral nerve syndromes. Steroids reduce inflammation. Tricyclic antidepressants help treat neuropathic pain. Benzodiazepines help relieve anxiety and muscle spasms. Anticonvulsants are used to relieve sharp or cutting pain related to peripheral nerve syndromes. Steroids reduce inflammation. Tricyclic antidepressants help treat neuropathic pain. Benzodiazepines help relieve anxiety and muscle spasms. Anticonvulsants are used to relieve sharp or cutting pain related to peripheral nerve syndromes. 1

CON: Comfort

2. The nurse is teaching a patient about nonpharmacological therapies. Which topics should the nurse include in the teaching? (Select all that apply.) 1. Use of guided imagery 2. Taking medication around the clock 3. Watching television for distraction 4. Biofeedback technique 5. Application of heat 6. Application of a Duragesic patch ANS: 1, 3, 4, 5 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 9. Recognize appropriate use of nonpharmacological pain management techniques. Page: 130 Heading: Nonpharmacological Therapies Integrated Process: Teaching/Learning Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate

1. 2. 3. 4. 5. 6. PTS:

Feedback This describes a nonpharmacological therapy. This is pharmacological therapy. This is a nonpharmacological therapy. This is a nonpharmacological therapy. This is a nonpharmacological therapy. This is a pharmacological therapy. 1

CON: Comfort

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3. The nurse is providing education for a patient being discharged with a fentanyl (Duragesic) patch. Which statements made by the patient indicate an understanding of the teaching? (Select all that apply.) 1. “This medication is good for me because I usually need something that works quickly.” 2. “I should place heat over the patch to help it stick better.” 3. “Since I smoke, this medication may not be as effective for me.” 4. “If I am running a fever, I should avoid this medication.” 5. “I should avoid touching the medication when applying the patch.” ANS: 3, 4, 5 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 8. Identify commonly used pain medication treatment modalities and their appropriate use. Page: 128 Heading: Routes for Analgesic Administration (Table 10.3) Integrated Process: Teaching/Learning Client Need: PHYS—Pharmacological Therapies Cognitive Level: Evaluation (Evaluating) Concept: Comfort Difficulty: Moderate

1. 2. 3. 4. 5. PTS:

Feedback This medication may take a while to work; it is not quick-acting. Heat should not be applied over the patch. Smoking may cause the medication to be less effective. Fever can increase absorption of the medication. The patient should avoid touching the medication when applying the patch. 1

CON: Comfort

COMPLETION 1. The nurse is preparing to administer morphine 5 mg intravenously to a patient with cancer. Available is morphine 10 mg/mL. How many mL will the nurse administer? Enter the numeral only. ANS: 0.5 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 8. Identify commonly used pain medication treatment modalities and their appropriate use. Page: 130 Heading: Analgesic and Adjuvant Agents (Table 10.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Comfort Difficulty: Moderate

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Feedback: The nurse is giving half of the ordered dose. Dividing by 2 equals 0.5 mL. PTS:

CON: Comfort

2. The nurse is preparing to administer midazolam (Versed) 1 mg intravenously. The available dose is midazolam (Versed) 1 mg/1 mL. How many mL will the nurse administer? Enter the numeral only ANS: 1 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 8. Identify commonly used pain medication treatment modalities and their appropriate use. Page: 130 Heading: Analgesic and Adjuvant Agents (Table 10.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Comfort Difficulty: Moderate Feedback: 1 mg is ordered, and the available dose is 1 mg/1 mL; therefore, 1 mL will be given. PTS:

CON: Comfort

3. The nurse is preparing to administer Roxanol 5 mg orally to a patient. The available dose is 20 mg/mL. How many mL will the nurse administer? Enter the numeral only. ANS: 0.25 Chapter: Chapter 10. Nursing Care of Patients in Pain Objective: 8. Identify commonly used pain medication treatment modalities and their appropriate use. Page: 130 Heading: Analgesic and Adjuvant Agents (Table 10.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Comfort Difficulty: Moderate Feedback: mL = 1 mL/20 mg × 5 mg = 0.25 mL PTS:

CON: Comfort

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Chapter 11. Nursing Care of Patients With Cancer MULTIPLE CHOICE 1. Which is the branch of medicine that deals with the prevention, diagnosis, and treatment of tumors or malignancies? 1. Cardiology 2. Podiatry 3. Oncology 4. Endocrinology ANS: 3 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 4. Discuss the plan of care for the patient receiving chemotherapy and/or radiation. Page: 144 Heading: Introduction to Cancer Concepts Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Comprehension (Understanding) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Cardiology deals with the heart and diseases effecting the heart. 2 Podiatry deals with the feet and problems occurring in the feet. 3 This definition describes oncology. 4 Endocrinology deals with the study of the endocrine system and problems that arise. PTS:

CON: Cellular Regulation

2. A patient is diagnosed with a malignant tumor of the bone. Which term should the nurse consider when documenting this patient’s health problem? 1. Sarcoma 2. Osteoma 3. Adenoma 4. Carcinoma ANS: 1 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 1. Explain the structures and functions of the normal cell wall. Page: 148 Heading: Tumor Descriptions (Table 11.2) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Comprehension (Understanding) Concept: Cellular Regulation Difficulty: Moderate

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1 2 3 4

Feedback Cancer cells affecting connective tissue, including fat, the sheath that contains nerves, cartilage, muscle, and bone, are called sarcomas. Osteomas are benign. Adenomas originate from glandular tissue. Neoplasms occurring in the epithelial cells are called carcinomas.

PTS:

CON: Cellular Regulation

3. A patient who has been treated for breast cancer is undergoing routine laboratory work. Which laboratory finding would cause the nurse to be most concerned about metastasis? 1. Elevated serum calcium 2. Decreased serum calcium 3. Elevated serum potassium 4. Decreased serum potassium ANS: 1 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 2. Describe changes that occur in a cell when it becomes malignant. Page: 152 Heading: Hematologic System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS: Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Hypercalcemia is associated with the release of calcium into the blood from bone deterioration related to metastasis and is common in patients with metastasis; it often occurs with breast cancer. 2 A drop in calcium level does not indicate bone metastasis. 3 Potassium imbalances are not commonly associated with metastasis. 4 Potassium imbalances are not commonly associated with metastasis. PTS:

CON: Cellular Regulation

4. A patient with prostate cancer asks the nurse the meaning of his high prostate-specific antigen (PSA) level. Which response by the nurse is correct? 1. “PSA is a tumor marker that is elevated in patients with prostate cancer.” 2. “PSA levels are done routinely to determine whether your prostate cancer has spread to a new site.” 3. “The doctor orders PSA measurements to monitor the level of chemotherapy medication in your blood.” 4. “A PSA test allows the pathologist to view the cancer cells under the microscope to monitor the progression of cancer.” ANS: 1 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 5. Identify data to collect when caring for a patient with cancer.

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Page: 153 Heading: Tumor Markers and Associated Cancers (Table 11.3) Integrated Process: Communication and Documentation Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 PSA is a tumor marker. Tumor markers, also called biochemical markers, are proteins, antigens, genes, hormones, and enzymes produced and secreted by tumor cells. Tumor markers help confirm a diagnosis of cancer, detect cancer origin, monitor the effect of cancer therapy, and determine cancer remission. 2 The PSA level does not determine if the cancer has spread to a new site. 3 PSA may monitor effectiveness of treatment, but it does not monitor blood levels of chemotherapy. 4 The PSA level does not view cancer cells to monitor the progression of cancer. PTS:

CON: Cellular Regulation

5. A patient asks the nurse what is meant by the term benign. Which response by the nurse is best? 1. “Benign tumors spread to other organs and lymph nodes.” 2. “An organ with a benign tumor will continue to function normally” 3. “It is a cluster of cells not normal to the body and is cancerous.” 4. “These types of tumors grow much quicker than cancer cells.” ANS: 2 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 2. Describe changes that occur in a cell when it becomes malignant. Page: 144 Heading: Benign Tumors Integrated Process: Communication and Documentation Client Need: PHYS—Physiological Adaptation Cognitive Level: Comprehension (Understanding) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Malignant tumors spread to other organs. 2 This statement regarding benign tumors is accurate. 3 Benign tumors are not cancerous. 4 These tumors grow much slower than cancer cells. PTS:

CON: Cellular Regulation

6. A patient with cancer is scheduled for palliative surgery. Which explanation should the nurse use to describe the purpose of this surgery? 1. Palliative surgery is done to reconstruct tissues damaged by the cancer. 2. Palliative surgery is done to increase the patient’s comfort when cure is not possible.

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3. Palliative surgery is done to remove a cancer completely and increase the chances for cure. 4. Palliative surgery is done to remove surrounding lymph nodes, reducing the risk for spread of the primary tumor. ANS: 2 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 4. Discuss the plan of care for the patient receiving chemotherapy and/or radiation therapy. Page: 153 Heading: Surgery Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Reconstructive surgery can be done for cosmetic enhancement or for return of function of a body part. 2 The goals of palliative surgery are to increase comfort and quality of life. 3 It is not done to treat or cure the cancer. 4 It is not done to treat or cure the cancer. PTS:

CON: Cellular Regulation

7. The nurse is caring for a patient who is receiving chemotherapy for breast cancer and states she is too nauseated to eat. Which intervention should the nurse implement first? 1. Prepare to start the patient on total parenteral nutrition (TPN). 2. Encourage the patient to brush her teeth before eating. 3. Administer promethazine (Phenergan) 1 hour before meals as ordered. 4. Bring the patient food she enjoys eating. ANS: 3 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 4. Discuss the plan of care for the patient receiving chemotherapy and/or radiation therapy. Page: 154 Heading: Expected Outcome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 The patient may not require TPN if antiemetics help relieve nausea. 2 Oral care does not help relieve nausea. 3 Antiemetics before meals may make it easier for the patient to eat. 4 It won’t matter if it is food the patient enjoys; if she is nauseated, she cannot eat.

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PTS:

CON: Cellular Regulation

8. The nurse is caring for a patient receiving chemotherapy who is in the nadir period. For which complication is the nurse at risk? 1. Infection 2. Stomatitis 3. Alopecia 4. Diarrhea ANS: 1 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 6. Recognize common oncological emergencies and related nursing care. Page: 160 Heading: Hematologic System Integrated Process: Clinical Problem Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Patients in the nadir period are at risk for infection, thrombocytopenia, and anemia. 2 Stomatitis is a complication of chemotherapy, but not a complication caused by low blood counts. 3 Alopecia is a complication of chemotherapy, but not caused by low blood counts. 4 Diarrhea is a complication of chemotherapy, but not caused by low blood counts. PTS:

CON: Cellular Regulation

9. The nurse is caring for a patient with cancer of the lymph tissue. What is the correct term for this cancer? 1. Melanoma 2. Sarcoma 3. Lymphoma 4. Carcinoma ANS: 3 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 2. Describe changes that occur in a cell when it becomes malignant. Page: 148 Heading: Tumor Descriptions (Table 11.2) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Moderate

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1 2 3 4

Feedback Melanoma is cancer of the skin cells. Sarcoma is cancer of the connective tissue, including bone and muscle. Lymphoma is cancer of the lymph tissue. Carcinoma is cancer of the tissue of the skin and glands and digestive, urinary, and respiratory tract linings.

PTS:

CON: Cellular Regulation

10. The nurse is caring for a patient with lung cancer who reports chest pain, dyspnea, facial redness, and swollen neck veins. Which oncological emergency does the nurse suspect this patient is experiencing? 1. Thrombocytopenia 2. Spinal cord compression 3. Superior vena cava syndrome (SVCS) 4. Hypercalcemia ANS: 3 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 6. Recognize common oncological emergencies and related nursing care. Page: 167 Heading: Superior Vena Cava Syndrome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 These are clinical manifestations of SVCS, not thrombocytopenia. 2 These are clinical manifestations of SVCS, not spinal cord compression. 3 These are clinical manifestations of SVCS. 4 These are clinical manifestations of SVCS, not hypercalcemia. PTS:

CON: Cellular Regulation

11. The IV line of a patient receiving a vesicant chemotherapy agent has disconnected and is lying on the floor. The medication is dripping all over the floor. Which action should the nurse take first? 1. Reconnect the IV tubing immediately. 2. Wipe it up as quickly as possible with disposable cloths. 3. No special precautions are needed for vesicant drug cleanups. 4. Use gloves and a protective gown to clean the spill according to agency policy. ANS: 4 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 3. Identify commonly used chemotherapeutic agents. Page: 156 Heading: Chemotherapy Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 An IV tube that is lying on the floor is no longer sterile and should not be reconnected. New tubing will be needed. 2 Disposable cloths are not used to clean a vesicant medication. 3 Special precautions are needed. 4 Chemotherapy agents are toxic and can be harmful to health care workers cleaning up spills. Agency policy, which will include protecting the nurse, should be followed when cleaning up the spill. PTS:

CON: Cellular Regulation

12. When inspecting the IV site of a patient receiving a vesicant chemotherapy agent, the licensed practical nurse (LPN) notes a small area of swelling. What should the LPN do first? 1. Check the site every hour. 2. Document the finding in the chart. 3. Discontinue the infusion and notify the registered nurse (RN). 4. No action is needed; this is an expected finding. ANS: 3 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 3. Identify commonly used chemotherapeutic agents. Page: 156 Heading: Chemotherapy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Serious damage can occur if the nurse takes time to document or rechecks in an hour. 2 Serious damage can occur if the nurse takes time to document or rechecks in an hour. 3 Vesicant drugs cause blistering of tissue, eventually leading to necrosis if the drugs infiltrate soft tissue by leaking out of the blood vessel. If this occurs, the infusion must be stopped immediately. 4 Serious damage can occur if the nurse takes time to document or rechecks in an hour. PTS:

CON: Cellular Regulation

13. The nurse is reviewing orders for a patient with suspected cancer. The nurse notes an order for a carcinoembryonic antigen (CEA). For which cancer does this test? 1. Breast cancer 2. Liver cancer

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3. Colon cancer 4. Ovarian cancer ANS: 3 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 5. Identify data to collect when caring for a patient with cancer. Page: 153 Heading: Tumor Markers and Associated Cancers (Table 11.3) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 CA 15-3 is a tumor marker for breast cancer. 2 AFP and CA 125 are tumor markers for liver cancer. 3 CEA is the tumor marker for colon and rectal cancers. 4 CA 125 is the tumor marker for ovarian cancer. PTS:

CON: Cellular Regulation

14. A patient on chemotherapy after surgery develops thrombocytopenia. Which manifestation should the nurse report immediately to the physician? 1. Headache 2. Tarry stools 3. Pain at the surgical site 4. Blood pressure 136/88 mm Hg ANS: 2 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 4. Discuss the plan of care for the patient receiving chemotherapy and/or radiation therapy. Page: 160 Heading: Expected Outcome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 This may be a problem also, but it is not life threatening and is therefore lower priority. 2 Tarry stools are a sign of gastrointestinal bleeding for which the patient with low platelets is at risk. 3 This may be a problem also, but it is not life threatening and is therefore lower priority. 4 This may be a problem also, but it is not life threatening and is therefore lower priority.

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PTS:

CON: Cellular Regulation

15. The nurse is reviewing orders for a patient receiving doxorubicin (Adriamycin). Which order should the nurse anticipate implementing before starting the chemotherapy? 1. A positron emission tomography (PET) scan 2. Kidney function tests 3. A chest x-ray 4. An echocardiogram ANS: 4 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 4. Identify commonly used chemotherapeutic agents. Page: 160 Heading: Injectable Chemotherapy Medications (Table 11.6) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 A PET scan may be done, but is not a priority. 2 Kidney function tests are important, but an echocardiogram is priority. 3 A chest x-ray is not required before beginning chemotherapy. 4 This medication can cause cardiac complications; a baseline echocardiogram is essential. PTS:

CON: Cellular Regulation

16. The nurse is planning care for a patient with leukopenia caused by chemotherapy. Which nursing intervention is most important for the nurse to include in this patient’s plan of care? 1. Protect the patient from injury. 2. Observe for bruising or bleeding. 3. Ensure that staff members practice good hand washing. 4. Assist the patient with activities of daily living (ADLs). ANS: 3 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 4. Discuss the plan of care for the patient receiving chemotherapy and/or radiation therapy. Page: 163 Heading: Expected Outcome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Bruising and bleeding and the resulting need for protection from injury result from low platelet count.

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2 3 4

Bruising and bleeding and the resulting need for protection from injury result from low platelet count. Leukopenia is low white blood cell (WBC) count, which places the patient at risk for infection. Hand washing is the best defense against infection. Patients with low red blood cell counts are often fatigued and need assistance with ADLs.

PTS:

CON: Cellular Regulation

17. A patient develops fatigue related to radiation therapy. Which intervention is the most appropriate for this patient? 1. Discuss the patient’s views concerning blood transfusion. 2. Encourage moderate exercise between radiation treatments. 3. Encourage larger portions of foods rich with calories and protein. 4. Encourage the patient to prioritize activities around frequent rest periods. ANS: 4 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 4. Discuss the plan of care for the patient receiving chemotherapy and/or radiation therapy. Page: 154 Heading: Nursing Care of the Patient Receiving Radiation Treatment Integrated Process: Clinical Problem-Solving Process Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 It is not the nurse’s role to diagnose need for blood transfusion. 2 Exercise is not appropriate at this time. 3 Food may be appropriate if the patient has lost weight, but there is no evidence of weight loss in the data. 4 Spacing activities with rest can help the patient have the energy to do activities that are important to him or her. PTS:

CON: Cellular Regulation

18. The nurse is providing education to a patient taking tamoxifen (Nolvadex). Which topic should the nurse include in the teaching? 1. Avoid antacids within 2 hours of tamoxifen. 2. Take with mesna (Mesnex) to protect the bladder. 3. Monitor daily weights. 4. Watch for changes in neurologic status. ANS: 1 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 6. Recognize common oncological emergencies and related nursing care. Page: 159 Heading: Oncological Emergencies

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Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Evaluation (Evaluating) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 The patient should avoid antacids within 2 hours of Tamoxifen. 2 Mesna is not used in conjunction with Tamoxifen. 3 It is not necessary to monitor weight while on Tamoxifen. 4 Altered neurologic status is not common in Tamoxifen. PTS:

CON: Cellular Regulation

19. The nurse is caring for a group of patients. Which patient should the nurse see first? 1. A patient with a calcium level of 9.2 mg/dL 2. A patient with a platelet level of 250,000/mm3 3. A patient with a white blood cell count of 2,000 cells/µL 4. A patient with a hemoglobin of 14.5g/dL ANS: 3 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 5. Identify data to collect when caring for a patient with cancer. Page: 152 Heading: Hematological System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Difficult Feedback 1 Calcium level is normal. 2 Platelet level is normal. 3 The WBC count is low; this patient should be seen first. 4 The hemoglobin is normal. PTS:

CON: Cellular Regulation

20. The nurse is providing teaching for a patient with thrombocytopenia. Which statement made by the patient indicates a need for further teaching? 1. “I should avoid taking my daily aspirin while my platelets are low.” 2. “I should use an electric razor instead of a regular one.” 3. “I will be careful when I blow my nose.” 4. “I need to be sure and floss every day.” ANS: 4 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 4. Discuss the plan of care for the patient receiving chemotherapy and/or radiation therapy. Page: 160

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Heading: Expected Outcome Integrated Process: Teaching/Learning Client Need: SECE—Safety and Infection Control Cognitive Level: Evaluation (Evaluating) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 This statement indicates teaching has been effective. 2 This statement indicates teaching has been effective. 3 This statement indicates teaching has been effective. 4 The patient should avoid flossing or brushing with a hard-bristle toothbrush. PTS:

CON: Cellular Regulation

21. The nurse is providing education regarding skin care to a patient undergoing radiation therapy. Which statement made by the patient indicates a need for further teaching? 1. “I should wear tight clothing to protect my skin.” 2. “I will wear a hat and use sunscreen when going outside.” 3. “I need to be careful to not wash off the radiation markings.” 4. “I will avoid using baby powder after my shower.” ANS: 1 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 4. Discuss the plan of care for the patient receiving chemotherapy and/or radiation therapy. Page: 154 Heading: Skin Reactions Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Tight clothing should be avoided. This statement requires further teaching. 2 This statement is correct; no further teaching is required. 3 This statement is correct; no further teaching is required. 4 This statement is correct; no further teaching is required. PTS:

CON: Cellular Regulation

22. The nurse is reviewing laboratory results and becomes concerned about one patient being treated for cancer. Which patient does the nurse suspect is in need of nutritional support? 1. An 18-year-old with an albumin of 2.5 g/dL 2. A 60-year-old with a calcium level of 8 mg/dL 3. A 43-year-old with a platelet level of 180,000/mm3 4. A 56-year-old with a white cell count of 6,000/mm3 ANS: 1 Chapter: Chapter 11. Nursing Care of Patients With Cancer

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Objective: 4. Discuss the plan of care for the patient receiving chemotherapy and/or radiation therapy. Page: 165 Heading: Expected Outcome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 Serum albumin less than 3 g/dL indicates poor nutrition and possible need for nutritional support. 2 Calcium levels, platelet levels, and WBC counts are not used to determine if nutritional support is needed. 3 Calcium levels, platelet levels, and WBC counts are not used to determine if nutritional support is needed. 4 Calcium levels, platelet levels, and WBC counts are not used to determine if nutritional support is needed. PTS:

CON: Cellular Regulation

23. The nurse is preparing an oral chemotherapeutic medication for a patient’s cancer treatment. What should the nurse do to ensure personal safety when preparing this medication? 1. Wear gloves while preparing. 2. Wash hands before administering. 3. Apply a lead apron when providing. 4. Crush the medication before providing. ANS: 1 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 3. Identify commonly used chemotherapeutic agents. Page: 156 Heading: Routes of Administration Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 The nurse administering oral chemotherapy should wear chemotherapy safety gloves. 2 Washing hands before administering will not ensure personal safety when preparing this medication. 3 A lead apron is not necessary when preparing oral chemotherapy medication. 4 Oral chemotherapy pills should never be crushed or broken. PTS:

CON: Cellular Regulation

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24. The nurse is caring for a patient who is prescribed cyclophosphamide (Cytoxan). Which medication should the nurse expect to administer to protect the bladder? 1. Dexrazoxane (Zinecard) 2. Mesna (Mesnex) 3. Filgrastim (Neupogen) 4. Doxorubicin (Adriamycin) ANS: 2 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 3. Identify commonly used chemotherapeutic agents. Page: 157 Heading: Cytoprotective Agents Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Difficult Feedback 1 Dexrazoxane (Zinecard) is used to protect the heart. 2 Mesna (Mesnex) is given to protect the bladder. 3 Filgrastim (Neupogen) is given to stimulate proliferation of stem cells into granulocytes (neutrophils). 4 Doxorubicin (Adriamycin) is an antitumor antibiotic. PTS:

CON: Cellular Regulation

MULTIPLE RESPONSE 1. The nurse is providing dietary teaching to help a patient reduce the risk of cancer. Which foods should the nurse instruct the patient to avoid? (Select all that apply.) 1. Alcohol 2. Whole grains 3. Smoked meats 4. Root vegetables 5. Charbroiled meat 6. Cruciferous vegetables ANS: 1, 3, 5 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 4. Discuss the plan of care for the patient receiving chemotherapy and/or radiation therapy. Page: 147 Heading: Risk Factors Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Moderate

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2. 3.

4. 5.

6. PTS:

Feedback Individuals should limit excessive meat, especially when smoked, salted, charbroiled, or cooked at high temperatures; excessive fat; excessive calories; and alcohol. Cruciferous vegetables and whole grains are encouraged. Individuals should limit excessive meat, especially when smoked, salted, charbroiled, or cooked at high temperatures; excessive fat; excessive calories; and alcohol. Root vegetables are neither encouraged nor discouraged in regard to cancer risk. Individuals should limit excessive meat, especially when smoked, salted, charbroiled, or cooked at high temperatures; excessive fat; excessive calories; and alcohol. Cruciferous vegetables and whole grains are encouraged. 1

CON: Cellular Regulation

2. The nurse is planning a teaching seminar for members of a Native American tribal community on ways to prevent the development of cancer. What should the nurse include in this teaching? (Select all that apply.) 1. Encourage traditional customs of physical fitness and exercise. 2. Provide teaching materials in the participants’ native language. 3. Identify healing practices that can be incorporated into tribal customs. 4. Emphasize the use of same-sex caregivers when seeking preventive care. 5. Discuss the importance of dietary portion control and healthy food preparation. ANS: 1, 3, 5 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 5. Identify data to collect when caring for a patient with cancer. Page: 147 Heading: Risk Factors Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Moderate

Feedback Teaching to decrease cancer risk among Native American populations should include encouraging traditional customs of physical fitness and exercise, identify healing practices that can be incorporated into tribal customs, and discussing the importance of dietary portion control and healthy food preparation. Teaching materials in the participants’ native language is not as important, since there is less of a language barrier when caring for individuals of Native American descent. Teaching to decrease cancer risk among Native American populations should include encouraging traditional customs of physical fitness and exercise, identify healing practices that can be incorporated into tribal customs, and

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4. 5.

PTS:

discussing the importance of dietary portion control and healthy food preparation. Same-sex caregivers is not a major concern with caring for individuals of Native American descent. Teaching to decrease cancer risk among Native American populations should include encouraging traditional customs of physical fitness and exercise, identify healing practices that can be incorporated into tribal customs, and discussing the importance of dietary portion control and healthy food preparation. 1

CON: Cellular Regulation

COMPLETION 1. The nurse is preparing to administer D5W 500 mL over 8 hours to a patient receiving chemotherapy experiencing nausea. The nurse is using a 15 gtt/mL set. Calculate the flow rate. Enter the numeral only. Round to the nearest whole number. ANS: 16 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 4. Discuss the plan of care for the patient receiving chemotherapy and/or radiation therapy. Page: 147 Heading: Nursing Care Plan for the Patient With Cancer Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Moderate Feedback: gtt/min = 15 gtt/mL × 500 mL/8 hr × 1 hr/60 min = 15.6 = 16 gtt/min PTS:

CON: Cellular Regulation

2. The nurse is preparing to administer ondansetron (Zofran) 4 mg intravenously. The available dose is 2mg/mL. How many mL will the nurse administer? Enter the numeral only. ANS: 2 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 4. Discuss the plan of care for the patient receiving chemotherapy and/or radiation therapy. Page: 147 Heading: Nursing Care Plan for the Patient With Cancer Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing)

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Concept: Cellular Regulation Difficulty: Moderate Feedback: mL = 1 mL/2 mg × 4 mg = 2 mL PTS:

CON: Cellular Regulation

3. The nurse is preparing to administer epoetin alfa (Procrit) to a patient with anemia. The prescribed dose is 50 units/kg to a patient who weighs 60 kg. The available dose is 3,000 units/mL. How many mL will the nurse administer? Enter the numeral only. ANS: 1 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 3. Identify commonly used chemotherapeutic agents. Page: 155 Heading: Colony-Stimulating Factors (Table 11.5) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Difficult Feedback: Multiply 50 × 60, which equals 3,000 units. The available dose is 3,000 units/mL. The nurse will administer 1 mL. PTS:

CON: Cellular Regulation

ORDERED RESPONSE 1. The nurse is caring for a group of patients. Place in order, from 1 to 5, the nurse should see the patients. 1. A patient who underwent a mastectomy awaiting discharge teaching 2. A patient with multiple myeloma who just received a blood transfusion 3. A patient with neutropenia who has a fever of 102.8°F 4. A patient with thrombocytopenia who received two units of platelets 5. A patient with colon cancer reporting level 6 pain on a 0-to-10 scale ANS: 3, 5, 4, 2, 1 Chapter: Chapter 11. Nursing Care of Patients With Cancer Objective: 6. Recognize common oncological emergencies and related nursing care. Page: 161 Heading: Nursing Care Plan for the Patient With Cancer Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Moderate

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Feedback: The neutropenic patient with a fever should be seen first. The patient with colon cancer reporting level 6 pain will be seen second followed by the patient with thrombocytopenia who received two units of platelets (risk for injury). The patient with multiple myeloma who received a blood transfusion should be seen fourth, and finally, the patient who underwent a mastectomy who is awaiting discharge teaching should be seen last. PTS:

CON: Cellular Regulation

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Chapter 12. Nursing Care of Patients Having Surgery MULTIPLE CHOICE 1. A patient who is NPO (nothing by mouth) for scheduled surgery has been on long-term oral steroid therapy and should receive a dose of Prednisone 10 mg by mouth at 0600. Which action should the nurse take? 1. Notify the registered nurse (RN). 2. Ask why the patient is taking steroid therapy. 3. Give the oral steroid with a small sip of water. 4. Contact the pharmacy to obtain an IV equivalent dose. ANS: 1 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 2. Identify the role of the licensed practical nurse/licensed vocational nurse (LPN/LVN) in each perioperative phase. Page: 177 Heading: Preoperative Instructions and Preparations Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 Patients on chronic oral steroid therapy cannot abruptly stop their medication even though they are told to take nothing by mouth before or after surgery. Serious complications, such as circulatory collapse, can develop if steroids are stopped abruptly. The RN should be notified and will need to clarify the medication with the physician. It is anticipated that the physician will order the patient’s steroid therapy to be given by a parenteral route as the patient is NPO. 2 Asking why the medication has been prescribed does not address the problem. 3 The nurse cannot provide the medication since the patient is prescribed to be NPO. 4 Pharmacists cannot convert oral steroid doses to IV doses without an order from the physician. PTS:

CON: Safety

2. A patient recovering from an abdominal hysterectomy is experiencing abdominal gas pain. Which action should the nurse take? 1. Offer a hot beverage. 2. Provide an extra blanket. 3. Help the patient ambulate. 4. Apply an abdominal binder. ANS: 3 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 5. Identify nursing interventions used for common postoperative patient needs.

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Page: 193 Heading: Expected Outcome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Elimination Difficulty: Moderate Feedback 1 A hot beverage, extra blanket, or abdominal binder will not help relieve the patient’s abdominal gas pains. 2 A hot beverage, extra blanket, or abdominal binder will not help relieve the patient’s abdominal gas pains. 3 If gas pains occur, encourage ambulation, have patient lie prone, and pull the knees up to the chest to relieve pain. Encouraging early ambulation helps promote restoration of gastrointestinal (GI) functioning, which is the goal and will help relieve the gas pains. 4 A hot beverage, extra blanket, or abdominal binder will not help relieve the patient’s abdominal gas pains. PTS:

CON: Elimination

3. The nurse answers a patient’s call light and finds the patient sitting up in bed with a wound evisceration. What action should the nurse take first? 1. Notify the physician immediately. 2. Prepare the patient for immediate surgery. 3. Place the patient in low Fowler position. 4. Cover the wound with sterile saline-soaked towels. ANS: 3 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 7. List signs and symptoms of common postoperative complications. Page: 196 Heading: Wound Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate

2 3 4

Feedback The nurse should notify the physician but first needs to get the patient in low Fowler position and cover the wound with sterile dressings to prevent further injury. Preparing the patient for surgery to close the wound occurs after the patient is stabilized and assessed. The nurse should first place the patient in low Fowler position with flexed knees. The nurse should cover the wound with sterile dressings or towels moistened with warm sterile normal saline after the patient has been placed in low Fowler

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position. PTS:

CON: Safety

4. The nurse is reviewing laboratory values for a patient who will undergo surgery. Which value requires notification of the surgeon? 1. Blood urea nitrogen (BUN) of 12 mg/dL 2. Glucose of 383 mg/dL 3. Potassium of 4.1 mEq/L 4. Sodium of 140 mEq/L ANS: 2 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 2. Explain the role of the licensed practical nurse/licensed vocational nurse (LPN/LVN) in each perioperative phase. Page: 175 Heading: Preoperative Diagnostic Tests (Table 12.4) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 The BUN is normal. 2 The glucose is high, and the surgeon should be notified. 3 Potassium is normal. 4 Sodium is normal. PTS:

CON: Metabolism

5. The licensed practical nurse/licensed vocational nurse (LPN/LVN) is working in the postoperative care unit. Which assessment finding should be reported to the RN? 1. Oxygen saturation of 82% 2. Temperature of 99.1°F 3. Pulse of 74 beats/min 4. Blood pressure 112/64 mm Hg ANS: 1 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 7. List signs and symptoms of common postoperative complications. Page: 187 Heading: Expected Outcome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Oxygenation Difficulty: Moderate Feedback 1 This oxygen level is very low and should be reported to the RN.

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2 3 4

This temperature is normal postoperatively. This pulse is normal postoperatively. This blood pressure is normal postoperatively. PTS:

CON: Oxygenation

6. The nurse is caring for a patient who is about to undergo a mastectomy. The nurse notes that the patient has not signed the consent. The patient tells the nurse, “The doctor didn’t explain the risks of the surgery to me.” Which action should the nurse take? 1. Read the consent to the patient, ask if he or she has questions, then have him or her sign. 2. Explain the risks and benefits of surgery to the patient and have him or her sign. 3. Sign the consent for the patient since the nurse was present during explanation. 4. Notify the surgeon and inform him or her the patient has not signed the form and does not understand the surgery. ANS: 4 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 3. Explain the role of the LPN/LVN in obtaining informed consent. Page: 179 Heading: Preoperative Consent Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Legal Difficulty: Moderate Feedback 1 The nurse cannot explain the procedure and obtain consent. 2 If the patient does not understand the procedure, the nurse must notify the surgeon. 3 The nurse cannot sign the consent if the patient states her or she does not understand. 4 The nurse should notify the surgeon that the patient has questions and has not signed the consent. PTS:

CON: Legal

7. The nurse is caring for a patient who underwent a colostomy yesterday morning. The nurse removed the catheter 1 hour after surgery, and the patient has not yet voided. Which action should the nurse take? 1. Reinsert the indwelling urinary catheter. 2. Notify the health care provider (HCP). 3. Perform an in-and-out catheterization. 4. Massage the patient’s bladder. ANS: 2 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 5. Identify nursing interventions used for common postoperative patient needs. Pages: 193–194

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Heading: Nursing Diagnoses, Planning, Implementation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Elimination Difficulty: Moderate Feedback 1 The nurse needs to have an order to reinsert the indwelling catheter. 2 The nurse should notify the HCP for orders. 3 The nurse needs an order for the in-and-out catheterization. 4 The patient is likely sore from abdominal surgery; massaging the bladder will cause discomfort. PTS:

CON: Elimination

8. The nurse is caring for a group of patients about to undergo surgery. Which patient is at highest risk for surgical complications? 1. A 32-year-old who plays volleyball daily 2. A 41-year-old who occasionally drinks 3. A 52-year-old construction worker who is vegan 4. A 65-year-old who smokes pack per day ANS: 4 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 1. Describe factors that influence surgical outcomes. Page: 174 Heading: Smoking and Alcohol and/or Drug Abuse Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate

1 2 3 4

Feedback This patient is young and active, not high risk for complications. This patient is not at high risk. This patient is not at high risk. This patient has two risk factors: age and smoker. PTS:

CON: Patient-Centered Care

9. The nurse is caring for a patient who has developed an increased temperature during the first 24 hours postoperatively. Which action should the nurse take? 1. Restrict oral fluids. 2. Give antipyretic medication. 3. Encourage coughing and deep breathing. 4. Provide passive range of motion exercises. ANS: 3

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Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 7. List signs and symptoms of common postoperative complications. Page: 187 Heading: Expected Outcome Integrated Process: Clinical Problem Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 Fluids should be encouraged as ordered, as dehydration can increase temperature. 2 Antipyretic medication does not affect the cause. 3 Usually, increased temperature during the first 24 hours postoperatively indicates atelectasis if no other cause exists, so coughing and deep breathing should be encouraged to open the alveoli and prevent pneumonia. 4 Range of motion exercises will not affect the temperature. PTS:

CON: Infection

10. The nurse is taking a medication history of a patient who is to undergo surgery the next morning. Which medication requires immediate notification of the surgeon? 1. Warfarin (Coumadin) 2. Regular insulin 3. Atenolol (Tenormin) 4. Gabapentin (Neurontin) ANS: 1 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 1. Describe factors that influences surgical outcomes. Page: 177 Heading: Preoperative Instructions and Preparation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1 The surgeon should be notified of any patient taking a blood thinner. 2 Regular insulin does not require immediate notification of the surgeon. 3 Atenolol does not require immediate notification of the surgeon. 4 Neurontin does not require immediate notification of the surgeon. PTS:

CON: Safety

11. The LPN/LVN is assisting in the operating room (OR). Which practice requires correction by the nurse? 1. The surgical technician is scrubbing for the OR while wearing a ring. 2. The scrub technician is wearing surgical scrubs, shoe covers, a cap, and a mask.

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3. The circulating nurse sets the temperature of the OR to 74.6°F. 4. The surgeon removes his watch prior to scrubbing for the surgery. ANS: 1 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 2. Identify the role of the licensed practical nurse/licensed vocational nurse (LPN/LVN) in each perioperative phase. Page: 184 Heading: Intraoperative Phase Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1 All jewelry should be removed prior to scrubbing. 2 This is appropriate OR attire. 3 This is an appropriate temperature for the OR. 4 All jewelry should be removed prior to scrubbing. PTS:

CON: Safety

12. The LPN/LVN is taking a history on a patient who is scheduled for surgery in which he was to remain NPO after midnight. The nurse asks the patient when he last had something to eat, to which the patient replies, “About 2 hours ago.” Which action should the nurse take? 1. Document the response and send the patient to surgery. 2. Notify the surgeon immediately. 3. Tell the patient to come back that afternoon. 4. Ask the patient what he ate; liquids are okay. ANS: 2 Chapter: Chapter12. Nursing Care of Patients Having Surgery Objective: 1. Describe factors that influence surgical outcomes. Page: 176 Heading: Preoperative Instructions and Preparation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 The surgeon must be notified; if the patient is receiving general anesthesia, surgery may need to be rescheduled. 2 The patient was NPO after midnight but ate 2 hours before surgery. The surgeon should be notified, as the surgery may be rescheduled. 3 It is not the role of the nurse to determine if surgery is to be rescheduled. 4 The nurse should still notify the surgeon. PTS:

CON: Safety

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13. The nurse is assisting during surgery when a patient develops malignant hyperthermia. Which protocol should the nurse prepare to assist with as directed? 1. Administer oxygen and continue the anesthesia and surgery. 2. Warm the patient, administer fluids, and then continue surgery. 3. Switch to a different type of anesthetic agent to continue the surgery. 4. Immediately cease anesthesia and surgery, cool patient, and administer dantrolene sodium. ANS: 4 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 7. List signs and symptoms of common postoperative complications. Page: 186 Heading: Cardiovascular Function Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Thermoregulation Difficulty: Moderate Feedback 1 These protocols are not appropriate for the patient experiencing malignant hyperthermia. 2 These protocols are not appropriate for the patient experiencing malignant hyperthermia. 3 These protocols are not appropriate for the patient experiencing malignant hyperthermia. 4 With malignant hyperthermia, surgery is stopped and anesthesia is discontinued immediately. Oxygen is given and the patient is cooled. Dantrolene sodium (Dantrium), a muscle relaxant, is given. PTS:

CON: Thermoregulation

14. The nurse is teaching a patient about following a high-protein diet before and after surgery to promote healing. Which food choice made by the patient indicates an understanding of the teaching? 1. One large apple and a plate of leafy greens 2. One small grilled chicken breast with one small egg 3. cup of rice and cup of broccoli 4. 1 cup of pasta with no sauce and a slice of bread ANS: 2 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 6. Describe how to evaluate effectiveness of nursing interventions. Page: 198 Heading: Nutrition Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Nutrition

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Difficulty: Moderate

1 2 3 4

Feedback This food choice is low in protein. This food choice is high in protein. This food choice is low in protein. This food choice is low in protein. PTS:

CON: Nutrition

15. The nurse is caring for a patient with stage IV lung cancer who is preparing to undergo surgery. What is most likely the purpose of the surgery? 1. Reconstructive 2. Curative 3. Diagnostic 4. Palliative ANS: 4 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 1. Describe factors that influence surgical outcomes. Page: 171 Heading: Surgery Urgency Level and Purpose (Table 12.2) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Analysis (Analyzing) Concept: Comfort Difficulty: Moderate Feedback 1 The purpose of the surgery is not reconstructive. 2 The purpose of the surgery is not curative. 3 The purpose of the surgery is not diagnostic. 4 This patient is undergoing palliative surgery. For this patient, it may be reducing tumor size to aid in breathing. PTS:

CON: Comfort

16. The nurse is caring for a patient after ambulatory surgery. Which oxygen saturation level should the nurse use as evidence that the patient is ready for discharge? 1. 70%-79% 2. 80%-85% 3. 86%-90% 4. Above 90% ANS: 4 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 8. List criteria for ambulatory discharge. Page: 189 Heading: Discharge Criteria Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: PHYS—Physiological Adaptation Cognitive Level: Evaluation (Evaluating) Concept: Oxygenation Difficulty: Moderate Feedback 1 These oxygen saturation levels do not meet the criteria to discharge from the ambulatory surgical center. 2 These oxygen saturation levels do not meet the criteria to discharge from the ambulatory surgical center. 3 These oxygen saturation levels do not meet the criteria to discharge from the ambulatory surgical center. 4 Oxygen saturation must be above 90% for discharge. PTS:

CON: Oxygenation

17. The nurse is assisting in the surgical holding area. When should the nurse administer a prophylactic antibiotic to a patient? 1. During surgery 2. 1 hour prior to surgery 3. 4 hours prior to surgery 4. Within the first 2 hours postoperatively ANS: 2 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 2. Identify the role of the licensed practical nurse/licensed vocational nurse (LPN/LVN) in each perioperative phase. Page: 181 Heading: Preoperative Medications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 The antibiotic is to be given before the surgery begins. 2 Studies have shown that preventing surgical site infections include giving prophylactic antibiotics within 1 hour prior to surgery (which means the actual incision time). 3 This period of time is too long before the surgery begins. 4 An antibiotic given after the surgery would not be a prophylactic dose. PTS:

CON: Safety

18. A patient recovering from hernia repair surgery reports pain level of 4 on a 0-to-10 scale. The patient’s orders include ibuprofen (Motrin) 400 mg orally every 6 hours prn (as needed) for pain. Which action should the nurse take? 1. Give the ibuprofen as ordered for pain. 2. Consult the physician for a stronger analgesic. 3. Start the ibuprofen on the second postoperative day.

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4. Hold the ibuprofen due to risk of GI upset. ANS: 1 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 5. Identify nursing interventions used for common postoperative patient needs. Page: 193 Heading: Nursing Diagnoses, Planning, Implementation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Moderate Feedback 1 Ibuprofen can be effectively used for postoperative pain relief. 2 The nurse does not need to consult the physician since the patient’s pain level is 4. 3 The medication is prescribed ibuprofen, which the nurse should provide. 4 There is no evidence to suggest that the patient will experience GI upset from the medication. PTS:

CON: Comfort

19. Which procedure involves removal of an organ? 1. Endoscopy 2. Urostomy 3. Angioplasty 4. Gastrectomy ANS: 4 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 1. Describe factors that influence surgical outcomes. Page: 171 Heading: Surgical Procedure Suffixes (Table 12.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 -oscopy means “to look into.” 2 -ostomy is the formation of a permanent artificial opening. 3 -plasty involves formation or repair. 4 -ectomy means “removal.” PTS:

CON: Patient-Centered Care

20. A patient is preparing to undergo an appendectomy for a ruptured appendix. Which level of urgency is this surgery? 1. Elective

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2. Emergency 3. Urgent 4. Optional ANS: 2 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 1. Describe factors that influence surgical outcomes. Page: 171 Heading: Surgery Urgency Level and Purpose (Table 12.2) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Inflammation Difficulty: Moderate Feedback 1 An appendectomy is not elective surgery. 2 An appendectomy for a ruptured appendix is emergent surgery. 3 An appendectomy for a ruptured appendix is not an urgent surgery. 4 An appendectomy for a ruptured appendix is not an optional surgery. PTS:

CON: Inflammation

21. The nurse assesses a patient’s pain level to be an 8 on a 0-to-10 scale. The nurse notes the patient has an order for morphine 4 mg IV as needed for pain. The patient’s blood pressure is 80/54 mm Hg, respirations 10 breaths/min, and pulse 64 beats/min. Which action should the nurse take? 1. Tell the patient he cannot have any more pain medication. 2. Administer half the dose of morphine, 2 mg IV. 3. Administer 4 mg of morphine IV as ordered. 4. Notify the RN. ANS: 4 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 7. List the signs and symptoms of common postoperative complications. Page: 189 Heading: Nursing Diagnoses, Planning, Implementation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 The patient is in pain and needs something to relieve it. The nurse should notify the RN or HCP to determine an alternative to the morphine. 2 It is not within the nurse’s scope of practice to change the dose; in addition, the nurse should not give the morphine when the patient has hypotension and bradypnea. 3 The nurse should not administer 4 mg of morphine with a low blood pressure and respiratory rate.

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The LPN/LVN should notify the RN about the abnormal vital signs.

PTS:

CON: Safety

MULTIPLE RESPONSE 1. The nurse is caring for a postoperative patient at risk for deep vein thrombosis. Which actions should the nurse recommend be included in the patient’s plan of care? (Select all that apply.) 1. Assist with early ambulatation. 2. Apply anti-embolic stockings. 3. Massage the patient’s legs daily. 4. Place a pillow under the patient’s knees. 5. Perform leg exercises 10 times hourly while awake. ANS: 1, 2, 5 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 7. List signs and symptoms of common postoperative complications. Page: 191 Heading: Nursing Process for Postoperative Patients Integrated Process: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Communication Difficulty: Moderate

3. 4. 5.

PTS:

Feedback For the patient at risk of developing deep vein thrombosis, it is important to encourage hourly leg exercises while awake, assist with early ambulation, apply knee- or thigh-length anti-embolic stockings, and give low molecular weight heparin if ordered. For the patient at risk of developing deep vein thrombosis, it is important to encourage hourly leg exercises while awake, assist with early ambulation, apply knee- or thigh-length anti-embolic stockings, and give low molecular weight heparin if ordered. Legs should not be massaged, as a clot, if present, could be dislodged and become an embolus. It is important to avoid pressure under the knee from pillows to prevent clot formation. For the patient at risk of developing deep vein thrombosis, it is important to encourage hourly leg exercises while awake, assist with early ambulation, apply knee- or thigh-length anti-embolic stockings, and give low molecular weight heparin if ordered. 1

CON: Communication

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2. The nurse has reinforced preoperative teaching with a patient about coughing and deepbreathing techniques. Which patient statements indicate a correct understanding of the teaching? (Select all that apply.) 1. “I should avoid deep breathing after surgery.” 2. “I should take shallow breaths after surgery to prevent pain.” 3. “Deep breathing and coughing helps prevent respiratory problems.” 4. “I should deep breathe and cough every hour while awake.” 5. “I should cough and deep breathe beginning 2 days after my surgery.” ANS: 3, 4 Chapter: Chapter12. Nursing Care of Patients Having Surgery Objective: 5. Identify nursing interventions used for common postoperative patient needs. Page: 176 Heading: Preoperative Instructions and Preparation Integrated Process: Teaching/Learning Client Need: Psychosocial Integrity Cognitive Level: Evaluation (Evaluating) Concept: Communication Difficulty: Moderate

1. 2. 3.

5. PTS:

Feedback These exercises should be done after surgery. Shallow breaths are not recommended. Deep breathing helps prevent the development of atelectasis. Coughing moves secretions to prevent pneumonia. They are done hourly while the patient is awake for 24 to 48 hours postoperatively. Deep breathing helps prevent the development of atelectasis. Coughing moves secretions to prevent pneumonia. They are done hourly while the patient is awake for 24 to 48 hours postoperatively. This exercise should be done up to 2 days after the surgery. 1

CON: Communication

3. The nurse is reviewing preoperative orders for a patient scheduled for a surgical repair of the liver. Which laboratory values should the nurse ensure are ready and placed in the chart before surgery? (Select all that apply.) 1. Potassium 2. Complete blood count 3. Type and crossmatch 4. Bleeding time 5. Amylase 6. Thyroid-stimulating hormone ANS: 1, 2, 3, 4 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 2. Identify the role of the licensed practical nurse/licensed vocational nurse (LPN/LVN) in each perioperative phase. Page: 175 Heading: Preoperative Diagnostic Tests (Table 12.4) Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Safety Difficulty: Difficult

1. 2. 3. 4. 5. 6. PTS:

Feedback This laboratory value should be ordered before surgery. This laboratory value should be ordered before surgery. This laboratory value should be ordered before surgery. This laboratory value should be ordered before surgery. It is not necessary to review this laboratory before surgery. This is not a recommended laboratory value to order before surgery. 1

CON: Safety

4. The nurse is witnessing an adult patient’s surgical consent. What should the nurse confirm before witnessing the surgical consent? (Select all that apply.) 1. The patient’s next of kin 2. When the patient last ate or drank 3. The last time a sedative was administered 4. Whether the patient is informed about the surgery 5. If family members have questions related to the surgery ANS: 3, 4 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 3. Explain the role of the LPN/LVN in obtaining informed patient consent. Page: 179 Heading: Preoperative Consent Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Legal Difficulty: Moderate

Feedback The nurse does not need to confirm the patient’s next of kin, when the patient last ingested food or fluids, or if the family members have questions about the surgery. The nurse does not need to confirm the patient’s next of kin, when the patient last ingested food or fluids, or if the family members have questions about the surgery. As the patient’s advocate, ensure before the consent is signed that the patient is informed about the surgery and has no further questions for the physician. If the patient has questions, the consent should not be signed and the physician should be contacted to answer the patient’s questions. The consent cannot be signed if the patient is under the influence of sedatives or narcotics, so timing of their administration must be verified. As the patient’s advocate, ensure before the consent is signed that the patient is informed about the surgery and has no further questions for the physician.

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PTS:

If the patient has questions, the consent should not be signed and the physician should be contacted to answer the patient’s questions. The consent cannot be signed if the patient is under the influence of sedatives or narcotics, so timing of their administration must be verified. The nurse does not need to confirm the patient’s next of kin, when the patient last ingested food or fluids, or if the family members have questions about the surgery. 1

CON: Legal

5. The nurse is reinforcing discharge teaching for a patient who underwent abdominal surgery. Which statements made by the patient indicate an understanding of the teaching? (Select all that apply.) 1. “I will need to schedule a follow-up appointment with the surgeon.” 2. “I can remove my own stitches in a few days; I have seen the nurse remove my son’s.” 3. “If the pain medication does not help with the pain, I will take an extra dose.” 4. “I need to have my spouse help change my dressing every day.” 5. “I will let the doctor know if I run a fever after I go home.” ANS: 1, 4, 5 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 8. List the criteria for ambulatory discharge. Page: 197 Heading: Postoperative Patient Discharge Integrated Process: Teaching/Learning Client Need: Psychosocial Integrity Cognitive Level: Evaluation (Evaluating) Concept: Communication Difficulty: Moderate

1. 2. 3. 4. 5. PTS:

Feedback This statement indicates an understanding. The patient should allow the nurse or surgeon to remove sutures. The patient should notify the surgeon of unrelieved pain, not take an extra dose of medication. This statement indicates understanding. This statement indicates understanding. 1

CON: Communication

6. The nurse provides recommendations for the plan of care for a patient scheduled to undergo a cholecystectomy. Why should the nurse include preoperative teaching of deep-breathing exercises to prevent postoperative complications for this patient? (Select all that apply.) 1. Incisional pain promotes decreased lung expansion. 2. Anesthesia increases retention of respiratory secretions. 3. Anesthesia decreases production of respiratory secretions. 4. Location of incision contributes to decreased lung expansion. 5. Immobility after surgery promotes retention of respiratory secretions.

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ANS: 2, 4, 5 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 7. List signs and symptoms of common postoperative complications. Page: 197 Heading: Respiratory Function Integrated Process: Teaching/Learning Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Communication Difficulty: Moderate

1. 2.

3. 4.

PTS:

Feedback Incisional pain does not promote decreased lung expansion. Lung expansion is needed to prevent complications such as pneumonia. During anesthesia, the patient is not taking deep breaths, so secretions are not being mobilized. The high incisional location near the diaphragm will decrease the patient’s willingness to take deep breaths, especially if painful. Immobility from anesthesia and recovery promotes the retention of respiratory secretions. Anesthesia does not decrease the production of respiratory secretions. Lung expansion is needed to prevent complications such as pneumonia. During anesthesia, the patient is not taking deep breaths, so secretions are not being mobilized. The high incisional location near the diaphragm will decrease the patient’s willingness to take deep breaths, especially if painful. Immobility from anesthesia and recovery promotes the retention of respiratory secretions. Lung expansion is needed to prevent complications such as pneumonia. During anesthesia, the patient is not taking deep breaths, so secretions are not being mobilized. The high incisional location near the diaphragm will decrease the patient’s willingness to take deep breaths, especially if painful. Immobility from anesthesia and recovery promotes the retention of respiratory secretions. 1

CON: Communication

7. The nurse is contributing to an education program for older adults who are preparing for joint replacement surgery. Which interventions should the nurse use to enhance older patient learning? (Select all that apply.) 1. Avoid repetition in presentation. 2. Utilize medical terminology to promote understanding. 3. Provide handouts with black print on white nonglare paper. 4. Conduct session in a room with bright, fluorescent lighting. 5. Convey positive attitude and self-care promotion for older adults. ANS: 3, 5 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 4. Develop a teaching plan to enhance learning for the older preoperative patient. Page: 173 Heading: Presentation Considerations

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Integrated Process: Teaching/Learning Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Communication Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback These actions should be avoided. These actions should be avoided. The nurse should provide handouts with black print on white nonglare paper and convey a positive attitude and self-care promotion or older adults. These actions should be avoided. The nurse should provide handouts with black print on white nonglare paper and convey a positive attitude and self-care promotion or older adults. 1

CON: Moderate

8. The nurse is assessing a patient who underwent an epidural block for a procedure 6 hours ago. Which findings should the nurse report to the RN? (Select all that apply.) 1. Clear fluid leaking from puncture site 2. Headache 3. Dizziness 4. Nausea 5. Oxygen saturation 97% 6. Visual disturbances ANS: 1, 2, 3, 4, 6 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 7. List signs and symptoms of common postoperative complications. Page: 199 Heading: Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS–Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate

1. 2. 3. 4. 5. 6. PTS:

Feedback This is a complication of regional anesthesia. This is a complication of regional anesthesia. This is a complication of regional anesthesia. This is a complication of regional anesthesia. This is not a complication of anesthesia. This is a complication of regional anesthesia. 1

CON: Safety

COMPLETION

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1. The nurse is calculating the intake of a patient who underwent surgery. The patient consumed two 240-mL juice boxes, 800 mL of water, 120 mL of gelatin, and two 40-mL cups of soda. The patient also received 1 L of lactated ringer’s IV. Calculate the patient’s total intake (in mL). Enter the numeral only. ANS: 2,480 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 2. Identify the role of the licensed practical nurse/licensed vocational nurse (LPN/LVN) in each perioperative phase. Page: 199 Heading: Nursing Diagnoses, Planning, and Implementation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Analysis (Analyzing) Concept: Nutrition Difficulty: Moderate Feedback: Add the following: 240 + 240 + 800 + 120 + 40 + 40 + 1,000 = 2480 mL PTS:

CON: Nutrition

2. The nurse is preparing to administer cefazolin (Ancef) 1 g in 100 mL of normal saline to run over 30 minutes intravenously to a patient as a surgical prophylactic medication. At what rate will the nurse set the infusion pump? Enter the numeral only. ANS: 200 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 2. Identify the role of the licensed practical nurse/licensed vocational nurse (LPN/LVN) in each perioperative phase. Page: 199 Heading: Preoperative Instructions and Preparation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS-Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: If a medication is infusing in 30 minutes, double the volume— 200 mL/hr. PTS:

CON: Safety

3. The nurse reviews an order to administer lactated Ringer 1,000 mL to run over 2 hours intravenously to a patient in the recovery room. At what rate will the nurse set the infusion pump? Enter the numeral only.

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ANS: 500 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 2. Identify the role of the licensed practical nurse/licensed vocational nurse (LPN/LVN) in each perioperative phase. Page: 199 Heading: Nursing Diagnoses, Planning, and Implementation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: mL/hr = 1,000 mL/2 hr = 500 mL PTS:

CON: Safety

4. The nurse receives an order to administer hydromorphone (Dilaudid) 1 mg IV for postoperative pain. The available dose is hydromorphone (Dilaudid) 2 mg/mL. How many mL will the nurse administer? Enter the numeral only. ANS: 0.5 Chapter: Chapter 12. Nursing Care of Patients Having Surgery Objective: 2. Identify the role of the licensed practical nurse/licensed vocational nurse (LPN/LVN) in each perioperative phase. Page: 199 Heading: Postoperative Pain Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: mL = 1 mL/2 mg × 1 mg = 0.5 mL PTS:

CON: Safety

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Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response MULTIPLE CHOICE 1. The nurse in the emergency department is caring for a patient with a partial-thickness thermal burn. Which treatment should the nurse expect to be prescribed for this patient? 1. Application of wet dressings 2. Use of clean dressing technique 3. Application of moisturizing lotion 4. Application of silver sulfadiazine cream ANS: 4 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 2. Plan nursing interventions for a trauma victim. Page: 211 Heading: Burns Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Trauma Difficulty: Moderate Feedback 1 Because the skin can no longer protect the patient, wet dressings provide a medium for bacterial invasion. Wet dressings can also cause a decrease in body temperature because the skin can no longer maintain thermoregulation. 2 Deep partial-thickness burns should be covered with dry dressings. 3 Over-the-counter lotions are never used on a major burn because they can promote infection, retain heat, and cause more pain. 4 Partial-thickness burns that involve a small area are cleaned with sterile saline solution, covered with a 1/8-inch layer of an anti-infective cream such as silver sulfadiazine (Silvadene, Flamazine), and covered with dry bulky, fluffed dressings. PTS:

CON: Trauma

2. A patient who has ingested a corrosive product is vomiting. For which potential complication should the nurse prepare to provide care to this client? 1. Coma 2. Esophageal burns 3. Chemical pneumonia 4. Aspiration pneumonia ANS: 2 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 6. Explain the priorities of care for poison overdose.

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Page: 211 Heading: Poisoning and Drug Overdose Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Trauma Difficulty: Moderate Feedback 1 Corrosive substances are not directly linked to the development of coma. 2 An ingested substance that is corrosive can cause esophageal burns if vomiting occurs as it travels back up the esophagus. 3 Chemical pneumonia is more likely to develop after an inhalation of a poisonous substance. 4 Aspiration pneumonia is more likely to occur if the patient is unable to control or maintain the airway. PTS:

CON: Trauma

3. The nurse is teaching a group of oilfield workers about care for a snake bite. Which statement indicates an understanding of the teaching? 1. “I will elevate the affected extremity above heart level.” 2. “I should avoid putting a dressing over the area.” 3. “I need to apply ice to the affected area.” 4. “I should clean the area with soap and water.” ANS: 4 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 2. Plan nursing interventions for a trauma victim. Page: 215 Heading: Snakebites Integrated Process: Teaching/Learning Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Evaluation (Evaluating) Concept: Trauma Difficulty: Moderate Feedback 1 The extremity should not be elevated. 2 A dressing should be placed over the area. 3 Ice should not be applied to the area. 4 The area should be cleaned with soap and water. PTS:

CON: Trauma

4. The health care provider (HCP) tells the nurse that a patient has blood leaking into the intrapleural space and has caused collapse of the lung. The nurse suspects which diagnosis? 1. Cardiac tamponade 2. Pneumothorax 3. Myocardial contusion

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4. Hemothorax ANS: 4 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 2. Plan nursing interventions for a trauma victim. Page: 208 Heading: Chest Trauma Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Trauma Difficulty: Moderate Feedback 1 Cardiac tamponade results when blood or fluid accumulates in the pericardial sac. 2 A pneumothorax results from air leaking into the intrapleural space and causing the lung to collapse. 3 A myocardial contusion is bruising to the heart. 4 Hemothorax involves blood entering the intrapleural space and causing the lung to collapse. PTS:

CON: Trauma

5. The nurse is caring for a group of patients. Which patient should the nurse see first? 1. A patient who received epinephrine for anaphylactic reaction and has wheezing 2. A patient in a motor vehicle accident who has been cleared of cervical injury 3. A patient who was bit by a snake and received antivenom yesterday 4. A patient who stepped on a nail and received a tetanus booster ANS: 1 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 2. Plan nursing interventions for a trauma victim. Page: 206 Heading: Expected Outcome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Trauma Difficulty: Moderate Feedback 1 This patient experienced anaphylaxis and still has wheezing and should be seen first. 2 This patient has been cleared of having cervical injury; nothing indicates the patient is unstable. 3 This patient should be seen, but not before the patient with wheezing since antivenom was given yesterday and nothing indicates the patient is unstable. 4 There is nothing to indicate this patient is unstable; the patient does not need to

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be seen first. PTS:

CON: Trauma

6. The nurse is caring for a patient with frostbite to the foot. Which intervention should the nurse implement? 1. Vigorously rub the affected area to promote circulation. 2. Apply a tight, wet, and sterile dressing to the affected area. 3. Encourage frequent ambulation. 4. Elevate the foot at or above heart level. ANS: 4 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 2. Plan nursing interventions for a trauma victim. Page: 212 Heading: Frostbite Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Trauma Difficulty: Moderate

1 2 3 4

Feedback The affected area should be handled gently and rubbing the area should be avoided. A dry, sterile dressing will be loosely applied. Walking should be avoided for patients with frostbite of the foot or leg. The extremity should be elevated at or above heart level to promote circulation.

PTS:

CON: Trauma

7. The nurse is reviewing laboratory values for a patient with heat exhaustion. Which result would be of most concern to the nurse? 1. Calcium 9.1 mg/dL 2. Sodium 128 mEq/L 3. Glucose 72 mg/dL 4. Potassium 4.0 mEq/L ANS: 2 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 5. Describe the stages of hyperthermia. Page: 213 Heading: Heat Exhaustion Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Trauma

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Difficulty: Moderate Feedback 1 The calcium level is normal. 2 The sodium level is low as a result of water loss. The HCP should be notified. 3 The glucose level is normal. 4 The potassium level is normal. PTS:

CON: Trauma

8. The nurse is caring for a patient with hypovolemic shock with a possible cause of internal hemorrhage. Which order should the nurse prepare to implement first? 1. Administer an antibiotic. 2. Start a large bore IV. 3. Administer blood products. 4. Administer IV fluids. ANS: 2 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 2. Plan nursing interventions for a trauma victim. Page: 205 Heading: Expected Outcome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Trauma Difficulty: Moderate Feedback 1 The patient would need an antibiotic for septic shock, not hypovolemic shock. 2 The patient first needs a large bore IV to receive large amounts of fluid or blood. 3 The nurse first needs to start an IV. 4 The nurse first needs to start a large bore IV. PTS:

CON: Trauma

9. The nurse is performing a Glasgow coma scale (GCS) assessment for a patient with a head injury. The patient opens eyes to pain, best verbal response is incomprehensible sounds, and best motor response is withdrawal from pain. What is the patient’s total GCS score? 1. 15 2. 11 3. 8 4. 3 ANS: 3 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 2. Plan nursing interventions for a trauma victim. Page: 203

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Heading: Evaluation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Trauma Difficulty: Moderate Feedback 1 A score of 15 is the highest score a patient can earn. 2 A score of 11 is a moderate score with minimal deficits. 3 A score of 8 is a low score with deficits. 4 A score of 3 is the lowest score a patient can receive. PTS:

CON: Trauma

10. The nurse is caring for a patient who has an injury of L2 to L4 vertebrae. The nurse should anticipate the patient’s inability to do what? 1. Tighten anus 2. Flex foot and extend toes 3. Extend and flex legs 4. Extend and flex arms ANS: 3 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 2. Plan nursing interventions for a trauma victim. Page: 204 Heading: Correlating Spinal Injury With Impairment of Motor Function (Table 13.2) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Trauma Difficulty: Moderate Feedback 1 This is an impairment from an injury from S3 to S5 or above. 2 This describes the impairment from an injury of L4 to L5. 3 This describes the impairment found in a patient with L2 to L4 or above injury. 4 This describes the impairment of an injury from C5 to C7. PTS:

CON: Trauma

11. Which of the following is a cause of an open penetrating injury? 1. A knife 2. A bullet 3. Fragments from an explosion 4. A baseball bat ANS: 1 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response

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Objective: 2. Plan nursing interventions for a trauma victim. Page: 208 Heading: Mechanism of Injury Integrated Process: Clinical Problem-Solving Process Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Trauma Difficulty: Moderate Feedback 1 A knife wound causes an open penetrating wound. 2 A bullet causes a closed penetrating injury. 3 Fragments from an explosion cause a closed penetrating injury. 4 A baseball bat causes blunt trauma. PTS:

CON: Trauma

12. A patient tells the nurse she stepped on a nail when working on the yard. Which question is most important for the nurse to ask? 1. “Was the nail an old nail or new nail?” 2. “How long was the nail?” 3. “When was your last tetanus shot?” 4. “Did the nail penetrate the skin?” ANS: 3 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 2. Plan nursing interventions for a trauma victim. Page: 210 Heading: Tetanus Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Trauma Difficulty: Moderate Feedback 1 It does not matter if the nail was old or new. 2 The length of the nail is not important. 3 The patient is at risk for tetanus; a booster is required every 10 years. 4 This is important to ask, but asking about a tetanus shot is more important. PTS:

CON: Trauma

13. The nurse is working at a sporting event when a football player is injured. What action by the nurse requires correction? 1. Assist the patient in sitting up slowly. 2. Ask the patient if he is having pain anywhere. 3. Assess vital signs. 4. Determine if the patient is experiencing difficulty breathing.

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ANS: 1 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 2. Plan nursing interventions for a trauma victim. Page: 210 Heading: Spinal Trauma Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Trauma Difficulty: Moderate Feedback 1 The nurse should not move the patient until a cervical injury has been ruled out. 2 The nurse should assess pain. 3 Vital signs should be assessed. 4 Assessing airway and breathing are a priority. PTS:

CON: Trauma

MULTIPLE RESPONSE 1. The nurse is caring for a patient who experienced a near-drowning. Which factors lead to a better outcome? (Select all that apply.) 1. Patient was submerged for over an hour. 2. The water was clean. 3. The temperature was lukewarm. 4. The patient was an older adult. 5. The patient has had a family member drown. ANS: 2, 3 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 2. Plan nursing interventions for a trauma victim. Page: 215 Heading: Near-Drowning Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Trauma Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback Being submerged for over an hour leads to poor outcomes. Clean water leads to a better outcome. Freezing temperatures lead to poor outcomes; warmer is better. The younger the patient, the better. An older adult has a poorer outcome. Having a family member drown has no impact on this patient’s outcome.

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PTS:

CON: Trauma

2. The nurse is caring for a patient diagnosed with botulism. Which interventions should the nurse plan to implement? (Select all that apply.) 1. Assess gag reflex. 2. Monitor oxygen saturation. 3. Administer blood products. 4. Infuse parenteral nutrition as prescribed. 5. Prepare the patient for a lumbar puncture. ANS: 1, 2, 4 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 8. Discuss bioterrorist agents and the care for an infection. Page: 217 Heading: Therapeutic Interventions Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Trauma Difficulty: Moderate

1. 2. 3. 4. 5. PTS:

Feedback The nurse should assess gag reflex, swallowing, and cough. The nurse will monitor oxygen saturation. Blood products are not typically required for botulism. The nurse should plan to infuse parenteral nutrition. A lumbar puncture is not required in the diagnosis of botulism. 1

CON: Trauma

3. The nurse is receiving a victim of a traumatic amputation in the emergency department. What should the nurse do with the amputated limb? (Select all that apply.) 1. Place on ice. 2. Rinse with saline. 3. Place in ice water. 4. Wrap in sterile gauze. 5. Place in a sealed plastic bag. ANS: 1, 2, 4, 5 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 2. Plan nursing interventions for a trauma victim. Page: 206 Heading: Surface Trauma Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Trauma

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Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback The amputated part is rinsed with saline solution, wrapped in sterile gauze, and placed in a sealed plastic bag, which is then placed on ice. The amputated part is rinsed with saline solution, wrapped in sterile gauze, and placed in a sealed plastic bag, which is then placed on ice. The amputated part is not covered with ice or in ice water. The amputated part is rinsed with saline solution, wrapped in sterile gauze, and placed in a sealed plastic bag, which is then placed on ice. The amputated part is rinsed with saline solution, wrapped in sterile gauze, and placed in a sealed plastic bag, which is then placed on ice. 1

CON: Trauma

ORDERED RESPONSE 1. The nurse in an emergency department is helping triage victims of an explosion. Rank, in order from 1 to 5, the following patients according to their need for priority treatment according to disaster response protocols and best chance of survival. 1. A 15-year-old with a laceration to the foot that is bleeding slightly 2. A 36-year-old who has no pulse or respirations and has an open head injury 3. A 70-year-old with shortness of breath but no detectable cardiac arrhythmias 4. A 5-year-old with a suspected fracture of the humerus 5. A 58-year-old woman with a distended abdomen who reports severe abdominal pain ANS: 3, 5, 4, 1, 2 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 7. Describe the role of the licensed practical nurse/licensed vocational nurse in a disaster response. Page: 216 Heading: Primary Survey Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Trauma Difficulty: Moderate Feedback: Patients who are seriously injured and have the greatest chance of full recovery are treated first. This would be the patient with shortness of breath without any cardiac arrhythmia. The next patient would be the patient with a distended abdomen reporting abdominal pain. The child with a fractured humerus should be treated next. Then the patient with the foot laceration would be treated. The patient without any pulse or respirations could be seen last.

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PTS:

CON: Trauma

2. Place in order, from 1 to 5, the primary survey a nurse conducts when a patient arrives to the emergency department. 1. Exposure 2. Breathing 3. Disability 4. Airway 5. Circulation ANS: 4, 2, 5, 3, 1 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 1. Explain the components of a primary survey. Page: 202 Heading: Primary Survey Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Trauma Difficulty: Moderate Feedback: The order of a primary survey is airway, breathing, circulation, disability, exposure. PTS:

CON: Trauma

COMPLETION 1. The nurse is preparing to administer morphine 6 mg IV to a patient with a gunshot wound. The available dose is morphine 10 mg/mL. How many mL will the nurse administer? Enter the numeral only. ANS: 0.6 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 2. Plan nursing interventions for a trauma victim. Page: 205 Heading: Nursing Diagnoses, Planning, and Implementation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: mL = 1 mL/10 mg × 6 mg = 0.6 mL

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PTS:

CON: Safety

2. The nurse is preparing to administer 1 L of D5 normal saline to run over 4 hours with a drip set of 15 gtt/mL. Calculate the drop rate for the IV fluid. Round to the nearest whole number. Enter the numeral only. ANS: 250 Chapter: Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response Objective: 2. Plan nursing interventions for a trauma victim. Page: 205 Heading: Nursing Diagnoses, Planning, and Implementation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: gtt/min = 15 gtt/mL × 1,000 mL/hr × 1 hr/60 min = 15,000/60 = 250 gtt/min PTS:

CON: Safety

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Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults MULTIPLE CHOICE 1. The nurse is caring for a group of patients. Which patient is at highest risk for the nursing diagnosis of risk for caregiver role strain? 1. A 20-year-old who attends college and works nights 2. A 30-year-old who recently got married and switched jobs 3. A 45-year-old with three children who is caring for his older father with cancer 4. A 65-year-old who is living with her daughter and son-in-law ANS: 3 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 3. Describe special needs that caregivers have. Page: 229 Heading: Roles Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Family Dynamics Difficulty: Moderate Feedback 1 This patient is not at risk for caregiver role strain. 2 This patient is not at risk for caregiver role strain. 3 This patient is at high risk for caregiver role strain because he is caring for children and a parent. 4 This patient is not at risk for caregiver role strain. PTS:

CON: Family Dynamics

2. The nurse is caring for a patient with a chronic illness. What should the nurse encourage the patient to use as a coping resource? 1. Empower caregivers. 2. Develop a power base. 3. Be hopeful for a disease cure. 4. Develop a realistic, hopeful attitude. ANS: 4 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 5. Plan interventions for a patient who is chronically ill. Page: 227 Heading: Nursing Care Integrated Process: Caring Client Need: Physiological Integrity Cognitive Level: Application (Applying)

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Concept: Stress Difficulty: Moderate Feedback 1 Empowering caregivers and developing a power base are not strategies to cope with a chronic illness. 2 Empowering caregivers and developing a power base are not strategies to cope with a chronic illness. 3 Hope should not be directed toward a cure that may not be possible, but rather at living a quality life with the functional capacity that the patient has. 4 Before coping resources can be used, hope must be established by the patient. False hope is not beneficial and should be replaced with realistic hope. Providing patients with accurate knowledge regarding his or her fears helps do this. PTS:

CON: Stress

3. The nurse is teaching an older adult about avoidance of risky behaviors. Which statement made by the patient would be of most concern to the nurse? 1. “I exercise after work to help alleviate stress.” 2. “My husband and I go to a meditation class every week.” 3. “I drink two or three beers after work to help me relax.” 4. “I play the piano a few times every week to unwind.” ANS: 3 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 4. Explain health promotion methods. Page: 223 Heading: Common Health Concerns Integrated Process: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Health Promotion Difficulty: Moderate Feedback 1 Exercise is a healthy way to relax. 2 Meditation is a good way to relax. 3 Drinking alcohol daily can lead to chronic illness. 4 Music is a healthy way to relax. PTS:

CON: Health Promotion

4. The nurse is assessing an older adult. The nurse would expect to classify the patient in which Erikson’s stage of development? 1. Trust versus mistrust 2. Industry versus inferiority 3. Identity versus role confusion 4. Integrity versus despair

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ANS: 4 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 1. List Erikson’s eight stages of psychosocial development. Page: 222 Heading: Erikson’s Stages of Psychosocial Development (Table 14.1) Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Self Difficulty: Moderate Feedback 1 An infant is in trust versus mistrust stage. 2 A school-age child is in the industry versus inferiority stage. 3 An adolescent is in the identity versus role confusion stage. 4 The patient is in integrity versus despair stage of development. PTS:

CON: Self

5. The nurse is discussing sexual intimacy with an older patient. Which statement made by the patient requires correction by the nurse? 1. “Getting my hair and nails done boosts my self-esteem.” 2. “Sexual intimacy is only achieved by sexual intercourse.” 3. “I may need to discuss medication to help with impotence with my doctor.” 4. “I am going to meet with a sexual counselor this week.” ANS: 2 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 5. Plan nursing interventions for a patient who is chronically ill. Page: 228 Heading: Sexuality Integrated Process: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Evaluation (Evaluating) Concept: Sexuality Difficulty: Moderate Feedback 1 This statement does not require correction. 2 Sexual intimacy can be achieved by hugging, touching, or spending time together. 3 This statement does not require correction. 4 This statement does not require correction. PTS:

CON: Sexuality

6. The nurse is caring for a patient with a chronic illness who no longer works and does not qualify for disability. To whom should the nurse refer the patient? 1. The physician

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2. A social worker 3. A pharmacist 4. A dietitian ANS: 2 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 5. Plan nursing interventions for a patient who is chronically ill. Page: 229 Heading: Finances Integrated Process: Caring Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate Feedback 1 A physician does not help the patient and family with finding financial resources. 2 A social worker can assist the patient and family with finding financial resources. 3 A pharmacist does not assist the patient and family with finding financial resources. 4 A dietitian does not assist the patient and family with finding financial resources. PTS:

CON: Health Promotion

7. The nurse is caring for a patient who just received a diagnosis of terminal cancer. Which might the nurse observe in this patient? 1. Despair 2. Hopefulness 3. Gratitude 4. Serenity ANS: 1 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 2. Identify the effects of chronic illness. Page: 226 Heading: Health, Wellness, and Illness Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Evaluation (Evaluating) Concept: Stress Difficulty: Moderate Feedback 1 This patient is likely experiencing despair. 2 This patient is likely not experiencing hopefulness. 3 This patient is likely not experiencing gratitude.

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This patient is likely not experiencing serenity.

PTS:

CON: Stress

8. The nurse is teaching a class about suicide prevention. Which individual is at highest risk for suicide? 1. A 25-year-old woman 2. A 30-year-old man 3. A 60-year-old woman 4. A 70-year-old man ANS: 4 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 2. Identify effects of chronic disease. Page: 224 Heading: Common Health Concerns Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Stress Difficulty: Moderate

Feedback An accumulation of losses for the older adult can lead to depression and a feeling of hopelessness. Hopelessness is related to a high rate of suicide in older adults, especially older men.

An accumulation of losses for the older adult can lead to depression and a feeling of hopelessness. Hopelessness is related to a high rate of suicide in older adults, especially older men.

PTS:

CON: Stress

9. The nurse is caring for a 23-year-old patient who is in the intimacy versus isolation stage of development. Which statement would confirm this? 1. “I wish I would have spent more time with my family when I was younger.” 2. “I feel like I’ve been working at my job and have nothing to show for.” 3. “I am considering going to dinner with a guy I like, but I am happy with my life the way it is.” 4. “I am not afraid to die because I will get to be with my darling husband.”

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ANS: 3 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 1. List Erickson’s eight stages of psychosocial development. Page: 223 Heading: Erikson’s Stages of Psychosocial Development (Table 14.1) Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Self Difficulty: Moderate Feedback 1 This is the integrity versus despair stage. 2 This is the generativity versus stagnation stage. 3 This is the intimacy versus isolation stage. 4 This is the integrity versus despair stage. PTS:

CON: Self

10. The nurse is talking to a 45-year-old patient who states she switched jobs, bought a red convertible, and pierced her nose. The nurse suspects the patient is experiencing which of the following? 1. Midlife crisis 2. Suicidal ideation 3. Empty nest 4. Chronic illness ANS: 1 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 1. List Erickson’s eight stages of psychosocial development. Page: 223 Heading: The Middle-Aged Adult Integrated Process: Psychosocial Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Stress Difficulty: Moderate Feedback 1 This individual is experiencing a midlife crisis. 2 The patient is not experiencing suicidal ideation. 3 The patient is not experiencing signs of empty nest. 4 The patient is not experiencing signs of chronic illness. PTS:

CON: Stress

11. Which is the leading cause of death among the middle-adult age group? 1. Emphysema

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2. Liver disease 3. Kidney failure 4. Cardiovascular disease ANS: 4 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 2. Identify the effects of chronic illness. Page: 223 Heading: Common Health Concerns Integrated Process: Caring Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 Emphysema is not the leading cause of death among middle-aged adults. 2 Liver disease is not the leading cause of death among middle-aged adults. 3 Kidney disease is not the leading cause of death among middle-aged adults. 4 Cardiovascular disease and cancer are the leading causes of death among the middle-aged adult group. PTS:

CON: Perfusion

MULTIPLE RESPONSE 1. Which are factors leading to the development of chronic disease? (Select all that apply.) 1. Frequent exercise 2. Exposure to air pollution 3. Substance abuse 4. Eating a balanced diet 5. Stress ANS: 2, 3, 5 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 2. Identify the effects of chronic illness. Page: 223 Heading: Incidence of chronic disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate

1. 2. 3.

Feedback Exercise does not contribute to the development of chronic disease. Exposure to air and water pollution can contribute to chronic disease. Substance abuse can contribute to chronic disease.

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4. 5.

Eating a balanced diet can prevent chronic disease. Stress is a contributing factor to chronic disease.

PTS:

CON: Health Promotion

2. The nurse is contributing to a staff education program about adult health concerns. Which common health concerns of middle-aged adults should the nurse include? (Select all that apply.) 1. Stroke 2. Hypertension 3. Kidney failure 4. Visual changes 5. Alzheimer disease 6. Cardiovascular disease ANS: 2, 4, 6 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 2. Identify the effects of chronic illness. Page: 223 Heading: Types of Chronic Illness Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5. 6.

PTS:

Feedback Kidney disease, stroke, and Alzheimer disease typically occur in older adults. Middle-aged adults are those ages 45 to 65 years. Visual changes, hypertension, and heart disease are major health concerns of middle age. Kidney disease, stroke, and Alzheimer disease typically occur in older adults. Middle-aged adults are those ages 45 to 65 years. Visual changes, hypertension, and heart disease are major health concerns of middle age. Kidney disease, stroke, and Alzheimer disease typically occur in older adults. Middle-aged adults are those ages 45 to 65 years. Visual changes, hypertension, and heart disease are major health concerns of middle age. 1

CON: Health Promotion

3. The nurse is contributing to a staff education program about chronic illness. What should the nurse include as being congenital diseases? (Select all that apply.) 1. Cancer 2. Spina bifida 3. Cystic fibrosis 4. Sickle cell anemia

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5. Huntington disease 6. Malabsorption syndrome ANS: 2, 6 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 2. Identify the effects of chronic illness. Page: 225 Heading: Examples of Chronic Illnesses by Cause Integrated Process: Teaching/Learning Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4. 5. 6.

Feedback Cancer is an acquired disease. Malabsorption syndrome and spina bifida are congenital diseases. Cystic fibrosis is a genetic disorder. Sickle cell anemia is a genetic disorder. Huntington disease is a genetic disorder. Malabsorption syndrome and spina bifida are congenital diseases.

PTS:

CON: Patient-Centered Care

4. The nurse is teaching health promotion to a group of patients. Which patients are at highest risk for developing chronic disease? (Select all that apply.) 1. A patient who smokes pack per day 2. A patient who drinks alcohol daily 3. A patient who exercises three times weekly 4. A patient who has a family history of heart disease 5. A patient who lives near a fossil fuel–burning plant ANS: 1, 2, 4, 5 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 2. Identify the effects of chronic illness. Page: 225 Heading: Common Health Concerns Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Health Promotion Difficulty: Moderate

1. 2. 3.

Feedback This patient is at high risk for developing chronic disease. This patient is at high risk for developing chronic disease. This patient is not at risk for developing chronic disease.

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4. 5.

This patient is at risk for developing chronic disease. This patient is at risk for developing chronic disease.

PTS:

CON: Health Promotion

5. The nurse is teaching a group of chronically ill adults about coping with their illness. Which statements indicate an understanding of the teaching? (Select all that apply.) 1. “If I have worse symptoms, I will call my doctor.” 2. “I will join a support group of others who have my disease.” 3. “If I feel better, I don’t need to take my daily medications.” 4. “I will check my blood glucose four times every day.” 5. “I should schedule activities during times I have less energy.” 6. “I am going to meet my daughter twice a week for lunch.” ANS: 1, 2, 4, 6 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 5. Plan nursing interventions for a patient who is chronically ill. Pages: 226–227 Heading: Nursing Care Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Health Promotion Difficulty: Moderate

Feedback The patient understands teaching when they state they will notify the doctor for worsening symptoms. Joining a support group indicates an understanding of the teaching. This requires further teaching; medication should be taken as prescribed. This indicates an understanding of the teaching. Activities should be scheduled when the patient has more energy; this requires further teaching. This indicates an understanding of teaching.

PTS:

1. 2. 3. 4. 5.

CON: Health Promotion

6. The nurse is teaching a group of caregivers about risk factors for elder abuse. Which of the following psychosocial factors should the nurse assess for in the caregiver? (Select all that apply.) 1. Depression 2. Grieving 3. Burnout 4. Stress 5. Extra energy 6. Role strain ANS: 1, 2, 3, 4, 6

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Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 3. Describe the special needs that caregivers have. Pages: 228–229 Heading: Roles Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Family Dynamics Difficulty: Moderate

1. 2. 3. 4. 5. 6.

Feedback A caregiver experiencing this emotion is at risk for abusing the patient. A caregiver experiencing this emotion is at risk for abusing the patient. A caregiver experiencing this emotion is at risk for abusing the patient. A caregiver experiencing this emotion is at risk for abusing the patient. This does not lead to elder abuse. A caregiver experiencing this emotion is at risk for abusing the patient.

PTS:

CON: Family Dynamics

7. Which can lead to a loss of independence for older adults? (Select all that apply.) 1. Inability to drive 2. Loss of hearing 3. Ability to cook 4. Loss of vision 5. Dementia ANS: 1, 2, 4, 5 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 2. Identify the effects of chronic illness. Page: 230 Heading: Common Health Concerns Integrated Process: Caring Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback Inability to drive leads to loss of dependence. Loss of hearing leads to loss of dependence. Ability to cook does not lead to loss of dependence. Loss of vision leads to loss of dependence. Dementia leads to loss of dependence.

PTS:

CON: Safety

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8. The nurse is participating in the creation of a teaching seminar about healthy behaviors for the young adult. What topics should the nurse suggest be included in this seminar? (Select all that apply.) 1. Diet and exercise 2. Avoiding tobacco use 3. Avoiding sun exposure 4. Restricting hours of sleep 5. Performing self-examinations ANS: 1, 2, 3, 5 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 4. Explain health promotion methods. Page: 222 Heading: Health Promotion Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate

Feedback Young adults should understand the importance of diet and exercise in maintaining health for themselves and their children. Lifelong positive health practices help prevent long-term health complications. Avoiding sun exposure and using sunscreen are important to avoid sunburn, permanent sun damage to the skin, and increased risk of skin cancer. Tobacco use started in the teen years is often carried on throughout young adulthood and is linked to chronic bronchitis; emphysema; and oral, throat, and lung cancer in later life. Additional preventive measures that may be taught at this stage include breast self-examination for women and testicular selfexamination for men. Young adults should understand the importance of diet and exercise in maintaining health for themselves and their children. Lifelong positive health practices help prevent long-term health complications. Avoiding sun exposure and using sunscreen are important to avoid sunburn, permanent sun damage to the skin, and increased risk of skin cancer. Tobacco use started in the teen years is often carried on throughout young adulthood and is linked to chronic bronchitis; emphysema; and oral, throat, and lung cancer in later life. Additional preventive measures that may be taught at this stage include breast self-examination for women and testicular selfexamination for men. Young adults should understand the importance of diet and exercise in maintaining health for themselves and their children. Lifelong positive health practices help prevent long-term health complications. Avoiding sun exposure and using sunscreen are important to avoid sunburn, permanent sun damage to the skin, and increased risk of skin cancer. Tobacco use started in the teen years is often carried on throughout young adulthood and

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4. 5.

PTS:

is linked to chronic bronchitis; emphysema; and oral, throat, and lung cancer in later life. Additional preventive measures that may be taught at this stage include breast self-examination for women and testicular selfexamination for men. Restricting hours of sleep is not a healthy behavior. Young adults should understand the importance of diet and exercise in maintaining health for themselves and their children. Lifelong positive health practices help prevent long-term health complications. Avoiding sun exposure and using sunscreen are important to avoid sunburn, permanent sun damage to the skin, and increased risk of skin cancer. Tobacco use started in the teen years is often carried on throughout young adulthood and is linked to chronic bronchitis; emphysema; and oral, throat, and lung cancer in later life. Additional preventive measures that may be taught at this stage include breast self-examination for women and testicular selfexamination for men. 1

CON: Health Promotion

9. The nurse is teaching a group of patients about illness caused by genetics. Which topics should the nurse include in the teaching? (Select all that apply.) 1. Emphysema 2. Multiple sclerosis 3. Huntington disease 4. Cystic fibrosis 5. Sickle cell anemia 6. Spina bifida ANS: 3, 4, 5 Chapter: Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults Objective: 2. Identify the effects of chronic illness. Page: 225 Heading: Examples of Chronic Illnesses by Cause (Box 14.1) Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5. 6.

Feedback Emphysema is an acquired condition. Multiple sclerosis is an acquired condition. Huntington disease is a genetic condition. Cystic fibrosis is a genetic condition. Sickle cell anemia is a genetic condition. Spina bifida is a congenital anomaly.

PTS:

CON: Health Promotion

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Chapter 15. Nursing Care of Older Adult Patients MULTIPLE CHOICE 1. The nurse is concerned about medication safety for a patient with confusion. Which action should the nurse recommend be included in the patient’s plan of care to address this issue? 1. Instruct the patient to take all of the medications together. 2. Have the patient set up the medications for an entire week. 3. Have a family member set up and administer the medications. 4. Have the patient turn medication bottles upside down after taking medication. ANS: 3 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 4. Plan nursing care for the physiological and psychological changes associated with advancing age. Page: 243 Heading: Medication Management Integrated Process: Communication and Documentation Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate

Feedback This is not helpful as medications have specific instructions for how to take and when to take them and taking them all at once could lead to complications.

This is not useful for a patient with confusion as he or she may have issues with known time or date which could lead to skipping or doubling the medication.

Having a family member assist with the medications is the best option for someone with confusion.

The patient could become more confused if expected to turn medication bottles upside down after use.

PTS:

CON: Safety

2. The nurse is caring for an older adult who is experiencing early signs of inadequate oxygenation. Which clinical manifestation can the nurse expect to find? 1. Increased energy 2. New-onset confusion 3. Elevated blood glucose 4. Respiratory rate of 18 ANS: 2 Chapter: Chapter 15. Nursing Care of Older Adult Patients

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Objective: 2. Describe basic physiological changes associated with advancing age. Page: 242 Heading: Nursing Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Analysis (Analyzing) Concept: Oxygenation Difficulty: Moderate Feedback 1 Increased energy is not an early sign of decreased oxygenation. 2 Cough, fatigue, and confusion are early signs of inadequate oxygenation. 3 Elevated blood glucose is not a sign of inadequate oxygenation. 4 The respiratory rate is normal and not a sign of inadequate oxygenation. PTS:

CON: Oxygenation

3. The nurse is caring for a group of older adult patients. Which patient should the nurse see first? 1. A patient awaiting education for foot care 2. A patient with a reduced gag reflex 3. A patient who just received a pneumonia vaccination 4. A patient reporting constipation ANS: 2 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 4. Plan nursing care for the physiological and psychological changes associated with advancing age. Page: 246 Heading: Nursing Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 This patient is not the highest priority. 2 This patient should be seen first. A reduced gag reflex can cause aspiration pneumonia or additional lung problems. 3 This patient is not a priority; he or she received a vaccination. 4 This patient should be seen but is not a priority. PTS:

CON: Patient-Centered Care

4. The nurse is providing care to a person who has difficulty hearing high-pitched tones. Which action should the nurse take when caring for this patient? 1. Speak loudly from across the room. 2. Speak softly, using a near-whisper tone. 3. Speak slowly, emphasizing lip movements. 4. Speak rapidly, using multiple hand gestures.

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ANS: 2 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 2. Describe basic physiological changes associated with advancing age. Page: 240 Heading: Nursing Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Communication Difficulty: Moderate Feedback 1 Speaking loudly, emphasizing lip movements, or speaking rapidly with hand gestures is not going to enhance communication with this patient. 2 For older patients, the first difficult sounds to discriminate are high-pitched tones. It is often more effective to whisper when communicating with the hearing-impaired individual, because whispering decreases the pitch of the sounds. 3 Speaking loudly, emphasizing lip movements, or speaking rapidly with hand gestures is not going to enhance communication with this patient. 4 Speaking loudly, emphasizing lip movements, or speaking rapidly with hand gestures is not going to enhance communication with this patient. PTS:

CON: Communication

5. A 70-year-old patient asks what can be done to protect his hearing. What should the nurse recommend to the patient? 1. Clean the ears of ear wax every day. 2. Cover the ears if loud noises are expected. 3. Have a hearing test performed twice a year. 4. Raise the volume on televisions and radios in the home. ANS: 2 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 4. Plan nursing care for the physiological and psychological changes associated with advancing age. Page: 240 Heading: Nursing Care Integrated Process: Communication and Documentation Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Communication Difficulty: Moderate Feedback 1 Cleaning the ears of earwax everyday could lead to an ear infection. 2 It is important to use hearing protection throughout life because noise damage to the ear is usually not reversible. The patient should be encouraged to cover the ears if loud noises are expected. 3 Hearing tests do not need to be performed twice a year.

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Raising the volume on televisions and radios could potentiate hearing loss.

PTS:

CON: Communication

6. The nurse is making a home health visit to a frail, but healthy 86-year-old patient. The nurse assesses a heart rate of 104 beats/minute. What action should the nurse take? 1. Inform the physician of the heart rate immediately. 2. Teach the patient deep-breathing exercises to reduce heart rate. 3. Ask about liquids the patient is drinking and urination frequency. 4. Have the patient request a tranquilizer from the physician at the next visit. ANS: 3 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 4. Plan nursing care for the physiological and psychological changes associated with advancing age. Page: 246 Heading: Nursing Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 Further data are needed to report to the physician. 2 Deep-breathing exercises may not affect the heart rate. 3 One of the first signs of dehydration is tachycardia. 4 The client does not need a tranquilizer for this heart rate. PTS:

CON: Fluid and Electrolyte Balance

7. The nurse is caring for a group of older adult patients. Which patient is at highest risk for suicide? 1. A patient who lives at a retirement center with his spouse and plays bingo daily 2. A patient with terminal lung cancer whose spouse recently suffered a debilitating stroke 3. A patient who is single and occasionally goes on cruises with a friend 4. A patient with diabetes who lives with her daughter and grandchildren ANS: 2 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 3. Describe psychological and cognitive changes associated with advancing age. Page: 242 Heading: Depression Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Mood Difficulty: Moderate Feedback

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1 2 3 4

This patient is not at highest risk for suicide. This patient is at high risk for suicide. This patient is not at highest risk for suicide. This patient is not at highest risk for suicide.

PTS:

CON: Mood

8. The nurse is caring for an older adult who has normal fine tremors of the hand. The nurse knows that which can cause these tremors to increase? 1. Overeating 2. Depression 3. Heat 4. Activity ANS: 4 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 2. Describe basic psychological and cognitive changes associated with advancing age. Page: 239 Heading: Nursing Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 Hunger can lead to fine tremors of the hand. 2 Excitement can cause fine tremors of the hand. 3 Cold can cause tremors of the hand. 4 Activity can lead to fine tremors of the hand. PTS:

CON: Neurologic Regulation

9. The nurse is teaching an older adult about methods to avoid constipation. Which statement made by the patient indicates a need for further teaching? 1. “I try to drink eight glasses of water each day.” 2. “I go walking for 30 minutes every day.” 3. “I take a suppository and enema daily.” 4. “My spouse bought me some high-fiber foods.” ANS: 3 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 4. Plan nursing care for the physiological and psychological changes associated with advancing age. Page: 237 Heading: Changes in the Gastrointestinal System Integrated Process: Teaching/Learning Client Need: PHYS—Basic Care and Comfort Cognitive Level: Evaluation (Evaluating)

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Concept: Elimination Difficulty: Moderate

1 2 3 4

Feedback This statement indicates an understanding of teaching. This statement indicates an understanding of teaching. This statement requires further education; the patient is overusing enemas and suppositories. This statement indicates an understanding of teaching.

PTS:

CON: Elimination

10. The nurse is reviewing a medication history for an older adult. Which medication would be of most concern to the nurse for a patient taking furosemide (Lasix)? 1. Atenolol (Tenormin) 2. Spironolactone (Aldactone) 3. Levothyroxine (Synthroid) 4. Azithromycin (Zithromax) ANS: 2 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 5. Identify nursing practices that promote safety for the older patient. Page: 244 Heading: Evidence Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1 Atenolol is not contraindicated with furosemide. 2 Spironolactone is a diuretic as is furosemide. The nurse should notify the health care provider (HCP) about polypharmacy. 3 Levothyroxine is not contraindicated to be taken with furosemide. 4 Azithromycin is not contraindicated to be taken with furosemide. PTS:

CON: Safety

11. The nurse is caring for a patient who is prone to developing constipation. Which action should the nurse take to help this patient? 1. Give the patient a Fleet enema. 2. Help the patient develop an exercise routine. 3. Instruct the patient to use suppositories once a week. 4. Instruct the patient to take an oral laxative every night. ANS: 2 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 4. Plan nursing care for the physiological and psychological changes associated with advancing age.

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Page: 238 Heading: Changes in the Gastrointestinal System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Elimination Difficulty: Moderate Feedback 1 Enemas, suppositories, and medications are considered only after dietary management is found to be ineffective. 2 Educate the older patient about the important relationship between intake of fiber and water and exercise in the promotion of effective bowel evacuation. 3 Enemas, suppositories, and medications are considered only after dietary management is found to be ineffective. 4 Enemas, suppositories, and medications are considered only after dietary management is found to be ineffective. PTS:

CON: Elimination

12. The nurse is caring for a group of older adult patients. Which patient is at highest risk for developing delirium? 1. A patient with autism attending outpatient support groups 2. A patient with a family history of dementia 3. A patient who is in the intensive care unit following hip surgery 4. A patient attending self-care seminars at the senior center ANS: 3 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 3. Describe the psychological and cognitive changes associated with advancing age. Pages: 242–243 Heading: Delirium Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Cognition Difficulty: Moderate Feedback 1 This patient is not at risk for delirium. 2 This patient is not at risk for delirium. 3 This patient is at risk for delirium being in an unfamiliar environment and undergoing surgery. 4 This patient is not at high risk for delirium. PTS:

CON: Cognition

13. A patient tells the nurse he hit a large sign at a store with his vehicle. The nurse suspects which as a contributing factor to the accident? 1. Longer reaction time

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2. Inability to maintain balance 3. Decreased hypothalamus function 4. Increased motor coordination ANS: 1 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 2. Describe basic physiological changes associated with advancing age. Page: 241 Heading: Key Changes in the Neurological System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Application) Concept: Safety Difficulty: Moderate Feedback 1 A longer reaction time means the patient may not have been able to react quickly to avoid hitting the sign. 2 This would not be a contributing factor to the accident. 3 This would affect body temperature, but not contribute to the accident. 4 A decrease in motor coordination, not an increase, could contribute to the accident. PTS:

CON: Safety

14. The nurse is teaching a patient with neuropathy about foot care. Which statement made by the patient indicates a need for further teaching? 1. “I should examine my feet once per week for any sores.” 2. “I will wear tennis shoes when working outside.” 3. “I should avoid putting lotion between my toes.” 4. “I need to ask my podiatrist to treat the corn on my foot.” ANS: 1 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 5. Identify nursing practices that promote safety for the older patient. Page: 246 Heading: Nursing Care Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Health Promotion Difficulty: Moderate Feedback 1 Feet should be examined daily, not weekly. 2 This statement indicates an understanding. 3 This statement indicates an understanding. 4 This statement indicates an understanding. PTS:

CON: Health Promotion

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15. Which does the nurse identify as an extrinsic factor of aging? 1. Environmental influences 2. Biological clock theory 3. Perception of aging 4. Wear-and-tear theory ANS: 1 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 1. Define aging. Page: 234 Heading: Nursing Care Tip Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Environmental influences, such as pollutants, are extrinsic factors of aging. 2 The biological clock theory is an intrinsic factor based on genetic theories of aging. 3 Perception of aging is not an extrinsic or intrinsic factor, but does influence how an individual adapts to body structure and function over time. 4 Wear-and-tear theory is an intrinsic factor based on physiological theories of aging. PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 1. The nurse is contributing to the care plan of an immobile patient. What should the nurse recognize as increasing the patient’s risk of developing a pressure ulcer on the heels? (Select all that apply.) 1. Being obese 2. Turning every hour 3. Lying on wet linens 4. Impaired circulation 5. Elevating legs on pillows 6. Wearing oxygen at 2 L per nasal cannula ANS: 3, 4 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 4. Plan nursing care for the physiological and psychological changes associated with advancing age. Page: 235 Heading: Nursing Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Mobility

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Difficulty: Moderate

1. 2. 3.

5. 6.

PTS:

Feedback Obesity does not necessarily increase the client’s risk for developing a pressure ulcer on the heels. Turning every hour, elevating the legs on pillows, and using oxygen would not contribute to the development of pressure ulcers. Pressure ulcers are caused by ischemia, which results from continuous pressure that reduces blood flow to the area. Those with impaired circulation are at greater risk of developing a pressure ulcer. Linens should be kept clean, dry, and wrinkle free. Pressure ulcers are caused by ischemia, which results from continuous pressure that reduces blood flow to the area. Those with impaired circulation are at greater risk of developing a pressure ulcer. Linens should be kept clean, dry, and wrinkle free. Turning every hour, elevating the legs on pillows, and using oxygen would not contribute to the development of pressure ulcers. Turning every hour, elevating the legs on pillows, and using oxygen would not contribute to the development of pressure ulcers. 1

CON: Mobility

2. The nurse is contributing to a staff education program about the physical changes of aging. What should the nurse include as a common change in the skeletal system of an older adult? (Select all that apply.) 1. Osteoporosis 2. Eroded cartilage 3. Thickening of bone 4. Increased flexibility 5. Shortening in height 6. Increasing bone density ANS: 1, 2, 5 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 2. Describe basic physiological changes associated with advancing age. Page: 234 Heading: Key Changes in the Skeletal System Integrated Process: Communication and Documentation Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Communication Difficulty: Moderate

1. 2. 3.

Feedback Some key age-related changes in the skeletal system include osteoporosis, eroding cartilage, and shortening of height. Some key age-related changes in the skeletal system include osteoporosis, eroding cartilage, and shortening of height. Age-related changes in bone structure include exaggerated bony

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5. 6.

PTS:

prominences. Flexibility decreases with aging. Bone density decreases with aging. Age-related changes in bone structure include exaggerated bony prominences. Flexibility decreases with aging. Bone density decreases with aging. Some key age-related changes in the skeletal system include osteoporosis, eroding cartilage, and shortening of height. Age-related changes in bone structure include exaggerated bony prominences. Flexibility decreases with aging. Bone density decreases with aging. 1

CON: Communication

3. The nurse is collecting data for a patient who has a developing pressure ulcer. What should the nurse expect to assess as early manifestations of a pressure ulcer? (Select all that apply.) 1. Coolness of site to touch 2. Cyanosis of site observed 3. Report of redness at the site 4. Report of burning at the site 5. Tenderness at site when touched 6. Report of decreased sensation at site ANS: 3, 4, 5 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 4. Plan nursing care for the physiological and psychological changes associated with advancing age. Page: 235 Heading: Key Changes in the Integumentary System Integrated Process: PHYS—Basic Care and Comfort Client Need: PHYS—Basic Care and Comfort Cognitive Level: Evaluation (Evaluating) Concept: Mobility Difficulty: Moderate

1. 2. 3. 4. 5. 6.

PTS:

Feedback Early manifestations of pressure ulcer formation do not include coolness, cyanosis, or decreased sensation at the site. Early manifestations of pressure ulcer formation do not include coolness, cyanosis, or decreased sensation at the site. Early signs of pressure ulcer formation are warmth, redness, tenderness, and a burning sensation at the potential ulcer site. Early signs of pressure ulcer formation are warmth, redness, tenderness, and a burning sensation at the potential ulcer site. Early signs of pressure ulcer formation are warmth, redness, tenderness, and a burning sensation at the potential ulcer site. Early manifestations of pressure ulcer formation do not include coolness, cyanosis, or decreased sensation at the site. 1

CON: Mobility

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4. The nurse is teaching a class about muscular age-related changes. Which should the nurse include in her education? (Select all that apply.) 1. Increased elasticity of tendons 2. Decreased muscle tone 3. Increased muscle mass 4. Slower muscle response 5. Decreased elasticity of ligaments ANS: 2 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 2. Describe basic physiological changes associated with advancing age. Page: 235 Heading: Key Changes in the Muscular System Integrated Process: Communication and Documentation Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback The patient will experience decreased elasticity of tendons. The patient will experience decreased muscle tone. The patient will experience a decrease in muscle mass. The patient will experience slower muscle response. The aging patient will experience a decreased elasticity of ligaments.

PTS:

CON: Patient-Centered Care

5. The nurse is teaching a group of older adults about medication safety. Which statements made by these individuals would be of most concern to the nurse? (Select all that apply.) 1. “I will not crush my pill that has a coating on it.” 2. “It is safe for me to take herbal medications with my prescription pills.” 3. “I need to cut my medication in half until my next Social Security check comes.” 4. “I will take my medicine just like my doctor explained to me.” 5. “I can’t see the label too well on my medication.” 6. “I put all my medicine in a dose divider.” ANS: 2, 3, 5 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 5. Identify nursing practices that promote safety for the older patient. Page: 243 Heading: Medication Management Integrated Process: Communication and Documentation Client Need: SECE—Safety and Infection Control Cognitive Level: Evaluation (Evaluating) Concept: Safety Difficulty: Moderate

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Feedback This statement is a safe way to take medication. This statement requires correction; the patient should notify the HCP before taking herbal medication. This statement is concerning; the patient should not cut pills in half to save money. The HCP may be able to prescribe a cheaper medication. This is a safe way to take medications. This should concern the nurse; the patient may not be taking medication accurately if he or she cannot see. This is a safe way to take medications.

PTS:

1. 2. 3. 4. 5.

CON: Safety

6. The nurse is teaching a patient at risk for osteoporosis about foods high in calcium. Which food choices made by the patient indicate an understanding of the teaching? (Select all that apply.) 1. 1/2 cup of spinach 2. One small chicken breast 3. 2 ounces of cheese 4. 1 cup of low-fat milk 5. 1/2 cup of black beans 6. 3/4 cup of yogurt ANS: 3, 4, 6 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 4. Plan nursing care for the physiological and psychological changes associated with advancing age. Page: 224 Heading: Nursing Care Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Nutrition Difficulty: Moderate

1. 2. 3. 4. 5. 6.

Feedback Spinach is low in calcium. Chicken is low in calcium. Cheese is high in calcium. Milk is high in calcium. Black beans are low in calcium. Yogurt is high in calcium.

PTS:

CON: Nutrition

7. The nurse is contributing to a staff education program to prevent falls in the older population. What should the nurse include as areas to assess for fall prevention? (Select all that apply.)

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1. 2. 3. 4. 5.

Use of alcohol History of falls Medication side effects Pressure sore development Gait and balance screening

ANS: 1, 2, 3, 5 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 5. Identify nursing practices that promote safety for the older patient. Page: 225 Heading: Evidence Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate

4. 5.

PTS:

Feedback Assessment may include the use of alcohol; a history of falls; and review for medications that may cause dizziness, weakness, or sleepiness, as well as gait and balance screening. Assessment may include the use of alcohol; a history of falls; and review for medications that may cause dizziness, weakness, or sleepiness, as well as gait and balance screening. Assessment may include the use of alcohol; a history of falls; and review for medications that may cause dizziness, weakness, or sleepiness, as well as gait and balance screening. Pressure sore development is not assessed for fall prevention in the older patient. Assessment may include the use of alcohol; a history of falls; and review for medications that may cause dizziness, weakness, or sleepiness, as well as gait and balance screening. 1

CON: Safety

8. The nurse is identifying ways to ensure environmental safety for an older patient. Which actions should the nurse recommend for this patient’s plan of care? (Select all that apply.) 1. Place call light within reach. 2. Demonstrate confidence during care. 3. Ask for permission before moving items. 4. Return items to patient’s preferred location. 5. Plan ahead and communicate plans to patient. ANS: 1, 3, 4 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 5. Identify nursing practices that promote safety for the older patient. Page: 225 Heading: Evidence Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate

2. 3.

PTS:

Feedback Nursing actions to ensure for environmental safety include placing the call light within reach, asking for permission before moving items, and returning items to the patient’s preferred location. Demonstrating confidence during care, planning ahead, and communicating plans to the patient are interventions to support deliberate actions. Nursing actions to ensure for environmental safety include placing the call light within reach, asking for permission before moving items, and returning items to the patient’s preferred location. Nursing actions to ensure for environmental safety include placing the call light within reach, asking for permission before moving items, and returning items to the patient’s preferred location. Demonstrating confidence during care, planning ahead, and communicating plans to the patient are interventions to support deliberate actions. 1

CON: Safety

9. The nurse is caring for a patient who reports an alteration in taste. When reviewing the health history, the nurse notes which contributing factors to altered taste? (Select all that apply.) 1. Periodontal disease 2. Loratadine (Claritin) 3. Smokes pack per day 4. Well-fitting dentures 5. Meticulous oral care ANS: 1, 2, 3 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 4. Plan nursing care for the physiological and psychological changes associated with advancing age. Page: 246 Heading: Nursing Care Integrated Process: Caring Client Need: PHYS—Basic Care and Comfort Cognitive Level: Evaluation (Evaluating) Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4.

Feedback Periodontal disease can result in alteration in taste. Loratadine (Claritin) can cause an alteration in taste. Smoking can lead to alteration in taste. Well-fitting dentures do not cause an alteration in taste.

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Meticulous oral care does not lead to alteration in taste.

PTS:

CON: Patient-Centered Care

10. The nurse is caring for an older adult who received 2 liters of IV fluid and now has edema of the lower extremities. Which interventions should the nurse implement? (Select all that apply.) 1. Administer another liter of IV fluid. 2. Apply compression stockings. 3. Notify the HCP. 4. Elevate the lower extremities. 5. Encourage ambulation. ANS: 2, 3, 4 Chapter: Chapter 15. Nursing Care of Older Adult Patients Objective: 4. Plan nursing care for the physiological and psychological changes associated with advancing age. Page: 236 Heading: Nursing Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

2. 3. 4. 5.

Feedback The patient has edema of the legs; more IV fluid will result in worsening of edema. Compression stockings will reduce edema. The HCP should be notified of the edema. Elevating the legs will reduce edema. The patient should not ambulate but elevate the legs to reduce edema.

PTS:

CON: Patient-Centered Care

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Chapter 16. Patient Care Settings MULTIPLE CHOICE 1. The nurse is making a home care visit and notes the patient who is usually talkative and alert has become lethargic and has low blood pressure. Which action should the nurse take first? 1. Notify the registered nurse (RN). 2. Take the patient to the emergency department (ED). 3. Administer a 1-liter bolus of normal saline. 4. Encourage the patient to drink some caffeine. ANS: 1 Chapter: Chapter 16. Patient Care Settings Objective: 15. Plan nursing interventions for the home health care patient and caregiver. Page: 257 Heading: Transition From Hospital-Based Nursing to Home Health Care Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

The licensed practical nurse/licensed vocational nurse (LPN/LVN) should first notify the RN for any further orders from the health-care provider (HCP). The nurse does not need to take the patient to the hospital unless orders received by the RN/HCP are not effective. The LPN/LVN needs to have an order to infuse IV fluid. The nurse needs to notify the RN for any further orders.

PTS:

CON: Patient-Centered Care

2. The nurse is working with a social worker to determine proper care for a group of patients. Which patient would be best suited for a private duty nurse? 1. A patient with dementia who requires total care and IV antibiotics 2. A patient who is incarcerated and requires insulin injections every 4 hours 3. A patient who needs assistance with cleaning and taking the correct medications 4. A patient who requires blood pressure monitoring and daily dressing changes ANS: 3 Chapter: Chapter 16. Patient Care Settings Objective: 9. Explain differences in hospital versus home health nursing care. Page: 255 Heading: Private-Duty Nursing Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

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Feedback 1 2 3 4

A private duty nurse provides companionship and respite care; this patient needs a long-term care facility. A private duty nurse provides companionship and respite care; this patient needs a correctional nurse. A private duty nurse provides companionship and respite care. A private duty nurse provides companionship and respite care; this patient needs home health care.

PTS:

CON: Patient-Centered Care

3. During a home visit, the nurse notes that an older patient is sitting in a poorly lit room listening to the radio. When the nurse turns on a light before starting to evaluate the patient and change a dressing on a wound, the patient says, “Oh, you don’t need that light. I try to keep the lights off. Electricity is too expensive.” Which response by the nurse is most appropriate? 1. “Oh, I didn’t realize you were pinching pennies. I’ll use my flashlight.” 2. “I will turn off the light as soon as I finish changing the dressing on your wound.” 3. “It sounds like it would be helpful for you to talk with the social worker who can identify financial programs that could help you.” 4. “If you can’t afford electricity, you may need to consider a new residence. I can set up a visit to a nice assisted-living complex near here.” ANS: 3 Chapter: Chapter 16. Patient Care Settings Objective: 12. Identify home safety interventions for the patient. Page: 260 Heading: Safety Considerations Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

Good lighting is important to provide safe care associated with the dressing change. This option does not recognize the potential financial hardship faced by the patient. The case manager can relay concerns of the home-care team to the physician and obtain an order for a social service visit. Social workers help the patient with financial assistive services. Identifying the patient’s wishes and financial options would be necessary before exploring alternative living arrangements.

PTS:

CON: Patient-Centered Care

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4. During a home visit, the nurse documents arrival and departure time, patient vital signs, data collected for the patient, and a narrative note of the patient’s response to medications and understanding of care being given. Which action does the nurse need to take prior to submitting this documentation? 1. Obtain signature of case manager. 2. Obtain signature of patient or caregiver. 3. Comment about patient’s home surroundings. 4. Record the time of documentation submission. ANS: 2 Chapter: Chapter 16. Patient Care Settings Objective: 14. Identify documentation required for a home visit with a patient. Page: 260 Heading: Documentation Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

3 4

The case manager does not need to sign the nurse’s documentation. Items generally included in all home health documentation are the arrival and departure times of the nurse, assessment findings, vital signs, a narrative note, and the patient’s signature verifying the nurse was present in the home. Information about the patient’s home surroundings is not necessary. The time of submission is not a part of the home-care documentation note.

PTS:

CON: Patient-Centered Care

5. During a home health visit, the nurse learns that the family member who is the primary caregiver of the patient is exhausted and tense. Which nursing diagnosis should the nurse recommend for the patient’s plan of care? 1. Social isolation 2. Caregiver role strain 3. Altered role performance 4. Ineffective therapeutic regimen management ANS: 2 Chapter: Chapter 16. Patient Care Settings Objective: 15. Plan nursing interventions for the home health care patient and caregiver. Page: 260 Heading: Nursing Diagnoses, Planning, and Implementation Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

The caregiver is not demonstrating signs of social isolation, altered role

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performance, or ineffective management of the therapeutic regimen. Caregiver role strain is related to the management of a chronic illness and lack of understanding of resources available. The caregiver is exhibiting signs of role strain: exhaustion and being tense. The caregiver is not demonstrating signs of social isolation, altered role performance, or ineffective management of the therapeutic regimen. The caregiver is not demonstrating signs of social isolation, altered role performance, or ineffective management of the therapeutic regimen.

PTS:

CON: Patient-Centered Care

6. While traveling to a patient’s home for a visit, the home-care nurse becomes lost in an unfamiliar part of town and sees a group of teenagers hanging around a boarded-up building. Which action should the nurse take? 1. Proceed to the next appointment. 2. Pull over to the curb to look at a map. 3. Seek assistance from one of the teens. 4. Drive to a familiar area and call the patient for directions. ANS: 4 Chapter: Chapter 16. Patient Care Settings Objective: 11. Explain safety practices for the nurse while making home visits. Page: 258 Heading: Safety Guidelines for Home Health Care Nursing (Box 16.3) Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Skipping the appointment could jeopardize the patient’s health and welfare. Pulling over to the curb to look at a map and asking for help could jeopardize the nurse’s safety. Pulling over to the curb to look at a map and asking for help could jeopardize the nurse’s safety. If lost in an unknown area, the home-care nurse should leave, go to a familiar place, and contact the patient for directions. The agency also can be contacted with any concerns about home safety.

PTS:

CON: Patient-Centered Care

7. The nurse is making home visits for a group of patients. Which patient should the nurse visit first? 1. A 35-year-old reporting chest pain and dyspnea 2. A 40-year-old with a blood glucose of 160 mg/dL 3. A 45-year-old who reports vomiting twice 4. A 50-year-old awaiting a dressing change on the lower leg ANS: 1

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Chapter: Chapter 16. Patient Care Settings Objective: 15. Plan nursing interventions for the home health patient and caregiver. Page: 257 Heading: Steps in the Home Health Care Visit Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

The nurse should see this patient first as she could be experiencing a myocardial infarction (MI). This blood glucose is slightly elevated, but this patient does not need to be seen urgently. This patient does not need to be seen urgently; the patient with chest pain should be seen first. This patient does not need to be seen urgently; the patient with symptoms of an MI should be seen first.

PTS:

CON: Patient-Centered Care

8. During a home visit, the patient asks if his spouse could take one of the patient’s prescribed pain pills for a severe headache. How should the nurse respond to this request? 1. Explain that only 1 dose is permitted to be taken. 2. Suggest the spouse use an over-the-counter pain medication instead. 3. Discuss how frequently the spouse can safely take the prescribed pain medication. 4. Ask the spouse to contact the HCP for a prescription for the medication. ANS: 4 Chapter: Chapter 16. Patient Care Settings Objective: 15. Plan nursing interventions for the home health patient and caregiver. Page: 259 Heading: Patient Education Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

The nurse cannot prescribe medication; therefore, explaining the number of doses to be taken, suggesting the use of over-the-counter pain medication, and discussing the frequency of taking the medication are all outside of the nurse’s scope of practice, could jeopardize the nurse’s license, and should not be done. The nurse cannot prescribe medication; therefore, explaining the number of doses to be taken, suggesting the use of over-the-counter pain medication, and discussing the frequency of taking the medication are all outside of the nurse’s scope of practice, could jeopardize the nurse’s license, and should not be done. The nurse cannot prescribe medication; therefore, explaining the number of doses to be taken, suggesting the use of over-the-counter pain medication, and

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discussing the frequency of taking the medication are all outside of the nurse’s scope of practice, could jeopardize the nurse’s license, and should not be done. Nurses are not able to prescribe medications. The best response would be for the spouse to contact the HCP and ask for a prescription for pain medication.

PTS:

CON: Patient-Centered Care

9. Prior to leaving a patient’s home after a visit, the nurse makes a note in the patient’s homecare folder. Why did the nurse write a note to be kept in the patient’s home? 1. Explains the amount of time each visit takes to complete 2. Provides a reminder to the patient of what care is needed 3. Serves as communication between HCPs who are visiting the patient 4. Provides information to justify the type and level of skilled care the patient requires ANS: 3 Chapter: Chapter 16. Patient Care Settings Objective: 14. Identify documentation required for a home health care nurse. Page: 259 Heading: Documentation Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

The communication note is not used to explain the amount of time each visit takes to complete. The communication note is not used by the patient. A folder with information is kept at the patient’s residence. It usually consists of relevant patient information and a communication form that all staff members complete at each visit. Similar to hospital charting, this documentation is important to ensure continuity of care. It is even more vital in the home setting because staff members do not receive verbal report. The communication note is not used to establish homebound status or skill level required when providing patient care.

PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 1. The nurse completes the Outcome and Assessment Information Set (OASIS) form upon a patient’s admission to a home health care program. For which reasons does the nurse complete this form? (Select all that apply.) 1. To determine per-visit payments 2. To collect information about patient outcomes 3. To document skills used in a specific home visit 4. To develop a plan of care that meets the patient’s needs

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5. To generate information about the home health care agency 6. To identify relatives who will be trained as patient caregivers ANS: 2, 4, 5 Chapter: Chapter 16. Patient Care Settings Objective: 14. Identify documentation required for a home visit with a patient. Page: 259 Heading: Documentation Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

PTS:

Feedback The OASIS form is not used to determine payment structures, document skills used during the visit, or identify relatives to train as caregivers for the patient. OASIS is used to generate information about the home health agency and patient outcomes, and to help develop a plan of care that best meets the patient’s problems. The OASIS form is not used to determine payment structures, document skills used during the visit, or identify relatives to train as caregivers for the patient. OASIS is used to generate information about the home health agency and patient outcomes, and to help develop a plan of care that best meets the patient’s problems. OASIS is used to generate information about the home health agency and patient outcomes, and to help develop a plan of care that best meets the patient’s problems. The OASIS form is not used to determine payment structures, document skills used during the visit, or identify relatives to train as caregivers for the patient. 1

CON: Patient-Centered Care

2. The nurse is visiting the home of an 80-year-old patient who has hypertension and diabetes. In addition to obtaining vital signs and blood glucose levels, what other actions would be appropriate for the nurse to do? (Select all that apply.) 1. Inspect bathroom cupboards for contents. 2. Search the kitchen for high-salt or sugar foods. 3. Ask why the bed has not been made or the dishes washed. 4. Check the bathroom for safety bars in the tub/shower area. 5. Note the presence of scatter rugs or other impediments to free movement. 6. Ask the patient about lighting at night when getting up to use the bathroom. ANS: 4, 5, 6 Chapter: Chapter 16. Patient Care Settings Objective: 12. Identify home safety interventions for the patient.

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Page: 260 Heading: Safety Considerations Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4.

PTS:

Feedback Searching the bathroom is not appropriate. Education related to appropriate dietary measures is important, but searching the kitchen is not appropriate. Housekeeping is not within the realm of the nurse unless it is noted to endanger the patient. Checks that the nurse should do during a home visit to promote safety for the patient include checking the bathroom for safety bars, noting the presence of scatter rugs or other hazards that impede movement, and checking for adequate lighting. Checks that the nurse should do during a home visit to promote safety for the patient include checking the bathroom for safety bars, noting the presence of scatter rugs or other hazards that impede movement, and checking for adequate lighting. Checks that the nurse should do during a home visit to promote safety for the patient include checking the bathroom for safety bars, noting the presence of scatter rugs or other hazards that impede movement, and checking for adequate lighting. 1

CON: Safety

3. The nurse is making a third home health visit. Which observations indicate that the patient and family have understood safety instructions and recommendations made by the nurse on an earlier visit? (Select all that apply.) 1. The patient is wearing an emergency response call device. 2. The family has removed scatter rugs and installed wall-to-wall carpeting. 3. The bathtub has no nonslip mat and there is no grab bar near the shower. 4. The patient’s telephone, eyeglasses, and TV remote are near the patient’s seat. 5. The patient reports getting up frequently at night, but there is no visible nightlight. 6. The patient’s medications are in labeled bottles with a checklist for medication times. ANS: 1, 2, 4, 6 Chapter: Chapter 16. Patient Care Settings Objective: 12. Identify home safety interventions for the patient. Page: 260 Heading: Safety Considerations Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying)

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Concept: Safety Difficulty: Moderate

3. 4.

5. 6.

PTS:

Feedback Observations that promote home safety include the patient wearing an emergency response call device; removal of scatter rugs throughout the home; personal items, such as eyeglasses and the remote for the TV, located in the patient’s seating area; and medications being appropriately labeled with a checklist. Observations that promote home safety include the patient wearing an emergency response call device; removal of scatter rugs throughout the home; personal items, such as eyeglasses and the remote for the TV, located in the patient’s seating area; and medications being appropriately labeled with a checklist. A lack of safety devices in the bathroom and insufficient lighting indicate that additional teaching is required by the nurse. Observations that promote home safety include the patient wearing an emergency response call device; removal of scatter rugs throughout the home; personal items, such as eyeglasses and the remote for the TV, located in the patient’s seating area; and medications being appropriately labeled with a checklist. A lack of safety devices in the bathroom and insufficient lighting indicate that additional teaching is required by the nurse. Observations that promote home safety include the patient wearing an emergency response call device; removal of scatter rugs throughout the home; personal items, such as eyeglasses and the remote for the TV, located in the patient’s seating area; and medications being appropriately labeled with a checklist. 1

CON: Safety

4. The nurse is preparing a home health bag to bring to a patient’s home visit. Which supplies should the nurse carry? (Select all that apply.) 1. Gloves 2. Alcohol wipes 3. Food 4. Biohazard bag 5. Disposable underpads ANS: 2, 4, 5 Chapter: Chapter 16. Patient Care Settings Objective: 13. Describe methods of infection control for the home health care nurse. Page: 258 Heading: Infection Control Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

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Feedback A nurse should always carry extra personal protective equipment (gloves, gown, mask, goggles). A nurse should always carry alcohol wipes to clean thermometers or other devices. Nurses do not need to carry food in the home care bag. The nurse should carry biohazard bags at all times. The nurse should carry disposable underpads. 1

CON: Patient-Centered Care

5. The LPN/LVN is planning to work at a long-term care facility. Which skills should the nurse plan to perform? (Select all that apply.) 1. Administer medications. 2. Supervise the RN. 3. Educate nursing assistants. 4. Document care provided. 5. Make rounds on residents. 6. Order necessary treatments. ANS: 1, 3, 4, 5 Chapter: Chapter 16. Patient Care Settings Objective: 6. Describe the role of the LPN/LVN in long-term care settings. Page: 253 Heading: Role of the LPN/LVN in Long-Term Care Services Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4. 5. 6. PTS:

Feedback The role of the LPN/LVN is to administer medication. The LPN/LVN does not supervise the RN. The role of the LPN/LVN is to educate and mentor nursing assistants. The role of the LPN/LVN is to document care provided. The LPN/LVN will make rounds on residents. It is not within the LPN/LVN scope of practice to write orders for patients. 1

CON: Patient-Centered Care

6. The nurse is making a first home-care visit to a patient recently discharged after hip replacement surgery. Which home observations should the nurse document as safety concerns? (Select all that apply.) 1. The patient’s recliner faces the television. 2. A safety bar has been installed in the shower. 3. A bathmat towel is on the floor in front of the tub.

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4. Smoke detectors are located in the kitchen and near the bedrooms. 5. The patient has a large birdcage sitting on the floor in the middle of the living room. 6. The hallway between the bedroom and bathroom is partially blocked by a cedar chest. ANS: 3, 5, 6 Chapter: Chapter 16. Patient Care Settings Objective: 12. Identify home safety interventions for the patient. Page: 258 Heading: Safety Considerations Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3.

4. 5.

PTS:

Feedback The recliner facing the television is not a safety risk. A safety bar in the shower is not a safety risk. Smoke detectors support home safety. The recliner facing the television is not a safety risk. A safety bar in the shower is not a safety risk. Smoke detectors support home safety. The home health nurse should always assess the patient’s safety in the home. Safety concerns would include an obstruction on the floor, such as a birdcage, and a walkway being blocked by a cedar chest. The bathmat towel needs to be replaced with a nonskid mat. The recliner facing the television is not a safety risk. A safety bar in the shower is not a safety risk. Smoke detectors support home safety. The home health nurse should always assess the patient’s safety in the home. Safety concerns would include an obstruction on the floor, such as a birdcage, and a walkway being blocked by a cedar chest. The bathmat towel needs to be replaced with a nonskid mat. The home health nurse should always assess the patient’s safety in the home. Safety concerns would include an obstruction on the floor, such as a birdcage, and a walkway being blocked by a cedar chest. The bathmat towel needs to be replaced with a nonskid mat. 1

CON: Patient-Centered Care

7. The nurse is preparing to make a telehealth visit to a patient with a foot wound. Which types of technology will the nurse use to complete this visit? (Select all that apply.) 1. E-mail 2. Telephone 3. Fax machine 4. Blood pressure cuff 5. Video conferencing ANS: 1, 2, 3, 5 Chapter: Chapter 16. Patient Care Settings

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Objective: 15. Plan nursing interventions for the home health patient and caregiver. Page: 260 Heading: Telenursing Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

4. 5.

PTS:

Feedback Telenursing, a branch of telehealth, uses information technology and telecommunication to provide nursing care. Various types of technology can be used, including telephone, fax, e-mail, and video/audio conferencing. Telenursing, a branch of telehealth, uses information technology and telecommunication to provide nursing care. Various types of technology can be used, including telephone, fax, e-mail, and video/audio conferencing. Telenursing, a branch of telehealth, uses information technology and telecommunication to provide nursing care. Various types of technology can be used, including telephone, fax, e-mail, and video/audio conferencing. A blood pressure cuff would not be used during a telehealth visit because the nurse is not in the same room as the patient. Telenursing, a branch of telehealth, uses information technology and telecommunication to provide nursing care. Various types of technology can be used, including telephone, fax, e-mail, and video/audio conferencing. 1

CON: Patient-Centered Care

8. The nurse is planning to make home-care visits throughout the day. What tasks should the nurse perform before beginning these visits? (Select all that apply.) 1. Place a map in the door sleeve. 2. Plug the cell phone into the charger. 3. Check that the car’s gas tank is full. 4. Check the home-care bag for a whistle. 5. Check the wallet for at least $50 in cash. ANS: 1, 2, 3, 4 Chapter: Chapter 16. Patient Care Settings Objective: 11. Explain safety practices for the nurse while making home visits. Page: 257 Heading: Safety Guidelines for Home Health Care Nurses Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate

Feedback Safety tips for the nurse preparing to conduct home-care visits includes having a map in the car, having a cell phone, making sure the car’s gas tank

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is full, and having a whistle in case help is needed. Safety tips for the nurse preparing to conduct home-care visits includes having a map in the car, having a cell phone, making sure the car’s gas tank is full, and having a whistle in case help is needed. Safety tips for the nurse preparing to conduct home-care visits includes having a map in the car, having a cell phone, making sure the car’s gas tank is full, and having a whistle in case help is needed. Safety tips for the nurse preparing to conduct home-care visits includes having a map in the car, having a cell phone, making sure the car’s gas tank is full, and having a whistle in case help is needed. Carrying a large sum of money is not required while conducting home-care visits. 1

CON: Patient-Centered Care

9. After entering a patient’s home for a visit, the nurse notes that the living room floor is littered with trash, and pet hair is on furniture and table stands. What should the nurse do to maintain a clean home-care bag? (Select all that apply.) 1. Take the bag back to the car. 2. Wear the bag as a shoulder bag. 3. Place the bag on a disposable pad. 4. Cleanse the bag after leaving the home. 5. Place the bag on the nearest unupholstered chair. ANS: 3, 4 Chapter: Chapter 16. Patient Care Settings Objective: 13. Describe methods of infection control for the home health care nurse Page: 258 Heading: Infection Control Integrated Process: Caring Client Need: SECE-Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback The nurse might need something from the bag during the visit, so taking the bag back to the car is not safe nursing care. Wearing the bag as a shoulder bag could limit the nurse’s ability to provide safe nursing care. Disposable pads can be put on the floor and the home health bag placed on these. After the visit, the nurse should disinfect the bag before the next visit. Disposable pads can be put on the floor and the home health bag placed on these. After the visit, the nurse should disinfect the bag before the next visit. Placing the bag on an unupholstered chair could expose the bag to environmental hazards. 1

CON: Patient-Centered Care

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Chapter 17. Nursing Care of Patients at the End of Life MULTIPLE CHOICE 1. A family member is concerned that a patient near the end of life is not eating or drinking and asks the nurse how the family can help the patient increase oral intake. Which response by the nurse is most appropriate? 1. “The best way to feed the patient is with a syringe and small amounts of water or liquid feeding.” 2. “The less the patient drinks, the less urination will be necessary, and urination can be uncomfortable at this point in the dying process.” 3. “The starvation process at the end of life is quite natural; a side benefit is that lower doses of medications are needed to keep the patient comfortable.” 4. “As your family member becomes dehydrated from not eating or drinking, natural endorphins will be released, which increase comfort near the end of life.” ANS: 4 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 5. Describe physical changes to expect during the dying process. Page: 267 Heading: Eating and Drinking Integrated Process: Communication and Documentation Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Grief and Loss Difficulty: Moderate Feedback 1

Feeding may not be the best action.

Urination is not uncomfortable.

Use of the word starvation may be distressing to the family.

Benefits in withholding artificial feeding and hydration in the final weeks of life in actively dying patients include fewer pharyngeal and lung secretions, which can reduce dyspnea; reduced swelling around tumors, which can reduce associated pain; and less urination, resulting in dryer skin with fewer breakdowns. It has also been theorized that as dehydration occurs, the body produces a form of endorphin, which enhances comfort.

PTS:

CON: Grief and Loss

2. The nurse is discussing a terminal diagnosis with a patient. Which is most appropriate for the nurse to include? 1. “Tell me what you know about your diagnosis.” 2. “You shouldn’t be angry or blame God for this.” 3. “The sooner you accept this diagnosis, the better.” 4. “There is a good support group you should attend.”

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ANS: 1 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 4. Demonstrate appropriate communication with dying patients and their families. Page: 270 Heading: Communicating With Dying Patients and Their Loved Ones Integrated Process: Communication And Documentation Client Need: Physiological Integrity Cognitive Level: Application (Applying) Concept: Grief and Loss Difficulty: Moderate Feedback 1

The nurse should find out what the patient knows about his or her diagnosis.

The nurse cannot tell the patient not to be angry.

The nurse should not force the patient to accept the diagnosis.

The patient may not be ready for a support group. First, find out what he or she knows about his or her diagnosis.

PTS:

CON: Grief and Loss

3. A patient with lung cancer who is expected to die within a few days is being given a blood transfusion. Family members, who realize death is imminent, ask, “Why are you giving a blood transfusion when we all know death is just around the corner?” Which response by the nurse to the family is most appropriate? 1. “That question is best answered by the physician during rounds.” 2. “It is my duty as a nurse to continue to administer life-prolonging treatments until the patient dies.” 3. “The blood will raise the hemoglobin level, which will increase energy level and sense of well-being.” 4. “The transfusion will help increase the patient’s oxygen levels. It will not prolong life, but will increase comfort.” ANS: 4 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 6. Plan nursing interventions for patients at the end of life. Page: 264 Heading: Nursing Care Plan for Patients at the End of Life Integrated Process: Communication and Documentation Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Grief and Loss Difficulty: Moderate Feedback 1 2

It is not necessary for the family to wait for an answer from the physician. Teaching is a nursing role. It is not the nurse’s duty to provide life-prolonging treatments until the patient

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dies. Nurses often administer comfort care at the end of life. Comfort is the goal at the end of life, not increased energy. Blood transfusions may be given to improve oxygenation and reduce dyspnea, and are not intended to prolong life, but to promote comfort.

PTS:

CON: Grief and Loss

4. The nurse is caring for a patient who is unconscious and begins to make a gurgling sound, or death rattle. Which action should the nurse take? 1. Administer oxygen as ordered. 2. Instruct the patient to cough. 3. Give the patient a sip of water. 4. Suction the patient. ANS: 4 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 6. Plan nursing interventions for patients at the end of life. Page: 270 Heading: The Dying Process Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Application) Concept: Grief and Loss Difficulty: Moderate Feedback 1

Oxygen will not help for secretions.

The patient is unconscious and cannot cough.

The patient is unconscious and cannot sip water.

Suctioning the patient will help remove secretions.

PTS:

CON: Grief and Loss

5. A patient asks what a do not resuscitate (DNR) order means. What should the nurse explain to the patient? 1. “A DNR order means that you will not be placed on a ventilator if your heart stops and you require CPR.” 2. “A DNR order means you will not be resuscitated if your heart stops and that all therapeutic support will be withdrawn.” 3. “A DNR order means that you will receive everything you need to remain comfortable, but you will not receive treatment that will prolong life.” 4. “A DNR order means you will not be resuscitated if your heart stops; you can specify whether you still want treatment to prolong your life or only care that keeps you comfortable.” ANS: 4 Chapter: Chapter 17. Nursing Care of Patients at the End of Life

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Objective: 2. List necessary legal documents for patients with life-limiting illness. Page: 265 Heading: Do Not Resuscitate Orders Integrated Process: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Grief and Loss Difficulty: Moderate Feedback 1 2 3 4

A DNR order does not direct care prior to death—type and extent of treatment prior to death is still determined by the patient. A DNR order does not direct care prior to death—type and extent of treatment prior to death is still determined by the patient. A DNR order does not direct care prior to death—type and extent of treatment prior to death is still determined by the patient. DNR simply means do not resuscitate if a patient’s heart stops.

PTS:

CON: Grief and Loss

6. A patient asks the nurse to explain a durable power of attorney. Which statement by the nurse is most accurate? 1. “A durable power of attorney is a person you choose to speak for you when you cannot make decisions.” 2. “It is a document that provides instruction to the health care provider regarding your preferences.” 3. “This is a document stating you do not want to be resuscitated if your heart stops.” 4. “This gives the nurse power to make any medical decisions on your behalf.” ANS: 1 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 2. List necessary legal documents for patients with life-limiting illness. Page: 265 Heading: Advance Directives, Living Wills, and Durable Medical Power of Attorney Integrated Process: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Grief and Loss Difficulty: Moderate Feedback 1

This describes a durable power of attorney.

This describes a living will.

This describes a DNR order.

This does not accurately describe a durable power of attorney.

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PTS:

CON: Grief and Loss

7. The licensed practical nurse/licensed vocational nurse (LPN/LVN) notifies the registered nurse (RN) that a patient under hospice care is in respiratory distress. Which clinical manifestation supports this finding? 1. Increased oxygen saturation 2. Decreased respiratory rate 3. Increased respiratory effort 4. Respiratory rate of 12 breaths/min ANS: 3 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 5. Describe physical changes to expect during the dying process. Page: 270 Heading: Nursing Care Plan for the Patient at the End of Life Integrated Process: Clinical Problem-Solving Process Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Grief and Loss Difficulty: Moderate Feedback 1

An increased oxygen saturation does not indicate respiratory distress.

Decreased respiratory rate does not indicate respiratory distress.

Increased respiratory effort indicates respiratory distress.

A respiratory rate of 12 breaths/min does not indicate respiratory distress.

PTS:

CON: Grief and Loss

8. During the last vital signs assessment, a patient with end-stage heart failure has a body temperature of 102.6°F. Which action should the nurse take at this time? 1. Provide additional blankets. 2. Assist to a side-lying position. 3. Encourage increased oral fluid intake. 4. Administer acetaminophen as prescribed. ANS: 4 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 6. Plan nursing interventions for patients at the end of life. Page: 275 Heading: Nursing Care Plan for the Patient at the End of Life Integrated Process: Caring Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Grief and Loss Difficulty: Moderate Feedback

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Providing additional blankets would be appropriate if the patient’s temperature was subnormal. Assisting to a side-lying position has no clinical significance for the client experiencing a fever. The client’s health status may not support an increase in oral fluids. For the terminally ill patient experiencing a fever, the nurse should provide acetaminophen, an antipyretic, as prescribed.

PTS:

CON: Grief and Loss

9. The nurse is reviewing the chart of a patient to determine if he is appropriate for hospice. Which qualification supports hospice care? 1. Patient unresponsive 2. Need for 24-hour care 3. Prognosis of 6 months or less 4. Diagnosis of cancer ANS: 3 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 3. Explain choices that are available to patients at the end of life. Page: 267 Heading: Hospice Care Integrated Process: Caring Client Need: SECE—Coordinated Care Cognitive Level: Application (Applying) Concept: Grief and Loss Difficulty: Moderate Feedback 1

Being unresponsive is not a qualification for hospice.

Hospice typically does not provide 24-hour care.

The qualification for hospice is a 6-month or less prognosis.

Hospice takes patients of any diagnosis as long as it is terminal.

PTS:

CON: Grief and Loss

10. The nurse is caring for a dying patient under hospice care. Which is an example of nonverbal communication? 1. Make eye contact with the patient. 2. Encourage the patient to reminisce. 3. Ask close-ended questions. 4. Answer any questions the patient may have. ANS: 1 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 4. Describe appropriate communication with dying patients and their families. Page: 264

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Heading: Communicating With Patients and Their Loved Ones Integrated Process: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Grief and Loss Difficulty: Moderate Feedback 1

Eye contact is a form of nonverbal communication.

This is verbal communication.

PTS:

CON: Grief and Loss

MULTIPLE RESPONSE 1. The nurse is providing care to a patient with a terminal illness. What should be the nurse’s priorities when providing care to this patient? (Select all that apply.) 1. Helping the patient define goals of care 2. Preparing the family for life after the patient has died 3. Encouraging the patient to have hope for a full recovery 4. Supporting the patient through losses leading to a good death 5. Helping the patient communicate care wishes to health care providers (HCPs) ANS: 1, 4, 5 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 6. Plan nursing interventions for patients at the end of life. Page: 264 Heading: Communicating With Patients and Their Loved Ones Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Grief and Los Difficulty: Moderate

2. 3.

Feedback The role of the nurse with patients nearing the end of life include helping to identify patients with life-limiting illnesses early, so they and their families have the opportunity to redefine their goals of care; help patients communicate their wishes to HCPs, both orally and in writing; to ensure that their wishes are understood; and give patients support and validation as they move through the series of losses leading to a good death. Preparing the family for life after the patient has died is not a priority at this time. Encouraging the patient to have hope for a full recovery would be unrealistic

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and not fair to the patient. The role of the nurse with patients nearing the end of life include helping to identify patients with life-limiting illnesses early, so they and their families have the opportunity to redefine their goals of care; help patients communicate their wishes to HCPs, both orally and in writing; to ensure that their wishes are understood; and give patients support and validation as they move through the series of losses leading to a good death. The role of the nurse with patients nearing the end of life include helping to identify patients with life-limiting illnesses early, so they and their families have the opportunity to re-define their goals of care; help patients communicate their wishes to HCPs, both orally and in writing; to ensure that their wishes are understood; and give patients support and validation as they move through the series of losses leading to a good death. 1

CON: Grief and Loss

2. The nurse is reviewing the nutritional status for a group of patients. In which patients would a feeding tube most likely be beneficial? (Select all that apply.) 1. An 80-year-old patent with dementia 2. A 76-year-old patient with terminal cancer 3. A 65-year-old patient recovering from pneumonia 4. A 90-year-old patient with diabetes and heart failure 5. A 55-year-old with esophageal cancer who is receiving radiation therapy 6. A 55-year-old patient receiving chemotherapy and experiencing loss of appetite ANS: 3, 5, 6 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 6. Plan nursing interventions for patients at the end of life. Page: 266 Heading: Artificial Feeding and Hydration Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Grief and Loss Difficulty: Moderate

Feedback Using a feeding tube for a patient with dementia will not improve quality of life. The patients with terminal cancer, heart failure, and diabetes are not going to survive and tube feeding can increase complications and reduce comfort at the end of life. Using a feeding tube for a patient with dementia will not improve quality of life. The patients with terminal cancer, heart failure, and diabetes are not going to survive and tube feeding can increase complications and reduce comfort at the end of life. Patients who are expected to recover from an acute process or are experiencing an intervention that currently complicates oral intake would benefit the most from a feeding tube. This includes the patient recovering from pneumonia, receiving radiation treatment for esophageal cancer, and

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receiving chemotherapy. Using a feeding tube for a patient with dementia will not improve quality of life. The patients with terminal cancer, heart failure, and diabetes are not going to survive and tube feeding can increase complications and reduce comfort at the end of life. Patients who are expected to recover from an acute process or are experiencing an intervention that currently complicates oral intake would benefit the most from a feeding tube. This includes the patient recovering from pneumonia, receiving radiation treatment for esophageal cancer, and receiving chemotherapy. Patients who are expected to recover from an acute process or are experiencing an intervention that currently complicates oral intake would benefit the most from a feeding tube. This includes the patient recovering from pneumonia, receiving radiation treatment for esophageal cancer, and receiving chemotherapy. 1

CON: Grief and Loss

3. A patient with terminal cancer has just died. Which actions should the nurse take during the immediate postmortem period? (Select all that apply.) 1. Bathe and dress the patient. 2. Ask the family if they want the patient’s face covered or uncovered. 3. Remove all tubes, medical supplies, and equipment from the bedside. 4. Provide the family a place away from the patient’s room to talk and grieve. 5. Notify the physician with the patient’s time of death per institutional policy. 6. Recommend that the family donate the patient’s organs as a way to find meaning from the death. ANS: 1, 2, 3, 5 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 7. Describe postmortem care. Page: 275 Heading: Care at the Time of Death and Afterward Integrated Process: Caring Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Grief and Loss Difficulty: Moderate

Feedback After death, the nurse will provide postmortem care. First, remove the tubes, medical supplies, and equipment. Bathing and dressing the patient and making him or her look presentable for the family shows respect. After death, the nurse will provide postmortem care. First, remove the tubes, medical supplies, and equipment. Bathing and dressing the patient and making him or her look presentable for the family shows respect. After death, the nurse will provide postmortem care. First, remove the tubes, medical supplies, and equipment. Bathing and dressing the patient and making him or her look presentable for the family shows respect.

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Allow the family time with the patient; do not remove the body until they are ready. Contacting the physician and funeral home are carried out according to institutional policy. Covering or uncovering the face at removal should be done according to the family’s wishes. After death, the nurse will provide postmortem care. First, remove the tubes, medical supplies, and equipment. Bathing and dressing the patient and making him or her look presentable for the family shows respect. Information about organ donation should be provided according to agency policy, but the nurse should not make recommendations. 1

CON: Grief and Loss

4. A dying patient is experiencing copious secretions, difficulty in swallowing, and labored breathing. Which interventions should the nurse perform? (Select all that apply.) 1. Suction secretions. 2. Encourage oral fluids. 3. Place a dehumidifier in the room. 4. Administer scopolamine as ordered. 5. Increase oxygen to 3 L per nasal cannula. 6. Place the patient in Fowler or semi-Fowler position. ANS: 1, 4, 6 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 6. Plan nursing interventions for the patients at the end of life. Page: 270-271 Heading: Nursing Care Plan for the Patient at the End of Life Integrated Process: Caring Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Grief and Loss Difficulty: Moderate Feedback 1.

Suctioning can help reduce aspiration of secretions and help with swallowing and breathing.

Encouraging oral fluids increases the risk of aspiration.

A dehumidifier is not helpful as it makes the air dryer and that may make the patient less comfortable.

Scopolamine (an anticholinergic medication) helps dry secretions, making breathing and swallowing less difficult.

Increasing oxygen will not reduce secretions.

Positioning the patient in an upright position can help reduce aspiration of secretions and helps with lung expansion for better breathing.

PTS:

CON: Grief and Loss

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5. The nurse is concerned that a patient has a short time left to live. Which criterion is the nurse using that indicates a prognosis of 6 months or less to live? (Select all that apply.) 1. Incontinence 2. Functional decline 3. Increased agitation 4. Recurrent infections 5. Frequent hospitalizations 6. Weight loss of 10% or more ANS: 2, 4, 5, 6 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 1. Identify characteristics of the patient who is approaching the end of life. Page: 268 Heading: Hospice Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Grief and Loss Difficulty: Moderate

1. 2.

3. 4.

PTS:

Feedback Agitation and incontinence can occur for many reasons and do not necessarily predict death. Some indicators of a prognosis of 6 months or less regardless of diagnosis are functional decline, recurrent infections, frequent hospitalizations, and a 10% loss of weight in 6 months. Agitation and incontinence can occur for many reasons and do not necessarily predict death. Some indicators of a prognosis of 6 months or less regardless of diagnosis are functional decline, recurrent infections, frequent hospitalizations, and a 10% loss of weight in 6 months. Some indicators of a prognosis of 6 months or less regardless of diagnosis are functional decline, recurrent infections, frequent hospitalizations, and a 10% loss of weight in 6 months. Some indicators of a prognosis of 6 months or less regardless of diagnosis are functional decline, recurrent infections, frequent hospitalizations, and a 10% loss of weight in 6 months. 1

CON: Grief and Loss

6. The nurse is scheduling a hospice team to meet with the family of a dying patient. Which individuals will most likely participate in this meeting? (Select all that apply.) 1. Nurse to manage symptoms of pain and nausea 2. Social worker to assist with community resources 3. Chaplain to provide spiritual and emotional support 4. Physical therapist working to regain patient ability to walk 5. Bereavement counselor to provide assistance to family and loved ones 6. Hospitalist to direct an emergency response team and provide cardiopulmonary

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resuscitation (CPR) ANS: 1, 2, 3, 5 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 6. Plan nursing interventions for patients at the end of life. Page: 267 Heading: Communicating With Patients and Their Loved Ones Integrated Process: Caring Client Need: SECE-Coordinated Care Cognitive Level: Application (Applying) Concept: Grief and Loss Difficulty: Moderate

4. 5.

6. PTS:

Feedback The hospice team is multidisciplinary and includes the nurse, social worker, chaplain, and bereavement counselor in addition to the physician and home health aide. The hospice team is multidisciplinary and includes the nurse, social worker, chaplain, and bereavement counselor in addition to the physician and home health aide. The hospice team is multidisciplinary and includes the nurse, social worker, chaplain, and bereavement counselor in addition to the physician and home health aide. Because the hospice philosophy is one of support and symptom management, physical therapy designed to restore function would not be involved. The hospice team is multidisciplinary and includes the nurse, social worker, chaplain, and bereavement counselor in addition to the physician and home health aide. CPR would not be appropriate for a hospice patient. 1

CON: Grief and Loss

7. The nurse is providing hospice care for a patient in the terminal phase of lung cancer. Which nursing actions would be appropriate? (Select all that apply.) 1. Provide low-dose morphine. 2. Place a fan at the patient’s bedside. 3. Encourage the patient to bathe daily. 4. Administer diuretic therapy as ordered. 5. Position the patient upright in a recliner with pillows. 6. Teach family members how to perform deep tracheal suctioning. ANS: 1, 2, 4, 5 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 6. Plan interventions for patients at the end of life. Page: 270 Heading: Nursing Care Plan for Patients at the End of Life Integrated Process: Caring Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying)

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Concept: Grief and Loss Difficulty: Moderate

3. 4.

PTS:

Feedback Activities should be planned to conserve energy. Low-dose morphine reduces pulmonary edema and anxiety. A fan or breeze reduces the feeling of dyspnea. Diuretic therapy may increase comfort and treat dyspnea. An upright position will help alleviate dyspnea. Activities should be planned to conserve energy. Low-dose morphine reduces pulmonary edema and anxiety. A fan or breeze reduces the feeling of dyspnea. Diuretic therapy may increase comfort and treat dyspnea. An upright position will help alleviate dyspnea. Daily bathing is not required. Activities should be planned to conserve energy. Low-dose morphine reduces pulmonary edema and anxiety. A fan or breeze reduces the feeling of dyspnea. Diuretic therapy may increase comfort and treat dyspnea. An upright position will help alleviate dyspnea. Activities should be planned to conserve energy. Low-dose morphine reduces pulmonary edema and anxiety. A fan or breeze reduces the feeling of dyspnea. Diuretic therapy may increase comfort and treat dyspnea. An upright position will help alleviate dyspnea. Deep tracheal suctioning would be invasive and painful and often irritates tissue rather than aiding with breathing. 1

CON: Grief and Loss

8. A terminally ill patient is experiencing mouth discomfort. Which actions should the nurse take to help this patient? (Select all that apply.) 1. Offer ice chips. 2. Offer sips of water. 3. Apply lanolin to the lips. 4. Provide an alcohol-based mouthwash. 5. Use sponge-tipped toothettes for mouth care. ANS: 1, 2, 3, 5 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 6. Plan nursing interventions for patients at the end of life. Page: 271 Heading: Nursing Care Plan for Patients at the End of Life Integrated Process: Caring Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Grief and Loss Difficulty: Moderate

Feedback In the terminally ill patient, a dry mouth can be due to lack of oral intake, disease process, or medication. The nurse should offer the patient ice chips or sips of water, apply lanolin to the lips, and use sponge-tipped toothettes for

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4. 5.

PTS:

mouth care. In the terminally ill patient, a dry mouth can be due to lack of oral intake, disease process, or medication. The nurse should offer the patient ice chips or sips of water, apply lanolin to the lips, and use sponge-tipped toothettes for mouth care. In the terminally ill patient, a dry mouth can be due to lack of oral intake, disease process, or medication. The nurse should offer the patient ice chips or sips of water, apply lanolin to the lips, and use sponge-tipped toothettes for mouth care. An alcohol-based mouthwash can cause the oral tissues to dry further adding to the patient’s discomfort. In the terminally ill patient, a dry mouth can be due to lack of oral intake, disease process, or medication. The nurse should offer the patient ice chips or sips of water, apply lanolin to the lips, and use sponge-tipped toothettes for mouth care. 1

CON: Grief and Loss

9. A terminally ill patient who is not able to talk is demonstrating restlessness. What actions can the nurse take to help this patient achieve comfort? (Select all that apply.) 1. Medicate for pain. 2. Elevate the head of the bed. 3. Measure oxygen saturation. 4. Reposition the patient in bed. 5. Ensure incontinence pad is clean and dry. ANS: 1, 3, 4, 5 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 6. Plan interventions for patients at the end of life. Page: 271 Heading: Terminal Restlessness Integrated Process: Caring Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Grief and Loss Difficulty: Moderate

2. 3.

Feedback For the terminally ill patient who is unable to verbally communicate needs but is demonstrating restlessness, the nurse can medicate for pain, measure oxygen saturation, reposition the patient in bed, and ensure that an incontinence pad is clean and dry. Elevating the head of the bed may increase discomfort and is used for the patient who is experiencing dyspnea or other respiratory difficulty. For the terminally ill patient who is unable to verbally communicate needs but is demonstrating restlessness, the nurse can medicate for pain, measure oxygen saturation, reposition the patient in bed, and ensure that an incontinence pad is clean and dry. For the terminally ill patient who is unable to verbally communicate needs

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but is demonstrating restlessness, the nurse can medicate for pain, measure oxygen saturation, reposition the patient in bed, and ensure that an incontinence pad is clean and dry. For the terminally ill patient who is unable to verbally communicate needs but is demonstrating restlessness, the nurse can medicate for pain, measure oxygen saturation, reposition the patient in bed, and ensure that an incontinence pad is clean and dry. 1

CON: Grief and Loss

10. The adult daughter of a terminally ill patient is upset because the patient is confused and is talking to people who are not in the room. What should the nurse do to help the patient and daughter? (Select all that apply.) 1. Encourage the patient to continue to talk. 2. Make sure that a dim light is on in the patient’s room. 3. Suggest the daughter provide the patient with sips of fluids. 4. Explain to the daughter that confusion is common and expected. 5. Encourage the daughter to provide tactile stimulation to the patient. ANS: 1, 2, 4 Chapter: Chapter 17. Nursing Care of Patients at the End of Life Objective: 4. Demonstrate appropriate communication with dying patients and their families. Page: 273 Heading: Communicating With Dying Patients and Their Loved Ones Integrated Process: Communication and Documentation Client Need: Psychosocial Integrity Cognitive Level: Application (Applying) Concept: Grief and Loss Difficulty: Moderate

3. 4.

5. PTS:

Feedback The terminally ill patient may demonstrate acute confusion. The family will be better prepared for this confusion if they understand why it is occurring, and that confusion is common and expected. The patient should be encouraged to talk. A dim light in the room helps the patient remain oriented. The terminally ill patient may demonstrate acute confusion. The family will be better prepared for this confusion if they understand why it is occurring, and that confusion is common and expected. The patient should be encouraged to talk. A dim light in the room helps the patient remain oriented. Providing the patient with sips of fluid would be helpful if the patient were experiencing a dry mouth. The terminally ill patient may demonstrate acute confusion. The family will be better prepared for this confusion if they understand why it is occurring, and that confusion is common and expected. The patient should be encouraged to talk. A dim light in the room helps the patient remain oriented. Tactile stimulation does not help reduce the patient’s confusion. 1

CON: Grief and Loss

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Chapter 18. Immune System Function, Assessment, and Therapeutic Measures MULTIPLE CHOICE 1. The nurse is caring for a patient who reports enlarged, painful, and moveable preauricular lymph nodes, postauricular lymph nodes, and cervical lymph nodes. Which does the nurse infer from these findings? 1. Infection 2. Cancer 3. Liver failure 4. Thyroid disorder ANS: 1 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 6. Explain objective data that are collected when caring for a patient with a disorder of the immune system. Page: 286 Heading: Objective Data Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1 2 3 4

A patient with an infection will experience tenderness and movable lymph nodes. A patient with cancer will experience nonmovable lymph nodes. These do not describe symptoms of liver disease. These do not describe symptoms of thyroid disease.

PTS:

CON: Infection

2. The nurse is caring for a group of patients. Which patient is at highest risk for developing systemic lupus erythematosus (SLE)? 1. An African American female 2. A Caucasian female 3. An Asian male 4. A Hispanic male ANS: 1 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 5. Explain subjective data that are collected when caring for a patient with a disorder of the immune system. Page: 309 Heading: Demographic Data Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing)

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Concept: Immunity Difficulty: Moderate Feedback 1

This patient is at highest risk for developing SLE. This patient is not as high risk as an African American female. This patient is not as high risk as an African American female. This patient is not as high risk as an African American female.

2 3 4

PTS:

CON: Immunity

3. The nurse is assisting a health care provider with subcutaneous immunotherapy (SCIT). Which is a priority to have readily available? 1. Emergency equipment 2. Restraints 3. Antibiotic 4. Family contact information ANS: 1 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 7. Describe nursing care provided for patients undergoing diagnostic tests for the immune system. Pages: 292–293 Heading: Immunotherapy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

Emergency equipment should be readily available in case of anaphylaxis. The patient should not be restrained. An antibiotic will not be useful in immunotherapy. Although contact information for family is important, it is more important to ensure emergency equipment is on hand.

PTS:

CON: Safety

4. The nurse is working in a clinic when a patient presents with shortness of breath, wheezing, and hives. The nurse should plan to implement which order first? 1. Administer morphine IV 2. Administer epinephrine IV 3. Administer ketorolac (Toradol) IV 4. Administer furosemide (Lasix) IV ANS: 2 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 8. Describe common therapeutic measures used for disorders of the immune system. Page: 297

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Heading: Allergies Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Inflammation Difficulty: Moderate Feedback 1 2 3 4

This patient is likely experiencing an anaphylactic reaction; morphine is not administered. This patient is likely experiencing an anaphylactic reaction; epinephrine will be administered. This patient is likely experiencing an anaphylactic reaction; Toradol will not be given. This patient is likely experiencing an anaphylactic reaction; Lasix may be given to ease breathing and remove fluid, but it is not a priority.

PTS:

CON: Inflammation

5. The nurse is caring for a group of patients. Which patients should the nurse see first? 1. A patient with allergic rhinitis reporting frequent sneezing 2. A patient who had an anaphylactic reaction 2 days ago 3. A patient who just received an influenza vaccination 4. A patient receiving chemotherapy with a temperature of 103°F ANS: 4 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 6. Explain objective data that are collected when caring for a patient with a disorder of the immune system. Page: 288 Heading: Objective Data Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1 2 3 4

This patient is not the highest priority. This patient should be seen, but is not as high a priority as an immunocompromised patient with a fever. This patient is not a priority. This patient should be seen first because he or she is immunocompromised and has a high fever.

PTS:

CON: Infection

6. The nurse is caring for a patient being tested for rheumatoid arthritis. In reviewing laboratory values, which should the nurse recognize as being diagnostic of rheumatoid arthritis? 1. C-reactive protein = 12 mg/L

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2. Negative rheumatoid factor 3. White blood cells (WBC) = 6,000/mm3 4. Negative antinuclear antibody (ANA) test ANS: 1 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 7. Describe nursing care provided for patients undergoing diagnostic tests for the immune system. Page: 289 Heading: Diagnostic Laboratory Tests for the Immune System (Table 18.4) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4

A normal C-reactive protein level is less than 10 mg/L; an elevated level is present in rheumatoid arthritis, cancer, and SLE. ANA and rheumatoid factor are positive in the presence of rheumatoid arthritis. This is a normal WBC count, which measures immune function. ANA and rheumatoid factor are positive in the presence of rheumatoid arthritis.

PTS:

CON: Immunity

7. The nurse is reinforcing teaching to a person who has tested positive for HIV. Which test should the nurse explain is done to confirm the diagnosis of HIV? 1. Western blot 2. Rheumatoid factor 3. ANA 4. Immunoglobulin assay ANS: 1 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 7. Describe nursing care provided for patients undergoing diagnostic tests for the immune system. Page: 290 Heading: Diagnostic Laboratory Tests for the Immune System Integrated Process: Clinical Problem-Solving Process (nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4

Western blot is used as a confirmation test for HIV. This test is done to determine the presence of rheumatoid arthritis. This test is done to determine the presence of rheumatoid arthritis. Immunoglobulin assays are completed to determine the presence of an infection.

PTS:

CON: Immunity

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8. The nurse is reviewing laboratory results for a group of patients and notes a CD4 count of 120 cells/µL. For which patient would the nurse expect to see this result? 1. A patient with gastroenteritis 2. A patient with HIV 3. A patient with allergic rhinitis 4. A patient with atrial fibrillation ANS: 2 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 7. Describe nursing care provided for patients undergoing diagnostic tests for the immune system. Page: 290 Heading: Diagnostic Laboratory Tests for the Immune System (Table 18.4) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4

A CD4 count is typically used to test treatment effectiveness for an HIV positive patient. This low CD4 count is seen in patients with HIV. A CD4 count is typically used to test treatment effectiveness for an HIV positive patient. A CD4 count is typically used to test treatment effectiveness for an HIV positive patient.

PTS:

CON: Immunity

9. The nurse is caring for a patient with a diagnosis of malaria. Which antibody would the nurse expect to see increased? 1. Immunoglobulin G (IgG) 2. IgM 3. IgA 4. IgE ANS: 2 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 3. Discuss the function of each class of immunoglobulin and how each behaves in a particular immune response. Page: 290 Heading: Diagnostic Laboratory Tests for the Immune System (Table 18.4) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback

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1 2 3 4

IgG is not increased in malaria. IgM is increased in malaria. IgA is not increased in malaria. IgE is not increased in malaria.

PTS:

CON: Immunity

10. The nurse is taking a medication history for a newly admitted patient. The patient states he is allergic to levofloxacin (Levaquin). Which response by the nurse is most appropriate? 1. “We will be sure to add this to your chart so you never receive this medication.” 2. “You need to wear a medical alert bracelet to show you have an allergy.” 3. “What happens to you when you take the medication?” 4. “You can take the medication as long as you carry an EpiPen.” ANS: 3 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 5. Explain subjective data that are collected when caring for a patient with a disorder of the immune system. Page: 288 Heading: Subjective Data Collection for the Immune System (Table 18.2) Integrated Process: Communication and Documentation Client Need: SECE—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

The nurse should first determine if the patient is truly allergic to the medication. The nurse should first determine if the patient is truly allergic to the medication. The nurse should determine if the patient is actually allergic to the medication or just has side effects. Many patients think an allergy is diarrhea and nausea. The nurse should never suggest a patient take a medication he or she may be allergic to and use an EpiPen.

PTS:

CON: Safety

11. The nurse has administered prescribed allergen injections twice a week for several weeks to an individual with a bee sting allergy. The patient misses three appointments. What action should the nurse take during the patient’s next visit? 1. Consult the physician to confirm the dosage to be given. 2. Administer the same dosage as was given at the last visit. 3. Administer the dosage as originally prescribed for that visit. 4. Tell the patient that the entire immunotherapy schedule needs to be restarted. ANS: 1 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 8. Discuss common therapeutic measures used for disorders of the immune system.

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Page: 291 Heading: Immunotherapy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1

2 3 4

It is important that the patient does not miss an allergen injection dose. If this happens, the allergen strength may need to be reduced, so the physician should be consulted. The same dose given during the last visit might be too strong since the patient missed three injections. The same dose given during the last visit might be too strong since the patient missed three injections. The physician will determine the immunotherapy schedule. This is beyond the nurse’s scope of practice.

PTS:

CON: Immunity

12. The nurse is caring for a group of patients. Which patient is at highest risk for developing a latex allergy? 1. A banker 2. A construction worker 3. A nurse 4. A computer technician ANS: 3 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 5. Explain subjective data that are collected when caring for a patient with a disorder of the immune system. Page: 286 Heading: Health History Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4

A banker is not at high risk for developing a latex allergy. A construction worker is not at high risk for developing a latex allergy. A nurse is at high risk for developing a latex allergy. A computer technician is not at high risk for developing a latex allergy. PTS:

CON: Immunity

13. The nurse is reviewing laboratory values for a patient and notes an absolute neutrophil count of 300 cells/µL. The nurse knows this result means the patient is experiencing which condition?

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1. 2. 3. 4.

Anemia Neutropenia Thrombocytopenia Leukopenia

ANS: 2 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 7. Describe nursing care provided for patients undergoing diagnostic tests for the immune system. Page: 289 Heading: Diagnostic Laboratory Tests for the Immune System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Moderate Feedback 1

Anemia is a low red blood cell (RBC) count. This patient is experiencing neutropenia and is at high risk for infection. Thrombocytopenia is low platelet count. Leukopenia is a low WBC count.

2 3 4

PTS:

CON: Immunity

14. The nurse is teaching a class for older adults regarding the importance of vaccinations. Which vaccine should the nurse suggest for this age group? 1. Meningococcal vaccine 2. Polio vaccine 3. Human papilloma virus (HPV) vaccine 4. Pneumococcal vaccine ANS: 4 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 4. Describe how the aging system affects immunity. Page: 285 Heading: Gerontological Issues Integrated Process: Communication and Documentation Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4

An older adult does not need a meningococcal vaccine. A polio vaccine is not required for an older adult. An older adult does not require an HPV vaccine. Older adults should receive the herpes zoster vaccine, influenza vaccine, pneumococcal vaccine, and a booster for tetanus and diphtheria every 10 years.

PTS:

CON: Immunity

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MULTIPLE RESPONSE 1. The nurse is teaching the family of a child who is allergic to peanuts about important topics regarding the allergy. Which statements made by the parents indicate an understanding of the teaching? (Select all that apply.) 1. “I will make sure my child wears a medical alert bracelet at all times.” 2. “I need to notify my child’s school of the peanut allergy.” 3. “I will be sure we seek medical care within hours after injecting the EpiPen.” 4. “I will make sure my child consumes a minimal amount of food with peanuts.” 5. “I am going to ensure my child carries an EpiPen at all times.” ANS: 1, 2, 5 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 8. Discuss common therapeutic measures used for disorders of the immune system. Page: 292 Heading: Allergies Integrated Process: Teaching/Learning Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate

1. 2. 3. 4. 5. PTS:

Feedback This statement indicates an understanding of the teaching. This statement indicates an understanding of the teaching. Emergency care should be sought immediately after injecting the EpiPen. The patient with a peanut allergy cannot be exposed to any amount of peanuts. This statement indicates an understanding of the teaching. 1

CON: Immunity

2. The nurse is caring for a patient with anemia. Which laboratory results should the nurse identify as being consistent with this diagnosis? (Select all that apply.) 1. Red blood cell distribution width (RDW) = 12% in a 28-year-old female 2. Mean corpuscular volume (MCV) = 72/mm3 in a 19-year-old female 3. WBC = 7 × 109/L in a 39-year-old male 4. RBC = 4.4 × 1012/L in a 31-year-old male 5. WBC = 5.2 × 109/L in a 22-year-old female 6. RBC = 5.7 × 1012/L in a 43-year-old female ANS: 2, 4, 6 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 7. Describe nursing care provided for patients undergoing diagnostic tests for the immune system. Page: 289 Heading: Diagnostic Laboratory Tests for the Immune System (Table 18.4)

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Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Difficult

1. 2.

3. 4.

5. 6.

PTS:

Feedback This is normal. The normal number of RBCs per mm of blood for a man is 4.7 to 6.1 × 1012/L; for a female is 4.2 to 5.4 × 1012/L; low values indicate anemia. MCV and RDW are used to help determine the cause of anemia. WBC count is indicative of immune function and is not used to determine the presence of anemia. The normal number of RBCs per mm of blood for a man is 4.7 to 6.1 × 1012/L; for a female is 4.2 to 5.4 × 1012/L; low values indicate anemia. MCV and RDW are used to help determine the cause of anemia. WBC count is indicative of immune function and is not used to determine the presence of anemia. The normal number of RBCs per mm of blood for a man is 4.7 to 6.1 × 1012/L; for a female is 4.2 to 5.4 × 1012/L; low values indicate anemia. MCV and RDW are used to help determine the cause of anemia. 1

CON: Immunity

3. The nurse is taking a health history of a patient who has a weakened immune system. Which does the nurse conclude contributed to weakening the immune system? (Select all that apply.) 1. Craniotomy 2. Parathyroidectomy 3. Knee replacement 4. Splenectomy 5. Rhinoplasty 6. Thymectomy ANS: 4, 6 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 5. Explain subjective data that are collected when caring for a patient with a disorder of the immune system. Page: 286 Heading: Health History Integrated Process: Communication and Documentation Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Moderate

1. 2.

Feedback A craniotomy does not place a patient at risk for a weakened immune system. A parathyroidectomy does not place a patient at risk for a weakened immune

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3. 4. 5. 6. PTS:

system. A knee replacement does not place a patient at risk for a weakened immune system. A splenectomy places a patient at risk for a weakened immune system. Rhinoplasty does not place a patient at risk for a weakened immune system. A thymectomy places a patient at risk for a weakened immune system. 1

CON: Immunity

4. While collecting data, the nurse suspects that a patient is experiencing an immune disorder. Which data did the nurse use to come to this conclusion? (Select all that apply.) 1. Rash 2. Fever 3. Joint pain 4. Muscle cramps 5. Swollen glands ANS: 1, 2, 3, 5 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 6. Explain objective data that are collected when caring for a patient with a disorder of the immune system. Page: 286 Heading: Objective Data Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate

1. 2. 3. 4. 5. PTS:

Feedback A rash is a common clinical manifestation of an immune disorder. Fever is a common clinical manifestation of an immune disorder. Joint pain can be indicative of an immune disorder. Muscle cramping is typical of an electrolyte imbalance, not an immune disorder. Swollen glands are a common clinical manifestation of an immune disorder. 1

CON: Immunity

COMPLETION 1. The nurse is preparing to administer diphenhydramine (Benadryl) 50 mg intravenously to a patient with severe allergies. Available is diphenhydramine (Benadryl) 25 mg/1 mL. How many mL will the nurse administer? Enter the numeral only. ANS: 2 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures

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Objective: 8. Discuss common therapeutic measures used for disorders of the immune system. Page: 286 Heading: Medications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: mL = 1 mL/25 mg × 50 mg = 2 mL PTS:

CON: Safety

2. The nurse is administering clindamycin (Cleocin) 300 mg in 100 mL of normal saline intravenously to run over 1 hour to a patient with an infection. At what rate will the nurse set the infusion pump? Enter the numeral only. ANS: 100 Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures Objective: 8. Discuss common therapeutic measures used for disorders of the immune system. Page: 286 Heading: Medications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: mL/hr = 100 mL/1 hr = 100 mL/hr PTS:

CON: Safety

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Chapter 19. Nursing Care of Patients With Immune Disorders MULTIPLE CHOICE 1. The nurse is contributing to a group of patients care plans. Which patient should the nurse identify as being at risk for developing serum sickness? 1. A patient who receives IV penicillin for an infection 2. A patient who has a transfusion with packed red blood cells (RBCs) 3. A patient who is given cryoprecipitate and factor IX after an abdominal injury 4. A patient given steroids and immunosuppressant therapy after organ transplantation ANS: 1 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 2. Explain the pathophysiology of disorders of the immune system. Page: 304 Heading: Pathophysiology and Etiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS–Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4

Serum sickness is seen occasionally after administration of penicillin and sulfonamide. Serum sickness is not associated with blood transfusions, cryoprecipitate, factor IX, steroids, or immunosuppressant therapy. Serum sickness is not associated with blood transfusions, cryoprecipitate, factor IX, steroids, or immunosuppressant therapy. Serum sickness is not associated with blood transfusions, cryoprecipitate, factor IX, steroids, or immunosuppressant therapy.

PTS:

CON: Immunity

2. The nurse is caring for a patient with idiopathic autoimmune hemolytic anemia. Which action should the nurse include in the plan of care for this patient? 1. Assist with ambulation 2. Teach good hand hygiene. 3. Avoid intramuscular injections. 4. Obtain manual blood pressures. ANS: 1 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 308 Heading: Nursing Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort

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Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

With anemia, the patient will be fatigued and may have activity intolerance and be a fall risk. Assistance with ambulation should be done for safety. This action would be appropriate if the patient had neutropenia. This action would be appropriate if the patient had thrombocytopenia. This action would be appropriate if the patient had thrombocytopenia.

PTS:

CON: Safety

3. The nurse is reviewing orders for a patient with systemic lupus erythematosus (SLE). For which medication should the nurse request clarification? 1. Levothyroxine (Synthroid) 2. Phenytoin (Dilantin) 3. Promethazine (Phenergan) 4. Pantoprazole (Protonix) ANS: 2 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 309 Heading: Medications Associated With Triggering Lupus Erythematosus (Box 19.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

Levothyroxine does not trigger SLE. Phenytoin is known to trigger SLE and should be avoided. Promethazine does not trigger SLE. Promethazine does not trigger SLE.

PTS:

CON: Safety

4. The nurse is caring for a patient who is stung by a wasp. Which manifestation should the nurse expect if an allergic reaction develops? 1. Hives 2. Retinal hemorrhage 3. Jugular vein distention 4. Pallor around the sting sites ANS: 1 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 3. Identify the etiologies, signs, and symptoms of immune system disorders. Page: 297

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Heading: Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4

Hives is one of several symptoms of an allergic reaction. This manifestation is not associated with an allergic reaction. This manifestation is not associated with an allergic reaction. This manifestation is not associated with an allergic reaction.

PTS:

CON: Immunity

5. A patient with type O blood is scheduled to undergo open heart surgery. Which blood type would this patient receive? 1. A 2. B 3. AB 4. O ANS: 4 Chapter: Chapter 19. Nursing Care of Patients with Immune Disorders Objective: 8. Plan nursing care for patients With disorders of the immune system. Page: 303 Heading: Etiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

Patients with type O blood can only receive type O blood. Patients with type O blood can only receive type O blood. Patients with type O blood can only receive type O blood. Patients with type O blood can only receive type O blood.

PTS:

CON: Safety

6. A patient is stabilized after having an allergic reaction. Which preventive instructions should the nurse reinforce with the patient? 1. Wear medical alert identification. 2. Stay indoor as much as possible. 3. Wear insect repellent when outdoors. 4. Take corticosteroids before going outdoor. ANS: 1 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders

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Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 299 Heading: Nursing Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1

2 3 4

The nurse should teach the patient to wear medical alert identification for allergies for prompt medical attention to be given if the patient is unable to give information. Being outside might not be the reason for the patient’s allergic reaction. The patient might not be allergic to stinging insects. This medication should not be taken prophylactically.

PTS:

CON: Safety

7. The nurse contributed to the teaching plan for a patient with a history of allergies to pollen. Which patient action indicates an understanding of how to control this disease? 1. Gardening outdoors on dry, windy days 2. Wearing a mask when mowing the lawn 3. Driving the car with the windows open during high pollen counts 4. Taking frequent walks outside in spring when the weather is warm ANS: 2 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 299 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1 2

3 4

This would increase the patient’s risk of having an allergic reaction. Allergen avoidance might involve wearing a mask when mowing the lawn or working outdoor, having heating ducts cleaned, or covering heating registers with filters. This would increase the patient’s risk of having an allergic reaction. This would increase the patient’s risk of having an allergic reaction.

PTS:

CON: Immunity

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8. The nurse is contributing to the teaching plan for a patient who is allergic to dust. Which environmental modification should the nurse recommend be included in the teaching plan to help control symptoms? 1. Installing a hot air heater 2. Covering heating ducts with filters 3. Installing wall-to-wall carpeting 4. Using heavy draperies on sunny windows ANS: 2 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 299 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4

A hot air heater will not reduce the amount of dust in the patient’s environment. Filtering the air will reduce dust particles, which the other items do not do. Carpeting traps dust and is harder to clean. Heavy draperies will trap dust.

PTS:

CON: Immunity

9. The nurse is preparing to administer levofloxacin (Levaquin) to a patient with pneumonia. Which is most important for the nurse to ask prior to administering the medication? 1. “Have you experienced nausea or vomiting from antibiotics?” 2. “Are you allergic to any medication?” 3. “Do you know why you are receiving this medication?” 4. “Do you have an allergy to latex?” ANS: 2 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 300 Heading: Nursing Care and Education Integrated Process: Communication and Documentation Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

The most important question to ask is about allergies to medications. The most important question to ask is about allergies to medications. The most important question to ask is about allergies to medications. The most important question to ask is about allergies to medications.

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CON: Safety

10. A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins, the patient reports low back pain and a headache. Which action should the nurse take first? 1. Stop the blood infusion. 2. Notify the physician STAT. 3. Start a normal saline infusion. 4. Check vital signs. ANS: 1 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 301 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1

2 3

Low back pain and headache can be symptoms of a transfusion reaction. If symptoms of a reaction are noted, the blood is immediately stopped so that no more blood is infused into the patient. The physician and blood should be notified after the transfusion is stopped and the saline infusion is started. A normal saline infusion with new tubing is started after the blood infusion is stopped. This will keep the vein patent should medications need to be administered as ordered. New tubing must be used so that not one more drop of blood enters the patient. The patients vital signs should be checked and monitored after the blood infusion has been stopped, a normal saline solution has been started, and the physician and blood bank have been notified.

PTS:

CON: Safety

11. A patient is to receive a transfusion of packed RBCs. Before administering the transfusion, which action should the nurse take? 1. Verify the patient’s kidney function. 2. Verify the patient’s hematocrit level. 3. Verify blood type of the patient and donor. 4. Verify the patient’s admitting medical diagnosis. ANS: 3 Chapter: Chapter 19. Nursing Care of Patients with Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 303 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2 3

This action will not help prevent the development of a transfusion reaction. This action will not help prevent the development of a transfusion reaction. Prevention of hemolytic reactions is crucial. At the bedside, double-check the patient’s name and identification number on the chart, unit of blood, and patient’s identification bracelet, as well as check the patient’s blood type in the chart, on the unit of blood, and paperwork with the unit of blood. This action will not help prevent the development of a transfusion reaction.

PTS:

CON: Safety

12. The nurse is caring for a patient with angioedema. Which nursing action should have the highest priority? 1. Monitor for restlessness. 2. Identify cause of the angioedema. 3. Identify the presence of skin lesions. 4. Teach the patient about immunotherapy. ANS: 1 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 298 Heading: Pathophysiology and Etiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1

2 3 4

If the angioedema reaction is severe, maintenance of a patent airway is a priority. Any symptoms of respiratory distress must be reported immediately and remain the highest priority. Because the condition is already present, monitoring the patient takes priority, although the cause needs to be identified. This may be addressed later, but is not the priority. This may be addressed later, but is not the priority.

PTS:

CON: Immunity

13. The nurse is caring for a patient with SLE. The nurse notes that the patient has foamy, “coke”-colored urine. Which action should the nurse take? 1. Notify the health care provider (HCP). 2. Encourage the patient to increase fluid intake.

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3. Prepare the patient for dialysis. 4. Instruct the patient to eat high-protein meals. ANS: 1 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 310 Heading: Education Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4

This is indicative of proteinuria and hematuria. The HCP should be notified immediately. The nurse should first notify the HCP before encouraging or restricting fluids. The patient may not require dialysis; the HCP should be notified. The patient should not follow a high-protein diet if he or she has proteinuria.

PTS:

CON: Immunity

14. The nurse is teaching a patient about atopic dermatitis (Eczema). Which statement made by the patient indicates an understanding of the teaching? 1. “I will keep my nails long so I can scratch easier.” 2. “I should soak in bleach daily.” 3. “I will soak in a lukewarm bath at night.” 4. “It is better for me to scratch than to rub the itchy area.” ANS: 3 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 297 Heading: Therapeutic Measures Integrated Process: Teaching/Learning Client Need: PHYS—Basic Care and Comfort Cognitive Level: Evaluation (Evaluating) Concept: Inflammation Difficulty: Moderate Feedback 1 2 3 4

The patient should keep his or her nails short. The patient can soak in diluted bleach twice weekly. This statement indicates an understanding of teaching. The patient should be taught to rub the area instead of scratch.

PTS:

CON: Inflammation

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15. The nurse is teaching a patient with SLE about avoiding triggers. Which statement made by the patient indicates a need for further teaching? 1. “Instead of working in the yard, I got plenty of rest.” 2. “I am practicing yoga to help alleviate stress in my life.” 3. “If I get plenty of sunlight, it will help reduce symptoms.” 4. “I need to check with my doctor before stopping any medication.” ANS: 3 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 309 Heading: Common Systemic Lupus Erythematosus Flare Triggers (Table 19.2) Integrated Process: Teaching/Learning Client Need: SECE—Safety and Infection Control Cognitive Level: Evaluation (Evaluating) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4

This statement indicates an understanding of the teaching. This statement indicates an understanding of the teaching. This statement requires correction; patients with SLE should avoid direct sunlight and wear a hat, sunscreen, and long sleeves. This statement indicates an understanding of the teaching.

PTS:

CON: Immunity

16. The nurse is caring for a group of patients. Which patient should the nurse see first? 1. A patient with SLE with a butterfly rash 2. A patient with Hashimoto thyroiditis who reports diarrhea and weight loss 3. A patient with allergic rhinitis with copious amounts of clear nasal drainage 4. A patient receiving a blood transfusion who is reporting chills and low back pain ANS: 4 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 301 Heading: Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4

A butterfly rash is a hallmark sign of patients with SLE. Diarrhea and weight loss are expected findings in a patient with Hashimoto thyroiditis. Nasal drainage is expected in a patient with allergic rhinitis. This patient is likely experiencing a hemolytic reaction and should be seen

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immediately. PTS:

CON: Immunity

17. The nurse is caring for a patient who underwent a liver transplant and is taking cyclosporine (Sandimmune) and azathioprine (Imuran). Which important information should the nurse teach the patient regarding the medication? 1. Take on an empty stomach. 2. Report signs of infection immediately. 3. Monitor for signs of abnormal bleeding. 4. Urine will turn orange. ANS: 2 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 306 Heading: Medications Used to Treat Systemic Lupus Erythematosus (SLE) (Table 19.7) Integrated Process: Communication and Documentation Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

These medications are taken with food. These medications are immunosuppressants; the patient should report signs of infection. These medications do not cause an increase in bleeding. These medications do not turn urine orange.

PTS:

CON: Safety

18. The nurse is caring for a patient with serum sickness. Which intervention should the nurse implement? 1. Administer acetaminophen (Tylenol) as ordered. 2. Prepare the patient for a blood transfusion. 3. Teach the patient about immunosuppressive drugs. 4. Restrict the patient’s fluid intake. ANS: 1 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 304 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate

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Feedback 1 2 3 4

Tylenol is given for fever and discomfort for patients with serum sickness. There is no indication this patient requires a blood transfusion. The patient will not require immunosuppressive drugs. The patient is at risk for hypovolemia; fluid is not restricted.

PTS:

CON: Immunity

19. The nurse is caring for a patient with pernicious anemia. Which deficiency is this patient experiencing? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin D ANS: 2 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 2. Explain the pathophysiology of disorders of the immune system. Page: 307 Heading: Pathophysiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Comprehension (Understanding) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4

The patient is not deficient in vitamin A. The patient is deficient in vitamin B12. The patient is not deficient in vitamin C. The patient is not deficient in vitamin D.

PTS:

CON: Immunity

20. The nurse is teaching a patient about allergic rhinitis. Which statement indicates a need for further teaching? 1. “I will wear a mask when I mow the yard.” 2. “I can take my nasal medication any time my allergies bother me.” 3. “I will dust my house every day.” 4. “I cannot receive immunotherapy since my allergies are not severe.” ANS: 2 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 296 Heading: Therapeutic Measures Integrated Process: Teaching/Learning Client Need: PHYS—Basic Care and Comfort Cognitive Level: Evaluation (Evaluating) Concept: Immunity

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Difficulty: Moderate Feedback 1 2 3 4

This statement indicates understanding. Nasal medication should be taken as prescribed; not only when allergies flare up. This statement indicates an understanding. This statement indicates an understanding.

PTS:

CON: Immunity

21. The nurse is caring for a group of patients. Which patient should the nurse see first? 1. A patient with serum sickness experiencing fever and malaise 2. A patient with atopic dermatitis with red, weeping lesions 3. A patient with ankylosing spondylitis reporting level 4 back pain 4. A patient stung by an insect experiencing angioedema ANS: 4 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 3. Identify the etiologies, signs, and symptoms of immune system disorders. Page: 298 Heading: Pathophysiology and Etiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4

This patient should be seen, but is not as high of a priority as the patient with angioedema (fever and malaise are common in serum sickness). This patient is not a high priority; red and weeping lesions are normal findings. This patient should be seen, but is not as high of a priority as the patient with angioedema; back pain and stiffness is common in ankylosing spondylitis. This patient should be seen first; the airway could be compromised.

PTS:

CON: Immunity

22. The nurse is caring for a patient who develops a hemolytic reaction during a blood transfusion. The nurse should expect to implement which order from the HCP first? 1. Call the blood bank to send up a different unit of blood. 2. Administer diphenhydramine (Benadryl) 50 mg IV. 3. Place the patient in Trendelenburg’s position. 4. Administer acetaminophen (Tylenol). ANS: 2 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 300 Heading: Medications Used in Hemolytic Transfusion Reactions (Table 19.3)

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Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4

The HCP may not want the patient to receive a blood transfusion for the time being, after experiencing a hemolytic reaction. The nurse should plan to administer diphenhydramine immediately. The patient should be placed in high-Fowler’s position. The patient may receive Tylenol, but not before the diphenhydramine.

PTS:

CON: Immunity

MULTIPLE RESPONSE 1. The nurse is assessing a patient with pernicious anemia. Which clinical manifestations can the nurse expect to document? (Select all that apply.) 1. Pallor 2. Wheals on the skin 3. Butterfly rash 4. Weakness 5. Glossitis 6. Peripheral neuropathy ANS: 1, 4, 5, 6 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 3. Explain the etiologies, signs, and symptoms of immune system disorders. Page: 307 Heading: Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate

1. 2. 3. 4. 5. 6. PTS:

Feedback Pallor is a clinical manifestation of pernicious anemia. Wheals is a sign of urticaria. A butterfly rash is a sign of SLE. Weakness is a clinical manifestation of pernicious anemia. Glossitis is a sign of pernicious anemia. Peripheral neuropathy is a sign of pernicious anemia. 1

CON: Immunity

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2. The nurse is contributing to the teaching plan for a patient diagnosed with Hashimoto thyroiditis who has progressed to hypothyroidism with a goiter. Which self-care instructions should the nurse recommend? (Select all that apply.) 1. Eat a soft diet. 2. Increase activity slowly. 3. Eat more foods high in iodine. 4. Keep home at a cool temperature. 5. Eat a high-carbohydrate, high-protein diet. 6. During low-energy periods, use anti-embolism stockings. ANS: 1, 2, 6 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 308 Heading: Nursing Care Integrated Process: Communication and Documentation Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Inflammation Difficulty: Moderate

3. 4. 5. 6.

PTS:

Feedback If the patient has a goiter, a soft diet may be necessary for comfort. Frequent rest periods may be necessary as well as slowly increasing patient activity. Anti-embolic stockings may help prevent venous stasis during the lowenergy, decreased-activity phase. If the patient has a goiter, a soft diet may be necessary for comfort. Frequent rest periods may be necessary as well as slowly increasing patient activity. Anti-embolic stockings may help prevent venous stasis during the lowenergy, decreased-activity phase. Foods high in iodine should be avoided. The patient will be sensitive to cold, so room temperature will need to be increased for comfort. During the hyperthyroidism phase, a diet high in protein and carbohydrates encourages weight gain. If the patient has a goiter, a soft diet may be necessary for comfort. Frequent rest periods may be necessary as well as slowly increasing patient activity. Anti-embolic stockings may help prevent venous stasis during the lowenergy, decreased-activity phase. 1

CON: Inflammation

3. The nurse is assisting in the care of a patient with ankylosing spondylitis. What should the nurse expect to find in the patient’s collaborative plan of care? (Select all that apply.) 1. Physical therapy daily 2. Sitz baths three times daily 3. Tylenol #3 every 4 hours prn for pain 4. Administering Remicade as prescribed 5. Activity as tolerated; up with assistance

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ANS: 1, 3, 4, 5 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 313 Heading: Nursing Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate

2. 3.

PTS:

Feedback Nursing care focuses on patient education and administration and evaluation of prescribed medications. Pain management, rest periods, and assistance with activities of daily living are provided. Sitz baths are not indicated for this health problem. Nursing care focuses on patient education and administration and evaluation of prescribed medications. Pain management, rest periods, and assistance with activities of daily living are provided. Nursing care focuses on patient education and administration and evaluation of prescribed medications. Pain management, rest periods, and assistance with activities of daily living are provided. Nursing care focuses on patient education and administration and evaluation of prescribed medications. Pain management, rest periods, and assistance with activities of daily living are provided. 1

CON: Immunity

4. The nurse is contributing to the plan of care for a patient with SLE. Which interventions should the nurse recommend for this patient? (Select all that apply.) 1. Eat a balanced diet. 2. Report “foamy urine” to physician. 3. Take cool showers or baths to relieve joint stiffness. 4. Avoid naps and obtain a minimum of 6 hours of sleep. 5. Exercise when pain and inflammation in joints are increased. 6. Use a daily personal schedule to plan activities to reduce fatigue. ANS: 1, 2, 6 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 311 Heading: Nursing Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate

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3. 4. 5. 6.

PTS:

Feedback Fatigue during activities of daily living is minimized through the use of a daily personal schedule. Additionally, a minimum of 8 hours of sleep per night with naps as necessary are important to combat fatigue. Because the majority of patients with SLE develop transitory arthralgia, maintaining fitness and joint range of motion through a regular fitness program while decreasing activity during flares is vital. Warm baths may help with morning stiffness. Because renal disease is a major complication of SLE, patients must learn the signs of impending problems that need to be relayed to the physician immediately. These are such findings as facial puffiness and “foamy” urine or “coke-colored” urine indicative of proteinuria and hematuria, respectively. Eating a well-balanced diet will also influence level of fatigue and weight gain from the corticosteroids. Fatigue during activities of daily living is minimized through the use of a daily personal schedule. Additionally, a minimum of 8 hours of sleep per night with naps as necessary are important to combat fatigue. Because the majority of patients with SLE develop transitory arthralgia, maintaining fitness and joint range of motion through a regular fitness program while decreasing activity during flares is vital. Warm baths may help with morning stiffness. Because renal disease is a major complication of SLE, patients must learn the signs of impending problems that need to be relayed to the physician immediately. These are such findings as facial puffiness and “foamy” urine or “coke-colored” urine indicative of proteinuria and hematuria, respectively. Eating a well-balanced diet will also influence level of fatigue and weight gain from the corticosteroids. Cool showers will not help relieve the pain and stiffness associated with this disorder. Rest is beneficial for this disorder. Exercise should be reduced during flare-ups. Fatigue during activities of daily living is minimized through the use of a daily personal schedule. Additionally, a minimum of 8 hours of sleep per night with naps as necessary are important to combat fatigue. Because the majority of patients with SLE develop transitory arthralgia, maintaining fitness and joint range of motion through a regular fitness program while decreasing activity during flares is vital. Warm baths may help with morning stiffness. Because renal disease is a major complication of SLE, patients must learn the signs of impending problems that need to be relayed to the physician immediately. These are such findings as facial puffiness and “foamy” urine or “coke-colored” urine indicative of proteinuria and hematuria, respectively. Eating a well-balanced diet will also influence level of fatigue and weight gain from the corticosteroids. 1

CON: Immunity

5. The nurse applies clean, white, cotton socks over the hands of a patient with contact dermatitis. What should the nurse explain to the patient about the purposes of this intervention? (Select all that apply.) 1. Cotton allows air movement. 2. White cotton has no dye in the material.

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3. White cotton prevents the wounds from spreading. 4. The cotton will absorb the drainage from the wounds. 5. Scratching is less during sleep when the area is covered. ANS: 1, 2, 5 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 297 Heading: Nursing Care Plan for the Patient with Contact Dermatitis Integrated Process: Communication and Documentation Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Inflammation Difficulty: Moderate

PTS:

Feedback Cotton allows air movement. White cloth is less irritating than those with dyes. Scratching is decreased during sleep with the use of gloves or mittens or by covering affected area. Cotton allows air movement. White cloth is less irritating than those with dyes. Scratching is decreased during sleep with the use of gloves or mittens or by covering affected area. The use of white, cotton socks over the hands of a patient with contact dermatitis is not done to prevent the wounds from spreading or to absorb the drainage from the wounds. The use of white, cotton socks over the hands of a patient with contact dermatitis is not done to prevent the wounds from spreading or to absorb the drainage from the wounds. Cotton allows air movement. White cloth is less irritating than those with dyes. Scratching is decreased during sleep with the use of gloves or mittens or by covering affected area. 1

CON: Inflammation

COMPLETION 1. A patient with SLE is prescribed Prednisone, 60 mg PO, in three equal doses. If using 5-mg tablets, how many tablets should the nurse provide for each dose? ANS: 4 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 5. Describe current medical treatment for immune system disorders. Page: 302 Heading: Medications Used to Treat Systemic Lupus Erythematosus (SLE) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Safety

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Difficulty: Moderate Feedback: The nurse should use the equation Dosage Required/Dosage Available × 1 tablet or 20 mg/5 mg × 1 = 4 tablets. PTS:

CON: Safety

2. The nurse is administering methylprednisolone (Solu-Medrol) 40 mg IM to a patient with SLE. The available dose is 80 mg/mL. How many mL will the nurse administer? Enter the numeral only. ANS: 0.5 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system. Page: 302 Heading: Medications Used to Treat Systemic Lupus Erythematosus (SLE) (Table 19.7) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: mL = 1 mL/80 mg × 40 mg = 0.5 mL PTS:

CON: Safety

ORDERED RESPONSE 1. A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins, the patient reports low back pain and a headache. Place the actions in order, from 1 to 5, of importance of performance. 1. Stop the blood infusion. 2. Notify the physician STAT. 3. Obtain vital signs and assess patient. 4. Start the new 0.9% normal saline infusion. 5. Prepare a new 0.9% normal saline infusion. ANS: 1, 3, 2, 5, 4 Chapter: Chapter 19. Nursing Care of Patients With Immune Disorders Objective: 8. Plan nursing care for patients with disorders of the immune system Page: 300 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Difficult

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Feedback: Low back pain and headache can be symptoms of a transfusion reaction. If symptoms of a reaction are noted, the blood transfusion is immediately stopped and agency policy for a suspected transfusion reaction is followed. A normal saline infusion with new tubing is started to keep the vein patent. The physician and blood bank are immediately notified. A nurse remains with the patient for reassurance and monitoring of symptoms and vital signs. If a blood incompatibility is suspected, the unused blood and blood tubing are returned to the blood bank for testing. A series of blood and urine specimens are collected and sent to the laboratory for analysis. The physician’s orders are followed to treat the patient’s symptoms. PTS:

CON: Safety

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Chapter 20. Nursing Care of Patients With HIV Disease and AIDS MULTIPLE CHOICE 1. The nurse is teaching a group of older adults about prevention of HIV. Which statement made by the patient indicates an understanding of the teaching? 1. “I will use a condom with each sexual contact.” 2. “I can share a needle with my friend when shooting up.” 3. “After 50, it is no longer necessary to get tested for HIV.” 4. “I have only had three partners, so it would be hard for me to get HIV.” ANS: 1 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 5. Develop a teaching plan for prevention of an HIV infection. Pages: 321–322 Heading: Prevention Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Health Promotion Difficulty: Moderate Feedback 1 2 3 4

This statement indicates an understanding of the teaching. A clean needle should be used with each injection. Individuals can contract HIV at any age; HIV testing is essential for all at-risk individuals. Any individual can contract HIV even if he or she only had one partner.

PTS:

CON: Health Promotion

2. The nurse is caring for a group of patients. Which patient is at highest risk for contracting HIV? 1. A 30-year-old IV drug user who is part of a clean needle program 2. A 40-year-old male who is in a monogamous relationship 3. A 50-year-old nurse at a health department who administers multiple vaccines 4. A 60-year-old homosexual male who has had two partners ANS: 4 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 2. Explain how HIV is transmitted. Page: 321 Heading: Sexual Transmission Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Health Promotion Difficulty: Moderate Feedback

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1 2 3

This patient is at moderate risk; he or she is using clean needles. This patient is not at high risk; he is in a monogamous relationship. This patient is at minimal risk; only if he or she experiences a needlestick injury from an HIV positive individual can HIV be transmitted, and that risk is still minimal. Anal sex has the highest risk for sexual transmission.

PTS:

CON: Health Promotion

3. The nurse is caring for a patient with cytomegalovirus (CMV) retinitis. The nurse should plan to teach the patient about which medication? 1. Trimethoprim-sulfamethoxazole (Bactrim) 2. Ethambutol (Myambutol) 3. Amphotericin B (Fungizone) 4. Ganciclovir (Cytovene) ANS: 4 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 7. Develop a teaching plan for a patient with HIV receiving antiretroviral therapy. Page: 326 Heading: Treatment for AIDS-Related Conditions Integrated Process: Teaching/Learning Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

This is used to treat phencyclidine. This is used to treat tuberculosis. This is used to treat candidiasis. The nurse will teach the patient about ganciclovir (Cytovene) for CMV retinitis.

PTS:

CON: Safety

4. The nurse is preparing to teach a group of patients about the pre-exposure prophylaxis (PrEP) to prevent HIV transmission. The nurse should plan to teach the group about which medication? 1. Delavirdine mesylate (Rescriptor) 2. Abacavir sulfate/lamivudine (Epzicom) 3. Emtricitabine/tenofovir disoproxil (Truvada) 4. Fosamprenavir calcium (Lexiva) ANS: 3 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 5. Develop a teaching plan for prevention of an HIV infection. Page: 321 Heading: Pre-Exposure Prophylaxis (PrEp) Integrated Process: Teaching and Learning

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Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Difficult Feedback 1 2 3 4

Emtricitabine/tenofovir disoproxil (Truvada) is the only medication approved to be used as PrEP. Emtricitabine/tenofovir disoproxil (Truvada) is the only medication approved to be used as PrEP. Emtricitabine/tenofovir disoproxil (Truvada) is the only medication approved to be used as PrEP. Emtricitabine/tenofovir disoproxil (Truvada) is the only medication approved to be used as PrEP.

PTS:

CON: Health Promotion

5. The nurse is reviewing the CD4 count results of a patient with AIDS. What can the nurse expect to find? 1. A CD4 count of 800/µL 2. A CD4 count of 500/µL 3. A CD4 count of 300/µL 4. A CD4 count of 100/µL ANS: 4 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 3. Explain tests for diagnosing HIV. Page: 323 Heading: HIV Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1 2 3 4

AIDS is diagnosed when a CD4 count is below 200 or opportunistic infections occur. AIDS is diagnosed when a CD4 count is below 200 or opportunistic infections occur. AIDS is diagnosed when a CD4 count is below 200 or opportunistic infections occur. AIDS is diagnosed when a CD4 count is below 200 or opportunistic infections occur.

PTS:

CON: Infection

6. The licensed practical nurse/licensed vocational nurse (LPN/LVN) is watching a nursing student administer medications to a patient with HIV. Which action by the student requires correction by the nurse? 1. The student recaps the needle and places it in the sharps container.

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2. The student uses a needleless system to administer the medication. 3. The student wears gloves when administering the medication. 4. The student washes her hands before and after administering the medication. ANS: 1 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 5. Develop a teaching plan for prevention of an HIV infection. Page: 322 Heading: Health Care Providers and HIV Prevention Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Evaluation (Evaluating) Concept: Safety Difficulty: Moderate Feedback 1

The student should never recap a needle. This action is appropriate and does not require correction. This action is appropriate and does not require correction. This action is appropriate and does not require correction.

2 3 4

PTS:

CON: Safety

7. The nurse is providing care to a patient who has had diagnostic testing for HIV. Which test should the nurse review to monitor the response to antiretroviral therapy? 1. Western blot 2. Viral load testing 3. P24 antigen testing 4. Enzyme-linked immunosorbent assay ANS: 2 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 3. Explain tests for diagnosing HIV. Page: 325 Heading: Viral Load Testing Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 2

3 4

The Western blot test is done to detect the presence of antibodies to four major HIV antigens. Viral load testing measures the amount of HIV RNA in plasma and is extremely important for determining prognosis and monitoring the response to antiretroviral therapy. These tests are not used to measure the response to antiretroviral therapy. These tests are not used to measure the response to antiretroviral therapy.

PTS:

CON: Infection

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8. The nurse is preparing to care for a patient who is HIV positive. Which action should the nurse take when following standard precautions for protection from HIV exposure? 1. Put on gloves before touching body fluids. 2. Recap intramuscular needles after injection. 3. Wash own open skin lesion after providing care. 4. Remove one finger on a glove during venipuncture. ANS: 1 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 2. Explain how HIV is transmitted. Page: 322 Heading: Mode of Transmission Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 2 3 4

Gloves should be worn before touching body fluids, as all patients are considered to be infected per standard precautions. Gloves should be worn before touching body fluids, as all patients are considered to be infected per standard precautions. A nurse should not provide care with open lesions. Do not remove one glove finger as it defeats the purpose of glove protection.

PTS:

CON: Infection

9. A patient who has HIV asks the nurse why blood work has to be done so frequently. Which response should the nurse make to the patient? 1. “B-lymphocyte levels increase if you have an acute infection.” 2. “Phagocytes are decreased when the disease is in an active phase.” 3. “Neutrophil counts help the doctor titrate medication levels to keep you healthy.” 4. “CD4+ lymphocyte counts are monitored to determine the progression of the disease.” ANS: 4 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 3. Explain tests for diagnosing HIV. Page: 325 Heading: CD4 T Lymphocyte Count Integrated Process: Teaching/Learning Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1

This response does not appropriately explain the need for frequent blood analyses in the patient with HIV.

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2 3 4

This response does not appropriately explain the need for frequent blood analyses in the patient with HIV. This response does not appropriately explain the need for frequent blood analyses in the patient with HIV. A low ratio of CD4 cells to CD8 cells is seen as HIV/AIDS progresses. It is recommended that CD4/CD8 T-lymphocyte counts be performed at 3-month intervals for most patients.

PTS:

CON: Infection

10. The nurse is contributing to a teaching plan. What should the nurse emphasize as being the most effective method known to control the spread of HIV infection? 1. Premarital serological screening 2. Prophylactic exposure treatment 3. HIV screening for pregnant women 4. Education about preventive behaviors ANS: 4 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 5. Develop a teaching plan for prevention of an HIV infection. Page: 322 Heading: Prevention Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate Feedback 1

Premarital screening, prophylactic exposure treatment, and screening for pregnant women are not the best approaches to control the spread of HIV infection. Premarital screening, prophylactic exposure treatment, and screening for pregnant women are not the best approaches to control the spread of HIV infection. Premarital screening, prophylactic exposure treatment, and screening for pregnant women are not the best approaches to control the spread of HIV infection. Prevention and education are the best ways to manage the HIV/AIDS epidemic. Education should begin with older, school-age children through older adults.

PTS:

CON: Health Promotion

11. The nurse is teaching a patient about antiretroviral therapy. Which statement made by the patient indicates an understanding of the teaching? 1. “If I feel sick from the medication, I need to stop taking it.” 2. “I will most likely take one medication daily.” 3. “I should set an alarm so I remember to take my pills.” 4. “I can’t infect anybody while I’m taking medications.”

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ANS: 3 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 7. Develop a teaching plan for a patient with HIV receiving antiretroviral therapy. Page: 325 Heading: Antiretroviral Therapy Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Health Promotion Difficulty: Moderate Feedback 1 2 3 4

The patient should contact the health care provider before stopping a medication. The patient will likely have to take multiple pills daily. This statement indicates an understanding of teaching. A patient is still contagious even while taking antiretroviral therapy.

PTS:

CON: Health Promotion

12. The nurse is caring for a group of patients with HIV. Which patient is at highest risk for developing CMV? 1. A patient who works on a farm 2. An individual who works in a homeless shelter 3. A patient who works in a day care 4. A patient who works as a gardener ANS: 3 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 6. Identify prevention methods used to decrease infection and opportunistic diseases for patients with HIV. Page: 324 Heading: Patient Teaching: Preventing Opportunistic Infections (Table 20.6) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1 2 3 4

Individuals who work in a childcare setting are at high risk for CMV. They should be instructed to wash hands after changing diapers. Individuals who work in a childcare setting are at high risk for CMV. They should be instructed to wash hands after changing diapers. Individuals who work in a childcare setting are at high risk for CMV. They should be instructed to wash hands after changing diapers. Individuals who work in a childcare setting are at high risk for CMV. They should be instructed to wash hands after changing diapers.

PTS:

CON: Infection

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13. A patient asks, “What is the main purpose of these medications I take for my HIV?” Which response by the nurse is most appropriate? 1. “They encapsulate the virus-infected cells.” 2. “They mark the virus for natural killer cells to destroy.” 3. “They attract macrophages to the cells making the virus.” 4. “They inhibit enzymes to interfere with viral production.” ANS: 4 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 7. Develop a teaching plan for a patient with HIV receiving antiretroviral therapy. Page: 326 Heading: Antiretroviral Therapy Integrated Process: Teaching/Learning Client Need: PHYS—Pharmacological Therapy Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 2 3 4

Antiretroviral drugs do not encapsulate the virus-infected cells, mark the virus to be destroyed, or attract macrophages to the cells making the virus. Antiretroviral drugs do not encapsulate the virus-infected cells, mark the virus to be destroyed, or attract macrophages to the cells making the virus. Antiretroviral drugs do not encapsulate the virus-infected cells, mark the virus to be destroyed, or attract macrophages to the cells making the virus. Antiretroviral drugs that inhibit reproduction of the virus in various ways by blocking enzyme action are used to treat HIV infection.

PTS:

CON: Infection

14. The nurse is caring for a patient receiving abacavir sulfate (Ziagen). For which complication should the nurse monitor the patient? 1. Breathing difficulty 2. Flu-like symptoms 3. Elevated blood glucose 4. Pancreatitis ANS: 2 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 7. Develop a teaching plan for a patient with HIV receiving antiretroviral therapy. Page: 327 Heading: Antiretroviral Medications for HIV Infection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Evaluation (Evaluating) Concept: Safety Difficulty: Difficult Feedback 1

Breathing difficulty is not a complication of abacavir sulfate (Ziagen).

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2 3 4

The nurse should monitor the patient for flu-like symptoms which could be life threatening. This medication does not cause an elevation in blood glucose. This medication does not cause pancreatitis.

PTS:

CON: Safety

15. The nurse is reviewing the use of a condom to prevent the transmission of HIV with a young adult patient seeking testing for HIV. Which patient statement indicates an understanding of how to use a condom? 1. Use a non-latex condom. 2. Apply adequate oil-based lubricant. 3. Apply condom before penile erection occurs. 4. Withdraw from partner while the penis is erect. ANS: 4 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 5. Describe a teaching plan for prevention of an HIV infection. Page: 321 Heading: Prevention Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Health Promotion Difficulty: Moderate Feedback 1 2 3 4

Use latex condom (or polyurethane if allergic to latex), because other materials have large pores that allow HIV to pass. Use water-soluble lubricants, as oil-based lubricants can damage latex condoms. Apply condom after erection for correct fit. When using a condom, withdraw from partner by holding condom against base of erect penis to avoid semen leakage.

PTS:

CON: Health Promotion

16. The nurse is caring for a patient with AIDS who develops oral candidiasis. Which action should the nurse take? 1. Encourage the patient to rinse with an antiseptic mouth wash. 2. Administer penicillin as ordered. 3. Encourage the patient to use a soft toothbrush. 4. Encourage the patient to eat spicy foods. ANS: 1 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 6. Identify prevention measures used to decrease infection and opportunistic diseases for patients with HIV. Page: 324 Heading: Impaired Oral Mucous Membrane

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Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1

Antiseptic mouth wash can make the lesions more painful. Penicillin is not used to treat oral candidiasis. A soft toothbrush will help decrease further discomfort. Spicy foods will make the lesions more painful.

2 3 4

PTS:

CON: Infection

17. A patient diagnosed with HIV asks the nurse how soon the virus can be transmitted to others. Which time frame should the nurse inform the patient? 1. 2 to 4 weeks 2. 6 to 8 weeks 3. 10 to 12 weeks 4. 14 to 16 weeks ANS: 1 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 2. Explain how HIV is transmitted. Page: 323 Heading: Learning Tip Integrated Process: Communication and Documentation Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 2 3 4

The HIV virus can be spread within 2 to 4 weeks of infection and throughout all stages of HIV and AIDS infection. The HIV virus can be spread within 2 to 4 weeks of infection and throughout all stages of HIV and AIDS infection. The HIV virus can be spread within 2 to 4 weeks of infection and throughout all stages of HIV and AIDS infection. The HIV virus can be spread within 2 to 4 weeks of infection and throughout all stages of HIV and AIDS infection.

PTS:

CON: Infection

18. A health care worker is exposed to blood from a patient who has HIV. What action should the worker take after the exposure? 1. Apply alcohol to the site. 2. Cleanse the site with soap and water. 3. Flush the site with hot running water. 4. Apply a topical antibiotic to the site.

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ANS: 2 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 5. Develop a teaching plan for prevention of an HIV infection. Page: 322 Heading: Health Care Providers and HIV Prevention Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1

3 4

Alcohol should not be applied to the site. Flushing the site with hot running water is not sufficient. Soap is needed. A topical antibiotic should not be applied to the site. Alcohol should not be applied to the site. Flushing the site with hot running water is not sufficient. Soap is needed. A topical antibiotic should not be applied to the site. After exposure to HIV, the site should be immediately washed with soap and water and then seek immediate medical care for assessment and treatment. Alcohol should not be applied to the site. Flushing the site with hot running water is not sufficient. Soap is needed. A topical antibiotic should not be applied to the site.

PTS:

CON: Safety

MULTIPLE RESPONSE 1. The nurse is caring for a patient in the symptomatic stage of HIV. Which clinical manifestations can the nurse expect to document? (Select all that apply.) 1. Constipation 2. Night sweats 3. Fever 4. Weight gain 5. Shortness of breath ANS: 2, 3, 5 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 1. Define human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). Page: 323 Heading: Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback

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1. 2. 3. 4. 5. PTS:

This is not a symptom of HIV. This is a symptom of HIV. This is a symptom of HIV. This is not a symptom of HIV. This is a symptom of HIV. 1

CON: Infection

2. The nurse has been discussing actions to prevent AIDS-related wasting syndrome with a patient being treated for AIDS. Which patient statements indicate an understanding of this teaching? (Select all that apply.) 1. Eat a low-residue diet. 2. Drink liquids before meals. 3. Enjoy food odors to stimulate appetite. 4. Numb painful oral sores with ice or popsicles. 5. Eat three high-calorie, high-protein meals a day, plus snacks. 6. Increase consumption of caffeine-containing foods and fluids. ANS: 1, 4, 5 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 8. Plan nursing care for patients with HIV and AIDS related to medications, coinfection prevention, and maintaining nutritional status. Page: 324 Heading: Imbalance Nutrition: Less Than Body Requirements Integrated Process: Teaching/Learning Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (evaluation) Concept: Nutrition Difficulty: Moderate

Feedback To prevent AIDS-related wasting syndrome the patient should eat a lowresidue diet to control diarrhea, numb painful oral sores with ice or popsicles so eating is not painful, and eat three high-calorie, high-protein meals a day, plus snacks, to maintain weight. Drinking before meals may fill patients up so they do not want to eat. Food odors may cause anorexia. Caffeine and alcohol should be avoided to help prevent diarrhea. Drinking before meals may fill patients up so they do not want to eat. Food odors may cause anorexia. Caffeine and alcohol should be avoided to help prevent diarrhea. To prevent AIDS-related wasting syndrome the patient should eat a lowresidue diet to control diarrhea, numb painful oral sores with ice or popsicles so eating is not painful, and eat three high-calorie, high-protein meals a day, plus snacks, to maintain weight. To prevent AIDS-related wasting syndrome the patient should eat a lowresidue diet to control diarrhea, numb painful oral sores with ice or popsicles so eating is not painful, and eat three high-calorie, high-protein meals a day, plus snacks, to maintain weight.

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PTS:

Drinking before meals may fill patients up so they do not want to eat. Food odors may cause anorexia. Caffeine and alcohol should be avoided to help prevent diarrhea. 1

CON: Nutrition

3. The nurse is teaching a group of individuals about HIV prevention. Which statements indicate an understanding of the teaching? (Select all that apply.) 1. “I wear gloves to protect my hands during genital contact.” 2. “My friends share needles only once after each injection.” 3. “I take birth control, so I am safe from contracting HIV.” 4. “My sister is pregnant, so she should get tested for HIV.” 5. “I have HIV, so I should take the PrEP for prophylaxis.” 6. “Condoms are the number-one way to prevent sexually transmitted HIV.” ANS: 1, 4 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 5. Develop a teaching plan for prevention of an HIV infection. Page: 321 Heading: Prevention Integrated Process: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5. 6. PTS:

Feedback This statement indicates teaching is understood. Needles should not be shared. Birth control does not prevent HIV. This statement indicates teaching is understood. PrEP is prophylactic (before HIV). Abstinence is the number-one method to prevent HIV transmission. 1

CON: Health Promotion

4. A patient with AIDS is prescribed the nucleoside reverse transcriptase inhibitor lamivudine (Epivir). What information should the nurse ensure that the patient receives about this medication? (Select all that apply.) 1. Report any onset of bleeding. 2. Report any yellowing of the skin. 3. Report any change in urine output. 4. Report any flu-like symptoms. 5. Report any numbness or tingling of the hands or feet. ANS: 2, 3, 4, 5 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 7. Develop a teaching plan for a patient with HIV receiving antiretroviral therapy. Page: 327

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Heading: Antiretroviral Medications for HIV Infection Integrated Process: Teaching/Learning Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Safety Difficulty: Difficult

1. 2.

PTS:

Feedback Bleeding is not an adverse reaction to this medication. When taking this medication, the patient should monitor and report any skin yellowing, which could indicate jaundice or liver failure; changes in urine output, which could indicate kidney failure; flu-like symptoms, which would be life threatening when taking this medication; and numbness or tingling of the hands or feet, which could indicate the onset of peripheral neuropathy. When taking this medication, the patient should monitor and report any skin yellowing, which could indicate jaundice or liver failure; changes in urine output, which could indicate kidney failure; flu-like symptoms, which would be life threatening when taking this medication; and numbness or tingling of the hands or feet, which could indicate the onset of peripheral neuropathy. When taking this medication, the patient should monitor and report any skin yellowing, which could indicate jaundice or liver failure; changes in urine output, which could indicate kidney failure; flu-like symptoms, which would be life threatening when taking this medication; and numbness or tingling of the hands or feet, which could indicate the onset of peripheral neuropathy. When taking this medication, the patient should monitor and report any skin yellowing, which could indicate jaundice or liver failure; changes in urine output, which could indicate kidney failure; flu-like symptoms, which would be life threatening when taking this medication; and numbness or tingling of the hands or feet, which could indicate the onset of peripheral neuropathy. 1

CON: Safety

5. While collecting admission data, the nurse suspects a patient with AIDS is experiencing an HIV-associated neurocognitive disorder. What observations did the nurse make to come to this conclusion? (Select all that apply.) 1. Audible bowel sounds 2. Inappropriate laughter 3. Inability to state home address 4. Knee buckling while walking 5. Asking if the bugs could be removed from the walls ANS: 2, 3, 4, 5 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 8. Plan nursing care for patients with HIV and AIDS related to medications, coinfection prevention, and maintaining nutritional status. Page: 324 Heading: HIV-Associated Neurocognitive Disorder Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control

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Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate

1. 2.

PTS:

Feedback Audible bowel sounds are not a manifestation of HIV-associated neurocognitive disorder. Symptoms of an HIV-associated neurocognitive disorder include memory impairment, personality changes, hallucinations, and leg weakness. Inappropriate laughter could indicate personality changes. Inability to state the home address could indicate memory impairment. Knee buckling while walking could indicate leg weakness. Asking for the bugs to be removed from the walls could indicate hallucinations. Symptoms of an HIV-associated neurocognitive disorder include memory impairment, personality changes, hallucinations, and leg weakness. Inappropriate laughter could indicate personality changes. Inability to state the home address could indicate memory impairment. Knee buckling while walking could indicate leg weakness. Asking for the bugs to be removed from the walls could indicate hallucinations. Symptoms of an HIV-associated neurocognitive disorder include memory impairment, personality changes, hallucinations, and leg weakness. Inappropriate laughter could indicate personality changes. Inability to state the home address could indicate memory impairment. Knee buckling while walking could indicate leg weakness. Asking for the bugs to be removed from the walls could indicate hallucinations. Symptoms of an HIV-associated neurocognitive disorder include memory impairment, personality changes, hallucinations, and leg weakness. Inappropriate laughter could indicate personality changes. Inability to state the home address could indicate memory impairment. Knee buckling while walking could indicate leg weakness. Asking for the bugs to be removed from the walls could indicate hallucinations. 1

CON: Infection

COMPLETION 1. The nurse is administering fluconazole (Diflucan) 100 mg in 50 mL of normal saline to run over 30 minutes using a 30 gtt/mL drop factor. Calculate the flow rate. Round to the nearest whole number. Enter the numeral only. ANS: 50 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 8. Plan nursing care for patients with HIV and AIDS related to medications, coinfection prevention, and maintaining nutritional status. Page: 326 Heading: Cancer and Opportunistic Infections Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: gtt/mL = 30 gtt/mL × 50 mL/30 min = 1,500 mL/30 min = 50 gtt/min PTS:

CON: Safety

2. The nurse is preparing to administer acyclovir (Zovirax) to a patient with HIV who also has a diagnosis of herpes zoster. The prescribed dose is 10 mg/kg to a patient who weighs 60 kg. Available are 200-mg tablets. How many tablets will the nurse administer? ANS: 3 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS Objective: 8. Plan nursing care for patients with HIV and AIDS related to medications, coinfection prevention, and maintaining nutritional status. Page: 326 Heading: Treatment for AIDS-Related Conditions Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS-Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: Figure out the weight-based dosing first: 10 × 60 = 600 mg. Available tablets are 200 mg. So, the number of tablets is 1 tab/200 mg × 600 mg = 3 tab. PTS:

CON: Safety

ORDERED RESPONSE 1. Place in order, from 1 to 7, the steps of the HIV replication process. 1. After fusion, the HIV capsid is released into the host cell. 2. Packaging of HIV RNA and IV proteins within a viral envelope created from part of the cell membrane occurs. 3. Immature, noninfectious HIV buds from the host cell. 4. HIV uses the machinery of the host cell to replicate long chains of HIV proteins for building more HIV. 5. Attachment to the CD4 receptor of the host cell occurs. 6. Binding leads to fusion of the HIV envelope and host cell membrane. 7. HIV releases integrase, which incorporates its HIV DNA into the host cell’s DNA. ANS: 5, 6, 1, 7, 4, 2, 3 Chapter: Chapter 20. Nursing Care of Patients With HIV Disease and AIDS

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Objective: 1. Define human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). Page: 320 Heading: Pathophysiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Comprehension (Understanding) Concept: Infection Difficulty: Moderate Feedback: The first is binding (attachment) to the CD4 receptor of the host cell. Binding leads to fusion of the HIV envelope (membrane) and host cell membrane. After fusion, the HIV capsid is released into the host cell. HIV releases the enzyme integrase, which incorporates its HIV DNA into the host cell’s DNA. HIV then uses the machinery of the host cell to replicate long chains of HIV proteins for building more HIV. Packaging of HIV RNA and HIV proteins within a viral envelope created from part of the cell membrane occurs next. The immature, noninfectious HIV then buds from the host cell. PTS:

CON: Infection

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Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures MULTIPLE CHOICE 1. A patient asks the nurse what the action of the arteries is. Which response by the nurse is most appropriate? 1. “The arteries act as valves of the heart.” 2. “The arteries carry blood from capillaries to the heart.” 3. “The arteries are the natural pacemaker of the heart.” 4. “The arteries carry blood from the heart to capillaries.” ANS: 4 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 2. Explain the normal function of the cardiovascular system. Page: 342 Heading: Arteries and Veins Integrated Process: Teaching/Learning Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Easy Feedback 1

This does not describe the role of arteries.

This describes veins.

Arteries do not act as a pacemaker.

This is the correct description of the action of arteries.

PTS:

CON: Perfusion

2. The nurse is assessing the heart rate for a person who plays basketball and runs track. Which heart rate can the nurse expect to document? 1. 50 beats/min 2. 70 beats/min 3. 90 beats/min 4. 110 beats/min ANS: 1 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 2. Explain the normal function of the cardiovascular system. Page: 341 Heading: Pulses Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation

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Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1

The nurse can expect an athlete to have a pulse rate around 50 beats/min.

PTS:

CON: Perfusion

3. The nurse is caring for a patient recovering from a cardiac catheterization with a right femoral artery entry site. Which action should the nurse take? 1. Ambulate every 2 hours. 2. Position knees with 40-degree bend. 3. Avoid movement of right leg as ordered. 4. Perform passive range of motion of right leg hourly. ANS: 3 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 5. Plan nursing care for patients undergoing diagnostic tests for cardiovascular disorders. Page: 356 Heading: Cardiac Catheterization Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

Since the extremity should not be moved, this action is contraindicated.

The extremity used for catheter insertion must not be moved or flexed for several hours after the procedure. Since the extremity should not be moved, this action is contraindicated.

PTS:

CON: Perfusion

4. The nurse is caring for a patient admitted with chest pain and suspected myocardial infarction (MI). Which laboratory value should the nurse expect to see an elevation? 1. Ammonia 2. Glucose 3. Amylase

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4. Troponin ANS: 4 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 4. Identify diagnostic tests commonly performed to diagnose disorders of the cardiovascular system. Page: 354 Heading: Cardiac Biomarkers Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

This laboratory value is used to determine liver disease.

Glucose does not determine cardiac damage or function.

This laboratory value is used to diagnose pancreatitis.

This laboratory value is used to assess cardiac damage for a patient with a suspected MI.

PTS:

CON: Perfusion

5. The nurse is caring for a group of patients. Which patient is at highest risk of death related to cardiovascular disease? 1. An African American male who smokes 2. A Caucasian female who works a high-stress job 3. A Hispanic female who exercises daily 4. An Asian male who is vegetarian ANS: 1 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 3. List data to collect when caring for a patient with a disorder of the cardiovascular system. Page: 346 Heading: Cultural Considerations Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2

This patient is at highest risk for death caused by cardiovascular disease; he is male, African American, and a smoker. This patient is not at highest risk for death caused by cardiovascular disease.

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This patient is not at highest risk for death caused by cardiovascular disease.

PTS:

CON: Perfusion

6. The nurse is explaining the regulation of blood pressure (BP) to a patient newly diagnosed with hypertension. What tissues within the artery wall that helps maintain diastolic BP should the nurse identify for the patient? 1. Smooth muscle and elastic connective tissue 2. Smooth muscle and simple squamous epithelium 3. Elastic connective tissue and fibrous connective tissue 4. Fibrous connective tissue and simple squamous epithelium ANS: 1 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 2. Explain the normal function of the cardiovascular system. Pages: 344–345 Heading: Blood Pressure Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

The middle artery layer of smooth muscle and elastic connective tissue maintains normal BP, especially diastolic BP, by changing the diameter of the artery. These tissues are not within the layers of the arterial walls.

These tissues are not within the layers of the arterial walls.

PTS:

CON: Perfusion

7. The nurse instructs a patient on beverages to avoid when taking the prescribed medication warfarin (Coumadin). Which beverage should the patient state that indicates teaching has been effective? 1. Beer 2. Orange juice 3. Grapefruit juice 4. Cranberry juice ANS: 4 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures

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Objective: 5. Plan nursing care for patients undergoing diagnostic tests for cardiovascular disorders. Page: 357 Heading: Nutrition Notes Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

There is no reason for the patient to avoid this beverage.

Warfarin is mainly metabolized by the cytochrome P450 isoenzyme CYP2C9, and cranberry juice contains flavonoids known to inhibit P450 enzymes. Bleeding problems and hemorrhage have been attributed to this interaction.

PTS:

CON: Perfusion

8. A patient has sustained damage to the sinoatrial (SA) node. Which heart rates indicate that the patient’s atrioventricular (AV) node has taken over as the pacemaker for the heart? 1. 10 to 20 2. 20 to 35 3. 40 to 60 4. 80 to 100 ANS: 3 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 2. Explain formal function of the cardiovascular system. Page: 341 Heading: Cardiac Conduction Pathway and Cardiac Cycle Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

No cardiac tissue will generate this heart rate.

The Bundle of His can generate a heartbeat at the rate of 20 to 35.

If the SA node becomes nonfunctional, the AV node can initiate each heartbeat, but at a slower rate of 40 to 60 beats per minute. This is a normal heartbeat that would be generated by the SA node.

PTS:

CON: Perfusion

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9. The nurse is reinforcing teaching to a patient about to undergo angiography. Which statement made by the patient indicates a need for further teaching? 1. “I cannot have anything to eat or drink for 4 hours before the test.” 2. “I will stay at the hospital after my test so the nurse can monitor the injection site.” 3. “This test will assess the electrical system of my heart.” 4. “I may feel a hot, burning feeling when I am injected with dye.” ANS: 3 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 5. Plan nursing care for patients undergoing diagnostic tests for cardiovascular disorders. Page: 355 Heading: Angiography Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

This statement indicates teaching has been effective.

This statement requires correction; this describes an electrophysiological study.

This statement indicates teaching has been effective.

PTS:

CON: Perfusion

10. The nurse is reviewing laboratory values for a patient and notes a potassium level of 6.4 mEq/L. Which clinical manifestation can the nurse expect the patient to report? 1. Constipation 2. Fast heart rate 3. Muscle cramps 4. High blood pressure ANS: 3 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 4. Identify diagnostic tests commonly performed to diagnose disorders of the cardiovascular system. Page: 355 Heading: Potassium Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

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Feedback 1

Constipation may be seen in hypokalemia.

Bradycardia is seen in hyperkalemia.

Muscle twitches and cramps may be seen with hyperkalemia.

Hypotension is seen with hyperkalemia.

PTS:

CON: Perfusion

11. The nurse is observing a patient apply antiembolism stockings. Which action by the patient requires correction by the nurse? 1. The patient pulls the stockings up to 1 to 2 inches below the bottom of the kneecap. 2. The patient uses an assistive device in applying the stockings. 3. The patient rolls the stockings down. 4. The patient wears the stockings all day as instructed. ANS: 3 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 6. Describe current therapeutic measures for disorders of the cardiovascular system. Page: 356 Heading: Elastic stockings Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

This action is correct.

This requires correction; allowing the stockings to roll down can cause stasis.

This action is correct.

PTS:

CON: Perfusion

12. The nurse is assessing a patient and notices the radial pulse has fewer beats than the apical pulse. Which action should the nurse take? 1. Document the finding as normal. 2. Encourage the patient to ambulate and recheck. 3. Notify the health care provider (HCP). 4. Encourage the patient to increase fluid intake. ANS: 3

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Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 2. Explain the normal function of the cardiovascular system. Page: 348 Heading: Pulses Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

This is not a normal finding.

The nurse should notify the HCP; this intervention will likely not change the assessment finding. The nurse should notify the HCP for further orders.

3 4

The HCP should be notified; this intervention will likely not change the assessment finding.

PTS:

CON: Perfusion

13. The nurse is caring for a patient who had a cardiac catheterization using the left femoral site for entry. Which data is most important for the nurse to monitor? 1. Pupil reaction 2. Left pedal pulse 3. Orientation status 4. Right foot sensation ANS: 2 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 5. Plan nursing care for patients undergoing diagnostic tests for cardiovascular disorders. Page: 355 Heading: Cardiac Catheterization Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

A cardiac catheterization should not affect pupil reaction or orientation status.

The priority assessment is to ensure that circulation is not compromised. The puncture site and, most important, the peripheral pulses, which are distal to the procedure site, are verified as being present. A cardiac catheterization should not affect pupil reaction or orientation status.

The patient’s left femoral artery was the entry site. The patient’s right foot

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should not be affected. PTS:

CON: Perfusion

14. A patient is being instructed about a Holter monitor. Which statement indicates that the patient knows what to do when a symptom occurs while wearing a Holter monitor? 1. “Call an ambulance.” 2. “Notify the physician.” 3. “Take an apical pulse.” 4. “Push the event button.” ANS: 4 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 5. Plan nursing care for patients undergoing diagnostic tests for cardiovascular disorders. Page: 353 Heading: Holter Monitoring (Ambulatory ECG) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

This action does not need to be taken if a symptom occurs while wearing the monitor. This action does not need to be taken if a symptom occurs while wearing the monitor. This action does not need to be taken if a symptom occurs while wearing the monitor. When wearing a Holter monitor, the patient is to record a diary of activities and symptoms and push the event button if symptoms occur.

PTS:

CON: Perfusion

15. A patient will be wearing a Holter monitor for 2 days. What should the nurse instruct the patient about bathing while wearing the monitor? 1. “Take a sponge bath.” 2. “You may take a tub bath.” 3. “Take a shower with the monitor on.” 4. “Remove the monitor before showering.” ANS: 1 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 5. Plan nursing care for patients undergoing diagnostic tests for cardiovascular disorders. Page: 353 Heading: Holter Monitoring (Ambulatory ECG)

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Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2

The patient wears loose-fitting clothing and may only sponge bathe while wearing the monitor. The patient should not take a tub bath, shower, or remove the monitor.

The patient should not take a tub bath, shower, or remove the monitor.

PTS:

CON: Perfusion

16. The nurse is assessing a patient and notes that the nailbed angle exceeds 180 degrees and feels spongy when squeezed. Which intervention should the nurse implement? 1. Tell the patient he has a congenital heart defect. 2. Document the normal finding in the chart. 3. Encourage the patient to elevate his extremities. 4. Notify the HCP. ANS: 4 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 3. List data to collect when caring for a patient with a disorder of the cardiovascular system. Page: 350 Heading: Inspection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback

It is not within the nurse’s scope of practice to tell a patient he or she has a congenital heart defect. This finding should not be documented as normal.

Elevating the extremities will not help.

The nurse should notify the HCP.

PTS:

CON: Perfusion

17. The nurse takes the BP of a patient with a result of 120/80 mm Hg. Which action should the nurse take? 1. Document the finding as normal.

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2. Notify the HCP. 3. Instruct the patient to follow a salt-free diet. 4. Prepare to administer a bolus of normal saline IV. ANS: 1 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 4. Identify diagnostic tests commonly performed to diagnose disorders of the cardiovascular system. Page: 346 Heading: Blood Pressure Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

This BP is normal and will be documented.

This is a normal BP reading.

Although all patients should follow a low-sodium diet, this BP reading is normal and diet modification is not necessary. This is a normal BP and does not require intervention.

PTS:

CON: Perfusion

18. The nurse is auscultating heart sounds and notes an S4 heart sound. The nurse knows an S4 sound may be heard in a patient with which condition? 1. Hypertension 2. Crohn disease 3. Liver failure 4. Asthma ANS: 1 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 2. Explain the normal function of the cardiovascular system. Page: 350 Heading: Auscultation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2

An S4 sound may be heard with hypertension, coronary artery disease, and pulmonary stenosis. An S4 sound may be heard with hypertension, coronary artery disease, and

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3 4

pulmonary stenosis. An S4 sound may be heard with hypertension, coronary artery disease, and pulmonary stenosis. An S4 sound may be heard with hypertension, coronary artery disease, and pulmonary stenosis.

PTS:

CON: Perfusion

19. The nurse is caring for a patient recovering from a cardiac catheterization. Which action should the nurse take? 1. Force 1,000 mL of fluid per hour. 2. Keep patient NPO until gag reflex is present. 3. Encourage the patient to drink plenty of liquids. 4. Hold fluid intake for 2 hours after the procedure. ANS: 3 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 5. Plan nursing care for patients undergoing diagnostic tests for cardiac disorders. Page: 355 Heading: Cardiac Catheterization Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

This volume of oral fluid intake is unrealistic for the patient to perform.

The procedure did not affect the patient’s gag reflex

The nurse should encourage the patient to drink plenty of liquids to help eliminate the dye, which helps to prevent damage to the kidneys. Fluids do not need to be held after the procedure.

PTS:

CON: Perfusion

20. The nurse is caring for a patient recovering from a cardiac catheterization. Which actions for site care should the nurse take? 1. Keep the site uncovered. 2. Apply an adhesive bandage to the site. 3. Maintain pressure dressing on the site. 4. Apply a gauze bandage to the puncture site. ANS: 3 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 5. Plan nursing care for patients undergoing diagnostic tests for cardiovascular disorders.

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Page: 355 Heading: Cardiac Catheterization Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

This action could promote bleeding at the site and should not be done.

Pressure is maintained at the site with a pressure dressing or sandbag to prevent bleeding and hematoma development. This action could promote bleeding at the site and should not be done.

PTS:

CON: Perfusion

21. The nurse is reviewing the medication history for a patient about to undergo cardiac surgery. Which medication should the nurse report to the surgeon? 1. Furosemide (Lasix) 2. Warfarin (Coumadin) 3. Metformin (Glucophage) 4. Lisinopril (Prinivil) ANS: 2 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 5. Plan nursing care for patients undergoing tests for cardiovascular disorders. Page: 357 Heading: Preparation for Surgery Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

This medication can be taken before surgery.

2 3

This medication is a blood thinner; the surgeon should be notified if the patient is taking this prior to surgery. This medication can be taken prior to surgery.

This medication can be taken prior to surgery.

PTS:

CON: Perfusion

22. The nurse is caring for a patient with a potassium level of 7.6 mEq/L. For which HCPordered test should the nurse prepare the patient?

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1. 2. 3. 4.

Angiography Electrocardiogram Nuclear radioisotope imaging Cardiac catheterization

ANS: 2 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 4. Identify diagnostic tests commonly performed to diagnose disorders of the cardiovascular system. Page: 355 Heading: Electrocardiogram Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

This test is used to assess blood clot formation, PV4, and test vessels for grafting use. The nurse should prepare the patient for an electrocardiogram. This test assesses cardiac blood flow, myocardial ischemia, and ventricle size and motion. This test provides information on cardiac output and oxygen saturation; it allows the heart’s anatomy and physiology to be studied.

PTS:

CON: Perfusion

23. The nurse is assessing a patient and notes a prolonged, very loud swishing sound. The nurse knows this describes which of the following? 1. Pericardial friction rub 2. Murmur 3. Ventricular gallop 4. Atrial gallop ANS: 2 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 3. List data to collect when caring for a patient with a disorder of the cardiovascular system. Page: 351 Heading: Auscultation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback

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This does not describe a pericardial friction rub.

This describes a murmur.

This does not describe a ventricular gallop.

This does not describe an atrial gallop.

PTS:

CON: Perfusion

24. A patient being treated for a severe blood loss has a BP of 90/56 mm Hg and urine output of 10 mL over the last hour. Which physiological mechanism should the nurse recall is occurring in this patient? 1. Starling’s law 2. Medulla-brainstem 3. Sodium-potassium pump 4. Renin-angiotensin-aldosterone ANS: 4 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 2. Explain the normal function of the cardiovascular system. Pages: 344–345 Heading: Hormones and the Heart Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Starling’s law is used to explain how the heart adjusts blood flow to the body based on activity. There is no specific medulla-brainstem mechanism that affects blood loss, BP, and urine output. The sodium-potassium pump is a mechanism to maintain electrolyte balance within the body. The kidneys are of great importance in the regulation of BP. If blood flow through the kidneys decreases, renal filtration decreases and urinary output decreases to preserve blood volume. Decreased BP stimulates the kidneys to secrete renin, which initiates the renin-angiotensin-aldosterone mechanism, raising BP.

PTS:

CON: Perfusion

25. While collecting data, a patient expectorates pink, frothy sputum. Which health problem should the nurse consider is occurring in this patient? 1. Gastritis 2. Pneumonia 3. Heart failure

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4. Hepatic failure ANS: 3 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 3. List data to collect when caring for a patient with a disorder of the cardiovascular system. Page: 347 Heading: Respirations Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Pink, frothy sputum is not associated with gastritis, pneumonia, or hepatic failure. Pink, frothy sputum is not associated with gastritis, pneumonia, or hepatic failure. Pink, frothy sputum is an indicator of acute heart failure. Pink, frothy sputum is not associated with gastritis, pneumonia, or hepatic failure.

PTS:

CON: Perfusion

26. The nurse notes that a patient’s lower legs are brown and the feet are blue when they are in the dependent position. For which health problem should the nurse collect additional data? 1. Anemia 2. Insufficient oxygenation 3. Decreased arterial blood flow 4. Venous blood flow problems ANS: 4 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 3. List data to collect when caring for a patient with a disorder of the cardiovascular system. Page: 350 Heading: Inspection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

Pallor may indicate anemia or lack of arterial blood flow.

Cyanosis shows an oxygen distribution deficiency.

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3 4

A reddish-brown discoloration (rubor) found in the lower extremities occurs from decreased arterial blood flow. A brown discoloration and cyanosis when the extremity is dependent may be seen in the presence of venous blood flow problems.

PTS:

CON: Perfusion

MULTIPLE RESPONSE 1. The nurse is caring for a patient with decreased arterial blood flow. Which clinical manifestations can the nurse expect to document? (Select all that apply.) 1. Decreased hair distribution 2. Varicose veins 3. Thick, brittle nails 4. Shiny skin 5. Moist skin ANS: 1, 3, 4 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 3. List data to collect when caring for a patient with a disorder of the cardiovascular system. Page: 340 Heading: Inspection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback In a patient with decreased arterial blood flow, the nurse will note a decrease in hair distribution; thick and brittle nails; and shiny, taught, and dry skin. In a patient with decreased arterial blood flow, the nurse will note a decrease in hair distribution; thick and brittle nails; and shiny, taught, and dry skin. In a patient with decreased arterial blood flow, the nurse will note a decrease in hair distribution; thick and brittle nails; and shiny, taught, and dry skin. In a patient with decreased arterial blood flow, the nurse will note a decrease in hair distribution; thick and brittle nails; and shiny, taught, and dry skin. In a patient with decreased arterial blood flow, the nurse will note a decrease in hair distribution; thick and brittle nails; and shiny, taught, and dry skin. 1

CON: Perfusion

2. The nurse is reinforcing teaching for a patient who is to wear a Holter monitor. Which of the following should the nurse include? (Select all that apply.) 1. Avoid strenuous activity. 2. Transmit data over the phone.

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3. 4. 5. 6.

Push the event button when symptoms occur. Keep an accurate diary of symptoms and activities. Avoid showers or baths while wearing the monitor. Take nothing by mouth for 6 hours before applying the monitor.

ANS: 3, 4, 5 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 4. Identify diagnostic tests commonly performed to diagnose disorders of the cardiovascular system. Page: 353 Heading: Holter Monitoring (Ambulatory ECG) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1. 2. 3.

PTS:

Feedback This action does not need to be done by the patient while wearing a Holter monitor. This action does not need to be done by the patient while wearing a Holter monitor. Patient teaching for wearing a Holter monitor includes keeping an accurate diary, pushing the event button for symptoms, to not take showers or baths, and making a return visit. Patient teaching for wearing a Holter monitor includes keeping an accurate diary, pushing the event button for symptoms, to not take showers or baths, and making a return visit. Patient teaching for wearing a Holter monitor includes keeping an accurate diary, pushing the event button for symptoms, to not take showers or baths, and making a return visit. This action does not need to be done by the patient while wearing a Holter monitor. 1

CON: Perfusion

3. The nurse is caring for a patient who is having an exercise treadmill test. What interventions would be appropriate for the test? (Select all that apply.) 1. Remove all metal objects. 2. Monitor vital signs throughout the test. 3. Administer antianxiety medication as ordered. 4. Monitor electrocardiogram before, during, and after the test. 5. Ask the patient about allergies to dyes used in diagnostic procedures. ANS: 2, 4 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures

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Objective: 4. Identify diagnostic tests commonly performed to diagnose disorders of the cardiovascular system. Page: 353 Heading: Exercise Stress Test Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1. 2. 3. 4. 5. PTS:

Feedback For magnetic resonance imaging, metal objects are contraindicated and antianxiety medications are used. Monitor vital signs and electrocardiogram before, during, and after the test to detect symptoms. For magnetic resonance imaging, metal objects are contraindicated and antianxiety medications are used. Monitor vital signs and electrocardiogram before, during, and after the test to detect symptoms. No dyes are used. 1

CON: Perfusion

4. The nurse is caring for a patient with peripheral vascular disease. Which signs or symptoms should the nurse expect to observe in this patient? (Select all that apply.) 1. Pain 2. Pruritus 3. Purpura 4. Paralysis 5. Paresthesia 6. Pulselessness ANS: 1, 4, 5, 6 Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 3. List data to collect when caring for a patient with a disorder of the cardiovascular system. Page: 354 Heading: Learning Tip Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1. 2.

Feedback The six Ps characterize peripheral vascular disease: pain, poikilothermia, pulselessness, pallor, paralysis, and paresthesia (decreased sensation). Pruritus and purpura are not manifestations of peripheral vascular disease.

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3. 4. 5. 6.

PTS:

Pruritus and purpura are not manifestations of peripheral vascular disease. The six Ps characterize peripheral vascular disease: pain, poikilothermia, pulselessness, pallor, paralysis, and paresthesia (decreased sensation). The six Ps characterize peripheral vascular disease: pain, poikilothermia, pulselessness, pallor, paralysis, and paresthesia (decreased sensation). The six Ps characterize peripheral vascular disease: pain, poikilothermia, pulselessness, pallor, paralysis, and paresthesia (decreased sensation). 1

CON: Perfusion

COMPLETION 1. A patient has a stroke volume of 75 mL and a heart rate of 88 beats/min. What should the nurse calculate this patient’s cardiac output to be? ANS: 6,600 mL/6.6 L Chapter: Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures Objective: 4. Identify diagnostic tests commonly performed to diagnose disorders of the cardiovascular system. Page: 342 Heading: Cardiac Output Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Difficult Feedback: Cardiac output is the amount of blood ejected from the left ventricle in 1 minute and is determined by multiplying stroke volume by heart rate. Stroke volume is the amount of blood ejected by a ventricle in one contraction and averages 60 to 80 mL/beat. With an average resting heart rate of 75 beats per minute, average resting cardiac output is 5 to 6 L. To calculate the stroke volume, the nurse should multiply: 75 mL × 88 = 6,600 mL or 6.6 L. PTS:

CON: Perfusion

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Chapter 22. Nursing Care of Patients With Hypertension MULTIPLE CHOICE 1. A patient on antihypertensive medication has no insurance, three children, and reports feeling great and exercising daily. What should the nurse include in this patient’s teaching plan to promote compliance? 1. Encourage increased rest periods. 2. Provide names of support groups. 3. Refer the patient for financial assistance. 4. Schedule an annual physical examination. ANS: 3 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 8. Plan nursing care for a patients with hypertension. Page: 369 Heading: Nursing Care Plan for the Patient With Hypertension Integrated Process: Communication and Documentation Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Rest, support groups, and annual physical examinations will not improve compliance with this patient’s teaching plan. Rest, support groups, and annual physical examinations will not improve compliance with this patient’s teaching plan. The nurse should refer the patient for financial assistance. If the patient cannot afford the medication, it will not be taken in spite of any teaching that is done. Rest, support groups, and annual physical examinations will not improve compliance with this patient’s teaching plan.

PTS:

CON: Perfusion

2. The nurse is reviewing orders for a patient taking digoxin (Lanoxin). Which additional medication should the nurse question? 1. Ramipril (Altace) 2. Carvedilol (Coreg) 3. Verapamil (Calan SR) 4. Clonidine (Catapres) ANS: 3 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 5. Describe classifications and treatment recommendations for hypertension in adults. Page: 369 Heading: Medications Used to Treat Hypertension (Table 22.3) Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1

This medication is not contraindicated with digoxin.

Calcium channel blockers can increase blood level of digoxin.

This medication is not contraindicated with digoxin.

PTS:

CON: Perfusion

3. The nurse is caring for a group of patients. Which patient should the nurse see first? 1. A patient with a blood pressure of 140/70 mm Hg who is asymptomatic 2. A patient with a blood pressure of 150/60 mm Hg who is anxious 3. A patient with a blood pressure of 170/80 mm Hg with a headache 4. A patient with a blood pressure of 180/120 mm Hg reporting a nosebleed ANS: 4 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 6. Define hypertensive emergency. Page: 363 Heading: Hypertensive Emergency Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1

This patient should be seen last.

This patient should be seen third.

This patient should be seen second.

This patient is showing signs of hypertensive emergency and should be seen first.

PTS:

CON: Perfusion

4. The nurse is measuring blood pressures during a screening clinic. Which recommended follow-up time frame should the nurse suggest to a patient for a blood pressure reading of 118/72 mm Hg? 1. 1 month 2. 2 months 3. l year

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4. 2 years ANS: 4 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 8. Plan nursing care for patients with hypertension. Page: 369 Heading: Nursing Care Plan for the Patient With Hypertension Integrated Process: Communication and Documentation Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate Feedback 1 2 3 4

Follow-up of 1 month, 2 months, or 1 year are not necessary for a normal blood pressure. Follow-up of 1 month, 2 months, or 1 year are not necessary for a normal blood pressure. Follow-up of 1 month, 2 months, or 1 year are not necessary for a normal blood pressure. This is a normal blood pressure and requires a 2-year follow-up.

PTS:

CON: Health Promotion

5. A patient tells the nurse he has started experiencing impotence since beginning treatment for hypertension. Which statement by the nurse is most appropriate? 1. “This is a normal side effect of the medication and you will get used to it.” 2. “You should stop taking this medication immediately.” 3. “I will talk to your doctor and see about referring you for sexual counseling.” 4. “You can start taking sildenafil (Viagra); this should fix the problem.” ANS: 3 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 7. List common complications of hypertension. Page: 367 Heading: Therapeutic Measures for Hypertension Integrated Process: Communication and Documentation Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2

The patient is telling the nurse because he wants to fix the side effect; the nurse should not suggest doing nothing. The nurse should not suggest the patient quit taking a medication.

This response is most appropriate.

The nurse cannot suggest a medication without speaking to the health care

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provider (HCP). PTS:

CON: Perfusion

6. The nurse is planning care for patients with hypertension. Which ethnic group should the nurse understand is most sensitive to the effects of the beta blocker propranolol (Inderal)? 1. Chinese 2. Koreans 3. African Americans 4. Japanese Americans ANS: 3 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 2. Identify causes and risk factors for hypertension. Page: 363 Heading: Race and Ethnicity Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

2 3

Chinese people are more sensitive than Caucasians to the effects of propranolol on heart rate and blood pressure, requiring only half the blood level of European Americans to achieve a therapeutic effect. Propranolol is eliminated from the bodies of many Chinese people at double the rate of European Americans. They are more likely to suffer fatigue as a side effect. The nurse must carefully monitor the Chinese patient for therapeutic and side effects. There is no information to suggest that individuals of Korean or Japanese descent cannot take propranolol (Inderal). Hypertension among African Americans is usually caused by increased renin activity resulting in greater sodium and fluid retention. African Americans respond better to diuretics such as furosemide (Lasix) than to beta blockers such as propranolol (Inderal). There is no information to suggest that individuals of Korean or Japanese descent cannot take propranolol (Inderal).

PTS:

CON: Perfusion

7. The nurse is planning care for a group of patients. Which individual should the nurse identify as being at the highest risk for developing hypertension? 1. A 60-year-old Japanese American man 2. A 56-year-old African American woman 3. A 45-year-old female tourist from China 4. A 51-year-old man who recently emigrated from Korea ANS: 2 Chapter: Chapter 22. Nursing Care of Patients With Hypertension

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Objective: 2. Identify causes and risk factors for hypertension. Page: 363 Heading: Race and Ethnicity Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Hypertension is not as serious of a health problem in individuals from Japan, China, or Korea. Hypertension continues to be the most serious health problem for African Americans in the United States. Hypertension is not as serious of a health problem in individuals from Japan, China, or Korea. Hypertension is not as serious of a health problem in individuals from Japan, China, or Korea.

PTS:

CON: Perfusion

8. A patient asks the nurse what the doctor meant by the phrase, “hypertensive emergency.” Which explanation should the nurse provide? 1. “It means that you’ve had a small stroke.” 2. “It refers to an episode of very high blood pressure.” 3. “It’s when the heart is failing to pump blood effectively.” 4. “It means the heart has become hyperactive and is beating too fast.” ANS: 2 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 6. Define hypertensive emergency. Page: 368 Heading: Hypertensive Emergency Integrated Process: Teaching/Learning Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

A hypertensive emergency is not a small stroke.

Hypertensive emergency is a severe type of hypertension, characterized by elevations in systolic blood pressure (SBP) greater than 180 mm Hg and diastolic blood pressure (DBP) greater than 120, which are complicated by risk for or progression of target organ dysfunction. This does not mean that the heart is failing to pump blood effectively.

This does not mean that the heart is hyperactive and beating too fast.

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PTS:

CON: Perfusion

9. The nurse is reinforcing teaching for a patient with hypertension. If a patient states, “I understand that if I do not eat or cook with salt, my hypertension will go away.” What is the nurse’s best response? 1. “Reducing salt in the diet increases blood pressure.” 2. “Patients who take diuretics do not need to reduce salt intake.” 3. “Excessive salt intake is responsible for most types of hypertension.” 4. “Some patients’ blood pressure may not respond to salt restriction alone.” ANS: 4 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 4. Describe therapeutic measures for hypertension. Page: 364 Heading: Modifiable Risk Factors Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Health Promotion Difficulty: Moderate Feedback 1

This statement is not necessarily true for all people.

The nurse should explain that some patients’ blood pressure may not respond to salt restriction alone, so it is important to follow prescribed therapy.

PTS:

CON: Health Promotion

10. The nurse is reinforcing teaching provided to a patient who has been taught ways to decrease blood pressure. Which patient statement indicates a need for further teaching? 1. “I eat fried foods three times a week.” 2. “I don’t add salt to my food anymore.” 3. “I walk my dog for 30 minutes every day.” 4. “I take high blood pressure medication daily.” ANS: 1 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 9. Evaluate effectiveness of nursing interventions. Page: 363–365 Heading: Modifiable Risk Factors Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Health Promotion Difficulty: Moderate

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Feedback 1

Fried foods should be reduced to decrease saturated fat intake.

This statement indicates teaching about ways to control blood pressure were effective. This statement indicates teaching about ways to control blood pressure were effective. This statement indicates teaching about ways to control blood pressure were effective.

3 4

PTS:

CON: Health Promotion

11. The nurse is teaching a patient with hypertension about the DASH diet. Which statement made by the patient indicates a need for further teaching? 1. “I will eat 3 ounces of baked fish for dinner.” 2. “I have eaten cup of cooked beans for dinner four times this week.” 3. “I ate a hamburger with a small order of fries last night.” 4. “My spouse has begun to cook using only 1 teaspoon of canola oil.” ANS: 3 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 4. Describe therapeutic measures for hypertension. Page: 364 Heading: Nutrition Notes Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Nutrition Difficulty: Moderate Feedback 1

This statement indicates an understanding of the DASH diet.

A burger and fries are not on the DASH diet.

This statement indicates an understanding of the DASH diet.

PTS:

CON: Nutrition

12. The nurse is teaching a group of patients about hypertension. Which patient is at highest risk for developing hypertension? 1. A 50-year-old Caucasian female who is 5 foot 6 inches and weighs 150 pounds 2. A 30-year-old Asian male who is 5 foot 5 inches and weighs 110 pounds 3. A 60-year-old African American female who is 5 foot 7 inches and weighs 275 pounds 4. A 40-year-old Hispanic female who is 5 foot 7 inches and weighs 120 pounds

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ANS: 3 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 2. Identify causes of risk factors for hypertension. Page: 363 Heading: Race and Ethnicity Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1

This patient is not at highest risk for hypertension.

This patient is not at high risk for hypertension.

This patient is overweight, African American, and female, making this patient at highest risk for hypertension. This patient is not at highest risk for hypertension.

PTS:

CON: Perfusion

13. The nurse is preparing to administer furosemide (Lasix) to a patient with hypertension. The nurse reviews the patient’s potassium and notes a level of 4.6 mEq/L. Which action should the nurse take? 1. Notify the HCP. 2. Administer the medication as prescribed. 3. Withhold the medication. 4. Wait an hour and administer the medication. ANS: 2 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 9. Evaluate effectiveness of nursing interventions. Page: 364 Heading: Medications Used to Treat Hypertension Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

There is no reason to notify the HCP.

This potassium level is normal; the medication should be administered.

The medication should not be withheld.

There is no reason to wait to administer the medication.

PTS:

CON: Perfusion

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14. A patient who has unsuccessfully implemented lifestyle modifications for high blood pressure asks what else can be done. What should the nurse respond to this patient? 1. “You should get more rest.” 2. “You should decrease your exercise plan.” 3. “You should consider more strenuous exercise.” 4. “Your doctor may discuss medication with you.” ANS: 4 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 2. Identify causes and risk factors for hypertension. Page: 363 Heading: Modifiable Risk Factors Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate Feedback 1

Rest is not going to reduce the patient’s blood pressure.

Exercise is helpful to reduce blood pressure.

Strenuous exercise is not recommended for anyone with high blood pressure.

The no- or low-risk hypertensive patient’s therapy begins with lifestyle modifications. If lifestyle modification alone does not result in a blood pressure at the target goal, then drug therapy is recommended.

PTS:

CON: Health Promotion

15. The nurse is caring for a patient who has possible kidney damage from high blood pressure. Which action should the nurse take? 1. Monitor glucose. 2. Encourage fluids. 3. Monitor urine color. 4. Review creatinine level. ANS: 4 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 7. List common complications of hypertension. Page: 354 Heading: Complications of Hypertension Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback

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Glucose level is not altered with kidney function.

Fluids will not reduce the amount of kidney damage.

Urine color is not going to be influenced by kidney function or damage.

Creatinine is a measurement of kidney function. With kidney damage, the creatinine level will be elevated.

PTS:

CON: Perfusion

16. The nurse is caring for a group of patients. Which patient should the nurse see first? 1. A patient who received a dose of furosemide (Lasix) and reports an increase in urine output 2. A patient receiving spironolactone (Aldactone) with a potassium level of 4.8 mEq/L 3. A patient who received a dose of Metoprolol (Lopressor) with a blood pressure of 126/74 mm Hg 4. A patient receiving atenolol (Tenormin) with a blood pressure of 188/114 mmHg ANS: 4 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 6. Define hypertensive emergency. Page: 353 Heading: Hypertensive Emergency Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1

The symptoms are not always present.

2 3

In hypertension, symptoms may not always be present. That is why hypertension is referred to as the silent killer. Symptoms can appear with all types of hypertension.

The presence of symptoms does not mean that a stroke is pending.

PTS:

CON: Perfusion

17. The nurse is caring for a patient with stage 1 hypertension. Which medication should the nurse expect to be prescribed for this patient? 1. Verapamil (Calan) 2. Minoxidil (Loniten) 3. Diltiazem (Cardizem) 4. Hydrochlorothiazide (HydroDIURIL) ANS: 4 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 4. Describe therapeutic measures for hypertension.

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Page: 362 Heading: Medications Used to Treat Hypertension Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

This medication is not appropriate for the patient with stage 1 hypertension.

For most patients with hypertension, initial drug therapy should be thiazidetype diuretics such as hydrochlorothiazide.

PTS:

CON: Perfusion

18. The nurse is teaching a patient about furosemide (Lasix). Which statement made by the patient indicates an understanding of the teaching? 1. “If my blood pressure is really high, I will take a second dose.” 2. “I will be sure to avoid potassium while taking this medication.” 3. “I should take the medication in the morning so I am not up all night going to the bathroom.” 4. “I need to be sure to take this pill without food or milk.” ANS: 3 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 4. Describe therapeutic measures for hypertension. Page: 365 Heading: Medications Used to Treat Hypertension (Table 22.3) Integrated Process: Teaching/Learning Client Need: SECE—Safety and Infection Control Cognitive Level: Evaluation (Evaluating) Concept: Perfusion Difficulty: Moderate Feedback 1

The patient should not take a second dose of Lasix without consulting the HCP.

2 3

The patient should not avoid potassium because Lasix is a potassium-wasting diuretic. This statement is accurate.

The medication should be taken with food or milk.

PTS:

CON: Perfusion

19. The nurse is contributing to a teaching session about hypertension. Which patient should the nurse identify as having the greatest risk for hypertension?

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1. 2. 3. 4.

A 43-year-old married mother of three teenagers A 40-year-old man whose brother has hypertension A 35-year-old male construction worker who smokes A 34-year-old single female who is an administrative assistant

ANS: 2 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 2. Identify causes and risk factors for hypertension. Page: 363 Heading: Risk Factors for Hypertension Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

This individual has risk factors that can be modified and reduce the risk of developing hypertension. Nonmodifiable risk factors—those that cannot be changed—include a family history of hypertension, age, ethnicity, and diabetes mellitus. This individual has risk factors that can be modified and reduce the risk of developing hypertension. This individual has risk factors that can be modified and reduce the risk of developing hypertension.

PTS:

CON: Perfusion

20. The nurse is assessing a patient who has been taking prazosin (Minipress) for 3 months. Which indicates treatment is effective? 1. The patient reports a 4-pound weight loss in 3 months. 2. The patient states they work out at the gym every morning. 3. The patient tells the nurse she has been following a low-sodium diet. 4. The patient’s blood pressure is 114/66 mm Hg. ANS: 4 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 9. Evaluate effectiveness of nursing interventions. Page: 365 Heading: Medications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Evaluation (Evaluating) Concept: Perfusion Difficulty: Moderate Feedback 1

Blood pressure within normal limits is indicative of effective treatment.

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Blood pressure within normal limits is indicative of effective treatment.

PTS:

CON: Perfusion

21. The nurse is taking a medication history of a patient with a chronic cough. Which medication can the nurse suspect as contributing to the cough? 1. Chlorothiazide (Diuril) 2. Furosemide (Lasix) 3. Nadolol (Corgard) 4. Lisinopril (Zestril) ANS: 4 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 4. Describe therapeutic measures for hypertension. Page: 365 Heading: Medications Used to Treat Hypertension (Table 22.3) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1

This medication doesn’t cause a cough.

This is an ace inhibitor and places the patient at risk for cough.

PTS:

CON: Perfusion

22. The nurse is preparing to administer atenolol (Tenormin) to a patient with hypertension. The patient’s blood pressure is 72/40 mm Hg. Which action should the nurse take? 1. Administer the medication as ordered. 2. Notify the HCP. 3. Reassess the patient’s blood pressure in 8 hours. 4. Administer half of the prescribed dose. ANS: 2 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 4. Describe therapeutic measures for hypertension Page: 365 Heading: Medications Used to Treat Hypertension (Table 22.3) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE-Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety

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Difficulty: Moderate Feedback 1 2 3 4

The patient’s blood pressure is low; the HCP should be notified before taking action. The patient’s blood pressure is low; the HCP should be notified before taking action. The patient’s blood pressure is low; the HCP should be notified before taking action. The patient’s blood pressure is low; the HCP should be notified before taking action.

PTS:

CON: Safety

23. The nurse is assessing a blood pressure of a patient and obtains a reading of 110/60 mm Hg. The nurse knows the patient falls under which category? 1. Stage 1 hypertension 2. Elevated blood pressure 3. Normal blood pressure 4. Stage 2 hypertension ANS: 3 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 1. Explain the pathophysiology of hypertension. Page: 362 Heading: Blood Pressure Categories (Table 22.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1

This blood pressure is normal.

PTS:

CON: Perfusion

24. The nurse is caring for a patient in hypertensive emergency. What should the nurse expect to be the goal when treatment is provided for this patient? 1. Increase urine output. 2. Negate the impact of sodium in the body. 3. Ensure an adequate potassium blood level. 4. Reduce blood pressure by 25% in 1 hour.

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ANS: 4 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 6. Define hypertensive emergency. Page: 368 Heading: Hypertensive Emergency Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

The goals of therapy for a patient in hypertensive emergency are not to increase urine output, negate the impact of sodium in the body, or to ensure an adequate potassium blood level. The goals of therapy for a patient in hypertensive emergency are not to increase urine output, negate the impact of sodium in the body, or to ensure an adequate potassium blood level. The goals of therapy for a patient in hypertensive emergency are not to increase urine output, negate the impact of sodium in the body, or to ensure an adequate potassium blood level. In some cases of hypertensive emergency, blood pressure may need to be reduced by 25% within 1 hour.

PTS:

CON: Perfusion

25. The nurse becomes concerned that a male patient’s blood pressure is 168/98 mm Hg after 6 months on antihypertensive medication. What question should the nurse ask after measuring this blood pressure? 1. Is the patient taking the medication? 2. What is the volume of alcohol ingested each day? 3. Which pharmacy is filling the prescribed medications? 4. How many hours of sleep does the patient receive each night? ANS: 1 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 9. Evaluate effectiveness of nursing interventions. Page: 369 Heading: Therapeutic Measures for Hypertension Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

Antihypertensive medications can have unpleasant side effects. For the male patient, erectile dysfunction might occur, and the patient may choose to stop the medication. The nurse needs to find out if the patient is taking the

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2 3 4

medication. These questions do not focus on why the patient’s blood pressure continues to be elevated after taking medication for 6 months. These questions do not focus on why the patient’s blood pressure continues to be elevated after taking medication for 6 months. These questions do not focus on why the patient’s blood pressure continues to be elevated after taking medication for 6 months.

PTS:

CON: Perfusion

MULTIPLE RESPONSE 1. The nurse is reviewing complications of hypertension with a patient. Which should the nurse include in the teaching? (Select all that apply.) 1. Heart failure 2. Liver disease 3. Hypothyroidism 4. Stroke 5. Myocardial infarction 6. Kidney Failure ANS: 1, 4, 5, 6 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 7. List common complications of hypertension. Page: 368 Heading: Hypertension Summary Integrated Process: Teaching/Learning Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1. 2. 3. 4. 5. 6. PTS:

Feedback This is a complication of hypertension. This is not a complication of hypertension. This is not a complication of hypertension. This is a complication of hypertension. This is a complication of hypertension. This is a complication of hypertension. 1

CON: Perfusion

2. The nurse is caring for a patient with hypertension who is being discharged home with a prescription of propranolol (Inderal). Which topics should the nurse include in the teaching? (Select all that apply.) 1. Check the heart rate and blood pressure before taking the medication. 2. Get up slowly to avoid dizziness. 3. Keep appointments to have potassium level checked.

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4. Wear sunscreen to avoid photosensitivity. 5. Talk to the doctor before the medication is stopped. ANS: 1, 2, 5 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 4. Describe therapeutic measures for hypertension. Page: 365 Heading: Medications Used to Treat Hypertension (Table 22.3) Integrated Process: Teaching/Learning Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback The patient will be taught to take a blood pressure and heart rate before taking the medication. The patient should be taught to rise slowly to avoid dizziness. This medication does not require monitoring potassium levels. This medication does not cause photosensitivity. The nurse should instruct the patient to avoid ceasing medication to avoid rebound hypertension. 1

CON: Perfusion

3. The infection control nurse observes a nurse on a cardiac unit. Which actions by the nurse would require intervention by the infection control nurse? (Select all that apply.) 1. Wipes stethoscope with a soft cloth before each patient use 2. Carries stethoscope in a laboratory coat pocket when not in use 3. Performs hand hygiene before and after contact with each patient 4. Leaves a thermometer in the room of a patient on contact precautions 5. Takes own stethoscope into the room of a patient on contact precautions 6. Uses a stethoscope and blood pressure cuff supplied in the patient’s room ANS: 1, 5 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 8. Plan nursing care for patients with hypertension. Page: 358 Heading: Therapeutic Measures for Hypertension Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Evaluation (Evaluating) Concept: Safety Difficulty: Moderate

1. 2.

Feedback The nurse should not wipe the stethoscope with a cloth before use or use own stethoscope for a patient on contact precautions. Stethoscopes become contaminated with patient use. To protect patients,

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5. 6.

PTS:

stethoscopes should be cleansed with ethanol-based cleanser or isopropyl alcohol pads as frequently between each patient use as hands are washed. Patients with contact precautions or isolation should have dedicated equipment in the room. Stethoscopes become contaminated with patient use. To protect patients, stethoscopes should be cleansed with ethanol-based cleanser or isopropyl alcohol pads as frequently between each patient use as hands are washed. Patients with contact precautions or isolation should have dedicated equipment in the room. Stethoscopes become contaminated with patient use. To protect patients, stethoscopes should be cleansed with ethanol-based cleanser or isopropyl alcohol pads as frequently between each patient use as hands are washed. Patients with contact precautions or isolation should have dedicated equipment in the room. The nurse should not wipe the stethoscope with a cloth before use or use own stethoscope for a patient on contact precautions. Stethoscopes become contaminated with patient use. To protect patients, stethoscopes should be cleansed with ethanol-based cleanser or isopropyl alcohol pads as frequently between each patient use as hands are washed. Patients with contact precautions or isolation should have dedicated equipment in the room. 1

CON: Safety

COMPLETION 1. The nurse is preparing to administer furosemide (Lasix) 20 mg intravenously to a patient with hypertension. The available dose is 40 mg/mL. How many mL will the nurse administer? Enter the numeral only. ANS: 0.5 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 5. Define classifications and treatment recommendations for hypertension in adults. Page: 365 Heading: Medications Used to Treat Hypertension (Table 22.3) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: mL = 1 mL/40 mg × 20 mg = 0.5 mL PTS:

CON: Safety

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2. The nurse is preparing to administer lisinopril (Prinivil) 40 mg by mouth to a patient with hypertension. The available does is 20 mg per tablet. How many tablets will the nurse administer? Enter the numeral only. ANS: 2 Chapter: Chapter 22. Nursing Care of Patients With Hypertension Objective: 5. Define classifications and treatment recommendations for hypertension in adults. Page: 365 Heading: Medications Used to Treat Hypertension (Table 22.3) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: tab = 1 tab/20 mg × 40 mg = 2 tablets PTS:

CON: Safety

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Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders MULTIPLE CHOICE 1. The nurse is reinforcing teaching for a patient who has had a mechanical valve replacement. What should be included regarding safety during warfarin (Coumadin) therapy? 1. Wear medial alert identification. 2. Use a straight razor when shaving. 3. Keep yearly blood test appointments. 4. Increase intake of green leafy vegetables. ANS: 1 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 3. Identify postoperative complications that can occur following any type of cardiac valve replacement. Page: 375 Heading: Nursing Diagnoses, Planning, Implementation, and Evaluation Integrated Process: Teaching/Learning Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

If the patient is on anticoagulants for mechanical valve replacement, medical identification should be used. Avoid a straight razor to avoid cuts and bleeding. Monthly blood tests are done. A steady (rather than fluctuating) amount of green leafy vegetables should be eaten so that international normalized ratio (INR) values do not fluctuate due to the vitamin K found in these foods.

PTS:

CON: Safety

2. The nurse is caring for a group of patients on the cardiac unit. Which patient is at highest risk for mitral valve prolapse? 1. A 12-year-old male 2. An 18-year-old female 3. A 25-year-old male 4. A 40-year-old female ANS: 2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for each of the valvular disorders. Page: 375

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Heading: Pathophysiology and Etiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

This patient is not at high risk for mitral valve prolapse. This patient is both between the ages of 15 and 30 and a female, placing this patient at highest risk. This patient is not at highest risk for mitral valve prolapse. This patient is not at highest risk for mitral valve prolapse.

PTS:

CON: Perfusion

3. The nurse is teaching a patient about mitral valve prolapse and lifestyle modifications. Which statement made by the patient indicates a need for further teaching? 1. “I should cut coffee out of my diet.” 2. “I need to avoid physical activity.” 3. “I have been practicing yoga to reduce stress.” 4. “I will need to follow a balanced diet.” ANS: 2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for each of the valvular disorders. Page: 375 Heading: Therapeutic Measures Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Heath Promotion Difficulty: Moderate Feedback 1 2 3 4

Caffeine should be avoided; this is an accurate statement. Exercise should be encouraged, not avoided. This is an accurate statement. This is an accurate statement. PTS:

CON: Health Promotion

4. The nurse is caring for a patient with aortic regurgitation. Which interventions should the nurse implement? 1. Encourage the patient to perform all activities of daily living at once. 2. Schedule activities with periods of rest. 3. Elevate the head of bed (HOB) to 30 degrees. 4. Apply oxygen at 2 liters/nasal cannula.

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ANS: 2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for each of the valvular disorders. Page: 376 Heading: Nursing Care Plan for the Patient With a Cardiac Valvular Disorder Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

The nurse should schedule activities with periods of rest. This is an appropriate intervention. The HOB should be elevated to 45 degrees. The nurse needs an order to apply oxygen. PTS:

CON: Perfusion

5. The nurse is caring for a patient receiving heparin for thrombophlebitis. The nurse observes the patient has bleeding gums and black tarry stools. Which prescribed medication should the nurse plan to administer? 1. Vitamin K 2. Naloxone (Narcan) 3. Protamine sulfate 4. Flumazenil (Romazicon) ANS: 3 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 6. Explain the pathophysiology, signs and symptoms, prevention, complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis. Page: 393 Heading: Anticoagulant Medications (Table 23.8) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

This is the antidote for Coumadin. This is given for opioid overdose. This is the antidote for heparin. This is the antidote for benzodiazepines. PTS:

CON: Safety

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6. The nurse is assessing a patient who underwent valve replacement surgery. Which finding should concern the nurse the most? 1. Wet lung sounds 2. Urine output 50 mL/hr 3. Temperature of 99.1°F 4. Chest tube drainage of 100 mL/hr ANS: 1 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 3. Identify postoperative complications that can occur following any type of cardiac valve replacement. Page: 379 Heading: Nursing Care Plan for the Postoperative Patient Undergoing Cardiac Surgery Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1

Wet lung sounds are indicative of heart failure or pulmonary edema. This is normal urine output. A low-grade temperature is not concerning in the first 24 hours. This is normal chest tube drainage.

2 3 4

PTS:

CON: Perfusion

7. The nurse is caring for a patient with infective endocarditis (IE). Which statement made by the patient leads the nurse to suspect the cause of the IE? 1. “When I was a child, I had rheumatic fever.” 2. “I have not been to the dentist in 8 years.” 3. “I had a myocardial infarction last year.” 4. “I have to sit in one spot for a long time for my job.” ANS: 2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for infective endocarditis, pericarditis, and myocarditis. Page: 384 Heading: Pathophysiology and Etiology Integrated Process: Communication and Documentation Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1

This does not lead to IE.

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Poor dental hygiene is a cause of IE. This does not lead to IE. This does not lead to IE.

3 4

PTS:

CON: Perfusion

8. The nurse is providing discharge teaching for a patient with mitral stenosis. What should the nurse include in this teaching? 1. “The medications you will be taking make your blood thicker, so you are at risk for small clots to form.” 2. “It is important that you increase your fluid intake and take iron supplements so that your body can make enough blood for your heart to pump around.” 3. “Your blood is rushing through your heart so fast that it may not give your heart enough oxygen and you may have something called angina, or heart pain.” 4. “Because of your heart condition, the blood flow through your heart is slower and blood may tend to pool in certain areas, which might allow tiny clots to form.” ANS: 4 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for each of the valvular disorders. Pages: 376–377 Heading: Therapeutic Measures Integrated Process: Teaching/Learning Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Patients are often placed on blood thinners, so this is a false statement. Iron supplementation is provided for iron deficiency anemia, not for valvular disorders. Blood flow through the heart is slowed, so this is a false statement. Emboli form from the stasis of blood in the heart caused by valvular disorders and decreased cardiac output.

PTS:

CON: Perfusion

9. The nurse is caring for a patient who has aortic stenosis. During data collection, which of these manifestations should indicate to the nurse that the patient is experiencing myocardial oxygen deficiency? 1. Angina 2. Sacral edema 3. Jugular vein distention 4. Pericardial friction rub ANS: 1

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Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for each of the valvular disorders. Page: 375 Heading: Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Angina results if cardiac oxygen needs are not met. A lack of myocardial oxygen does not cause sacral edema, jugular vein distention, or pericardial friction rub. A lack of myocardial oxygen does not cause sacral edema, jugular vein distention, or pericardial friction rub. A lack of myocardial oxygen does not cause sacral edema, jugular vein distention, or pericardial friction rub.

PTS:

CON: Perfusion

10. The nurse is evaluating care provided to a patient with the nursing diagnosis of activity intolerance because of aortic regurgitation. Which outcome indicates that care has been effective? 1. Stated maintained bedrest to reduce fatigue 2. Engaged in desired daily and social activities 3. Completed activities of daily living with assistance 4. Reported no longer participates in gardening hobby ANS: 2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for each of the valvular disorders. Pages: 378–379 Heading: Nursing Care Plan for the Patient With a Cardiac Valvular Disorder Integrated Process: Psychosocial Integrity Client Need: PHYS—Physiological Adaptation Cognitive Level: Evaluation (Evaluating) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3

Needing bedrest to reduce fatigue indicates that interventions to address activity intolerance have not been effective. The desired outcome for activity intolerance would be for the patient to be able to engage in desired daily and social activities. Needing assistance to complete activities of daily indicates that interventions to address activity intolerance have not been effective.

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No longer participating in a gardening hobby indicates that interventions to address activity intolerance have not been effective.

PTS:

CON: Perfusion

11. The nurse is reviewing care for a group of patients. Which patient with a heart valve disorder should the nurse identify as being susceptible to developing the complication of fluid volume excess? 1. A 27-year-old male on atenolol (Tenormin) 2. A 68-year-old female on digoxin (Lanoxin) 3. A 44-year-old male taking amoxicillin (Amoxil) 4. An 18-year-old female taking warfarin (Coumadin) ANS: 2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for each of the valvular disorders. Page: 375 Heading: Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2

3 4

These patients would be less prone to developing fluid volume excess with a heart valve disorder. Older adults generally would be more likely to experience the complication of fluid volume excess due to aging changes and less cardiac reserve. None of the listed medications are expected to cause fluid volume retention. These patients would be less prone to developing fluid volume excess with a heart valve disorder. These patients would be less prone to developing fluid volume excess with a heart valve disorder.

PTS:

CON: Perfusion

12. The nurse is reinforcing teaching about dilated cardiomyopathy. Which statement made by the patient indicates a need for further teaching? 1. “My condition could be genetic; I should get my kids tested.” 2. “I may have heart failure since I have the dilated type of cardiomyopathy.” 3. “I have the more common type of cardiomyopathy.” 4. “I will not have to receive treatment, since it is not useful.” ANS: 4 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders

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Objective: 5. Explain the pathophysiology, etiology, signs and symptoms, complications, diagnostic tests, therapeutic measures, and nursing care for dilated, hypertrophic, and restrictive cardiomyopathy. Page: 391 Heading: Therapeutic Measures Integrated Process: Teaching/Learning Client Need: PHYS—Physiological Adaptation Cognitive Level: Evaluation (Evaluating) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

This statement is accurate. This statement is accurate. This statement is accurate. Treatment is not useful for restrictive cardiomyopathy. PTS:

CON: Perfusion

13. The nurse is caring for a group of patients. Which patient is at highest risk for developing deep vein thrombosis (DVT)? 1. A cashier 2. A truck driver 3. A nurse 4. A mail carrier ANS: 2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention, complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis. Page: 394 Heading: Immobility Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

A cashier is not at high risk for developing a DVT. A truck driver is at highest risk because of siting for long periods of time. A nurse is not at high risk for developing a DVT. A mail carrier is not at high risk for developing a DVT. PTS:

CON: Perfusion

14. A patient who has aortic stenosis develops severe dyspnea and chest pain. Which action should the nurse take? 1. Obtain vital signs.

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2. Give nitroglycerin. 3. Raise the head of the bed. 4. Encourage the patient to sleep. ANS: 1 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for each of the valvular disorders. Page: 378 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Data collection is the first action the nurse should take in any situation to plan further care. These actions can be done after the vital signs are assessed. These actions can be done after the vital signs are assessed. A patient with severe dyspnea and chest pain is not going to be able to sleep.

PTS:

CON: Perfusion

15. The nurse is monitoring a patient with aortic stenosis and notes crackles in the lungs and a cough. Which complication should the nurse suspect is occurring in this patient? 1. Pneumonia 2. Heart failure 3. Hypertension 4. Rheumatic fever ANS: 2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for each of the valvular disorders. Page: 378 Heading: Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2

Change in lung sounds and a cough does not necessarily indicate the development of pneumonia, hypertension, or rheumatic fever. Heart failure can occur with heart valve disorders. Lung symptoms are

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3 4

indicative of heart failure. Change in lung sounds and a cough does not necessarily indicate the development of pneumonia, hypertension, or rheumatic fever. Change in lung sounds and a cough does not necessarily indicate the development of pneumonia, hypertension, or rheumatic fever.

PTS:

CON: Perfusion

16. A patient with mitral stenosis is prescribed a preoperative antibiotic. Which patient statement indicates an understanding for taking this medication? 1. “To prevent postoperative pneumonia.” 2. “To prevent an increase in body temperature.” 3. “To prevent a bacterial infection in the heart.” 4. “To prevent infection of the surgical incision.” ANS: 3 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 2. Compare and contrast the difference between commissurotomy, annuloplasty, and valve replacement. Page: 377 Heading: Cardiac Valve Repairs Integrated Process: Teaching/Learning Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3

This medication is not provided to prevent postoperative pneumonia, fever, or infection of the surgical incision. This medication is not provided to prevent postoperative pneumonia, fever, or infection of the surgical incision. Prophylactic antibiotic therapy helps prevent a bacterial infection in the heart, rheumatic fever, and subsequent rheumatic heart disease and is recommended to prevent valvular disease. This medication is not provided to prevent postoperative pneumonia, fever, or infection of the surgical incision.

PTS:

CON: Perfusion

17. The nurse is caring for a group of patients. Which patient is at highest risk for developing pericarditis? 1. A patient with DVT of the right leg 2. A patient with a history of rheumatic fever 3. A patient with ankylosing spondylitis 4. A patient with renal disease and systemic lupus erythematosus (SLE) ANS: 4

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Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, complications, diagnostic tests, therapeutic measures, and nursing care for infective endocarditis, pericarditis, and myocarditis. Page: 389 Heading: Pathophysiology and Etiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1

This patient is not at risk for pericarditis. This patient is at moderate risk for pericarditis. This patient is not at risk for pericarditis. This patient is at highest risk for pericarditis.

2 3 4

PTS:

CON: Perfusion

18. The nurse is caring for a patient with pericarditis who develops hypotension, confusion, tachycardia, tachypnea, and jugular venous distension. For which procedure should the nurse prepare the patient? 1. Pericardiocentesis 2. Myectomy 3. Endometrial biopsy 4. Commissurotomy ANS: 1 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for infective endocarditis, pericarditis, and myocarditis. Page: 389 Heading: Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

The patient is experiencing cardiac tamponade. A pericardiocentesis is the treatment. This is not the treatment for cardiac tamponade. This is not the treatment for cardiac tamponade. This is not the treatment for cardiac tamponade.

PTS:

CON: Perfusion

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19. The nurse is collecting data on a patient recovering from a hysterectomy who is experiencing left calf tenderness. Data include the following: left calf 17.5 inches; right calf 14 inches; left thigh 32 inches; right thigh 28 inches; shiny, warm, and reddened left leg. Which actions should the nurse recommend for this patient’s plan of care? 1. Maintain bedrest. 2. Encourage ambulation daily. 3. Place anti-embolism stocking on left leg. 4. Place anti-embolism stocking on both legs. ANS: 1 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention, complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis. Page: 394 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Patient has developed thrombophlebitis, and bedrest should be maintained as ordered until acute phase is resolved to prevent an emboli. Ambulation could lead to a pulmonary embolism and should be avoided. Anti-embolism stockings are placed on the unaffected leg only during the acute phase to prevent emboli. Anti-embolism stockings are placed on the unaffected leg only during the acute phase to prevent emboli.

PTS:

CON: Perfusion

20. The nurse is caring for a patient who develops a fever and reports right calf pain with a reddened and swollen calf. Which action should the nurse take? 1. Massage the affected calf. 2. Place ice on the affected calf. 3. Place elastic stocking on right leg. 4. Measure bilateral calf circumference daily. ANS: 4 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention, complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis. Page: 394 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying)

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Concept: Perfusion Difficulty: Moderate Feedback 1

Massaging the calf is contraindicated, and anti-embolism stockings are placed on the unaffected leg only during acute phase to prevent emboli. Warm, moist heat may be used for superficial thrombophlebitis. Massaging the calf is contraindicated, and anti-embolism stockings are placed on the unaffected leg only during acute phase to prevent emboli. Warm, moist heat may be used for superficial thrombophlebitis. Massaging the calf is contraindicated, and anti-embolism stockings are placed on the unaffected leg only during acute phase to prevent emboli. Warm, moist heat may be used for superficial thrombophlebitis. The calf should be measured bilaterally for comparison and documented daily to note changes.

PTS:

CON: Perfusion

21. The nurse is caring for a group of patients. Which patient should the nurse see first? 1. A patient with IE who is receiving IV antibiotic therapy 2. A patient who underwent valve replacement surgery 4 hours ago and reports level 9 pain 3. A patient with aortic regurgitation awaiting an echocardiogram 4. A patient with myocarditis who has a 99.1°F fever ANS: 2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 3. Identify postoperative complications that can occur following any type of cardiac valve replacement. Page: 382 Heading: Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

It is typical for this patient to receive antibiotics; this patient is not the highest priority. This patient should be seen first and given pain medication. This patient is not the highest priority. This patient should be seen after the patient with level 9 pain.

PTS:

CON: Perfusion

22. A healthy postoperative patient who has been on bedrest for 3 days suddenly develops dyspnea, tachypnea, restlessness, and chest pain. The patient says, “I feel as if something is going to happen to me.” Which action should the nurse take? 1. Perform a bilateral Homans’ test.

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2. Give a narcotic for pain as ordered. 3. Notify the health care provider (HCP) immediately. 4. Reassure the patient that everything is fine. ANS: 3 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention, complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis. Page: 397 Heading: Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS-Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3

These actions are not appropriate for the potential life-threatening condition. The physician will prescribe orders when notified. These actions are not appropriate for the potential life-threatening condition. The physician will prescribe orders when notified. The patient likely has pulmonary emboli, which is a life-threatening condition and requires prompt medical intervention, so the physician must be notified immediately. This would provide false reassurance, which should never be done.

PTS:

CON: Perfusion

23. The nurse is reviewing the prothrombin time (PT) value for a patient prescribed warfarin (Coumadin). The laboratory’s PT range is 9 to 11 seconds. What would be the therapeutic time for the patient? 1. 12.5 seconds 2. 17 seconds 3. 26 seconds 4. 30 seconds ANS: 2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention, complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis. Page: 395 Heading: Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback

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1 2

3 4

The value of 12.5 seconds is subtherapeutic. Warfarin’s therapeutic range is 1.5 to 2 times the normal PT range. To monitor the patient’s therapeutic PT, compare the patient’s result with the therapeutic range. The therapeutic range is 13.5 to 22 seconds. The value of 26 seconds is above therapeutic. The value of 30 seconds is above therapeutic.

PTS:

CON: Perfusion

24. A patient with a history of mitral valve replacement surgery is instructed to take prophylactic antibiotics before a scheduled root canal. Which patient statement indicates to the nurse that teaching has been effective? 1. “I know I need to call my doctor if I notice a dry cough.” 2. “If I notice any ankle edema, I should lower my salt intake.” 3. “If I develop a fever in the next week or so, I need to call my doctor right away.” 4. “Endocarditis causes rapid weight gain so I need to weigh myself every day for a full week.” ANS: 3 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 3. Identify postoperative complications that can occur following any type of cardiac valve replacement. Page: 381 Heading: Cardiac Valve Repairs Integrated Process: Teaching/Learning Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Dry cough, ankle edema, and weight gain are not manifestations of acute endocarditis. Dry cough, ankle edema, and weight gain are not manifestations of acute endocarditis. A fever is a manifestation of acute endocarditis Dry cough, ankle edema, and weight gain are not manifestations of acute endocarditis.

PTS:

CON: Perfusion

25. The nurse is collecting data from a patient 3 days after a motor vehicle crash in which the patient hit the steering wheel. The data reveal symptoms of pericarditis. Which finding indicates the presence of pericarditis? 1. Pain on expiration 2. Pericardial friction rub 3. Jugular vein distention 4. Crackles in lung bases

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ANS: 2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for infective endocarditis, pericarditis, and myocarditis. Page: 388 Heading: Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

In pericarditis, pain occurs with inspiration. A pericardial friction rub due to inflammation of pericardium is the classic sign of pericarditis. Jugular vein distention and crackles in the lung bases are manifestations of heart failure. Jugular vein distention and crackles in the lung bases are manifestations of heart failure.

PTS:

CON: Perfusion

26. The nurse is caring for a patient with pericarditis. Which type of medication should the nurse expect to be prescribed for the patient? 1. Beta blocker 2. Antihypertensive 3. Anti-inflammatory 4. Calcium channel blocker ANS: 3 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for infective endocarditis, pericarditis, and myocarditis. Page: 388 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2

Beta blockers, antihypertensives, and calcium channel blockers do not treat inflammation or pain. Beta blockers, antihypertensives, and calcium channel blockers do not treat inflammation or pain.

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3 4

Anti-inflammatory medication reduces pericardial inflammation, which decreases pain and should be included in the pain management plan. Beta blockers, antihypertensives, and calcium channel blockers do not treat inflammation or pain.

PTS:

CON: Perfusion

27. The licensed practical nurse/licensed vocational nurse (LPN/LVN) is observing the student nurse administer enoxaparin (Lovenox). Which step taken by the student requires correction by the nurse? 1. The student cleans the area with alcohol. 2. The student removes any air bubbles. 3. The student injects the medication into the subcutaneous tissue (SQ). 4. The student asks the patient to verify any allergies. ANS: 2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention, complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis. Page: 388 Heading: Anticoagulant Medications (Table 23.8) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

This does not require correction. The air bubble remains in the syringe. This requires correction. This does not require correction. This does not require correction. PTS:

CON: Safety

28. The nurse is reinforcing teaching provided to a patient with thrombophlebitis. Which diagnostic test should the nurse explain is used to confirm thrombophlebitis? 1. Chest radiograph 2. IV pyelogram 3. Duplex venous scanning 4. Arterial Doppler ultrasonography ANS: 3 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention, complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis. Page: 393 Heading: Pathophysiology and Etiology

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Integrated Process: Teaching/learning Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Chest x-ray, IV pyelogram, or arterial Doppler ultrasound is not used to diagnose thrombophlebitis. Chest x-ray, IV pyelogram, or arterial Doppler ultrasound is not used to diagnose thrombophlebitis. Duplex venous scanning confirms thrombophlebitis. Chest x-ray, IV pyelogram, or arterial Doppler ultrasound is not used to diagnose thrombophlebitis.

PTS:

CON: Perfusion

29. The nurse is collecting data from a patient. Which approach should the nurse use to determine the presence of a Homans’ sign? 1. Observing the calf and thigh color bilaterally 2. Listening with a Doppler to posterior bilateral tibial pulses 3. Measuring the patient’s calf and thigh circumference bilaterally 4. Dorsiflexing the patient’s foot sharply and asking if calf pain occurs ANS: 4 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, prevention, complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis. Page: 394 Heading: Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

These approaches are not used to determine the presence of a Homans’ sign. These approaches are not used to determine the presence of a Homans’ sign. These approaches are not used to determine the presence of a Homans’ sign. Homans’ sign is performed prior to confirmation of thrombophlebitis by dorsiflexing the patient’s foot sharply and asking if calf pain occurred. Pain is positive for thrombophlebitis.

PTS:

CON: Perfusion

30. The nurse is caring for a patient with a DVT who is receiving IV heparin. The nurse should monitor which of these laboratory tests specifically for the effects of the heparin? 1. PT 2. Partial thromboplastin time (PTT)

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3. Platelets 4. Bleeding time ANS: 2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention, complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis. Page: 395 Heading: Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

These laboratory tests are not used to monitor the effectiveness of heparin. PTT monitors the effects of heparin. These laboratory tests are not used to monitor the effectiveness of heparin. These laboratory tests are not used to monitor the effectiveness of heparin.

2 3 4

PTS:

CON: Perfusion

31. The nurse is monitoring a patient with pericarditis. What health problem is this patient at risk for developing? 1. Emboli begin to form. 2. Pericardial sac fluid increases. 3. Cardiac workload increases by 15%. 4. Cardiac output decreases more than 10%. ANS: 2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for infective endocarditis, pericarditis, and myocarditis. Page: 375 Heading: Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3

Emboli formation and changes in cardiac workload or output are not typically associated with pericarditis. Cardiac tamponade is a life-threatening compression of the heart by fluid accumulated in the pericardial sac. Emboli formation and changes in cardiac workload or output are not typically

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associated with pericarditis. Emboli formation and changes in cardiac workload or output are not typically associated with pericarditis.

PTS:

CON: Perfusion

32. A postoperative patient suddenly develops dyspnea, tachypnea, restlessness, and chest pain. Which complication should the nurse suspect is occurring in this patient? 1. Pulmonary edema 2. Respiratory arrest 3. Pulmonary embolus 4. Myocardial infarction ANS: 3 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention, complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis. Page: 390 Heading: Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Sudden dyspnea, tachypnea, restlessness, and chest pain are not all associated with pulmonary edema, respiratory arrest, or myocardial infarction. Sudden dyspnea, tachypnea, restlessness, and chest pain are not all associated with pulmonary edema, respiratory arrest, or myocardial infarction. The patient likely has a pulmonary embolus, which is a life-threatening condition and requires prompt medical intervention. Sudden dyspnea, tachypnea, restlessness, and chest pain are not all associated with pulmonary edema, respiratory arrest, or myocardial infarction.

PTS:

CON: Perfusion

33. The nurse caring for patients on the cardiac unit reviews the standards related to DVT prophylaxis. Which approach should the nurse recognize as being the most effective to prevent the development of deep vein thrombosis? 1. Using bilateral thigh-high stockings throughout hospitalization 2. Using low molecular weight heparin given subcutaneously daily 3. Using bilateral leg compression devices while the patient is in bed 4. Using a combination of pharmacological and compression interventions ANS: 4 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders

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Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, prevention, complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis. Page: 396 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

These approaches use single treatment for the prevention of DVT. These approaches use single treatment for the prevention of DVT. These approaches use single treatment for the prevention of DVT. The evidence shows that use of combined treatments for those at high risk for venous thromboembolism is more effective than a single treatment.

PTS:

CON: Perfusion

MULTIPLE RESPONSE 1. The nurse is reviewing the medical histories for a group of patients. Which patients should receive prophylactic antibiotics to prevent infective IE? (Select all that apply.) 1. A 68-year-old with a history of atrial fibrillation scheduled for a root canal 2. A 55-year-old with a history of angina scheduled for arthroscopic knee surgery 3. A 76-year-old with a history of cardiac valve repair scheduled for a colonoscopy 4. A 71-year-old with a history of IE scheduled for a tooth extraction 5. A 69-year-old with a history of congenital heart disease who is having an abscess drained 6. A 56-year-old with a history of mitral valve prolapse scheduled for routine dental cleaning ANS: 3, 4, 5 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for infective endocarditis, pericarditis, and myocarditis. Page: 385 Heading: Pathophysiology and Etiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1.

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IE, a heart transplant with abnormal valve function, or specific congenital heart defects. Prophylaxis for procedures on the genitourinary or gastrointestinal tract or for most people who have orthopedic implants is no longer recommended.

Antibiotic prophylaxis guidelines (AHA/ACC, 2017) recommend prophylactic antibiotics before dental procedures for only the highest risk of individuals who have an artificial heart valve or a valve repaired with artificial material, a history of IE, a heart transplant with abnormal valve function, or specific congenital heart defects. Prophylaxis for procedures on the genitourinary or gastrointestinal tract or for most people who have orthopedic implants is no longer recommended.

PTS:

CON: Perfusion

2. A patient is being admitted to the intensive care unit after cardiac surgery. Which nursing actions should the nurse include in this patient’s plan of care? (Select all that apply.) 1. Note any patient shivering. 2. Assess breath sounds every shift. 3. Assist in head-to-toe data collection. 4. Place the patient in a cool environment. 5. Connect the patient to a cardiac monitor. 6. Palpate chest and neck for signs of crepitus. ANS: 1, 2, 3, 5, 6

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Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 3. Identify postoperative complications that can occur following any type of cardiac valve replacement. Page: 398 Heading: Data Collection Integrated Process: Clinical Problem-Solving Process Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

PTS:

Feedback All actions should be performed for this patient except for placing the patient in a cool environment because the patient will likely be cool from surgery and need warming. All actions should be performed for this patient except for placing the patient in a cool environment because the patient will likely be cool from surgery and need warming. All actions should be performed for this patient except for placing the patient in a cool environment because the patient will likely be cool from surgery and need warming. All actions should be performed for this patient except for placing the patient in a cool environment because the patient will likely be cool from surgery and need warming. All actions should be performed for this patient except for placing the patient in a cool environment because the patient will likely be cool from surgery and need warming. All actions should be performed for this patient except for placing the patient in a cool environment because the patient will likely be cool from surgery and need warming. 1

CON: Perfusion

3. The nurse is caring for a patient with aortic regurgitation. Which clinical manifestations can the nurse expect to document? (Select all that apply.) 1. Forceful heartbeat more pronounced when laying down 2. Exertional dyspnea 3. Fatigue 4. Corrigan pulse 5. Bloody sputum 6. Petechiae ANS: 1, 2, 3, 4 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for each of the valvular disorders. Page: 376

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1. 2. 3. 4. 5. 6. PTS:

Feedback This is a clinical manifestation of aortic regurgitation. This is a clinical manifestation of aortic regurgitation. This is a clinical manifestation of aortic regurgitation. This is a clinical manifestation of aortic regurgitation. This is a clinical manifestation of mitral stenosis. Petechiae is a clinical manifestation of IE. 1

CON: Perfusion

4. A patient with obstructive hypertrophic cardiomyopathy is being released from the hospital and is to continue treatment with atenolol (Tenormin) and disopyramide (Norpace) at home. Which information should be included in the patient’s teaching plan? (Select all that apply.) 1. Eat small meals. 2. Drink fluids to remain hydrated. 3. Plan activities in small amounts. 4. Have one alcoholic drink per day. 5. Participate in sports, such as tennis. 6. Check the pulse daily before taking medications. ANS: 1, 2, 3 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 5. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for dilated, hypertrophic, and restrictive cardiomyopathy. Page: 382 Heading: Nursing Care Integrated Process: Teaching/Learning Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1. 2. 3. 4.

Feedback Scheduling activities in small amounts and providing small meals that require less energy to digest than large meals reduce strain on the heart. Hydration is important to maintain cardiac output. Avoid alcohol as it decreases cardiac function. Scheduling activities in small amounts and providing small meals that require less energy to digest than large meals reduce strain on the heart. Avoid alcohol as it decreases cardiac function.

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5. 6. PTS:

Strenuous exercise and athletic sports are restricted to prevent sudden death. Pulse does not need to be taken with these two medications. 1

CON: Perfusion

5. The nurse is reinforcing discharge teaching to a patient with IE. Which topics will the nurse include in the teaching? (Select all that apply.) 1. Brushing teeth with a soft-bristle toothbrush 2. Avoiding biting nails 3. Avoiding applying ointment to cuts 4. Reporting fever or chills to the HCP 5. Instruction on proper handwashing ANS: 1, 2, 4, 5 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 4. Explain the pathophysiology, etiology, signs, and symptoms, diagnostic tests, therapeutic measures and nursing care for infective endocarditis, pericarditis, and myocarditis. Page: 395 Heading: Nursing Diagnoses, Planning, Implementation, and Evaluation Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5. PTS:

Feedback This topic should be included in the teaching. This topic should be included in the teaching. Ointment should be applied to cuts. This topic should be included in the teaching. This topic should be included in the teaching. 1

CON: Health Promotion

6. The nurse is caring for a patient with thrombophlebitis of the left leg. Which interventions should the nurse implement? (Select all that apply.) 1. Administer acetaminophen (Tylenol) as ordered. 2. Apply ice to the affected area. 3. Encourage the patient to wear constricting clothing. 4. Apply compression stockings per order. 5. Elevate the feet above heart level. ANS: 1, 4, 5 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention, complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis.

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Page: 394 Heading: Nursing Care Plan for the Patient With Thrombophlebitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback This is an appropriate intervention. The nurse should apply heat, not ice. The nurse should encourage loose clothing. This is an appropriate intervention. This is an appropriate intervention.

PTS:

CON: Perfusion

COMPLETION 1. A patient with aortic stenosis experiencing angina and syncope is prescribed 0.25 mg of digoxin (Lanoxin). The nurse has available digoxin, 0.125 mg tablet. How many tablets should the nurse administer to the patient? ANS: 2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 1. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for each of the valvular disorders. Page: 375 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback: 0.25 mg

PTS:

1 tablet 0.125 mg

= 2 tablets

CON: Perfusion

2. The nurse is preparing to administer Heparin 5,000 units SQ to a patient to prevent DVT. The available dose is Heparin 2,500 units/mL. How many mL will the nurse administer? Enter the numeral only. ANS:

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2 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 6. Explain the pathophysiology, etiology, signs and symptoms, prevention, complications, diagnostic tests, therapeutic measures, and nursing care for thrombophlebitis. Page: 395 Heading: Anticoagulant Medications (Table 23.8) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: mL = 1 mL/2,500 units × 5,000 units = 2 mL PTS:

CON: Safety

3. The nurse is preparing to administer Vancomycin 2 mg in 250 mL normal saline IVPB to run over 2 hours. At what rate will the nurse set the infusion pump? Enter the numeral only. ANS: 125 Chapter: Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders Objective: 4. Explain the pathophysiology, etiology, signs and symptoms, diagnostic tests, therapeutic measures, and nursing care for infective endocarditis, pericarditis, and myocarditis. Page: 395 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: mL = 250 mL/2 mg × 2 mg/2 hr = 125 mL/hr PTS:

CON: Safety

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Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders MULTIPLE CHOICE 1. The nurse is caring for a group of patients. Which patient is at highest risk for having a myocardial infarction (MI) at a young age? 1. A 21-year-old male who drinks socially 2. A 20-year-old male who smokes socially and works a high-stress job 3. A 22-year-old female who lives a sedentary lifestyle but follows a low-fat diet 4. A 23-year-old female who smokes and uses oral contraceptives ANS: 4 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 1. Explain the etiologies, signs, symptoms, and therapeutic measures of coronary artery disease, angina pectoris, and myocardial infarction. Page: 401 Heading: Perfusion Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

This patient is not at highest risk for an MI at a young age. This patient is not at highest risk for an MI at a young age. This patient is not at highest risk for an MI at a young age. Females who smoke and take oral contraceptives are at risk for an MI at a young age.

PTS:

CON: Perfusion

2. A patient with peripheral venous disease (PVD) is sitting in a chair and has edematous and purple feet. What action should the nurse to take? 1. Notify the physician. 2. Cover the patient with a blanket. 3. Place the patient’s legs on a tall footstool. 4. Have the patient lie in bed with a pillow under the knees. ANS: 3 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 6. Plan nursing care for patients with peripheral vascular disorders. Page: 424 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion

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Difficulty: Moderate Feedback 1 2 3 4

It is not necessary to notify the physician, as the patient has PVD, unless there is a significant change. The patient’s feet are not purple due to being cold. Placing the patient’s legs on a footstool will increase blood return while the patient is sitting up for short time periods. Placing a pillow under the knees would constrict blood return, further increasing edema.

PTS:

CON: Perfusion

3. The nurse is teaching a class about coronary artery disease and explains atherosclerosis. Which statement made by the patient indicates an understanding of the teaching? 1. “This means my heart isn’t pumping like it should.” 2. “This is an inflammation of the sac around the heart.” 3. “Atherosclerosis is the loss of elasticity and calcification of arterial walls.” 4. “I have plaque in my arteries that can cause coronary artery disease.” ANS: 4 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 1. Explain the etiologies, signs, symptoms, and therapeutic measures of coronary artery disease, angina pectoris, and myocardial infarction. Page: 402 Heading: Atherosclerosis Integrated Process: Teaching/Learning Client Need: PHYS—Physiological Adaptation Cognitive Level: Evaluation (Evaluating) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

This describes heart failure. This describes pericarditis. This describes arteriosclerosis. This accurately describes atherosclerosis. PTS:

CON: Perfusion

4. The nurse is contributing to the teaching plan for a patient who is taking nitroglycerin. Which action should be included if chest pain occurs? 1. Take two tablets every 3 hours for four doses until pain is relieved. 2. Take three tablets every 3 minutes for four doses until pain is relieved. 3. Take one tablet every 5 minutes for three doses until pain is relieved. 4. Take two tablets every 2 minutes for three doses until pain is relieved. ANS: 3 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery disease, angina pectoris, and myocardial infarction.

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Page: 407 Heading: Vasodilators Integrated Process: Teaching/Learning Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

The patient should not be instructed to take more than one nitroglycerin tablet at a time. The patient should not be instructed to take more than one nitroglycerin tablet at a time. The patient should take one tablet every 5 minutes for three doses until pain is relieved. If pain is not relieved, call 911. The patient should not be instructed to take more than one nitroglycerin tablet at a time.

PTS:

CON: Perfusion

5. The nurse is assessing a patient with a myocardial infarction who may receive tissue plasminogen activator [t-PA]. Which question is most important for the nurse to ask? 1. “What time did the chest pain begin?” 2. “Have you received t-PA within the last year?” 3. “Have you taken any nitroglycerin?” 4. “Are you experiencing any nausea?” ANS: 1 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery disease, angina pectoris, and myocardial infarction. Page: 415 Heading: Medications Used to Treat Myocardial Infarction (Table 24.7) Integrated Process: Communication and Documentation Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

The t-PA must be given within 6 hours of the cardiac event, or 90 minutes upon arrival to the emergency room. This question does not determine if the patient receives t-PA. This question does not determine if the patient can receive t-PA. The patient with nausea can still receive t-PA.

PTS:

CON: Perfusion

6. The nurse is teaching a patient about a low-cholesterol diet. Which food choice made by the patient indicates teaching has been effective? 1. Small bowl of oatmeal

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2. 4 ounces of sardines 3. Medium order of fried shrimp 4. 3 ounces of bacon ANS: 1 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery disease, angina pectoris, and myocardial infarction. Page: 406 Heading: Nutrition Notes Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Perfusion Difficulty: Moderate Feedback 1

This food choice indicates an understanding of food low in cholesterol. This food is high in cholesterol. This food is high in cholesterol. This food is high in cholesterol.

2 3 4

PTS:

CON: Perfusion

7. The nurse is assessing a patient who is receiving rosuvastatin (Crestor) to reduce cholesterol. Which finding should concern the nurse? 1. The patient reports black and tarry stools. 2. The patient reports muscle pain. 3. The apical pulse is 58 beats/min. 4. The patient reports feeling dizzy. ANS: 2 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery disease, angina pectoris, and myocardial infarction. Page: 415 Heading: Medications Used to Lower Lipid Levels (Table 24.3) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Statins do not typically cause bleeding. This can be indicative of rhabdomyolysis; the nurse should notify the health care provider (HCP). Statins do not cause bradycardia. Statins do not reduce blood pressure.

PTS:

CON: Perfusion

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8. The nurse is caring for a group of patients. Which patient should the nurse see first? 1. A patient with stable angina reporting chest pain 2. A patient with an aneurysm reporting sudden back pain 3. A patient with varicose veins reporting heaviness in the legs 4. A patient with Raynaud disease reporting white and numb skin ANS: 2 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 5. Explain therapeutic measures used to treat peripheral vascular disorders. Page: 406 Heading: Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Stable angina is not as high of a priority as a rupturing aneurysm. This patient has symptoms of a rupturing aneurysm and should be seen immediately. This is a normal symptom of varicose veins. This is a normal symptom of Raynaud disease.

PTS:

CON: Perfusion

9. The nurse is teaching a patient with an abdominal aortic aneurysm about activity. Which statement made by the patient indicates an understanding of the teaching? 1. “I am starting back to work as a stocker next week.” 2. “I am going to continue my marathon training tomorrow.” 3. “I will walk 20 minutes every other day.” 4. “Instead of taking my car, I will ride my bike.” ANS: 3 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 6. Plan nursing care for patients with a peripheral vascular disorder. Page: 410 Heading: Therapeutic Measures Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Heavy lifting should be avoided. Gentle exercise is okay, but not vigorous activity. This statement indicates understanding. Gentle exercise is encouraged, not vigorous exercise.

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PTS:

CON: Perfusion

10. A patient who develops chest pain says the pain is a 9 on a scale of 0 to 10. Which action should the nurse take? 1. Notify the registered nurse (RN). 2. Apply telemetry. 3. Administer aspirin. 4. Listen to breathing sounds. ANS: 1 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 2. List data to collect for patients with coronary artery disease, angina pectoris, and myocardial infarction. Page: 412 Heading: Nursing Care Plan for the Patient With Myocardial Infarction Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

The RN needs to be informed immediately so the physician can be notified for orders. Telemetry may also be used, but is not the highest priority at this time. Vital signs, oxygen, and nitroglycerin are appropriate interventions; however, administering aspirin is not. Breathing sounds will not clarify the patient’s clinical status because chest pain is a symptom of an acute MI.

PTS:

CON: Perfusion

11. The nurse is teaching a patient with venous stasis ulcers. Which information should the nurse include in the teaching? 1. Encourage the patient to keep legs in a dependent position. 2. Encourage frequent ambulation. 3. Apply compression stockings. 4. Instruct the patient to wear constrictive clothing. ANS: 3 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 6. Plan nursing care for patients with a peripheral vascular disorder. Page: 425 Heading: Therapeutic Measures Integrated Process: Teaching/Learning Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback

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1 2 3 4

The patient should elevate the legs. Bedrest is encouraged; activity is okay during nonacute periods. Compression stockings will prevent edema. The patient should wear loose clothing.

PTS:

CON: Perfusion

12. The nurse is caring for a patient who underwent vascular surgery. During a neurovascular check, the nurse notes the extremity is cool to touch and dusky. Which action should the nurse take? 1. Apply a warm compress to the extremity. 2. Elevate the extremity. 3. Notify the HCP. 4. Document the finding as normal. ANS: 3 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 6. Plan nursing care for patients with a peripheral vascular disorder. Page: 425 Heading: Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

A warm compress should not be applied. The extremity should not be elevated unless instructed to do so by the HCP. The nurse should notify the HCP immediately. This is not a normal finding; the HCP should be notified. PTS:

CON: Perfusion

13. A patient being treated for an acute MI reports severe chest pressure, “as if someone is standing on my chest.” What should the nurse do first? 1. Obtain vital signs. 2. Notify the physician. 3. Administer nitroglycerin. 4. Order an electrocardiogram. ANS: 1 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 2. List data to collect for patients with coronary artery disease, angina pectoris, myocardial infarction. Page: 419 Heading: Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying)

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Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Data collection should be done first and then reported to the physician so that appropriate orders can be obtained. Data collection should be done first and then reported to the physician so that appropriate orders can be obtained. After the physician is notified, additional orders may be provided which may include nitroglycerin or an electrocardiogram. After the physician is notified, additional orders may be provided which may include nitroglycerin or an electrocardiogram.

PTS:

CON: Perfusion

14. The nurse is reviewing laboratory values for a patient with chest pain. Which requires notification of the healthcare provider? 1. Magnesium 2.0 mEq/L 2. Potassium 4.8 mEq/L 3. Troponin 0.70 ng/mL 4. Sodium 140 mEq/L ANS: 3 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 2. List data to collect for patients with coronary artery disease, angina pectoris, or myocardial infarction. Page: 419 Heading: Diagnostic Tests Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

This magnesium level is normal. This potassium level is normal. The troponin is high, indicative of an MI. The sodium level is normal. PTS:

CON: Perfusion

15. The nurse is reinforcing teaching a patient about resuming sexual activity following an MI 3 days ago. Which statement indicates patient understanding? 1. “I will no longer be able to participate in sexual activity.” 2. “Once I can climb two flights of stairs, I should be able to resume sexual activity.” 3. “I can resume sexual activity in 1 to 2 weeks.” 4. “I can resume sexual intercourse now as long as I take a nitroglycerin tablet before.” ANS: 2

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Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery disease, angina pectoris, and myocardial infarction. Page: 426 Heading: Patient Education Integrated Process: Teaching/Learning Client Need: PHYS—Physiological Adaptation Cognitive Level: Evaluation (Evaluating) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

The patient does not have to abstain from sexual activity. This is an accurate statement. One to 2 months, not 1 to 2 weeks is normal for resumption of sexual activity. The patient needs to wait 1 to 2 months or until he or she can climb one to two flights of stairs.

PTS:

CON: Perfusion

16. The nurse is reinforcing teaching provided to a patient with Raynaud disease. Which measure should the nurse include to prevent an attack? 1. Get plenty of outdoor exercise all year. 2. Keep affected body areas covered at all times. 3. Avoid stimulation that causes vasoconstriction. 4. Take vasopressors to prevent exacerbation of symptoms. ANS: 3 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 5. Identify therapeutic measures used to treat peripheral vascular disorders. Page: 427 Heading: Raynaud Disease Integrated Process: Teaching/Learning Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Going out in the cold should be avoided. Wearing gloves is only needed when being exposed to cold. Teach avoiding causes of vasoconstriction, such as smoking, alcohol, caffeine, and reducing stress levels. Vasodilators help avoid peripheral vasoconstriction.

PTS:

CON: Perfusion

17. The nurse is reinforcing teaching provided to a patient with an aneurysm. Which patient statement indicates correct understanding of a dissecting aneurysm? 1. “An outpouching of one side of the arterial wall.” 2. “A communication between an artery and a vein.”

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3. “A separation of the inner layer of the arterial wall.” 4. “An enlargement of the entire circumference of the artery.” ANS: 3 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 4. Explain the etiologies, signs, and symptoms for each of the peripheral vascular disorders. Page: 425 Heading: Aneurysms Integrated Process: Teaching/Learning Client Need: PHYS—Physiological Adaptation Cognitive Level: Evaluation (Evaluating) Concept: Perfusion Difficulty: Moderate Feedback 1

This statement does not explain the mechanism of an aneurysm. This statement does not explain the mechanism of an aneurysm. A dissecting aneurysm is a separation of the inner layer of the arterial wall. This statement does not explain the mechanism of an aneurysm.

2 3 4

PTS:

CON: Perfusion

18. The nurse is collecting data on a patient with varicose veins. What should the nurse document as a subjective finding of varicosities? 1. Ankle edema 2. Purple lesions 3. Aching of legs 4. Palpable nodules ANS: 3 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 4. Explain the etiologies, signs, and symptoms for each of the peripheral vascular disorders. Page: 429 Heading: Signs and Symptoms Integrated Process: Communication and Documentation Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

Ankle edema, purple lesions, and palpable nodules are all observable and can be assessed objectively by the nurse

Ankle edema, purple lesions, and palpable nodules are all observable and can be assessed objectively by the nurse.

The patient’s aching legs are a subjective finding, which is a feeling or

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symptom the patient reports, but may not be seen or observed by the nurse. 4

Ankle edema, purple lesions, and palpable nodules are all observable and can be assessed objectively by the nurse.

PTS:

CON: Perfusion

19. The nurse is assessing a patient with an aneurysm. Which finding should be reported to the RN immediately? 1. The patient reports nausea. 2. The patient reports sudden flank pain. 3. The patient reports feeling full. 4. The patient reports abdominal pain. ANS: 2 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 4. Explain the etiologies, signs, and symptoms for each of the peripheral vascular disorders. Page: 425 Heading: Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Evaluation (Evaluating) Concept: Perfusion Difficulty: Moderate Feedback 1 2

3 4

Nausea can be a symptom of an abdominal aortic aneurysm (AAA), but because it is a vague symptom it is not often associated with an AAA. Back or flank pain is the classic symptom of an abdominal aortic aneurysm (AAA). Sudden back or flank pain should be reported immediately; this is a sign the aneurysm could rupture. Feeling full can be a symptom of an abdominal aortic aneurysm (AAA), but because it is a vague symptom it is not often associated with an AAA. Abdominal pain can be a symptom of an abdominal aortic aneurysm (AAA), but because it is a vague symptom it is not often associated with an AAA.

PTS:

CON: Perfusion

20. The nurse is caring for a patient with lymphangitis. Which interventions should the nurse implement first? 1. Keep the extremity in the dependent position. 2. Apply ice to the extremity as ordered. 3. Prepare the patient for intubation. 4. Administer analgesics as prescribed. ANS: 4 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 6. Plan nursing care for patients with a peripheral vascular disorder.

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Page: 430 Heading: Lymphangitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

The extremity should be elevated. Warm packs will be applied, not ice. There is nothing to indicate the patient is unstable enough to be intubated. Analgesics are administered for comfort.

2 3 4

PTS:

CON: Perfusion

21. The nurse is caring for a patient with an abdominal aortic aneurysm. Which statement indicates that the patient understands this condition? 1. “A blood clot in a vein.” 2. “An incompetent valve in a large vein.” 3. “An outpouching in the wall of an artery.” 4. “A deposit of plaque in the wall of an artery.” ANS: 3 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 4. Explain etiologies, signs, and symptoms for each of the peripheral vascular disorders Page: 425 Heading: Aneurysms Integrated Process: Teaching/Learning Client Need: PHYS—Basic Care and Comfort Cognitive Level: Evaluation (Evaluating) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

An aneurysm is not a blood clot in the vein, an incompetent valve, or a plaque deposit in an arterial wall. An aneurysm is not a blood clot in the vein, an incompetent valve, or a plaque deposit in an arterial wall. An aneurysm is a bulging, ballooning, or dilation at a weakened point of an artery. An aneurysm is not a blood clot in the vein, an incompetent valve, or a plaque deposit in an arterial wall.

PTS:

CON: Perfusion

22. The nurse is collecting data from a patient experiencing an MI. Which finding should the nurse expect? 1. Flushed face 2. Extreme thirst

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3. A moist cough 4. Profuse diaphoresis ANS: 4 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 1. Explain the etiologies, signs, symptoms, and therapeutic measures of coronary artery disease, angina pectoris, myocardial infarction. Page: 416 Heading: Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Facial flushing, thirst, and a moist cough are not manifestations of an acute MI. Facial flushing, thirst, and a moist cough are not manifestations of an acute MI. Facial flushing, thirst, and a moist cough are not manifestations of an acute MI. Symptoms during an MI may include chest pain, shortness of breath, fatigue, weakness, or dizziness caused by decreased blood supply and oxygen to the heart. Other symptoms may include diaphoresis or nausea.

PTS:

CON: Perfusion

23. The nurse is collecting data from a patient who has chronic venous insufficiency of the lower extremities. Which finding should the nurse expect? 1. Leathery, brown skin 2. Diminished pedal pulse 3. Absence of pedal pulses 4. Pallor in the extremities ANS: 1 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 4. Explain the etiologies, signs, and symptoms for each of the peripheral vascular disorders. Page: 425 Heading: Pathophysiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

2 3

In chronic venous insufficiency, dysfunctional valves cause venous stasis, which results in edema and a brownish discoloration of the leg and foot, with the surrounding skin hardened and leathery in appearance. Changes in pulses and pallor are not associated with chronic venous insufficiency. Changes in pulses and pallor are not associated with chronic venous

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insufficiency. Changes in pulses and pallor are not associated with chronic venous insufficiency.

PTS:

CON: Perfusion

24. The nurse is caring for a patient who has long-standing asthma and stable angina. Which medication can the nurse safely provide to the patient? 1. Pindolol (Visken) 2. Nadolol (Corgard) 3. Atenolol (Tenormin) 4. Propranolol (Inderal) ANS: 3 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery disease, angina pectoris, and myocardial infarction. Page: 415 Heading: Medications Used to Treat Angina Pectoris (Table 24.4) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3

The nurse should question before administering this medication. The nurse should question before administering this medication. With asthma or chronic obstructive pulmonary disease, nonselective betaadrenergic blockers are avoided due to bronchoconstriction. Metoprolol and atenolol are more cardioselective and are used with asthma. The nurse should question before administering this medication.

PTS:

CON: Perfusion

25. The physician prescribes nitroglycerin for a patient with anterior MI. The patient’s vital signs are apical pulse 52 beats/min and blood pressure 80/60 mm Hg. What action should the nurse take? 1. Administer the drug as ordered. 2. Report the vital signs to the RN. 3. Recheck vital signs in 30 minutes. 4. Give medication at half the prescribed dose. ANS: 2 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 2. List data to collect for patients with coronary artery disease, angina pectoris, myocardial infarction. Page: 415 Heading: Nursing Care Plan for the Patient With a Myocardial Infarction Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2

3 4

Administering the drug as prescribed would not be safe. The vital signs are low and should be reported to the RN prior to giving medication, as the physician should be notified and will likely give orders to hold the medication Rechecking the vital signs in 30 minutes would be unsafe. Changing a prescribed dose of medication is beyond the nurse’s scope of practice.

PTS:

CON: Perfusion

26. The nurse is assessing a patient who underwent repair for an abdominal aortic aneurysm. Which finding should the nurse report to the RN? 1. Report of level 5 pain on a 0-to-10 scale 2. An increase in abdominal girth 3. Temperature of 98.9°F 4. Urine output of 60 mL/hr ANS: 2 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 6. Plan nursing care for patients with a peripheral vascular disorder. Page: 425 Heading: Nursing Care Plan for the Patient after Vascular Surgery Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

This is normal after surgery; the licensed practical nurse/licensed vocational nurse (LPN/LVN) can administer prescribed medication. An increase in abdominal girth should be reported; this is indicative of abdominal bleeding. The patient is afebrile. The urine output is normal.

PTS:

CON: Perfusion

27. The nurse is teaching a patient about Buerger disease. Which is most important for the nurse to include in the teaching? 1. Avoiding caffeine 2. Smoking cessation 3. Limiting exposure to cold 4. Reducing emotional stress

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ANS: 2 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 4. Explain the etiologies, signs, and symptoms for each of the peripheral vascular disorders. Page: 426 Heading: Buerger Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

This is a teaching topic for Raynaud disease. Cessation of all tobacco products is essential for preventing Buerger disease. This is a teaching topic for Raynaud disease. This is a teaching topic for Raynaud disease. PTS:

CON: Perfusion

28. The nurse is teaching a group of patients about risk factors for heart disease. Which does the nurse identify as a modifiable risk factor? 1. Hypertension 2. Gender 3. Age 4. Ethnicity ANS: 1 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 2. List data to collect for patient with coronary artery disease, angina pectoris, or myocardial infarction. Page: 413 Heading: Risk Factors for Atherosclerosis (Coronary Artery Disease) (Table 24.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension (Understanding) Concept: Perfusion Difficulty: Easy Feedback 1 2 3 4

Hypertension is a modifiable risk factor. Gender is a nonmodifiable risk factor. Age is a nonmodifiable risk factor. Ethnicity is a nonmodifiable risk factor. PTS:

CON: Perfusion

MULTIPLE RESPONSE

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1. The nurse is contributing to the plan of care for a patient experiencing chest pain for 7 hours. The laboratory tests reveal elevated troponin I and myoglobin levels. What action should the nurse take when caring for this patient? (Select all that apply.) 1. Elevate head of bed. 2. Encourage ambulation. 3. Provide rest in bed or chair. 4. Offer regular diet with hot tea. 5. Provide bedpan for elimination. ANS: 3 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery disease, angina pectoris, and myocardial infarction. Page: 416 Heading: Nursing Care Plan for the Patient With Myocardial Infarction Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback Elevating the head of the bed, encouraging ambulation, and offering a regular diet with hot tea would increase strain on the heart. Elevating the head of the bed, encouraging ambulation, and offering a regular diet with hot tea would increase strain on the heart. Rest and providing a bedpan for elimination will reduce the strain on the heart. Elevating the head of the bed, encouraging ambulation, and offering a regular diet with hot tea would increase strain on the heart. Rest and providing a bedpan for elimination will reduce the strain on the heart. 1

CON: Perfusion

2. The nurse is contributing to a patient’s teaching plan. What should be included when teaching a patient about the use of nitroglycerin? (Select all that apply.) 1. Take tablet every morning. 2. Place tablet under the tongue. 3. Rise slowly after taking tablet. 4. Sit or lie down when taking tablet. 5. Take before activity known to cause angina. 6. Have a year’s supply of the medication at home. ANS: 2 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery disease, angina pectoris, and myocardial infarction. Page: 418

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Heading: Medications Used to Treat Angina Pectoris (Table 24.4) Integrated Process: Teaching/Learning Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1. 2.

6. PTS:

Feedback This medication is not taken routinely every morning. The patient should be instructed on how to take the medication sublingually, taking time to rise slowly after taking the medication, to sit or lie down when taking the medication, and to take the medication before an activity known to cause chest pain. The patient should be instructed on how to take the medication sublingually, taking time to rise slowly after taking the medication, to sit or lie down when taking the medication, and to take the medication before an activity known to cause chest pain. The patient should be instructed on how to take the medication sublingually, taking time to rise slowly after taking the medication, to sit or lie down when taking the medication, and to take the medication before an activity known to cause chest pain. The patient should be instructed on how to take the medication sublingually, taking time to rise slowly after taking the medication, to sit or lie down when taking the medication, and to take the medication before an activity known to cause chest pain. The patient needs a 6-month supply of the medication. 1

CON: Perfusion

3. The nurse is teaching a group of patients about stable versus unstable angina. Which should the nurse include in the teaching? (Select all that apply.) 1. Stable angina occurs at rest. 2. Unstable angina is relieved by medication. 3. Pain with stable angina is predictable. 4. Unstable angina can lead to an MI. 5. Angina is caused by a lack of oxygen to the heart. ANS: 3 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 1. Explain the etiologies, signs, symptoms, and therapeutic measures of coronary artery disease, angina pectoris, and myocardial infarction. Page: 415 Heading: Types of Angina Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

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1. 2. 3. 4. 5. PTS:

Feedback Unstable angina occurs at rest. Stable angina is relieved by medication. Pain with stable angina is predictable. Unstable angina can lead to an MI. Angina is caused by lack of oxygen to the heart. 1

CON: Perfusion

COMPLETION 1. The nurse is preparing to administer morphine 6 mg IV to a patient having an MI. Available is morphine 10 mg/mL. How many mL will the nurse administer? Enter the numeral only. ANS: 0.6 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery disease, angina pectoris, and myocardial infarction. Page: 415 Heading: Medications Used to Treat Myocardial Infarction (Table 24.7) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback: mL = 1 mL/10 mg × 6 mg = 0.6 mL PTS:

CON: Perfusion

2. The HCP prescribes enoxaparin (Lovenox) 1 mg/kg to a patient who weighs 80 kg. The available dose is 80 mg/0.8 mL. How many mL will the nurse administer? Enter the numeral only. ANS: 0.8 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery disease, angina pectoris, and myocardial infarction. Page: 415 Heading: Medications Used to Treat Myocardial Infarction (Table 24.7) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate

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Feedback: The dose is the same as the prefilled syringe 80 mg/0.8mL. PTS:

CON: Perfusion

3. The nurse has administered two doses 5 minutes apart of nitroglycerin (Nitrostat) 0.4 mg per dose sublingually. How many milligrams did the patient receive total? Enter the numeral only. ANS: 0.8 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 3. Describe therapeutic measures used to treat coronary artery disease, angina pectoris, and myocardial infarction. Page: 415 Heading: Medications Used to Treat Angina Pectoris (Table 24.4) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback: 0.4 mg × 2 = 0.8 mg PTS:

CON: Perfusion

ORDERED RESPONSE 1. The nurse is caring for a group of patients. Place in order, from the highest to lowest priority (from 1 to 4), the nurse should see patients. 1. A patient receiving enoxaparin (Lovenox) for experiencing an MI 3 days ago 2. A patient with coronary artery disease who reports chest pain radiating to the jaw 3. A patient with peripheral artery disease with a diminished pulse to the right leg 4. A patient with venous insufficiency with 2+ pitting edema ANS: 2, 3, 1, 4 Chapter: Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders Objective: 1. Explain the etiologies, signs, symptoms, and therapeutic measures of coronary artery disease, angina pectoris, and myocardial infarction. Page: 421 Heading: Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate

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Feedback: The patient with symptoms of an MI should be seen first followed by the patient with a diminished pulse. The third patient to be seen should be the patient who had an MI 3 days ago followed by the patient with venous insufficiency with 2+ edema. PTS:

CON: Perfusion

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Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias MULTIPLE CHOICE 1. After reviewing an electrocardiogram, the nurse determines that an electrical impulse originated in a patient’s sinoatrial node. What did the nurse see on this tracing? 1. An upright T wave 2. An inverted T wave 3. A positive P wave before a QRS complex 4. A negative P wave before a QRS complex ANS: 3 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 1. Describe how electrical activity flows through the heart. Page: 437 Heading: Cardiac Conduction System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

This wave does not indicate that the electrical impulse originated in the sinoatrial (SA) node. This wave does not indicate that the electrical impulse originated in the SA node. A positive P wave before a QRS complex indicates that an electrical impulse originated in the SA node. This wave does not indicate that the electrical impulse originated in the SA node. 1

CON: Perfusion

2. The nurse is reinforcing teaching for a patient who has a pacemaker. Which measure should the nurse include when explaining how the pulse should be monitored? 1. Take radial pulse for 1 minute. 2. Take apical pulse for 1 minute. 3. Take jugular pulse for 30 seconds. 4. Take brachial pulse for 30 seconds. ANS: 1 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 6. Plan nursing care for patients with an implanted device. Page: 451 Heading: Nursing Care of Patients With Pacemakers Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying)

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Concept: Perfusion Difficulty: Moderate Feedback 1

2 3 4

PTS:

Patients are taught to take a radial pulse, as it is easier to learn than an apical pulse, for 1 minute and to report if it is five beats over or under the set pacemaker rate It is difficult for a patient to learn how to take his or her own apical pulse. This pulse point is difficult for the patient to learn. This pulse point is difficult for the patient to learn. 1

CON: Perfusion

3. The nurse is sitting at the desk watching the telemetry monitors and notes a patient’s rhythm suddenly shows asystole. Which action should the nurse take first? 1. Start cardiopulmonary resuscitation (CPR). 2. Document the rhythm as normal. 3. Prepare to administer adenosine (Adenocard). 4. Prepare the patient for cardioversion. ANS: 1 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with an arrhythmia. Page: 450 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

When the rhythm reads asystole, CPR is started immediately. When the rhythm reads asystole, CPR is started immediately. When the rhythm reads asystole, CPR is started immediately. When the rhythm reads asystole, CPR is started immediately. 1

CON: Perfusion

4. The nurse is caring for a patient receiving warfarin (Coumadin). Which finding would be of most concern to the nurse? 1. The patient reports blood in the urine. 2. The patient reports nausea. 3. The patient’s apical heart rate is 72 beats/min. 4. The patient has a dry cough. ANS: 1 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 3. Explain current medical treatments for cardiac arrhythmias. Page: 447 Heading: Medications Used in Treatment of Arrhythmias (Table 25.2)

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Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

PTS:

Hematuria indicates the patient may be receiving too much Coumadin. Nausea is not a priority. The heart rate is normal. Dry cough is not the most concerning effect. 1

CON: Safety

5. A patient is diagnosed with ventricular fibrillation. For which emergency intervention should the nurse anticipate preparing? 1. Defibrillation 2. Endotracheal intubation 3. Synchronized cardioversion 4. Cardiopulmonary resuscitation ANS: 1 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with an arrhythmia. Page: 450 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

Defibrillation is the best treatment for ventricular fibrillation to terminate it and increase survival. Endotracheal intubation will ensure oxygenation; however, it will not affect the lethal heart rhythm. Synchronized cardioversion is not indicated for this heart rhythm. CPR may need to be started if defibrillation is not effective. 1

CON: Perfusion

6. The nurse is reviewing the cardiac strip for a patient and notes the following: No identifiable P waves, QRS complex measures 0.06 second and irregular, and heart rate 120 beats/min. The nurse should interpret this as which arrhythmia? 1. Normal sinus rhythm 2. Atrial fibrillation 3. Sinus bradycardia 4. Ventricular fibrillation ANS: 2

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Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 2. List the six steps used for arrhythmia interpretation. Page: 447 Heading: Atrial Fibrillation Rules Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

This describes atrial fibrillation. This describes atrial fibrillation. This describes atrial fibrillation. This describes atrial fibrillation. 1

CON: Perfusion

7. The nurse is reinforcing teaching for a patient with premature ventricular contractions (PVCs) and is being discharged. Which lifestyle recommendation should be the most important for the nurse to include? 1. “It is important for you to drink decaffeinated beverages.” 2. “You should increase the amount of exercise you do each day.” 3. “It is important for you to reduce the amount of fat in your diet.” 4. “Weight gain and fluid retention are likely causing your abnormal heart rhythm.” ANS: 1 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with an arrhythmia. Page: 448 Heading: Therapeutic Measures Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

The ingestion of caffeine is a common cause of PVCs. The patient should be instructed to avoid caffeine. Exercise, dietary fat, body weight, and fluid level are not identified as causes for PVCs. Exercise, dietary fat, body weight, and fluid level are not identified as causes for PVCs. Exercise, dietary fat, body weight, and fluid level are not identified as causes for PVCs. 1

CON: Perfusion

8. The nurse is caring for a patient who develops sinus tachycardia. What action should the nurse take?

NURSING TEST BANK

1. 2. 3. 4.

Inform the registered nurse (RN) promptly. Turn the patient onto the left side. Recheck vital signs in 15 minutes. Have the patient cough forcefully.

ANS: 1 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with an arrhythmia. Page: 442 Heading: Sinus Tachycardia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

Inform the RN promptly so the physician can be notified immediately for treatment. Turning the patient onto the left side will not alter the patient’s rhythm. Waiting 15 minutes to recheck vital signs is unsafe for the patient. Coughing forcefully will not alter the patient’s rhythm. 1

CON: Perfusion

9. The nurse is reinforcing teaching for a patient who has had a pacemaker implanted in the right side of the chest. Which patient statement indicates correct understanding of the discharge teaching? 1. “I may lift 20 pounds safely.” 2. “I may move my arm freely.” 3. “I may resume normal activity in 1 week.” 4. “Grounded microwave ovens may be safely used.” ANS: 4 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 6. Plan nursing care for patients with an implanted device. Page: 451 Heading: Cardiac Pacemakers Integrated Process: Teaching/Learning Client Need: PHYS—Basic Care and Comfort Cognitive Level: Evaluation (Evaluating) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3

The patient is going to have activity, limb movement, and weight-lifting restrictions after the insertion of a pacemaker. The patient is going to have activity, limb movement, and weight-lifting restrictions after the insertion of a pacemaker. The patient is going to have activity, limb movement, and weight-lifting restrictions after the insertion of a pacemaker.

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PTS:

Grounded microwave ovens may be safely used around pacemakers, which are now encased for protection. 1

CON: Perfusion

10. The nurse is caring for a patient in respiratory acidosis who also had a myocardial infarction (MI). For which rhythm should the nurse assess? 1. Ventricular fibrillation 2. Atrial fibrillation 3. Ventricular tachycardia 4. Atrial flutter ANS: 3 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with an arrhythmia. Page: 445 Heading: Etiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

Patients with respiratory acidosis and an MI are at risk for ventricular tachycardia. Patients with respiratory acidosis and an MI are at risk for ventricular tachycardia. Patients with respiratory acidosis and an MI are at risk for ventricular tachycardia. Patients with respiratory acidosis and an MI are at risk for ventricular tachycardia. 1

CON: Perfusion

11. A patient is experiencing palpitations that are found to be PVCs. Which manifestation should the nurse expect to observe in this patient? 1. Headache 2. Confusion 3. Lightheadedness 4. Tingling of extremities ANS: 3 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with an arrhythmia. Page: 448 Heading: Premature Ventricular Contractions Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying)

NURSING TEST BANK

Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

Headache, confusion, and tingling extremities are not manifestations of PVCs. Headache, confusion, and tingling extremities are not manifestations of PVCs. Lightheadedness is a manifestation of PVCs. Headache, confusion, and tingling extremities are not manifestations of PVCs. 1

CON: Perfusion

12. The nurse is caring for a group of patients. Which patient is at risk for developing premature atrial contractions (PACs)? 1. A 40-year-old smoker who takes digoxin (Lanoxin) 2. A 50-year-old who occasionally drinks alcohol who takes atenolol (Tenormin) 3. A 60-year-old with sinus tachycardia who takes diltiazem (Cardizem) 4. A 70-year-old with atrial flutter who metoprolol succinate (Lopressor) ANS: 1 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with an arrhythmia. Page: 445 Heading: Etiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

Smoking and digoxin (Lanoxin) places a patient at risk for PACs. This patient is not at risk for PACs. This patient is not at risk for PACs. This patient is not at risk for PACs. 1

CON: Perfusion

13. The nurse observes two PACs in 1 minute on a patient’s cardiac monitor. The patient is asymptomatic. What action is required by the nurse? 1. Administer digoxin (Lanoxin). 2. Notify the physician. 3. Continue monitoring the patient. 4. Take vital signs every 15 minutes. ANS: 3 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with an arrhythmia Page: 445 Heading: Premature Atrial Contractions Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation

NURSING TEST BANK

Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

It is not necessary to take the other actions at this time. It is not necessary to take the other actions at this time. PACs are usually not dangerous, and often no treatment is required other than correcting the cause if they are frequent, so continue to monitor the patient. It is not necessary to take the other actions at this time. 1

CON: Perfusion

14. The nurse is reviewing laboratory results for a patient receiving warfarin (Coumadin) and notes the international normalized ratio (INR) is 6.2. Which medication should the nurse prepare to administer? 1. Adenosine (Adenocard) 2. Lidocaine (Xylocaine) 3. Vitamin K 4. Atropine sulfate ANS: 3 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 3. Explain current medical treatments for cardiac arrhythmias. Page: 447 Heading: Medications Used in Treatment of Arrhythmias (Table 25.2) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

This medication is not the reversal agent for Coumadin. This medication is not the reversal agent for Coumadin. Vitamin K is the reversal agent for Coumadin. This medication is not the reversal agent for Coumadin. 1

CON: Perfusion

15. The nurse is reading a cardiac monitor of a patient and observes a regular rhythm, a flutter of P waves with a sawtooth pattern, QRS interval 0.08 second, and an atrial rate of 300 beats/min. The nurse recognizes this as which arrhythmia? 1. Atrial fibrillation 2. Atrial flutter 3. Sinus tachycardia 4. Ventricular tachycardia ANS: 2 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with arrhythmia.

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Page: 445 Heading: Atrial Flutter Rules Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

This describes atrial flutter. This describes atrial flutter. This describes atrial flutter. This describes atrial flutter. 1

CON: Perfusion

16. The nurse is preparing to administer digoxin (Lanoxin). The nurse assesses the apical pulse and notes a rate of 54 beats/min. Which action should the nurse take? 1. Notify the health care provider (HCP). 2. Prepare to administer atropine sulfate. 3. Administer the medication. 4. Withhold the medication. ANS: 1 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with an arrhythmia. Page: 452 Heading: Medications Used in Treatment of Arrhythmias (Table 25.2) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

The HCP should be notified of the low heart rate. The HCP should be notified to receive any further orders. The heart rate is low; the medication should not be administered without notifying the HCP. The medication should not be held without notifying the HCP. 1

CON: Perfusion

17. The nurse notices that the ST segment is depressed on a patient reporting chest pain. What action should the nurse take? 1. Review the electrocardiogram (ECG) recordings in the patient’s chart. 2. Auscultate chest sounds and continue physical assessment. 3. Alert the supervising RN and patient’s physician immediately. 4. Continue to monitor the ECG to determine if ST segment depression continues.

NURSING TEST BANK

ANS: 3 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with an arrhythmia. Page: 439 Heading: ST Segment Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3

PTS:

Reviewing the ECG recordings in the patient’s chart is wasting valuable time. Auscultating chest sounds and other physical assessment parameters is wasting time. The nurse should alert the supervising RN and patient’s physician immediately as the ST segment depression indicates cardiac ischemia. The patient requires prompt treatment to prevent complications. Continuing to monitor the cardiac tracing could lead to a potentially lethal situation. 1

CON: Perfusion

18. The nurse is caring for a group of patients on the telemetry unit. Which patient should the nurse see first? 1. A patient with sinus bradycardia with a heart rate of 58 beats/min 2. A patient with sinus tachycardia with a heart rate of 104 beats/min 3. A patient with premature atrial contractions who is asymptomatic 4. A patient with atrial fibrillation reporting dyspnea ANS: 4 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with an arrhythmia. Page: 439 Heading: Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

There is nothing indicating this patient is unstable. There is nothing indicating this patient is unstable. There is nothing indicating this patient is unstable. This patient is reporting dyspnea and should be seen first. 1

CON: Perfusion

19. The nurse is conducting a community health screening. Which individual should the nurse recognize as being the highest risk for atrial fibrillation?

NURSING TEST BANK

1. 2. 3. 4.

A 44-year-old obese male with asthma A 62-year-old male smoker with a history of rheumatic heart disease A 56-year-old female with diabetes who has elevated cholesterol levels A 68-year-old female with Parkinson disease who takes carbidopa-levodopa (Sinemet)

ANS: 2 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with an arrhythmia. Page: 446 Heading: Etiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2

3 4

PTS:

Asthma, elevated cholesterol levels, and Parkinson disease do not increase the risk of developing atrial fibrillation. A history of cigarette smoking raises the risk of developing atrial fibrillation even after quitting. Other causes of atrial fibrillation include aging (increases after age 60 and is the most common sustained dysrhythmia), rheumatic or ischemic heart diseases, heart failure, hypertension, pericarditis, pulmonary embolism, and postoperative coronary artery bypass surgery. Medications can also cause this dysrhythmia. Asthma, elevated cholesterol levels, and Parkinson disease do not increase the risk of developing atrial fibrillation. Asthma, elevated cholesterol levels, and Parkinson disease do not increase the risk of developing atrial fibrillation. 1

CON: Perfusion

20. The nurse is reviewing orders for a patient and notes an order for epinephrine. Which medication in the patient’s history should cause the nurse to question this order? 1. Propranolol (Inderal) 2. Amlodipine (Norvasc) 3. Lisinopril (Prinivil) 4. Verapamil (Calan) ANS: 1 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 3. Explain current medical treatments for cardiac arrhythmias. Page: 444 Heading: Medications Used in Treatment of Arrhythmias (Table 25.2) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback

NURSING TEST BANK

1 2 3 4

PTS:

Nonselective beta blockers are contraindicated with epinephrine. This is a calcium channel blocker and is not contraindicated. This is an ace inhibitor and is not contraindicated. This is a calcium channel blocker and is not contraindicated. 1

CON: Perfusion

21. The nurse is reviewing laboratory results for a patient with ventricular fibrillation. The nurse should anticipate which finding? 1. Sodium 140 mEq/L 2. Magnesium 1.7 mEq/L 3. Calcium 9.1 mg/dL 4. Potassium 7.8 mEq/L ANS: 4 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with an arrhythmia. Page: 448 Heading: Etiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

The sodium level is normal. The magnesium level is normal. The calcium level is normal. Hyperkalemia is known to cause ventricular fibrillation. 1

CON: Perfusion

22. A patient recovering from an acute MI has a heart rate of 30 beats/min. Which area of the heart should the nurse consider as pacing this patient’s heart rate? 1. SA node 2. Ventricular rate 3. Aortic valve rate 4. Atrioventricular (AV) node ANS: 2 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 1. Describe how electrical activity flows through the heart. Page: 452 Heading: Cardiac Conduction System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

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Feedback 1 2 3 4

PTS:

The SA node is the primary pacemaker of the heart and normally fires at a rate of 60 to 100 beats/min. The ventricular rate is 20 to 40 beats/min. The aortic valve does not have a mechanism to provide heart pacing. The AV node has an inherent rate of 40 to 60 beats/min. 1

CON: Perfusion

23. The nurse is interpreting a cardiac strip. The strip reveals a regular QRS complex and regular P wave. The PR interval is 0.16 second and the QRS complex measures 0.06 second. The patient’s heart rate is 62 beats/min. Which is the correct interpretation of this rhythm? 1. Sinus bradycardia 2. Atrial flutter 3. Normal sinus rhythm 4. Atrial fibrillation ANS: 3 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 2. List the six steps used for arrhythmia interpretation. Page: 441 Heading: Normal Sinus Rhythm Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PTS:

This describes normal sinus rhythm. This describes normal sinus rhythm. This describes normal sinus rhythm. This describes normal sinus rhythm. 1

CON: Perfusion

MULTIPLE RESPONSE 1. The nurse is reinforcing discharge teaching for a patient who has had a permanent pacemaker inserted. What is important for the nurse to include? (Select all that apply.) 1. Patient should avoid all grounded appliances. 2. Patient should wear medical alert identification. 3. Patient should avoid magnetic fields and high voltage. 4. Patient should avoid lifting anything more than 10 pounds. 5. Patient may return to normal activities, including sports, in 3 weeks. 6. Patient should report dizziness, irregular heartbeats, and palpitations. ANS: 2, 3, 4, 6 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 6. Plan nursing care for patients with an implanted device.

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Page: 451 Heading: Cardiac Pacemakers Integrated Process: Teaching/Learning Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1. 2.

5. 6.

PTS:

Feedback Grounded appliances are not a hazard. The patient should wear medical alert identification; report symptoms such as dizziness, irregular heartbeats, and palpitations; avoid magnetic fields and high voltage; and avoid lifting more than 10 pounds. The patient should wear medical alert identification; report symptoms such as dizziness, irregular heartbeats, and palpitations; avoid magnetic fields and high voltage; and avoid lifting more than 10 pounds. The patient should wear medical alert identification; report symptoms such as dizziness, irregular heartbeats, and palpitations; avoid magnetic fields and high voltage; and avoid lifting more than 10 pounds. Normal activity is resumed after 6 weeks, including sports. The patient should wear medical alert identification; report symptoms such as dizziness, irregular heartbeats, and palpitations; avoid magnetic fields and high voltage; and avoid lifting more than 10 pounds. 1

CON: Perfusion

2. The nurse is caring for a patient with failure of the SA node and the AV node is unable to initiate an impulse. The ventricular rate ranges from 20 to 40 beats/min. Which clinical manifestations can the nurse expect to document? (Select all that apply.) 1. Dyspnea 2. Decreased level of consciousness 3. Syncope 4. Energetic 5. Chest pain ANS: 1, 2, 3, 5 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with an arrhythmia. Page: 445 Heading: Cardiac Conduction System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Evaluation (Evaluating) Concept: Perfusion Difficulty: Moderate

1. 2.

Feedback This is a sign of low ventricular rate. This is a sign of low ventricular rate.

NURSING TEST BANK

3. 4. 5. PTS:

This is a sign of low ventricular rate. This is not a sign of low ventricular rate. This is a sign of low ventricular rate. 1

CON: Perfusion

3. The nurse is caring for a patient recovering from cardioversion. For what should the nurse monitor in this patient? (Select all that apply.) 1. Skin burns 2. Blood pressure 3. Sensory disturbances 4. Respiratory problems 5. Rhythm disturbances 6. Changes in ST segment ANS: 1, 2, 4, 5, 6 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 5. Plan nursing care for patients with an arrhythmia. Page: 453 Heading: Cardioversion Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1. 2. 3. 4. 5. 6.

PTS:

Feedback The nurse should monitor for skin burns, blood pressure, respiratory problems, rhythm disturbances, and changes in the ST segment. The nurse should monitor for skin burns, blood pressure, respiratory problems, rhythm disturbances, and changes in the ST segment. It is unlikely that the patient will experience sensory disturbances after cardioversion. The nurse should monitor for skin burns, blood pressure, respiratory problems, rhythm disturbances, and changes in the ST segment. The nurse should monitor for skin burns, blood pressure, respiratory problems, rhythm disturbances, and changes in the ST segment. The nurse should monitor for skin burns, blood pressure, respiratory problems, rhythm disturbances, and changes in the ST segment. 1

CON: Perfusion

ORDERED RESPONSE 1. Place in order, from 1 to 6, the six-step process for arrhythmia interpretation. 1. QRS interval 2. P waves 3. Heart rate

NURSING TEST BANK

4. 5. 6.

Regularity of the rhythm PR Interval QT interval

ANS: 4, 3, 2, 5, 1, 6 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 2. List the six steps used for arrhythmia interpretation. Pages: 439–441 Heading: Six-Step Process for Arrhythmia Interpretation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback: The six steps of arrhythmia interpretation include the following: (1) Regularity of rhythm, (2) heart rate, (3) P waves, (4) PR interval, (5) QRS interval, and (6) QT interval. PTS:

CON: Perfusion

2. Place in order, from 1 to 5, the sequence for normal electrical impulse movement through the cardiac conduction system. 1. Internodal tracts 2. SA node 3. AV node 4. Purkinje fibers 5. Bundle of His ANS: 2, 1, 3, 5, 4 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 1. Explain how electrical activity flows through the heart. Page: 440 Heading: Cardiac Conduction System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Difficult Feedback: The electrical pathway is SA node, intermodal tracts, AV node, bundle of His, and Purkinje fibers. PTS:

CON: Perfusion

COMPLETION

NURSING TEST BANK

1. The nurse is preparing to administer atropine sulfate (Atropine) 2 mg IV. Available vials are 0.4 mg/mL. How many mL will the nurse administer? Enter the numeral only. ANS: 2.5 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 3. Explain current medical treatments for cardiac arrhythmias. Page: 430 Heading: Medications Used in Treatment of Arrhythmias (Table 25.2) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback: mL = 1 mL/0.4 mg × 1 mg = 2.5 mL PTS:

CON: Perfusion

2. The nurse is preparing to administer adenosine (Adenocard) 6 mg IV. Available is 6 mg/2 mL. How many mL will the nurse administer? Enter the numeral only. ANS: 2 Chapter: Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias Objective: 3. Explain current medical treatments for cardiac arrhythmias. Page: 432 Heading: Medications Used in Treatment of Arrhythmias (Table 25.2) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback: mL = 2 mL/6 mg × 6 mg = 2 mL PTS:

CON: Perfusion

NURSING TEST BANK

Chapter 26. Nursing Care of Patients With Heart Failure MULTIPLE CHOICE 1. The nurse is caring for a group of patients. Which patient is at highest risk for developing heart failure? 1. An African American female with hypertension 2. An Asian male with liver disease 3. A Hispanic female with renal failure 4. A Caucasian male with atrial fibrillation ANS: 1 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 3. List causes of acute and chronic heart failure. Page: 458 Heading: Overview of Heart Failure Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

This patient is African American, female, and has hypertension, which are three risk factors for developing heart failure. This patient is not at high risk for heart failure. This patient is not at risk for heart failure. This patient is at risk, but not at highest risk.

PTS:

CON: Perfusion

2. The nurse is caring for a patient with pulmonary edema. The nurse should place the patient in which position? 1. Right side-lying 2. Trendelenburg’s 3. Fowler’s 4. Prone ANS: 3 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 7. Plan nursing care for acute and chronic heart failure. Page: 460 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

NURSING TEST BANK

Feedback 1 2 3 4

The patient should be placed in semi-Fowler’s or Fowler’s position, not rightside lying position. The patient should be placed in semi-Fowler’s or Fowler’s position, not Trendelenburg’s. The patient should be placed in semi-Fowler’s or Fowler’s position. The patient should be placed in semi-Fowler’s or Fowler’s position, not prone.

PTS:

CON: Perfusion

3. A patient is receiving digoxin (Lanoxin) daily. Which symptom should the nurse report for follow-up related to the digoxin? 1. Anorexia 2. Constipation 3. Skin flushing 4. Blood pressure 118/68 mm Hg ANS: 1 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 6. Explain medication treatments used for acute and chronic heart failure. Page: 474 Heading: Medications Used for Heart Failure (Table 26.5) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Anorexia is a symptom of digoxin toxicity. A digoxin level should be done, and digoxin held until the results are reviewed by the physician. This finding does not indicate digoxin toxicity. This finding does not indicate digoxin toxicity. This finding does not indicate digoxin toxicity.

PTS:

CON: Perfusion

4. A patient with heart failure is prescribed bedrest, but becomes angry and walks to the bathroom independently to use the commode. How should the nurse handle this situation? 1. Obtain a bedside commode. 2. Walk the patient to the bathroom. 3. Obtain a bedpan for the patient to use. 4. Call for help while holding the patient in bed. ANS: 1 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 7. Plan nursing care for acute and chronic heart failure. Page: 473 Heading: Rest and Activity Integrated Process: Clinical Problem-Solving Process (Nursing Process)

NURSING TEST BANK

Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

A bedside commode can ensure for the patient’s safety, puts less strain on the heart than using a bedpan, and maintains the bedrest order. This action would not support the order for bedrest. A bedpan puts strain on the heart. The nurse cannot restrain the patient in bed.

PTS:

CON: Safety

5. The nurse is reviewing laboratory results for a newly admitted patient. Which result should be of most concern to the nurse? 1. B-type natriuretic peptide (BNP) 900 pg/mL 2. Thyroid-stimulating hormone (TSH) 3.2 mµ/L 3. Blood urea nitrogen (BUN) 18 mg/dL 4. Sodium 138 mEq/L ANS: 1 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Page: 465 Objective: 5. Plan nursing care for patients undergoing diagnostic tests for heart failure. Heading: Diagnostic Tests Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

The BNP is very high. Normal range is less than 100 pg/mL. The TSH is normal. Normal range is 0.4 to 4.9 mµ/L. The BUN is normal. Normal range is 7 to 20 mg/dL. The sodium level is normal. Normal range is 135 to 145 mEq/L. PTS:

CON: Perfusion

6. The nurse is caring for a group of patients. Which patient should the nurse see first? 1. A patient with a sodium level of 137 mEq/L 2. A patient with urine output of 50 mL/hr 3. A patient with an elevated BNP level 4. A patient with sudden onset of confusion ANS: 4 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 7. Plan nursing care for acute and chronic heart failure.. Page: 465 Heading: Oxygen Therapy

NURSING TEST BANK

Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1

This is a normal sodium level. This is a normal urine output. This is an expected finding in a patient with heart failure. This patient has symptoms of decreased oxygenation and should be seen first.

2 3 4

PTS:

CON: Perfusion

7. The nurse is caring for a patient and notes the patient is coughing up pink, frothy sputum. Which action should the nurse take? 1. Document the finding as normal. 2. Encourage the patient to drink more fluids. 3. Notify the health care provider (HCP). 4. Instruct the patient to ambulate frequently. ANS: 3 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 4. Identify signs and symptoms of acute and chronic heart failure. Page: 462 Heading: Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

This is not a normal finding. The patient is exhibiting signs of pulmonary edema; drinking more fluids will not help. The HCP should be notified immediately; this is a sign of pulmonary edema. The patient should not ambulate unless instructed to do so by the HCP.

PTS:

CON: Perfusion

8. The HCP informs the licensed practical nurse/licensed vocational nurse (LPN/LVN) that the patient has stage 3 heart failure. The patient asks what this means. Which explanation by the nurse is most appropriate? 1. “This means you are at risk for heart failure.” 2. “This means you have no symptoms of heart failure but structural disease.” 3. “This means you have heart failure with reduced ejection fraction and symptoms.” 4. “This means you have refractory heart failure, which requires extraordinary support of hospice care.” ANS: 3

NURSING TEST BANK

Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 1. Describe the pathophysiology of left- and right-heart failure. Page: 466 Heading: Medication Therapy Integrated Process: Communication and Documentation Client Need: PHYS—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

This describes stage 1. This describes stage 2. This describes stage 3. This describes stage 4.

2 3 4

PTS:

CON: Perfusion

9. The nurse is reinforcing teaching for a patient being discharged home on captopril (Capoten). Which statement made by the patient indicates an understanding of the teaching? 1. “I should take the first doses in the morning so I don’t get dizzy.” 2. “I will check my heart rate and blood pressure before taking the medication.” 3. “I cannot take this medication with any other medication.” 4. “I will weigh myself daily and monitor urine output.” ANS: 2 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 6. Explain medical treatments used for acute and chronic heart failure. Page: 466 Heading: Medications Used for Heart Failure Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Evaluation (Evaluating) Concept: Perfusion Difficulty: Moderate Feedback 1 2

3 4

The first doses should be taken at night. The patient should check her heart rate and blood pressure before taking the medication, and report a heart rate of less than 60 and a systolic BP less than 100 mm Hg. This medication may be taken with other medications. It is not necessary to monitor daily weights and input and output while on this medication.

PTS:

CON: Perfusion

10. A patient with heart failure has clavicle muscle retractions, nostril flaring, and labored breathing. Vital signs are blood pressure 162/84 mm Hg, pulse 120 beats/min, and respirations 32/min. Which patient data requires immediate action?

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1. 2. 3. 4.

Quiet, shallow respirations Jaw jutting forward to inhale Leaning on the over-bed table Use of neck accessory muscles

ANS: 1 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 4. Identify signs and symptoms of acute and chronic heart failure. Page: 464 Heading: Nursing Care Plan for the Patient With Chronic Heart Failure Integrated Process: Clinical Problem Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

2 3 4

As the body is less able to compensate for decreased cardiac output, respirations will slow and become shallow. This patient is in serious difficulty and would need immediate treatment to survive. These are signs of the body working to compensate and provide more oxygen. These are signs of the body working to compensate and provide more oxygen. These are signs of the body working to compensate and provide more oxygen.

PTS:

CON: Perfusion

11. During a visit to the home of a patient with heart failure and diabetes, the nurse learns that the patient “feels strange.” Data collected includes blood pressure 172/94 mm Hg, pulse 112 beats/min, respirations 22/min, heart rhythm regular, and coarse crackles in lower lung bases. What action should the nurse take? 1. Consult the registered nurse (RN). 2. Give the patient orange juice. 3. Assist patient to bed for a nap. 4. Recheck vital signs in 30 minutes. ANS: 1 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 7. Plan nursing care for acute and chronic heart failure. Page: 464 Heading: Nursing Care Plan for the Patient With Chronic Heart Failure Integrated Process: Clinical Problem Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

The RN or supervisor should be consulted immediately so that the patient’s symptoms of heart failure, which could progress to pulmonary edema, can be treated. The physician will then be contacted for treatment orders. There is no evidence that orange juice is needed.

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3 4

There is no evidence that the patient is fatigued, and waiting to reassess vital signs in 30 minutes could be dangerous for the patient. There is no evidence that the patient is fatigued, and waiting to reassess vital signs in 30 minutes could be dangerous for the patient.

PTS:

CON: Perfusion

12. A patient with a potassium level of 3.0 mEq/L is to receive furosemide (Lasix) 20 mg by mouth. What action should the nurse take? 1. Give the Lasix 30 minutes early. 2. Give the Lasix as scheduled now. 3. Consult the RN before giving Lasix. 4. Hold this scheduled dose of the Lasix. ANS: 3 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 6. Explain medical treatments used for acute and chronic heart failure. Page: 465 Heading: Medications Used for Heart Failure Integrated Process: Clinical Problem Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3

This action should not be done before consulting with the RN. This action should not be done before consulting with the RN. Furosemide (Lasix) is a potassium-wasting diuretic. The potassium level is low, so the Lasix should not be given, and the RN or physician should be notified of the potassium level for further orders. This action should not be done before consulting with the RN.

PTS:

CON: Perfusion

13. The nurse is reviewing orders for a patient and notes the patient is prescribed valsartan/sacubitril (Entresto). Which medication in the patient’s medication history would lead the nurse to seek clarification before administering the Entresto? 1. Bumetanide (Bumex) 2. Lanoxin (Digoxin) 3. Metoprolol succinate (Toprol XL) 4. Enalapril (Vasotec) ANS: 4 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 6. Explain medical treatments used for acute and chronic heart failure. Page: 466 Heading: Medications Used for Heart Failure (Table 26.5) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies

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Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

This is not contraindicated with an angiotensin receptor neprilysin inhibitor (ARNi). This is not contraindicated with an angiotensin receptor neprilysin inhibitor (ARNi). This is not contraindicated with an angiotensin receptor neprilysin inhibitor (ARNi). Enalapril (Vasotec) is an ACE inhibitor which is contraindicated with angiotensin receptor neprilysin inhibitors (ARNis).

PTS:

CON: Safety

14. The nurse is assessing a patient who underwent cardiac surgery. Which finding warrants a phone call to the HCP? 1. The nurse notes 80 mL of drainage in the chest tube collection chamber. 2. The patient reports level 4 and dull incision pain. 3. The nurse notes 240 mL of clear yellow urine after 2 hours. 4. The patient has a cough producing yellow-green sputum. ANS: 4 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 7. Plan nursing care for acute and chronic heart failure. Page: 477 Heading: Nursing Care Plan for the Postoperative Patient Undergoing Cardiac or Transplant Surgery Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

This is normal output for a chest tube after surgery. Pain is normal after surgery. This is normal urine output. This can be indicative of an infection. PTS:

CON: Perfusion

15. The nurse is auscultating the lungs of a patient with heart failure. Which can the nurse expect to document? 1. Pericardial rub 2. Stridor 3. Crackles 4. Rhonchi ANS: 3

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Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 4. Identify signs and symptoms of acute and chronic heart failure. Page: 458 Heading: Crackles and Wheezes Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Comprehension (Understanding) Concept: Perfusion Difficulty: Moderate Feedback 1

Pericardial rub is not auscultated with heart failure. Stridor is not auscultated in heart failure. Crackles are auscultated in heart failure. Rhonchi are not common in heart failure.

2 3 4

PTS:

CON: Perfusion

16. During a home visit, the nurse learns that a patient with chronic heart failure is planning to quit cardiac rehabilitation because of the fear of dying while on the treadmill. Which response by the nurse is best? 1. “I don’t blame you for feeling frustrated, I hate to exercise too.” 2. “People don’t die on the treadmill; it’s to make your heart stronger.” 3. “It sounds like you want to give up. I’ll call the doctor and have you transferred to the hospice program.” 4. “You sound upset. Did you know research shows that cardiac rehab programs give people better medical outcomes and a higher quality of life?” ANS: 4 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 8. Plan teaching for patients with heart failure and their families. Page: 460 Heading: Nursing Care Plan for the Patient With Chronic Heart Failure Integrated Process: Teaching/Learning Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Therapeutic responses should focus on the patient, use open-ended statements, and provide education when possible. Therapeutic responses should focus on the patient, use open-ended statements, and provide education when possible. Therapeutic responses should focus on the patient, use open-ended statements, and provide education when possible. Cardiac rehabilitation programs for patients with chronic heart failure have been shown to improve quality of life. In a randomized controlled study of 123 medically stable heart failure patients over 10 years, exercise training demonstrated improved functional capacity and quality of life over patients who did not exercise regularly.

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PTS:

CON: Perfusion

17. The nurse is teaching a patient who is receiving information about food choices high in potassium. Which food choice made by the patient indicates an understanding of the teaching? 1. 1 cup of spaghetti noodles 2. 1 large baked potato 3. 1/2 cup of rice 4. Two slices of white bread ANS: 2 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 7. Plan teaching for patients with heart failure and their families. Page: 466 Heading: Medications Used for Heart Failure (Table 26.5) Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Evaluation (Evaluating) Concept: Nutrition Difficulty: Moderate Feedback 1

This food is low in potassium. This food is high in potassium and indicates a good food choice. This food is low in potassium. This food is low in potassium.

2 3 4

PTS:

CON: Nutrition

18. The nurse is teaching a patient about prevention of paroxysmal nocturnal dyspnea. Which topic should the nurse include in the teaching? 1. Sleep in the prone position. 2. Sleep on the right side. 3. Lay flat with legs elevated. 4. Use three pillows to sleep upright. ANS: 4 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 7. Plan nursing care for acute and chronic heart failure. Page: 459 Heading: Dyspnea Integrated Process: Teaching/Learning Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1

The patient should not sleep in the prone position.

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The patient should not sleep on the right side. The patient should not lay flat in bed. The patient should use two or more pillows to sleep upright.

3 4

PTS:

CON: Perfusion

MULTIPLE RESPONSE 1. As part of discharge teaching, the nurse is instructing a patient on the use of digoxin (Lanoxin). What should be included in the teaching? (Select all that apply.) 1. Report if a persistent cough occurs. 2. Change position quickly to avoid orthostatic hypotension. 3. Take medication exactly as directed at the same time each day. 4. Report blurred vision, photophobia, or seeing yellowish green halos. 5. Take pulse before taking medication and if below 60 or above 100, call the physician. ANS: 3, 4, 5 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 6. Explain medical treatments used for acute and chronic heart failure. Page: 467 Heading: Medications Used for Heart Failure (Table 26.5) Integrated Process: Teaching/Learning Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback A persistent cough occurs with angiotensin-converting enzyme inhibitor medications. Orthostatic hypotension is a concern with medications that affect blood pressure, not digoxin. Pulse rate should be taken and vision changes reported, as they indicate toxicity, and medication should be taken as directed. Pulse rate should be taken and vision changes reported, as they indicate toxicity, and medication should be taken as directed. Pulse rate should be taken and vision changes reported, as they indicate toxicity, and medication should be taken as directed. 1

CON: Safety

2. The nurse reinforced teaching for a patient awaiting a heart transplant. Which statements indicate that the patient understands the usual criteria used for a potential heart donor? (Select all that apply.) 1. Age less than 55 years 2. No hypertension or diabetes 3. Absence of malignant disease

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4. Presence of no active infections 5. Presence of no significant cardiac disease 6. Weight within 35 lb of prospective recipient ANS: 2, 3, 4, 5 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 6. Explain medical treatments used for acute and chronic heart failure. Page: 476 Heading: Cardiac Transplantation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate

1. 2. 3. 4. 5. 6.

PTS:

Feedback Donors should be younger than 45 years and donor body weight should be no greater than 30% below the recipient’s weight. Donors should not have infections, significant cardiac or malignant disease, hypertension, or diabetes. Donors should not have infections, significant cardiac or malignant disease, hypertension, or diabetes. Donors should not have infections, significant cardiac or malignant disease, hypertension, or diabetes. Donors should not have infections, significant cardiac or malignant disease, hypertension, or diabetes. Donors should be younger than 45 years and donor body weight should be no greater than 30% below the recipient’s weight. 1

CON: Perfusion

3. The nurse is reviewing compensatory mechanisms with a patient in heart failure. What should the nurse include when providing this teaching? (Select all that apply.) 1. Urine output increases. 2. Muscle mass of the heart decreases. 3. Oxygen demand of the heart is lowered. 4. Epinephrine and norepinephrine are released. 5. Kidneys activate the renin-angiotensin-aldosterone system. 6. Heart muscles stretch to increase the force of myocardial contraction. ANS: 4, 5, 6 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 1. Describe the pathophysiology of left- and right-sided heart failure. Page: 439 Heading: Overview of Heart Failure Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Physiological Adaptation Cognitive Level: Comprehension (Understanding) Concept: Perfusion

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Difficulty: Moderate

1. 2. 3. 4. 5. 6.

PTS:

Feedback Muscle mass of the heart increases, urine output decreases, and the oxygen demand of the heart is increased. Muscle mass of the heart increases, urine output decreases, and the oxygen demand of the heart is increased. Muscle mass of the heart increases, urine output decreases, and the oxygen demand of the heart is increased. Epinephrine and norepinephrine are released, the renin-angiotensinaldosterone system is activated, and heart muscles stretch. Epinephrine and norepinephrine are released, the renin-angiotensinaldosterone system is activated, and heart muscles stretch. Epinephrine and norepinephrine are released, the renin-angiotensinaldosterone system is activated, and heart muscles stretch. 1

CON: Perfusion

COMPLETION 1. The HCP wants to be notified if a patient recovering from a heart transplant has a urine output less than 0.5 mL/kg/hr. The patient weighs 176 lb. What is the amount of urine the patient has to produce before the HCP is notified? ANS: 40 mL Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 5. Plan nursing care for acute and chronic heart failure. Page: 479 Heading: Cardiac Transplantation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback: The patient’s weight in kg is 176 lb/2.2 = 80 kg. If the patient needs to produce 0.5 mL of urine per hour per kg, then multiply the patient’s weight by the volume or 80 kg × 0.5 mL = 40 mL. The patient needs to produce 40 mL of urine per hour. PTS:

CON: Perfusion

2. The nurse is preparing to administer bumetanide (Bumex) 0.50 mg IV. The available dose is 0.25 mg/mL. How many mL will the nurse administer? Enter the numeral only. ANS: 2 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure

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Objective: 6. Explain medical treatments used for acute and chronic heart failure. Page: 466 Heading: Medications Used for Heart Failure (Table 26.5) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: mL = 1 mL/0.25 mg × 0.50 mg = 2 mL PTS:

CON: Safety

3. The nurse is calculating the intake for a patient who received 50 mL of an antibiotic, 120 mL of juice, 60 mL of water, and 240 mL of green tea. Calculate the patient’s total intake. Enter the numeral only. ANS: 470 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 7. Plan nursing care for acute and chronic heart failure. Pages: 471–473 Heading: Nursing Care Plan for the Patient With Chronic Heart Failure Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback: 50 + 120 + 60 + 240 = 470 mL PTS:

CON: Perfusion

4. The nurse is caring for a patient with heart failure receiving enalapril (Vasotec) 5 mg by mouth daily. The available dose is 10-mg tablets. How many tablets will the nurse administer? Enter the numeral only. ANS: 0.5 Chapter: Chapter 26. Nursing Care of Patients With Heart Failure Objective: 7. Plan nursing care for acute and chronic heart failure. Page: 466 Heading: Nursing Care Plan for the Patient With Chronic Heart Failure Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate

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Feedback: tab = 1 tab/10 mg × 5 mg = 0.5 mg PTS:

CON: Safety

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Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures MULTIPLE CHOICE 1. The patient asks the nurse how much blood is in the body. Which response by the nurse is accurate? 1. 1–3 liters 2. 4–6 liters 3. 7–9 liters 4. 10–12 liters ANS: 2 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 1. List the components of blood. Page: 484 Heading: Blood Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Hematological Regulation Difficulty: Moderate Feedback 1 2 3 4

The human body contains 4 to 6 liters of blood. The human body contains 4 to 6 liters of blood. The human body contains 4 to 6 liters of blood. The human body contains 4 to 6 liters of blood. PTS:

CON: Hematological Regulation

2. The nurse is reviewing laboratory values for a patient with thrombocytopenia. Which result would concern the nurse the most? 1. White blood cells (WBCs) 7,400/mm3 2. Hemoglobin 14.5 g/100 mL 3. Platelets 50,000/mm3 4. Red blood cells (RBCs) 5.0 million/mm3 ANS: 3 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 6. Identify laboratory and diagnostic studies that are used when evaluating the hematological and lymphatic systems. Page: 508 Heading: Review of Blood Cell Values and Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing)

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Concept: Hematological Regulation Difficulty: Moderate Feedback 1 2 3 4

WBCs are normal. Normal range is 4,500 to 11,000/mm3. Hemoglobin is normal. Normal range is 11.7 to 15.5 g/100 mL for females and 13.2 to 17.3 g/100 mL for males. The platelets are low; normal range is 150,000 to 450,000/mm3. The RBCs are normal. Normal range is 4.71 to 5.14 million/mm3 for males and 4.2 to 4.87 million mm3 for females.

PTS:

CON: Hematological Regulation

3. The nurse is taking a health history and notes the patient has a history of a splenectomy. For which condition is this patient at risk? 1. Liver disease 2. Renal failure 3. Meningitis 4. Asthma ANS: 3 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 3. Describe how changes in the blood or lymph systems can manifest as disease processes. Page: 520 Heading: Spleen Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Hematological Regulation Difficulty: Moderate Feedback 1 2 3 4

The patient is not at risk for liver disease. The patient is not at risk for renal failure. The patient is at risk for splenectomy and pneumonia. The patient is not at risk for asthma. PTS:

CON: Hematological Regulation

4. The nurse is caring for a patient who reports feeling several enlarged lymph nodes. The nurse should plan to prepare the patient for which test? 1. A bone marrow biopsy 2. A complete blood count (CBC) 3. Lymphangiography 4. A computerized tomography (CT) scan ANS: 3

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Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 6. Identify laboratory and diagnostic studies that are used when evaluating the hematological and lymphatic systems. Page: 517 Heading: Lymphatic Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Hematological Regulation Difficulty: Moderate Feedback 1 2

The patient likely has lymphoma; a bone marrow biopsy is not necessary but a lymph node biopsy may be conducted later. A CBC will likely be ordered, but is not used to diagnose lymphoma.

Lymphangiography may be performed to view the flow of lymph in the lymph network which helps evaluate for suspected lymphoma.

A CT scan is not as effective as a lymphangiogram in diagnosing lymphoma.

PTS:

CON: Hematological Regulation

5. The nurse is reviewing laboratory values for a female patient and notes a hemoglobin level of 8.2 g/100 mL and a hematocrit level of 21%. These levels are found in patients with which condition? 1. Acute bronchitis 2. Thyroid disease 3. Anemia 4. Hemochromatosis ANS: 3 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 6. Identify laboratory and diagnostic studies that are used when evaluating the hematological and lymphatic system. Page: 499 Heading: Review of Blood Cell Values and Disorders (Table 27.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Hematological Regulation Difficulty: Moderate Feedback 1 2 3 4

A reduced hemoglobin and hematocrit is not seen in acute bronchitis. A reduced hemoglobin and hematocrit is not seen in thyroid disease. A reduced hemoglobin and hematocrit is seen in anemia. A reduced hemoglobin and hematocrit is not seen in hemochromatosis.

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PTS:

CON: Hematological Regulation

6. A patient has a bone marrow aspiration from the posterior iliac crest. Before the procedure, the patient’s vital signs were blood pressure 132/82 mm Hg and pulse 88 beats/min. One hour after the procedure, the blood pressure is 108/70 mm Hg and pulse is 96 beats/min. Which assessment is the least important for the patient at this time? 1. Observe the puncture site. 2. Check the patient’s most recent CBC report. 3. Ask the patient about feelings of lightheadedness or dizziness. 4. Determine if the patient had any medications before the procedure. ANS: 2 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 7. Plan nursing care for patients undergoing diagnostic tests of the hematological or lymphatic systems. Page: 508 Heading: Bone Marrow Biopsy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Hematological Regulation Difficulty: Moderate Feedback 1

2 3

The vital signs indicate a change in status following the biopsy; possible causes include bleeding from the site or a medication response. Symptoms of low blood pressure include lightheadedness or dizziness. The most recent blood count is not immediately helpful unless it is used to compare with a new, post-biopsy report. The vital signs indicate a change in status following the biopsy; possible causes include bleeding from the site or a medication response. Symptoms of low blood pressure include lightheadedness or dizziness. The vital signs indicate a change in status following the biopsy; possible causes include bleeding from the site or a medication response. Symptoms of low blood pressure include lightheadedness or dizziness.

PTS:

CON: Hematological Regulation

7. The nurse is caring for a group of patients. Which patient should the nurse see first? 1. A patient with a platelet level of 200,000/mm3 2. A patient with a WBC count of 4,500/mm3 3. A patient with a hemoglobin of 13.4 g/100 mL 4. A patient with an RBC count of 2.4 million/mm3 ANS: 4 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 3. Describe how changes in the blood or lymph systems can manifest as disease processes.

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Page: 499 Heading: Review of Blood Cell Values and Disorders (Table 27.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Hematological Regulation Difficulty: Moderate Feedback 1

This level is within normal range. This level is within normal range. This level is within normal range. The RBC count is low; this patient should be seen first.

2 3 4

PTS:

CON: Hematological Regulation

8. A patient is prescribed to receive two units of packed red blood cells (PRBCs). What approach should the nurse use to ensure that the correct blood will be provided to this patient? 1. Check the patient’s arm band. 2. Check the order on the medical record. 3. Follow the organization’s verification process. 4. Assume the correct blood was provided by the blood bank. ANS: 3 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 9. Discuss the role of the LPN/LVN in administering blood products. Pages: 493–495 Heading: Blood Administration Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Hematological Regulation Difficulty: Moderate Feedback 1 2 3

More than the patient arm band and order need to be checked. More than the patient arm band and order need to be checked. Before initiating a blood or blood component transfusion, the blood should be matched with the order, matched with the patient, verified using a two-person or one-person process with bar coding, and verified according to the organization’s verification process. The nurse should never assume that the blood bank has provided the correct blood for a patient.

PTS:

CON: Hematological Regulation

9. A patient is being prepared to receive a prescribed blood transfusion. What is the best way that the licensed practical nurse (LPN) can assist the health team to prevent a transfusion reaction?

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1. 2. 3. 4.

Monitor vital signs every 15 minutes. Warm blood to 98.6°F (37°C) before infusion. Administer diphenhydramine (Benadryl) before the infusion. Assist the registered nurse (RN) to correctly identify the patient and the blood product.

ANS: 4 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 9. Discuss the role of the LPN/LVN in administering blood products. Pages: 493–495 Heading: Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Hematological Regulation Difficulty: Moderate Feedback 1

Warming blood, administering diphenhydramine, and frequent vital sign monitoring may be appropriate in specific cases, but are not the best way to prevent reactions in most patients. Warming blood, administering diphenhydramine, and frequent vital sign monitoring may be appropriate in specific cases, but are not the best way to prevent reactions in most patients. Warming blood, administering diphenhydramine, and frequent vital sign monitoring may be appropriate in specific cases, but are not the best way to prevent reactions in most patients. Correct identification is essential to all blood transfusions.

PTS:

CON: Hematological Regulation

10. The nurse is caring for a patient who underwent a bone marrow biopsy. What is the role of the licensed practical nurse/licensed vocational nurse (LPN/LVN) in this patient’s care? 1. Monitor the site for bleeding and infection. 2. Position the patient in high Fowler’s position. 3. Anesthetize the area with 1% lidocaine. 4. Obtain consent from the patient. ANS: 1 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 7. Plan nursing care for patients undergoing diagnostic tests of the hematological or lymphatic systems. Page: 519 Heading: Bone Marrow Biopsy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Hematological Regulation Difficulty: Moderate

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Feedback

The nurse’s role is to monitor the site for bleeding and infection. The patient is not placed in high Fowler’s position. It is not within the nurse’s scope of practice to anesthetize the area. The health care provider (HCP) will consent the patient.

1 2 3 4

PTS:

CON: Hematological Regulation

11. A patient who underwent lymphangiography the day before asks the LPN, “Why does my urine look blue?” What should the LPN respond to this patient’s concern? 1. “It is nothing to be concerned about.” 2. “I will notify the RN and physician immediately.” 3. “This indicates that the procedure found abnormal results.” 4. “The dye used in the procedure may cause bluish skin and urine for 2 days.” ANS: 4 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 7. Plan nursing care for patients undergoing diagnostic tests of the hematological or lymphatic systems. Page: 518 Heading: Lymphangiography Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Hematological Regulation Difficulty: Moderate Feedback 1 2 3 4

Stating that it is nothing to be concerned about does not address the patient’s concern. There is no reason to notify the RN or physician. It is inappropriate to advise the patient about results and incorrect to state that it indicates an abnormal finding. Lymphangiography uses a dye that may turn skin, urine, or feces bluish for about 2 days.

PTS:

CON: Hematological Regulation

12. The nurse is caring for a patient with folic acid deficiency anemia. Which patient is at risk for this condition? 1. A patient who smokes occasionally 2. A patient who drinks alcohol daily 3. A patient who is vegan 4. A patient who takes herbal remedies ANS: 2 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures

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Objective: 5. Identify data to collect when caring for a patient with a disorder of the hematological or lymphatic system. Page: 499 Heading: Subjective Data Collection for the Hematological and Lymphatic Systems (Table 27.3) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Hematological Regulation Difficulty: Moderate Feedback 1 2 3 4

This patient is not at risk for anemia. This patient is at risk for folic acid deficiency anemia. This patient is at risk for iron deficiency anemia. This patient is at risk for bleeding disorders, but not folic acid deficiency anemia.

PTS:

CON: Hematological Regulation

13. The nurse is preparing a patient for a blood transfusion. The patient has type O blood. Which blood type can this patient receive? 1. Type A 2. Type B 3. Type AB 4. Type O ANS: 4 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 8. List common therapeutic measures used for patients with hematological and lymphatic disorders Pages: 493–495 Heading: ABO Blood Types (Table 27.2) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Hematological Regulation Difficulty: Moderate Feedback 1 2 3 4

A patient with type O can only receive type O. A patient with type O can only receive type O. A patient with type O can only receive type O. A patient with type O can only receive type O. PTS:

CON: Hematological Regulation

14. The nurse is caring for a patient with a clotting disorder. Which should the nurse plan to administer? 1. PRBCs

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2. Platelets 3. Albumin 4. Fresh frozen plasma (FFP) ANS: 4 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 8. List common therapeutic measures used for patients with hematological and lymphatic disorders. Page: 494 Heading: Blood Products (Table 27.6) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Hematological Regulation Difficulty: Moderate Feedback 1

PRBCs are not used for clotting disorders. Platelets are not used for clotting disorders. Albumin is not used for clotting disorders. FFP is given for clotting disorders.

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PTS:

CON: Hematological Regulation

MULTIPLE RESPONSE 1. While receiving a unit of PRBCs, the patient begins to experience hives around the neck and upper chest. What actions should the nurse perform because of this reaction? (Select all that apply.) 1. Stop the transfusion. 2. Notify the HCP. 3. Return the blood to the blood bank. 4. Administer prescribed antihistamines. 5. Restart the infusion and carefully monitor. ANS: 1, 2, 4, 5 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 9. Discuss the role of the LPN/LVN in administering blood products. Page: 494 Heading: Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Hematological Regulation Difficulty: Moderate

Feedback On discovery of an urticarial reaction, the nurse should stop the transfusion

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3. 4.

PTS:

and notify the HCP immediately. Expect that the patient will be given a dose of an antihistamine, such as diphenhydramine (Benadryl). If the transfusion is restarted, continue to monitor the patient closely. On discovery of an urticarial reaction, the nurse should stop the transfusion and notify the HCP immediately. Expect that the patient will be given a dose of an antihistamine, such as diphenhydramine (Benadryl). If the transfusion is restarted, continue to monitor the patient closely. The blood will most likely not be returned to the blood bank, but transfused into the patient. On discovery of an urticarial reaction, the nurse should stop the transfusion and notify the HCP immediately. Expect that the patient will be given a dose of an antihistamine, such as diphenhydramine (Benadryl). If the transfusion is restarted, continue to monitor the patient closely. On discovery of an urticarial reaction, the nurse should stop the transfusion and notify the HCP immediately. Expect that the patient will be given a dose of an antihistamine, such as diphenhydramine (Benadryl). If the transfusion is restarted, continue to monitor the patient closely. 1

CON: Hematological Regulation

2. The nurse is caring for a patient with anemia. Which clinical manifestations can the nurse expect to document? (Select all that apply.) 1. Moist skin 2. Pallor 3. Elevated respiratory rate 4. Clubbed fingers 5. Fever 6. Petechiae ANS: 2, 3, 4 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 3. Describe how changes in the blood or lymph systems can manifest as disease processes. Page: 499 Heading: Objective Data Collection for the Hematological and Lymphatic Systems (Table 27.4) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: PHYS—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Hematological Regulation Difficulty: Moderate

1. 2. 3. 4. 5.

Feedback Dry skin is a sign of anemia. Pallor is a sign of anemia. Increased respirations are a sign of anemia. Clubbed fingers are a sign of anemia. Fever is not seen with anemia.

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6. PTS:

Petechiae is not seen with anemia. 1

CON: Hematological Regulation

ORDERED RESPONSE 1. The nurse is caring for a patient who received a blood transfusion and experienced a hemolytic reaction. Place in order, from 1 to 5, the steps the nurse should take. 1. Administer IV fluid. 2. Have a colleague notify the HCP. 3. Stop the transfusion. 4. Call the blood bank. 5. Stay with the patient. ANS: 3, 5, 2, 1, 4 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 9. Discuss the role of the LPN/LVN in administering blood products. Page: 494 Heading: Hemolytic Reaction Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: SECE—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Difficult Feedback: The nurse should stop the transfusion and stay with the patient while instructing a colleague to notify the HCP. The nurse should then administer IV fluids, and lastly, notify the blood bank. PTS:

CON: Safety

COMPLETION 1. The nurse is preparing to infuse a liter of normal saline over 4 hours IV to a patient who experienced a hemolytic reaction to blood. The drop factor is 15 gtt/mL. Calculate the drip factor. Enter the numeral only. Round to the nearest whole number. ANS: 63 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 8. List common therapeutic measures used for patients with hematological and lymphatic disorders. Page: 495 Heading: Hemolytic Reaction Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: gtt/min = 15 gtt/mL × 1,000 mL/4 hr × 4 hr/240 min = 15,000/240 = 62.5 gtt/min rounded to 63 gtt/min PTS:

CON: Safety

2. The nurse is preparing to administer a cyanocobalamin (B12) injection 1,000 mcg IM to a patient with B12 deficiency. Available vials are 1,000 mcg/mL. How many mL will the nurse administer? Enter the numeral only. ANS: 1 Chapter: Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures Objective: 8. List common therapeutic measures used for patients with hematological and lymphatic disorders Page: 495 Heading: Red Blood Cells Integrated Process: Clinical Problem Solving Process (Nursing Process) Client Need: PHYS—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback: mL = 1 mL/1,000 mcg × 1,000 mcg = 1 mL PTS:

CON: Safety

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Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders MULTIPLE CHOICE 1. The nurse is providing education to a patient newly diagnosed with iron deficiency anemia. Which of the following would be a component of the education? 1. Avoid green leafy vegetables as they will counteract the medication. 2. Include citrus fruits while taking the medication for this disorder. 3. Avoid immunizations with live viruses for 3 months. 4. Avoid intramuscular (IM) injections while on the medication. ANS: 2 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 6. Plan nursing care for patients with hematological disorders. Page: 499 Heading: Anemias Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Health Promotion Difficulty: Moderate Feedback 1 2 3 4

This would be education for a patient taking warfarin to avoid vitamin K–rich foods. Citrus fruits would be rich in vitamin C, which would enhance the absorption of the iron supplements. This would be education for the patient who is immunocompromised. IM injections are to be avoided for conditions such as thrombocytopenia, not iron deficient anemia.

PTS:

CON: Health Promotion

2. The nurse is assisting in the development of a care plan for a patient with pernicious anemia. Which of the following would be the most common nursing diagnosis with this medical condition? 1. Activity intolerance related to tissue hypoxia 2. Ineffective airway clearance related to dyspnea. 3. Chronic pain related to bone marrow dysfunction 4. Risk for infection related to reduction in white blood cells (WBCs) ANS: 1 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 6. Plan nursing care for patients with hematological disorders. Page: 498

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Heading: Anemias Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Easy Feedback 1 2 3 4

Activity intolerance is the most common issue with anemia due to poor tissue perfusion. Although the patient may experience shortness of breath, this is not an airway clearance issue. Chronic pain is often a symptom of sickle cell anemia, not pernicious anemia. Risk for infection is often a problem for low WBCs, not hemoglobin or intrinsic factors.

PTS:

CON: Patient-Centered Care

3. The nurse is providing care to the patient with thrombocytopenia. Which of the following activities should the patient avoid? 1. Planting tulip bulbs in the garden 2. Using an electric razor to shave 3. Attending church services 4. Receiving an influenza vaccination ANS: 4 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 9. Describe precautions you should institute to prevent bleeding in patients with clotting disorders. Page: 502 Heading: Idiopathic Thrombocytopenic Purpura Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Health Promotion Difficulty: Moderate Feedback 1

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Planting tulip bulbs or exposure to dirt and soil pathogens would be of a higher concern for the patient with a compromised immunity from leukemia or lack of WBCs. Using an electric razor would be appropriate due to the tendency to bleed from a regular razor blade. Attending church would expose the patient to possible infections, which is not a major concern with bleeding tendencies. Receiving an IM injection from the influenza vaccine is contraindicated as it could cause a bleeding issue.

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PTS:

CON: Health Promotion

4. The nurse is caring for a patient in sickle cell crisis. What is the rationale for providing warm compresses and blankets for this patient? 1. Sickle cell crisis pain can be exacerbated with shivering. 2. Heat relaxes the muscles and distracts the patient from the pain. 3. Heat promotes proper formation of red blood cells (RBCs) and prevents sickling. 4. Heat increases circulation by preventing vasoconstriction. ANS: 4 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 4. Describe current therapeutic measures for each disorder. Page: 508 Heading: Sickle Cell Anemia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension (Understanding) Concept: Perfusion Difficulty: Easy Feedback 1 2 3 4

Shivering is not associated with sickle cell crisis. Heat may relax the muscles and distract the patient, but this is not the reason for the heat application. Heat does not prevent formation of sickle cells. Heat facilitates dilation of the vessels to reduce clumping of the cells.

PTS:

CON: Perfusion

5. The nurse is preparing to provide therapeutic treatment to the patient with an exacerbation of polycythemia vera (PV). Which of the following is the expected treatment for this patient? 1. Alternated heat and cold packs 2. Schedule for a splenectomy 3. Therapeutic phlebotomy 4. Weekly injections of erythropoietin ANS: 3 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 4. Describe current therapeutic measures for each disorder. Page: 509 Heading: Polycythemia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension (Understanding) Concept: Infection Control Difficulty: Moderate

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Feedback 1 2 3 4

Alternated heat and cold packs would be a treatment for pain. A splenectomy is not associated with a treatment for PV. Phlebotomy would reduce the RBCs and viscosity of the blood, which often promotes relief from the symptoms. Erythropoietin is a colony-stimulating factor that would exacerbate the symptoms.

PTS:

CON: Infection Control

6. The nurse is providing care to a patient with a hematological disorder. Which of the following would be a manifestation of disseminated intravascular coagulation (DIC)? 1. Absent peripheral pulses 2. Hypertension and bounding pulses 3. Presence of scattered petechiae 4. Weakness or one-sided paralysis ANS: 1 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 2. Describe the etiologies, signs, and symptoms of each disorder. Page: 507 Heading: Hemorrhagic Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension (Understanding) Concept: Perfusion Difficulty: Easy Feedback 1 2 3 4

Absent peripheral pulses is a general symptom that could indicate many other disorders. Hypertension and bounding pulses are often indicators of fluid volume deficit, not a bleeding disorder. Presence of scattered petechiae is often an early indication of DIC. One-sided weakness may indicate many other disorders, such as a cerebral vascular disorder.

PTS:

CON: Perfusion

7. The nurse is caring for a patient with thrombocytopenia. Which of the following products would the nurse anticipate being prescribed? 1. Albumin 2. Cryoprecipitate 3. Lactated Ringer’s 4. Packed RBCs ANS: 2

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Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 4. Describe current therapeutic measures for each disorder. Page: 508 Heading: Idiopathic Thrombocytopenic Purpura Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension (Understanding) Concept: Perfusion Difficulty: Easy Feedback 1 2 3 4

Albumin is often given to expand volume. Cryoprecipitates replace specific missing clotting factors. Lactated Ringer’s is not a blood product and would be used to rehydrate the patient. Packed RBCs replace lost blood for anemia or hemorrhage.

PTS:

CON: Perfusion

8. The nurse is triaging several patients in an urgent care center. One patient states that he has hemophilia and is bleeding, with no apparent signs of bleeding. Which action by the nurse is most appropriate at this time? 1. Palpate the suspected area of bleeding for tenderness and edema. 2. Have the patient take a number and stay in the waiting area. 3. Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis. 4. Send the patient for routine x-rays to locate the source of bleeding and place him in an examination room. ANS: 3 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 9. Describe precautions you should institute to prevent bleeding in patients with clotting disorders. Page: 511 Heading: Hemophilia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

Palpation of the suspected area may increase the bleeding. Delay of treatment may be disastrous. Health care workers should pay attention to a patient who may know from experience if bleeding is starting. Sending a patient to the examination room without notifying the physician may

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prove disastrous as it may delay treatment. PTS:

CON: Safety

9. The nurse caring for a patient with chronic leukemia in an acute care setting. The patient asks the nurse to observe the patient’s last bowel movement as it is very dark. The nurse immediately contacts the primary health care provider (HCP). What would explain the nurse’s action? 1. The patient may have a gastrointestinal bleed. 2. The patient may have overdosed on iron supplements. 3. The patient is most likely severely dehydrated. 4. The patient is ready for discharge to home. ANS: 1 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 9. Describe precautions you should institute to prevent bleeding in patients with clotting disorders. Page: 510 Heading: Chronic Leukemias Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Black or very dark stools are a sign of gastrointestinal bleeding and necessitate further treatment provided by the primary HCP. Black stools may be caused by iron supplements, but the patient’s diagnosis of leukemia puts him at a higher risk for bleeding. Usually, when a patient is constipated, the stools are hard, not dark. This patient may need to remain in the acute care setting for further treatment and is not ready for discharge to home.

PTS:

CON: Perfusion

10. The home care nurse is providing teaching to the family of a patient with multiple myeloma. Which nursing diagnosis should guide the nurse for this teaching? 1. Ineffective airway clearance related to swelling of the lymph nodes 2. Ineffective tissue perfusion related to vascular occlusion 3. Risk for deficit fluid volume related to a bleeding disorder 4. Risk for injury related to compromised bone integrity ANS: 4 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 7. Plan nursing care for patients with lymphatic disorders. Page: 514

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Heading: Multiple Myeloma Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Moderate Feedback 1

Multiple myeloma does not directly affect airway clearance. Multiple myeloma does not directly affect tissue perfusion. Multiple myeloma does not directly affect fluid volume. Multiple myeloma causes destruction of the bone and widespread osteoporosis.

2 3 4

PTS:

CON: Cellular Regulation

11. The nurse is assisting the patient with multiple myeloma in arranging a meal plan to lower the risk of complications from hypercalcemia. Which of the following would be the most important component of the patient’s intake? 1. The patient should increase intake of fresh fruits. 2. The patient should increase intake of fluids. 3. The patient should decrease intake of red meat. 4. The patient should avoid alcoholic beverages. ANS: 2 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 7. Plan nursing care for patients with lymphatic disorders. Page: 514 Heading: Multiple Myeloma Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension (Understanding) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

Fresh fruits will not directly affect calcium levels. Water will dilute calcium and flush the kidneys to reduce the risk of kidney stones. Red meat will not directly affect calcium levels. Alcoholic beverages will not directly affect calcium levels.

PTS:

CON: Safety

12. The nurse is providing care to the patient with Hodgkin disease who has cervical lymph node enlargement. Which of the following symptoms should the nurse attend to first? 1. Pain 2. Fever 3. Fatigue

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4. Stridor ANS: 4 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 7. Plan nursing care for patients with lymphatic disorders. Page: 516 Heading: Hodgkin Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Oxygenation Difficulty: Easy Feedback 1 2 3 4

Pain is important, but should be addressed once the airway is cleared. Fever is important, but should be addressed once the airway is cleared. Fatigue is important, but should be addressed once the airway is cleared. Stridor indicates airway involvement, possibly due to enlarged lymph nodes and take priority over the other issues.

PTS:

CON: Oxygenation

13. The nurse is caring for a patient with stage IV Hodgkin disease. Where should the nurse expect to find enlarged lymph nodes during the assessment? 1. Two or more areas on the same side of the diaphragm 2. Localized in the cervical neck area only 3. Generalized throughout the body within multiple organs 4. Two areas of lymph nodes above and below the diaphragm ANS: 3 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 2. Describe the etiologies, signs, and symptoms of each disorder. Page: 516 Heading: Hodgkin Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 2 3 4

Stage II is noted as two or more lymph nodes on the same side of the diaphragm. The lymph nodes localized in one area of the body is stage I. This is widespread disease and may not involve the lymph nodes, which is stage IV. Lymph node involvement on both sides of the diaphragm denotes stage III.

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PTS:

CON: Patient-Centered Care

14. The nurse is caring for the patient with iron deficiency anemia, who has been taking oral iron supplements. Which of the following laboratory tests would determine the effectiveness of this intervention? 1. Hemoglobin and hematocrit 2. WBC and platelet count 3. Electrolytes, blood urea nitrogen (BUN), and creatinine 4. Activated partial thromboplastin time (APTT) and prothrombin time (PT) ANS: 1 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 3. Identify tests used to diagnose each of the disorders. Page: 502 Heading: Anemias Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Health Promotion Difficulty: Easy Feedback 1 2 3 4

Hemoglobin and hematocrit are below normal in anemia. WBCs monitor effectiveness of antibiotic therapy and platelet counts monitor effectiveness of anticoagulant therapy Electrolytes, BUN, and creatinine usually indicate kidney pathology. APTT and PT are used to determine clotting ability for effectiveness of anticoagulant therapy.

PTS:

CON: Health Promotion

15. The nurse is caring for the patient with pernicious anemia. The patient asks why this happened when she has regularly taken iron supplements while following a strict vegetarian diet. Which of the following would be the nurse’s most appropriate response? 1. “Increase dairy products such as yogurt to increase your intake of vitamin B12.” 2. “Drinking a glass of orange juice would facilitate the absorption of the iron supplements.” 3. “Would you be able to take liver tablets to increase your intake of Vitamin B12?” 4. “Perhaps your HCP will prescribe an injection of erythropoietin.” ANS: 1 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 1. Explain the pathophysiology of each of the hematological and lymphatic disorders discussed in this chapter. Page: 502 Heading: Anemias Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension (Understanding) Concept: Health Promotion Difficulty: Moderate Feedback 1 2 3 4

Pernicious anemia is a deficiency in vitamin B12, and this is found in meat, fish, shellfish, poultry, eggs, and dairy products such as yogurt. Vitamin C would enhance the absorption of iron, but pernicious anemia is due to lack of vitamin B12, not iron. This is culturally insensitive, as the patient is a vegetarian and would not be able to follow her diet with the liver tablet. Erythropoietin is a colony-stimulating medication and would not resolve the pernicious anemia.

PTS:

CON: Health Promotion

16. The nurse is caring for a patient receiving treatment for a hemolytic anemia due to a reaction from a mismatched blood transfusion. The nurse understands that hemolytic anemia is a definition of what type of anemia? 1. Malformed RBCs 2. An abundance of immature RBCs 3. A deficiency in vitamin B12 4. Destruction of RBCs ANS: 4 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 1. Explain the pathophysiology and each of the hematological and lymphatic disorders discussed in this chapter. Page: 502 Heading: Hemolysis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Knowledge (Remembering) Concept: Perfusion Difficulty: Easy Feedback 1 2 3 4

Malformed RBCs could be a definition of sickle cell anemia, with the RBCs formed like a “sickle” instead of a circle or disc. An abundance of immature RBCs would not define this disease process, rather it may be an indication of recent injections of a colony-stimulating hormone. Vitamin B12 deficiency is pernicious anemia. Hemolytic anemia is the result of destruction of RBCs, caused by exposure to certain toxins.

PTS:

CON: Perfusion

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17. The nurse is caring for a patient with iron deficiency anemia, which of the following would be the most appropriate nursing intervention for this patient? 1. Instruct the patient to notify the HCP of nausea or constipation. 2. Take the iron supplement at the same time every day with meals. 3. Stop taking the iron supplement when symptoms are resolved. 4. Take advantage of energy spurts and cluster activities at that time. ANS: 1 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 6. Plan nursing care for patients with hematological disorders. Page: 503 Heading: Anemias Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate Feedback 1 2 3 4

The patient should notify the HCP of any side effects related to the iron supplements. The iron supplement should be administered 1 hour before or 2 hours after meals to enhance absorption. Prescriptions and/or treatments should not be discontinued without instructions from the prescriber. Activities should be planned to conserve and balance energy.

PTS:

CON: Health Promotion

18. The nurse is providing care to the patient with suspected aplastic anemia. The HCP has completed a bone marrow biopsy. Which of the following would be a description of the bone marrow that would signify a positive diagnosis of aplastic anemia? 1. The bone marrow is red and gelatinous. 2. The bone marrow is pale, fatty, and fibrous. 3. The bone marrow is thin and serosanguinous. 4. The bone marrow is pale pink and serous. ANS: 2 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 2. Describe the etiologies, signs, and symptoms of each disorder. Page: 504 Heading: Aplastic Anemia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Difficult

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Feedback 1 2 3 4

This is the normal finding or description of bone marrow, where it is manufacturing blood cells. This is an indication that bone marrow is not manufacturing blood cells and is essentially dead tissue. This is not an indicator of healthy bone marrow, but is not an indication of aplastic anemia. This is not an indicator of healthy bone marrow, but it is not an indication of aplastic anemia, where the bone marrow is essentially dead.

PTS:

CON: Cellular Regulation

19. The nurse is caring for the patient with hemoglobin less than 6 g/dL. Which of the following clinical manifestations would the nurse expect the patient to present? 1. Mild palpitations, thirst, and fatigue 2. Tachycardia, fatigue, and exertional dyspnea 3. Orthopnea, blurred vision, and pruritus 4. Petechiae, ecchymosis, and restlessness ANS: 3 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 2. Describe the etiologies, signs, and symptoms of each disorder. Page: 498 Heading: Clinical Manifestations of Anemia (Table 28.1) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Mild palpitations and fatigue are signs of moderate anemia. Thirst is not a sign of anemia. Tachycardia, fatigue, and exertional dyspnea are signs of mild to moderate anemia. Orthopnea, blurred vision, and pruritus are signs of severe or critical anemia. Petechiae, ecchymosis, and restlessness may be signs of another disease process, not of anemia.

PTS:

CON: Perfusion

20. The nurse is following the care plan risk for ineffective peripheral perfusion related to sickled cells and infarction. Which of the following would be the most appropriate intervention? 1. Increase the patient’s activity daily to achieve previous energy levels. 2. Provide 325 mg aspirin between doses of narcotic pain medications. 3. Apply cold compresses and maintain a cool environment. 4. Avoid restrictive clothing and raising the knee gatch in the bed.

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ANS: 4 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 6. Plan nursing care for patients with hematological disorders. Page: 498 Heading: Nursing Process for the Patient with Sickle Cell Anemia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Encourage bedrest during the acute phase of the crisis to reduce oxygen demand. Avoid giving aspirin because it may increase acidosis and worsen the crisis. Cold compresses may exacerbate the pain and cause a vasoconstrictive effect that will decrease circulation. Avoid restrictive clothing and the knee gatch as these can restrict circulation.

PTS:

CON: Perfusion

21. The nurse is caring for a patient with chronic episodes of hypoxia secondary to chronic obstructive pulmonary disease. The nurse will monitor the patient’s laboratory results for increased RBCs due to the low oxygen levels. Which of the following blood disorders will the nurse expect to find? 1. Aplastic anemia 2. DIC 3. Chronic lymphatic leukemia (CLL) 4. PV ANS: 1 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 1. Explain the pathophysiology of each of the hematological and lymphatic disorders discussed in this chapter. Page: 503 Heading: Polycythemia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension (Understanding) Concept: Perfusion Difficulty: Easy Feedback 1 2 3

Aplastic anemia is often not caused by chronic hypoxia. DIC is not caused by chronic hypoxia. CLL is not caused by chronic hypoxia.

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PV can be caused by the body’s response to produce more RBCs in response to the low oxygen levels as a compensatory mechanism.

PTS:

CON: Perfusion

22. The nurse is caring for a patient who has CLL when the patient suddenly develops petechiae, nausea, and severe back pain. The nurse recognizes this life-threatening event as which of the following? 1. DIC 2. Sickle cell crisis 3. Thrombocytopenia 4. Pancytopenia ANS: 1 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 2. Describe the etiologies, signs, and symptoms of each disorder. Page: 511 Heading: Chronic Leukemias Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Comprehension (Understanding) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

These are cardinal signs of DIC and necessitate emergency interventions. Sickle cell crisis often does not present with nausea or petechiae. Thrombocytopenia, lack of clotting ability, may have petechiae, but does not often present with nausea or severe back pain. Pancytopenia may have petechiae, but does not often present with nausea or back pain.

PTS:

CON: Perfusion

23. The nurse is caring for the patient who recently underwent a colectomy due to a bowel perforation and peritonitis. The nurse is preparing to administer the anticoagulant heparin to prevent which of the following blood disorders? 1. PV 2. DIC 3. Pancytopenia 4. Thrombocytopenia ANS: 2 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 9. Describe precautions you should institute to prevent bleeding in patients with clotting disorders. Page: 516

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Heading: Disseminated Intravascular Coagulation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

PV is described as overproduction of the RBC count, which can be either a genetic mutation or a result of hypoxia. DIC could result from tissue necrosis secondary to extensive abdominal surgery with leakage of intestinal contents. Pancytopenia may be a result of aplastic anemia, which has varied causes that do not include peritonitis. Thrombocytopenia would not be treated with the anticoagulant heparin, as it would exacerbate the issue of lack of clotting factors.

PTS:

CON: Perfusion

24. The nurse is caring for the patient who underwent emergency treatment for DIC. The patient voices concern over how to explain the tubes and extensive bruising to his family members. Which of the following would be an appropriate nursing intervention for disturbed body image related to physical evidence of aggressive treatment procedures? 1. Cover the ecchymotic areas with bandages and disconnect the IV tubes temporarily. 2. Limit the number of visitors to two at a time for short intervals. 3. Enlist the aid of other members of the health care team to support the family. 4. Place educational materials in the waiting area prior to visitor’s arrival. ANS: 3 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 9. Describe precautions you should institute to prevent bleeding in patients with clotting disorders. Page: 508 Heading: Disseminated Intravascular Coagulation Integrated Process: Caring Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Collaboration Difficulty: Difficult Feedback 1

2 3

This could exacerbate the patient’s perception of disturbed body image by covering the areas. Disconnecting the IV tubing could cause a disruption of treatment for the disorder. This may be a policy of the intensive care unit, but this would not be an intervention for the body image disturbance. Enlisting the aid form other health care team members, such as social workers

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and chaplains, may facilitate acceptance of the signs of DIC treatment and support the family members. Educational materials placed in the visiting area may be missed as the visitors may not recognize that the material is placed for them to review prior to seeing the patient.

PTS:

CON: Collaboration

25. The nurse is caring for a patient who must undergo a splenectomy for treatment for idiopathic thrombocytopenic purpura (ITP).Which of the following statements best describes the rationale for the splenectomy? 1. The spleen becomes engorged and ischemic during an ITP crisis. 2. The spleen causes an overabundance of immature platelets. 3. The spleen is at risk for infection due to the critical loss of WBCs. 4. The spleen is the primary site for platelet destruction. ANS: 4 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 1. Explain the pathophysiology of each of the hematological and lymphatic disorders discussed in this chapter. Page: 516 Heading: Idiopathic Thrombocytopenic Purpura Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Difficult Feedback 1 2 3 4

ITP is a bleeding disorder due to antibodies destroying platelets. The spleen would not cause an overabundance of immature platelets, rather the spleen would destroy viable platelets. If the spleen would be infected, the treatment typically does not include removal of the spleen. The spleen would destroy platelets, leaving immature platelets that would have a considerably short life span of a few hours.

PTS:

CON: Perfusion

26. The nurse is providing education to a patient with mild hemophilia on how to avoid bleeding episodes. Which one of the following would be most appropriate to include in the teaching plan? 1. Administer desmopressin intranasally prior to any dental procedure or sports. 2. Carry an epinephrine pen (EpiPen) that is readily available for emergencies. 3. Maintain compression to injection sites for at least 4 hours with a sterile pads. 4. Prepare for blood transfusions after any invasive procedure such as dental extractions.

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ANS: 1 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 6. Plan nursing care for patients with hematological disorders. Page: 510 Heading: Hemophilia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Safety Difficulty: Easy Feedback 1 2 3 4

Desmopressin stimulates the body to release more clotting factors, which would be administered prior to any dental procedures or sports. An epinephrine pen is not used for clotting disorders or bleeding emergencies, rather it is used for allergic reactions. Maintaining compression would not increase the clotting factors that are diminished with hemophilia. Blood transfusions may be a component of severe trauma or surgery, which is not often the case for dental procedures.

PTS:

CON: Safety

27. The nurse is assisting in developing a plan of care for the patient with hemophilia who is experiencing severe acute pain. Which of the following would be the most appropriate intervention based on the nursing diagnosis acute pain related to bleeding into tissues? 1. Administer desmopressin injections as prescribed prior to any invasive procedure. 2. Administer opioids as prescribed, avoiding IM injections. 3. Instruct the patient on bleeding precautions and signs and symptoms of bleeding. 4. Instruct the patient on community services and hemophilia treatment centers. ANS: 2 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 9. Describe precautions you should institute to prevent bleeding in patients with clotting disorders. Page: 510 Heading: Hemophilia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Easy Feedback 1 2

Desmopressin would be effective for mild hemophilia prior to invasive procedures, not for pain control. Opioid administered via IV, possibly a patient-controlled analgesia (PCA),

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3 4

would be an effective pain control option. IM injections could exacerbate the bleeding and pain. Instructing the patient on bleeding precautions would be a teaching to prevent a bleeding issue after the patient is stabilized. Community services and hemophilia treatment centers may be used after the crisis of severe pain were resolved. This may be a component of discharge teaching.

PTS:

CON: Comfort

28. The nurse is assessing the patient recently diagnosed with chronic myelogenous leukemia (CML). What of the following indicates a positive diagnosis for CML? 1. CBC reveals decrease of platelets and RBCs. 2. Lumbar puncture shows presence of Reed-Sternberg cells. 3. Genetic analysis of bone marrow reveals Philadelphia chromosome. 4. Laboratory results reveal a prolonged PTT and low factor IX. ANS: 3 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 3. Identify tests used to diagnose each of the disorders. Page: 511 Heading: Chronic Leukemias Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Difficult Feedback 1 2 3 4

This could be a screening laboratory result for any number of disorders. Reed-Stenberg cells are indicative of Hodgkin lymphoma. This would be definitive result, especially from the bone marrow. This would be indicative of hemophilia. PTS:

CON: Cellular Regulation

29. The nurse is providing education to the patient with the nursing diagnosis of impaired oral membrane integrity related to chemotherapy and pancytopenia. The nurse is aware that the patient understands the teaching by which of the following actions? 1. The patient keeps her dentures in at all times except for cleaning. 2. The patient chooses orange juice and hot coffee for breakfast. 3. The patient avoids smoking and commercial mouthwash. 4. The patient chooses ice cream and popsicles for between-meal snacks. ANS: 1 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 6. Plan nursing care for patients with hematological disorders.

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Page: 518 Heading: Nursing Care Plan for the Patient With Leukemia Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Health Promotion Difficulty: Moderate Feedback 1 2 3 4

The dentures should be removed for cleaning and at bedtime to improve circulation and decrease risk for lesions. Acidic and hot foods can be irritating to the mucosa. Smoking and commercial mouthwashes can irritate the mucosa. Extremely hot or cold foods can irritate the mucosa lining.

PTS:

CON: Health Promotion

30. The nurse is caring for the patient who is 1 day status postsplenectomy. The patient complains of pain with breathing especially with inspiration. What would be the most appropriate nursing intervention for this patient? 1. Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate. 2. Contact the surgeon to obtain orders for a nebulizer treatment from respiratory therapy. 3. Provide the patient with a heating pad alternated with a cold pack for incisional pain. 4. Contact the surgeon to request a chest x-ray and a laboratory draw for CBC with differential. ANS: 1 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 10. Identify nursing care and teaching you will provide for patients undergoing a splenectomy. Page: 516 Heading: Splenectomy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application (Applying) Concept: Comfort Difficulty: Difficult Feedback 1

2 3

Respiratory problems may occur due to the incision’s location near the diaphragm. If these problems are not addressed early on, the patient is at risk for pneumonia and respiratory problems. The nebulizer treatment may be appropriate if the patient is not able clear the lungs, but at this time, there is no indication of this problem. Although alternating heat and cold for pain control may help other medical

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issues, it may not work as well as medicating. The chest x-ray and laboratory draw may not be necessary on day 1 after surgery.

PTS:

CON: Comfort

MULTIPLE RESPONSE 1. The nurse is caring for a patient with a folic acid deficiency. What foods should the nurse encourage the patient to improve this deficiency? (Select all that apply.) 1. Almond milk and toasted white bread 2. Split pea soup with whole grain crackers 3. Garden salad with green leafy vegetables 4. Cereals made with fortified grain and wheat germ 5. Yogurt and aged cheeses with crackers ANS: 2, 3, 4 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 4. Describe current therapeutic measures for each disorder. Page: 502 Heading: Anemias Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Moderate

1. 2. 3. 4. 5.

PTS:

Feedback Almonds and white bread that is not made from fortified flour are not good sources of folic acid. Good sources of folic acid include dried peas and wheat germ. Good sources of folic acid include green leafy vegetables. Cereals made with fortified grains and wheat germ are good sources of folic acid. Dairy products, such as yogurt and aged cheeses, are rich in calcium not, folic acid. 1

CON: Health Promotion

2. The nurse is assessing a patient in a family practice clinic. The patient had extensive testing to rule out Hodgkin disease. Which of the following characteristics would indicate Hodgkin disease? (Select all that apply.) 1. The patient complained of blurred vision and excessive thirst. 2. The patient complained of skeletal and generalized pain. 3. The laboratory results show presence of Reed-Sternberg cells. 4. The patient has painless swelling of the cervical and axillary nodes. 5. The patient’s laboratory results indicate presence of Philadelphia chromosomes.

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ANS: 3, 4 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 2. Describe the etiologies, signs, and symptoms of each disorder. Page: 515 Heading: Hodgkin Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate

1. 2. 3. 4. 5. PTS:

Feedback Blurred vision and excessive thirst may indicate another disease process other than Hodgkin. Skeletal pain can indicate leukemia or multiple myeloma, not Hodgkin. Reed-Sternberg cells indicate Hodgkin disease. Hodgkin disease is a lymphoma, and painless swelling in one or more common lymph chains is a usual presentation. Philadelphia chromosomes can indicate CML. 1

CON: Patient-Centered Care

3. The nurse is caring for a patient who has been recently diagnosed with aplastic anemia. Which of the following are indicators of this disease process? (Select all that apply.) 1. Bone marrow that is pale, fatty, and fibrous 2. A CBC with all low values 3. Presence of Reed-Sternberg cells 4. Decreased serum iron levels 5. Increased total iron-binding capacity (TIBC) ANS: 1, 2, 5 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 3. Identify tests used to diagnose each of the disorders. Page: 502 Heading: Aplastic Anemia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension (Understanding) Concept: Cellular Regulation Difficulty: Moderate

1. 2. 3.

Feedback Bone marrow that is pale, fatty, yellow, and fibrous denotes dead bone marrow, which is an indicator of aplastic anemia. Often a low CBC can be an indicator for anemia. Reed-Sternberg cells are indicative of Hodgkin lymphoma, not aplastic anemia.

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4. 5.

PTS:

Typically, the iron levels will increase as the RBCs are not being produced and not using the stores of iron in the production of hemoglobin. Increased TIBC can be an indicator of aplastic anemia due to the overabundance of unused iron stores. 1

CON: Cellular Regulation

4. The nurse is caring for a patient with a platelet count of <20,000/mm3. Which of the following precautions should the nurse take in providing care for this patient? (Select all that apply.) 1. Immediately report any fever to the HCP. 2. Administer NSAIDs for pain control. 3. Monitor for black tarry stools. 4. Avoid blood draws when possible. 5. Use soft toothbrush to clean the teeth. ANS: 3, 4, 5 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 5. List data you should collect when caring for patients with disorders of the hematological or lymphatic systems. Page: 502 Heading: Idiopathic Thrombocytopenic Purpura Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Easy

1. 2. 3. 4. 5.

PTS:

Feedback This patient is at risk for bleeding, not infection due to the low platelet count. The patient should avoid any drugs that interfere with platelet functions, such as NSAIDs or aspirin. Black tarry stools can be indicative of a gastrointestinal bleed. Avoid blood draws whenever possible; use established access sites or group specimen collections into once-daily draws. Avoid trauma to the oral mucosa; use a soft toothbrush or gauze to clean the teeth. 1

CON: Cellular Regulation

5. The nurse is providing care to the patient who has arrived at the clinic to discuss his diagnostic results. The HCP suspects multiple myeloma. Which of the following results may confirm the HCP’s suspicions? (Select all that apply.) 1. Reed-Stenberg cells are present in the bone marrow. 2. Magnetic resonance imaging (MRI) shows diffuse osteoporosis in the bones. 3. Blood chemistries reveal an increase in serum calcium. 4. Lymph node biopsies reveal Philadelphia chromosome. 5. Blood and urine studies are positive for M-type globulins.

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ANS: 2, 3, 5 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 2. Describe the etiologies, signs, and symptoms of each disorder. Page: 514 Heading: Multiple Myeloma Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback Reed-Stenberg cells are not indicative of multiple myeloma. X-rays and MRIs may show changes in the lungs and diffuse osteoporosis. Blood chemistries will reveal increases in serum calcium due to the breakdown of the bones. Philadelphia chromosomes can indicate CML, which is a blood test, not lymph node. Blood and urine studies are positive for M-type globulins in 40 percent of patients. 1

CON: Cellular Regulation

COMPLETION 1. The nurse is providing a blood transfusion and sets the infusion pump to run at 300 mL/hr for 15 minutes. What is the amount of blood that will be transfused at that time (in mL)? ANS: 75 Chapter: Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders Objective: 6. Plan nursing care for patients with hematological disorders. Page: 498 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

Feedback: PTS:

= CON: Patient-Centered Care

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Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures MULTIPLE CHOICE 1. The nurse is reviewing a patient’s pulmonary function tests. Which of the following best describes functional residual capacity? 1. It is the air inspired and expired in one breath. 2. It is the maximum amount of air beyond tidal volume. 3. It is the air remaining in the lungs after normal expiration. 4. It is the amount of air expired forcefully after maximum inspiration. ANS: 3 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 5. Identify common diagnostic tests performed to diagnose disorders of the respiratory system. Page: 537 Heading: Normal Values for Pulmonary Function Studies (Table 29.6) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge (Remembering) Concept: Health Promotion Difficulty: Easy Feedback 1 2 3 4

Tidal volume is the air inspired and expired in one breath. Expiratory reserve is the amount of air beyond tidal volume in the most forceful exhalation. Functional residual capacity is the air remaining in the lungs after normal expiration. Forced vital capacity is the amount of air expired forcefully after maximum inspiration.

PTS:

CON: Health Promotion

2. The nurse recognizes that the elderly patient’s poor perfusion of body tissues is due to the patient’s diagnosis of a blood disorder. Which of the following would best explain the patient’s issue? 1. The patient’s dehydration prevents circulation of free oxygen in the blood plasma. 2. The patient’s low red blood cell (RBC) count prevents oxygen from adhering to the membranes. 3. The patient’s low hemoglobin count provides less surface for the adherence of oxygen. 4. The patient’s high white blood cell (RBC) count signifies an infection and need for more oxygen. ANS: 3 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures

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Objective: 2. Identify how aging affects the respiratory system. Page: 538 Heading: Exhalation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Knowledge (Remembering) Concept: Health Promotion Difficulty: Easy Feedback 1 2 3 4

Dehydration is not considered a blood disorder, rather a symptom. Oxygen is not transported or perfused via the membranes of RBCs. Hemoglobin carries oxygen in the blood, which is in the RBCs, not in the membranes or plasma. Although an infection may increase the demand for oxygen, it is not the best answer to this issue, which is the decreased hemoglobin.

PTS:

CON: Health Promotion

3. The nurse is caring for a patient who becomes dyspneic, which the patient states is a “6 out of 10” on the dyspnea scale. Which action should the nurse do first? 1. Contact the health care provider (HCP) for an order for supplemental oxygen. 2. Assist the patient to sit at the edge of the bed to lean over the bedside table. 3. Apply nasopharyngeal suction intermittently until the airway is cleared. 4. Apply supplemental oxygen and notify the HCP of this action. ANS: 2 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help patients with respiratory disorders. Pages: 539–540 Heading: Nursing Assessment of the Respiratory System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application (Applying) Concept: Oxygenation Difficulty: Moderate Feedback 1 2 3 4

This may be a step after assisting the patient to breathe easier, once the urgency of the matter is controlled. The tripod position may facilitate easier breathing by displacing the diaphragm. There is no indication for suction at this time. Applying supplemental oxygen without an order is working outside the scope of the nurse’s practice.

PTS:

CON: Oxygenation

4. The nurse is auscultating a patient’s chest and hears an adventitious sound in the left lower lobe. What is the first step in determining whether this is an abnormality?

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1. 2. 3. 4.

Ask the patient to cough and note the characteristics of secretions. Ask the patient to drink some water and then reassess the breath sounds. Have the HCP listen and verify what the nurse is hearing. Listen to the corresponding area in the patient’s right lower lobe.

ANS: 4 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and auscultating the chest. Page: 533 Heading: Abnormal Lung Sounds (Table 29.4) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

There is no indication of a cough, secretions, or of the type of adventitious sounds. This would help thin any secretions, but this does not facilitate auscultation of the lung fields. This may help once the nurse is able to locate and identify the type of sounds to notify the HCP. Comparing sounds on each side can help identify normal versus abnormal sounds.

PTS:

CON: Patient-Centered Care

5. The nurse is assessing the patient diagnosed with pulmonary edema and hears lung sounds, and moist bubbling sounds are heard on inspiration and expiration. What medical term best defines the sound? 1. Coarse crackles 2. Fine crackles 3. Pleural friction rub 4. Wheezing ANS: 1 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and auscultating the chest. Page: 534 Heading: Abnormal Lung Sounds (Table 29.4) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Knowledge (Remembering) Concept: Patient-Centered Care Difficulty: Moderate Feedback

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1 2 3 4

Moist bubbling sounds heard on inspiration and expiration define coarse crackles. Fine crackles are finer and less “bubbly,” and occur with heart failure or atelectasis. Pleural friction rub sounds like leather rubbing together. Wheezing sounds are often described as musical.

PTS:

CON: Patient-Centered Care

6. A patient’s arterial blood gas analysis shows a PaCO2 of 68 mm Hg. What action should the nurse take first? 1. Notify the HCP. 2. Remove the patient’s oxygen mask. 3. Have the patient breathe into a paper bag. 4. Place the patient in a Fowler’s position. ANS: 4 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 5. Identify common diagnostic tests performed to diagnose disorders of the respiratory system. Page: 538 Heading: Arterial Blood Gas Analysis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Acid/Base Balance, Collaboration Difficulty: Moderate Feedback 1 2 3 4

The patient’s abnormally high PaCO2 should be reported but the patient’s immediate needs must be met first. Removing the oxygen will exacerbate the PaCO2 levels. Breathing into a paper bag will exacerbate the PaCO2 levels via retention. Placing the patient into a Fowler’s position will help with ventilation while contacting the HCP. The patient’s immediate needs must be met first.

PTS:

CON: Acid/Base Balance | Collaboration

7. The patient returns to the medical unit after a pulmonary angiography. Which instructions by the nurse would help prevent complications from the test? 1. “Lie flat for 8 hours so the injection site does not bleed.” 2. “You may sit up for short periods of time, such as mealtime.” 3. “To prevent irritation to your throat, try not to cough for 6 hours.” 4. “Don’t drink anything for 6 hours after the test, as you may choke.” ANS: 1 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 5. Identify common diagnostic tests performed to diagnose disorders of the respiratory system.

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Page: 537 Heading: Pulmonary Angiography Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

Post angiography, place the patient in the supine position for 3 to 8 hours, as ordered by the HCP. Sitting up for short periods of time may add pressure to the insertion site and cause bleeding. The throat is not affected by an angiography. Fluids are encouraged to promote excretion of the dye used in the testing.

PTS:

CON: Safety

8. The nurse places a patient who is experiencing dyspnea in the Fowler’s position. What is the rationale for the nurse to use this position? 1. Fowler’s position moves the tonsils from the back of the throat. 2. Fowler’s position allows maximum lung expansion. 3. Fowler’s position augments the use of accessory muscles. 4. Fowler’s position relieves stress on the abdominal cavity. ANS: 2 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help patients with respiratory disorders. Page: 539 Heading: Positioning Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

There is no indication of the tonsils obstructing the throat. Fowler’s position allows maximum lung expansion by keeping the abdominal contents from crowding the lungs and thoracic area. Use of accessory muscles is a sign of respiratory distress. Relieving stress on the abdominal cavity does not necessarily improve breathing.

PTS:

CON: Patient-Centered Care

9. The nurse is caring for a patient with chronic lung disease who is receiving oxygen via a nonrebreathing mask. Which observation indicates to the nurse that the system is functioning as expected?

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1. 2. 3. 4.

Both side vents open on expiration, reservoir bag inflated Both side vents open on inspiration, reservoir bag deflated Both side vents closed on inspiration, reservoir bag inflated Both side vents closed on expiration, reservoir bag deflated

ANS: 3 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 3. List data to collect when caring for a patient with a respiratory disorder. Page: 540 Heading: Masks Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analysis (Analyzing) Concept: Oxygenation Difficulty: Moderate Feedback 1

A nonrebreather mask has one or both sides closed to limit the mixing of room air with oxygen. When a patient is using a partial rebreather or nonrebreather mask, ensure that the reservoir is never allowed to collapse to less than half full. This would allow outside oxygen to mix with the concentrated oxygen supply. When a patient is using a partial rebreather or nonrebreather mask, ensure that the reservoir is never allowed to collapse to less than half full. The nonrebreather mask has one or both side vents closed to limit the mixing of room air with oxygen. The vents open to expiration but close on inspiration. It is used to deliver oxygen concentration of 70 to 100 percent. The nonrebreather mask has one or both side vents closed to limit the mixing of room air with oxygen. The vents open to expiration but close on inspiration When a patient is using a partial rebreather or nonrebreather mask, ensure that the reservoir is never allowed to collapse to less than half full.

PTS:

CON: Oxygenation

10. The nurse is providing discharge instructions for a patient who is to use an adrenergic bronchodilator. Which of the following responses would best demonstrate the patient’s understanding? 1. “The metered-dose inhaler (MDI) may keep me up at night, so I will avoid using the MDI at night.” 2. “If my symptoms are not relieved, I may take one puff every 5 minutes until I feel better.” 3. “Using the MDI more often than prescribed can result in worsening symptoms.” 4. “Whenever I feel short of breath, I will take 2 puffs, but no more than 12 puffs a day.” ANS: 3 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help patients with respiratory disorders. Page: 541 Heading: Inhalers

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Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Health Promotion Difficulty: Moderate Feedback 1 2 3 4

MDIs are used at night to prevent nighttime symptoms. Using as needed may be too frequent, and every 5 minutes is not appropriate. Adrenergic bronchodilators, when used too often, can cause severe rebound bronchoconstriction and even death. Adrenergic bronchodilators, when used too often, can cause severe rebound bronchoconstriction and even death.

PTS:

CON: Health Promotion

11. The patient arrives to the emergency department with a stab wound to the chest. The HCP places two chest tubes to drain air and blood from the patient’s thoracic cavity. The nurse sets up the chest tube drainage system. Where should the nurse place the system? 1. Attached to the foot of the bed 2. Along the side of the patient’s knee 3. Below the level of the patient’s chest 4. At the level of the patient’s clavicle ANS: 3 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help patient with respiratory disorders. Page: 544 Heading: Chest Drainage Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1 2

3 4

If the chest tube system were attached to the foot of the bed, whenever the foot was raised or lowered, it could cause excessive tension in the tubing. If it were along the knee, it may not be upright while the patient was in the bed. Although it would be below the chest, it may be pulled by the patient’s movements while in bed and not stabilized. The drainage system must always be kept upright and below the level of the chest to prevent drainage from returning to the chest. The clavicle is at chest level and could cause the drainage to return to the chest.

PTS:

CON: Safety

12. A patient with a chest drainage system is admitted to the medical-surgical unit. The nurse notes vigorous bubbling in the water seal chamber of the system. What should the nurse do?

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1. 2. 3. 4.

Decrease the level of suction until bubbling ceases. Ask the patient to splint the site and cough forcefully. No action is necessary; this is an expected finding. Examine the entire system and tubing for air leaks.

ANS: 4 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 3. List data to collect when caring for a patient with a respiratory disorder. Page: 544 Heading: Chest Drainage Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

Lowering the suction level will help if vigorous bubbling is seen in the suction control chamber. Coughing forcefully can help mobilize clots. Doing nothing is inappropriate and could cause harm to the patient. Vigorous bubbling in the water seal chamber indicates an air leak.

PTS:

CON: Safety

13. The nurse is preparing to suction a patient’s tracheostomy. What is the maximum of time that the nurse can suction safely with each pass of the catheter? 1. 3 to 5 seconds 2. 10 to 15 seconds 3. 15 to 25 seconds 4. 25 to 45 seconds ANS: 2 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help patients with respiratory disorders. Page: 543 Heading: Tracheostomy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Easy Feedback 1 2 3 4

Less than 15 seconds may not clear the secretions. The nurse can safely suction the patient for 15 seconds. More than 15 seconds can irritate mucosa and suction out too much oxygen. More than 15 seconds can irritate mucosa and suction out too much oxygen.

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PTS:

CON: Patient-Centered Care

14. The nurse is caring for a patient who is on a ventilator and the high-pressure alarm sounds. What should the nurse consider as the cause for this alarm? 1. The patient is being weaned. 2. The tubing is disconnected. 3. The electricity is interrupted. 4. The tubing is obstructed. ANS: 4 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help patients with respiratory disorders. Page: 550 Heading: Ventilator Alarms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

There would not be an alarm for the weaning process. Disconnected tubing causes a low-pressure alarm. Loss of power causes its own alarm. High-pressure alarms sound for higher-than-normal resistance to air flow. This might occur if the patient needs to be suctioned; if the patient is biting on the tube, coughing, or trying to talk; if tubing is kinked or otherwise obstructed; or if worsening respiratory disease causes decreased lung compliance.

PTS:

CON: Patient-Centered Care

15. The nurse is caring for patients in a respiratory unit and hears a ventilator alarm from the hallway. Which action should the nurse take first? 1. Assess the patient. 2. Call a code blue. 3. Check the machine. 4. Suction the patient. ANS: 1 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help patients with respiratory disorders. Page: 550 Heading: Ventilator Alarms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Comprehension (Understanding) Concept: Patient-Centered Care Difficulty: Easy Feedback

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Always check the patient first, in case the patient needs support while the ventilator is being checked. The nurse would need to check the patient and ventilator before calling for help or a code blue. Once it is assured that the patient is safe, the machine can be checked. Always check the patient first and then determine the next action, whether it is checking the machine, providing suction, or calling a code.

PTS:

CON: Patient-Centered Care

16. The nurse is reviewing the results of a patient’s pulmonary function studies. Which result indicates the patient’s resting tidal volume is within normal limits? 1. 200 to 400 mL 2. 400 to 600 mL 3. 600 to 800 mL 4. 800 to 1,000 mL ANS: 2 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 5. Identify common diagnostic tests performed to diagnose disorders of the respiratory system. Page: 538 Heading: Pulmonary Function Studies Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Health Promotion Difficulty: Moderate Feedback 1 2 3 4

This is too low tidal volume, which may not be compatible with life. The normal values for tidal volume at rest are 400 to 600 mL. These are too high and should be questioned for potential reading errors. These are too high and should be questioned for potential reading errors. PTS:

CON: Health Promotion

17. The nurse instructs the patient with chronic obstructive pulmonary disease (COPD) on methods to lower the risk of lung complications. One technique is the “long huff” cough. What is the rationale for this type of coughing exercise? 1. Increases oxygenation 2. Removes excess carbon dioxide 3. Ensures thorough lung expansion 4. Helps to open and clear smaller airways ANS: 4 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help patients with respiratory disorders. Page: 538

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Heading: Huff Coughing Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Evaluation (Evaluating) Concept: Health Promotion Difficulty: Moderate Feedback 1 2 3 4

The shorter “huff” is used to clear larger airways, such as the bronchus and throat. The shorter “huff” is used to clear larger airways, such as the bronchus and throat, not the longer huff. The shorter “huff” is used to clear larger airways, such as the bronchus and throat, not the smaller airways. The longer “huff” held out for several seconds helps open and clear smaller airways, such as the bronchioles, which connect the alveoli to the bronchus.

PTS:

CON: Health Promotion

18. The nurse recognizes that the patient is experiencing a respiratory emergency when the patient has wheezes and stridor. What do these sounds indicate? 1. This is an indication of bronchospasm. 2. This is an indication of a foreign body in the alveoli. 3. This is an indication of fluid in the bases of the lungs. 4. This is an indication of a crepitus in the thoracic area. ANS: 1 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and auscultating the chest. Page: 534 Heading: Trachea and Bronchial Tree Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension (Understanding) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

Bronchioles have no cartilage in the wall to maintain patency and can close completely by bronchoconstriction. A foreign body in the alveoli would not induce stridor or wheezes, as that is in the lower airway. This would be rales or crackles in the bases of the lung fields. Crepitus in the thoracic area is an indication of an air leak, typically from a leaky chest tube.

PTS:

CON: Safety

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19. The nurse is caring for a patient who has been diagnosed with respiratory acidosis. Which of the following medical condition would be the contributing factor? 1. Acetaminophen overdose 2. Chronic obstructive pulmonary disease 3. End-stage renal disease 4. Acute hypoxemia due to high altitudes ANS: 2 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 5. Identify common diagnostic tests performed to diagnose disorders of the respiratory system. Page: 528 Heading: Respiration and Acid–Base Balance Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Acid/Base Balance Difficulty: Difficult Feedback 1 2 3 4

Acetaminophen overdose would cause metabolic acidosis. This could cause an accumulation of excess hydrogen and CO2, thus increase the acidity via the respiratory system. Chronic kidney disease would cause metabolic acidosis, not respiratory acidosis. Acute hypoxemia, caused by “altitude sickness,” would cause a temporary respiratory alkalosis, due to the hyperventilation needed to acclimate to the higher altitude.

PTS:

CON: Acid/Base Balance

20. The nurse is caring for the patient who is experiencing uncontrolled diabetes mellitus. The patient is exhibiting Kussmaul’s respirations. What best describes the compensatory action for the respirations? 1. The body is compensating for the metabolic acidosis by releasing CO2 via the lungs. 2. The body is compensating for the metabolic alkalosis by retaining CO2 via the lungs. 3. The body is compensating for the respiratory acidosis by retaining the CO2 in the lungs. 4. The body is compensating for the respiratory alkalosis by releasing the CO2 in the lungs. ANS: 1 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 5. Identify common diagnostic tests performed to diagnose disorders of the respiratory system. Page: 550 Heading: Respiration and Acid–Base Balance Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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2 3 4

Kussmaul’s respirations are a sign of diabetic ketoacidosis (DKA), a form of metabolic acidosis. The lungs compensate by releasing the acidic CO2 with deep frequent respirations. Kussmaul’s respirations releases the CO2 to compensate for metabolic acidosis, not alkalosis. Kussmaul’s respirations are a sign of metabolic acidosis, not respiratory acidosis. The respiratory system is compensating for the metabolic state. Kussmaul’s respirations releases the CO2 to compensate for metabolic acidosis, not alkalosis.

PTS:

CON: Acid/Base Balance

21. The nurse is caring for the patient who has recently recovered from a spontaneous pneumothorax. The nurse palpates the patient’s left shoulder area and feels a “Rice Krispies” presence under the skin. What best describes this symptom? 1. It is a sign of recovery from a pneumothorax. 2. It occurs when air leaks into the subcutaneous tissues. 3. It is a symptom of a pending recurrence of a pneumothorax. 4. It is a sign that the chest tube was removed too soon. ANS: 2 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and auscultating the chest. Page: 560 Heading: Palpation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

This is not a sign of recovery from a pneumothorax. It is crepitus, which is air trapped into the subcutaneous tissues, from either a pneumothorax or leaking chest tube. This is not a sign of a recurrence of a pneumothorax. It is crepitus, which is air trapped into the subcutaneous tissues.

PTS:

CON: Safety

22. The nurse has obtained a noninvasive measurement of the patient’s oxygen saturation. What is this test called?

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Arterial blood gas (ABG) Incentive spirometer Peak flow meter Pulse oximetry

ANS: 4 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 5. Identify common diagnostic tests performed to diagnose disorders of the respiratory system. Page: 550 Heading: Oxygen Saturation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Knowledge (Remembering) Concept: Patient-Centered Care Difficulty: Easy Feedback 1 2 3 4

ABG is an invasive method of measuring the patient’s gases, to diagnose an abnormality in the body regarding homeostasis of the blood chemistry. Incentive spirometer is a device used to facilitate expansion of the lungs, not diagnosis an issue. Peak flow meter measures lung capacity to monitor breathing disorders. Pulse oximetry measure the oxygen saturation by placing a probe on the patient’s finger or ear.

PTS:

CON: Patient-Centered Care

23. The LPN/LVN is caring for a patient with COPD who is using oxygen therapy at 2 L/min. The patient becomes short of breath and requests that the oxygen flow rate to be increased. What is the LPN/LVN’s next step? 1. Increase the flow rate by 2 L. 2. Increase the flow rate by 1 L. 3. Contact the respiratory therapist (RT) for guidance. 4. Instruct the patient on huff coughing. ANS: 3 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help patients with respiratory disorders. Page: 541 Heading: Risks of Oxygen Therapy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Oxygenation Difficulty: Moderate Feedback 1

It is outside the scope of practice for the LPN/LVN to increase the oxygen rate

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without an order. It is outside the scope of practice for the LPN/LVN to increase the oxygen rate without an order. The RT would be a valuable resource when questions arise. Instructing the patient during an episode of huff coughing will not help the patient at that time.

PTS:

CON: Oxygenation

24. The nurse is caring for the patient receiving oxygen therapy. Which of the following is correct regarding a simple face mask? 1. Is can deliver a precise percentage of oxygen therapy. 2. It can be worn while the patient is eating or drinking. 3. It is less claustrophobic for the patient than the other masks. 4. It can deliver oxygen at a concentration from 40 to 60 percent. ANS: 4 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help patients with respiratory disorders. Page: 540 Heading: Oxygen Therapy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Comprehension (Understanding) Concept: Oxygenation Difficulty: Moderate Feedback 1 2 3 4

Precise percentages of oxygen therapy are delivered via a venture mask. Oxygen masks prevent patients from eating or drinking, so a nasal cannula may be used temporarily while the patient eats or drinks. It appears that all oxygen masks may give the patient a feeling of claustrophobia. When delivered at rate between 5 to 10 L/min, it can deliver a concentration from 40 to 60 percent.

PTS:

CON: Oxygenation

25. The nurse is coaching a patient who is using a transtracheal catheter. The nurse recognizes that the patient understands the care for the catheter by which of the following statements? 1. “I will clean the catheter once a day to prevent mucous obstructions.” 2. “I will be able cover the site with a loose scarf or collar.” 3. “I will use a nasal cannula when I want to eat or drink.” 4. “I will not remove the catheter until the site is healed.” ANS: 2 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help patients with respiratory disorders. Page: 555

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Heading: Transtracheal Catheter Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Health Promotion Difficulty: Difficult Feedback 1 2 3 4

The catheter should be removed and cleaned two to three times a day to remove mucous obstructions. This is an alternative to a face mask as the patient may cover the site with a loose scarf or collar. The nasal cannula will not deliver a high flow rate and the transtracheal catheter does not obstruct the nose or mouth. The catheter should be removed and cleaned two to three times a day to remove mucous obstructions.

PTS:

CON: Health Promotion

26. The LPN/LVN is caring for a patient with a chest tube. The nurse notes that the dressing over the insertion site is soiled. What is the most appropriate step for the nurse to take? 1. Change the dressing with sterile petroleum gauze and label the dressing with date and initials. 2. Cleanse the area after removing the old dressing and apply a sterile petroleum gauze over the site. 3. Reinforce the dressing and contact the HCP and assist with the changing of the dressing. 4. Apply the two padded clamps at the bedside and change the dressing using sterile technique. ANS: 3 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help patients with respiratory disorders. Page: 545 Heading: Chest Tube Insertion Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application (Applying) Concept: Professionalism Difficulty: Moderate Feedback 1 2 3 4

The LPN/LVN scope of practice does not include changing the dressing. The LPN/LVN scope of practice does not include changing the dressing. The LPN/LVN scope of practice does not include changing the dressing, so the LPN/LVN will contact the HCP and assist with the care. The LPN/LVN scope of practice does not include changing the dressing; the clamps are to be used if the chest tube becomes accidentally disconnected from the tubing.

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PTS:

CON: Professionalism

27. The LPN/LVN is caring for a patient with a chest tube and notices that the tubing appears to be occluded with clots. What is the LPN/LVN’s next step with this issue? 1. Gently squeeze portions of the tubing form the patient to the system until the clots are moved to the system. 2. Hold the proximal end of the tubing between two fingers while sliding the fingers toward the system. 3. Document the findings and prepare to assist the HCP for removal of the chest tube. 4. If tubing appears to be occluded, consult with the HCP for specific orders. ANS: 4 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help patients with respiratory disorders. Page: 545 Heading: Stripping and Milking Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application (Applying) Concept: Professionalism Difficulty: Moderate Feedback 1 2

3 4

This is milking, which is somewhat safer than stripping, but not done routinely. This is stripping and can cause harm to the patient by causing negative pressure at the openings in the tubing and can suck lung tissue into the system and cause damage. Documenting and preparing for removal is not the appropriate nursing action, as there is no indication that this is necessary. The HCP should be notified and the orders carried out per the scope of practice of the LPN/LVN.

PTS:

CON: Professionalism

28. The nurse is assessing a patient’s respiratory system and notices upon auscultation bibasilar crackles. How would the nurse explain these findings to the patient? 1. “When you said ‘99’ during my assessment, I heard some unusual vibrations.” 2. “When you said ‘ee’ during my assessment, it sounded like ‘ay.’” 3. “When you took a deep breath, I heard sounds like cellophane being crumpled.” 4. “When I placed my hands on your back during a deep breath, I felt unusual movement.” ANS: 3 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and auscultating the chest. Page: 540 Heading: Auscultation

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Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Easy Feedback 1 2 3 4

This would define bronchophony. Usually the sounds are muffled. This is indicative of egophony. The “ee’ would be understandable when auscultated. This is indicative of fluid buildup in the lungs and can sound like cellophane being crumpled or bubbling. This would not indicate crackles, which are auscultated, not palpated.

PTS:

CON: Patient-Centered Care

29. The nurse is preparing to perform a routine cleaning of the patient’s cuffed tracheostomy. The nurse notes that the cuff has been deflated since the patient’s weaning off of the mechanical ventilator. What is the nursing intervention at this time? 1. Contact the HCP for further orders. 2. Do not start the cleaning until the cuff is properly inflated. 3. Continue with the cleaning of the tracheostomy. 4. Contact the RT to have the cuff inflated. ANS: 3 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help patients with respiratory disorders. Page: 560 Heading: Tracheostomy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application (Applying) Concept: Oxygenation, Safety Difficulty: Moderate Feedback 1 2 3

The cuff is to be deflated routinely to prevent tissue damage. No need to contact the HCP. The cuff is to be deflated routinely to prevent tissue damage. Continue with the cleaning, as the cuff is deflated routinely after mechanical ventilation is discontinued. The cuff is used to prevent air leakage during mechanical ventilation. The cuff is to be deflated routinely to prevent tissue damage. No need to contact the RT.

PTS:

CON: Oxygenation | Safety

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30. The nurse is using the nursing diagnosis of ineffective airway clearance. The nurse is implementing the intervention of ambulating or turning the patient every 2 hours. What is the rationale for this intervention? 1. Movement helps mobilize secretions. 2. Movement facilitates intestinal motility. 3. Movement facilitates circulation of the extremities. 4. Movement protects the patient from pressure ulcers. ANS: 1 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help the patient with respiratory disorders. Page: 562 Heading: Nursing Care Plan for the Patient With a Tracheostomy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Patient-Centered Care, Health Promotion Difficulty: Easy Feedback 1 2 3 4

Movement helps to mobilize secretions. Although the other rationales are appropriate to explain movement, they do not pertain to the airway clearance. Although this rationale is appropriate to explain movement, it does not pertain to the airway clearance, the focus of the plan of care. Although this rationale is appropriate to explain movement, it does not pertain to the airway clearance, the focus of the plan of care. Although this rationale is appropriate to explain movement, it does not pertain to the airway clearance, the focus of the plan of care.

PTS:

CON: Patient-Centered Care | Health Promotion

31. The nurse is administering a pneumococcal vaccine to an older patient. What is the rationale for this vaccine? 1. There is a decline in effectiveness of lung defense mechanisms. 2. Many older adults are exposed to more pathogens as they age. 3. Many older adults develop immunity to viral pneumonia, not bacterial. 4. Many older adults become residents in extended-care facilities (ECFs). ANS: 1 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 2. Identify how aging affects the respiratory system. Page: 567 Heading: Effects of Aging on the Respiratory System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge (Remembering) Concept: Health Promotion Difficulty: Easy

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Feedback 1 2 3 4

The aging process decreases lung defense mechanisms, such as effective coughing, airway clearance, and lung expansion. Exposure to pathogens facilitates immunity if the patient is healthy overall. There is no differentiation between immunity from viral versus bacterial pneumonia. There is no correlation between patients in extended care facilities and pneumonia, other than patients in an ECF are often immunocompromised due to comorbidity.

PTS:

CON: Health Promotion

32. The nurse is preparing a patient for a spirometer test to diagnose COPD. The patient asks how to prepare for this test. How should the nurse respond? 1. “Refrain from using a short-acting inhaler 6 to 8 hours prior to testing.” 2. “Do not eat or drink anything for 6 to 8 hours prior to the testing.” 3. “Refrain from vigorous exercise 6 to 8 hours prior to the testing.” 4. “Take all medications, including inhalers prior to the testing.” ANS: 1 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 6. Plan nursing care for patients undergoing each of the diagnostic tests. Page: 555 Heading: Incentive Spirometry Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Health Promotion Difficulty: Easy Feedback 1 2

3 4

As the spirometer test is assessing function of inhalation and exhalation, the short-acting inhaler may skew the results. This is not necessary as this is a lung function test performed without anesthesia and there typically is no risk for aspiration. Should the patient need a bronchoscopy, the patient would be NPO. This should not affect the testing. This may skew the results if the patient takes all inhalers; the usual daily medications should be taken, but if the patient is taking a short-acting inhaler, it may skew the results.

PTS:

CON: Health Promotion

MULTIPLE RESPONSE 1. A patient is diagnosed with respiratory acidosis. Which health problems should the nurse consider as causing this patient’s diagnosis? (Select all that apply.) 1. Acute aspirin overdose

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Kidney failure Hyperventilation Shallow respirations Chronic lung disease

ANS: 4, 5 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and auscultating the chest. Page: 528 Heading: Respiration and Acid–Base Balance Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension (Understanding) Concept: Acid/Base Balance Difficulty: Easy

1. 2. 3. 4. 5.

PTS:

Feedback Acute aspirin overdose can cause initial respiratory alkalosis. Kidney or renal failure is associated with metabolic acidosis. Hyperventilation is associated with respiratory alkalosis. Chronic lung disease and shallow respirations both are associated with hypoventilation, which causes respiratory acidosis. Chronic lung disease and shallow respirations both are associated with hypoventilation, which causes respiratory acidosis. 1

CON: Acid/Base Balance

2. The nurse is providing care to a patient who has been receiving high oxygen concentration therapy for 36 hours. Which of the following symptoms, if exhibited by the patient, should the nurse contact the HCP for suspected lung damage from this therapy? (Select all that apply.) 1. Numbness in the extremities 2. Hypoactive bowel sounds 3. Crepitus in the scapular area 4. Dry cough, and chest pain 5. PaO2 greater than 100 mm Hg ANS: 1, 5 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measure Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and auscultating the chest. Page: 530 Heading: Masks Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Oxygenation Difficulty: Difficult

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1. 2. 3. 4. 5.

PTS:

Feedback Numbness in the extremities can be a sign of lung damage from the high oxygen concentration given over 24 hours. Nausea, not hypoactive bowel sounds, can be a sign of lung damage from the high oxygen concentration over 24 hours. Crepitus is trapped air in the subcutaneous tissue from either a pneumothorax or leaky chest tube. Dry cough and chest pain can be signs of lung damage from the high oxygen concentration given over 24 hours. PaO2 >100 mm Hg can be a sign of lung damage from the high oxygen concentration given over 24 hours. 1

CON: Oxygenation

3. Which of the following are effects of aging on the respiratory system? (Select all that apply.) 1. Decrease in peak airflow and gas exchange 2. Weakening of respiratory muscles 3. Increased lung surfactant levels 4. Decline of effectiveness of lung defense mechanisms 5. Increased tidal lung capacity ANS: 1, 2, 4 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 2. Identify how aging affects the respiratory system. Page: 532 Heading: Effects of Aging on the Respiratory System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge (Remembering) Concept: Patient-Centered Care Difficulty: Easy

1. 2. 3. 4.

5. PTS:

Feedback The lung capacity decreases with age. All muscles decrease with the effects of aging, including the respiratory muscles. There is no correlation of the lung surfactant levels. As the body ages, the ability to defend against pathogens decreases, hence the need for influenza and pneumonia immunizations for the older population. The tidal volume actually decreases with aging. 1

CON: Patient-Centered Care

4. The nurse is assessing a patient who has a history of COPD. What are some of the expected findings during the assessment? (Select all that apply.) 1. Barrel chest 2. Bradypnea

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3. Chronic cough 4. Nail clubbing 5. Weight loss ANS: 1, 4, 5 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 4. Recognize expected findings when inspecting, palpating, percussing, and auscultating the chest. Page: 535 Heading: Huff Coughing Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge (Remembering) Concept: Oxygenation Difficulty: Easy

1. 2. 3. 4. 5.

PTS:

Feedback Barrel chest occurs with the chronic retention within the alveolar tissue. This is not a typical finding of COPD. The patient may have a longer than normal exhalation. A chronic cough may indicate other health issues. This is a sign of chronic tissue hypoxia. Weight loss may occur due to dyspnea, interfering with eating and need for extra calories for breathing. 1

CON: Oxygenation

COMPLETION 1. The HCP ordered azithromycin 500 mg for the first day, then 250 mg a day for 4 days for a patient with pneumonia. The pharmacy has azithromycin 250-mg tablets in stock. How many tablets will be sent to the facility for the patient’s medication? ANS: 6 Chapter: Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures Objective: 7. Discuss therapeutic measures used to help patients with respiratory disorders. Page: 535 Heading: Respiratory System Function, Assessment, and Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Pharmacologic Therapies Cognitive Level: Application (Applying) Concept: Collaboration Difficulty: Easy Feedback: The medication order is 500 mg for 1 day, followed by 4 days of 250 mg. The supply is 250-mg tablets. The first day will be two tablets, followed by 4 days of 250-mg = 4 tablets. The total needed to complete this order/prescription is 2 + 4 = 6 tablets.

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PTS:

CON: Collaboration

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Chapter 30. Nursing Care of Patients With Upper Respiratory Tract Disorders MULTIPLE CHOICE 1. The nurse instructs a patient with a nosebleed to sit up and lean slightly forward. For which reason does the nurse teach the patient to maintain this posture? 1. To prevent dizziness or syncope 2. To reduce bleeding from the anterior plexus 3. To help prevent symptoms of shock due to blood loss 4. To avoid unseen blood from being swallowed or aspirated ANS: 4 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 3. Describe current therapeutic measures for disorders of the upper respiratory tract. Pages: 556–567 Heading: Disorders of the Nose and Sinuses—Epistaxis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Professionalism Difficulty: Moderate Feedback 1 2 3 4

The suggested position is not used to prevent dizziness or syncope. The question does not provide specific information regarding the bleeding site. The positioning of the patient will not prevent shock due to blood loss. Instructing the patient with a nosebleed to sit in a chair and lean slightly forward is done to avoid aspirating or swallowing blood.

PTS:

CON: Professionalism

2. After positioning a patient with epistaxis, which action will the nurse take next? 1. Monitor for the level of pain. 2. Place warm packs on the nose. 3. Apply ice to the nose and eye area. 4. Irrigate the nasal passages with sterile saline. ANS: 3 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 4. Plan nursing care for the patient with an upper respiratory disorder. Page: 567 Heading: Disorders of the Nose and Sinuses—Epistaxis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Professionalism Difficulty: Moderate

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Feedback 1 2 3 4

There is no information that indicates the patient is experiencing pain. Warm compresses will cause vasodilation and promote bleeding. Ice packs to the nose and eye area may be used to constrict the bleeding vessels. Irrigation can dislodge clots, resulting in bleeding.

PTS:

CON: Professionalism

3. A patient is discharged from the emergency department after treatment for epistaxis. The physician orders that all home medications be continued. Which medication will the nurse question? 1. Ibuprofen 2. Furosemide 3. Amlodipine 4. Montelukast sodium ANS: 1 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 3. Describe current therapeutic measures for disorders of the upper respiratory tract. Page: 567 Heading: Disorders of the Nose and Sinuses—Epistaxis Integrated Process: Communication and Documentation Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies Cognitive Level: Analysis (Analyzing) Concept: Professionalism Difficulty: Moderate Feedback 1 2 3 4

NSAIDs, such as ibuprofen, have antiplatelet action and can increase bleeding risk. Antihypertensives and diuretics can control high blood pressure, a risk factor for epistaxis. Antihypertensives and diuretics can control high blood pressure, a risk factor for epistaxis. Leukotriene inhibitors do not influence bleeding.

PTS:

CON: Professionalism

4. A patient returns to the observation area after outpatient septoplasty for a deviated septum. Which observation will most concern the nurse? 1. The patient swallows frequently. 2. The patient’s blood pressure is 136/88 mm Hg. 3. The patient complains of tenderness in the nasal area. 4. The patient’s moustache dressing has a 2-centimeter area of blood on it. ANS: 1

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Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 4. Plan nursing care for the patient with an upper respiratory disorder. Page: 558 Heading: Deviated Septum Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Frequent swallowing is an indication of continued bleeding after septoplasty; the blood runs down the back of the throat. The blood pressure is within normal limits. Some tenderness and bleeding is expected. The area of blood on the dressing is not indicative of abnormal bleeding.

PTS:

CON: Patient-Centered Care

5. The nurse is collecting data from a patient with a sinus infection. The patient has purulent nasal drainage, fever, and pain over the cheeks and upper teeth. Which sinuses does the nurse identify as being involved in the patient’s condition? 1. Ethmoid 2. Frontal 3. Nasal 4. Maxillary ANS: 4 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 1. Explain the pathophysiology of disorders of the upper respiratory tract. Page: 560 Heading: Sinusitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

In ethmoid sinusitis, pain occurs between and behind the eyes. Pain in the forehead typically indicates frontal sinusitis. All of the mentioned sinuses are generally referred to as nasal sinuses. The patient usually has pain over the region of the affected sinuses and purulent nasal discharge. If a maxillary sinus is affected the patient experiences pain over the cheek and upper teeth.

PTS:

CON: Patient-Centered Care

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6. An obese patient is being evaluated by the health care provider (HCP) for sleep apnea. Which recommendation by the HCP does the nurse find unexpected? 1. Using a sedative before sleeping 2. Implementing a weight loss program 3. Removing excess tissue with surgery 4. Using a mandibular advancement device ANS: 1 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 3. Describe current therapeutic measures for disorders of the upper respiratory tract. Page: 553 Heading: Sleep Apnea Integrated Process: Caring Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1

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Using a sedative before sleeping can worsen the patient’s sleep apnea by relaxing the muscles of the pharynx. Alcohol consumption will have the same effect. Weight loss is important for the patient with sleep apnea. If all interventions and treatments fail, surgery may be needed to remove excess tissue in the throat and around the pharynx. Use of a mandibular advancement device is prescribed early in treatment for sleep apnea.

PTS:

CON: Safety

7. The nurse is providing care for an adult patient with a diagnosis of viral rhinitis. The HCP orders acetaminophen and a decongestant. Comfort measures include rest and an increase in vitamin C and oral fluids. Which patient health information will cause the nurse to question one of the treatments? 1. Urinary stress incontinence 2. History of hypertension 3. Allergic reaction to sulfa 4. Gastric irritation and reflux ANS: 2 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 3. Describe current therapeutic measures for disorders of the upper respiratory tract. Page: 560 Heading: Viral Rhinitis/Common Cold Integrated Process: Physiological Integrity—Pharmacological Therapies Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety

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Difficulty: Moderate Feedback 1 2

3 4

None of the prescribed treatments are questionable for a patient with urinary stress incontinence. Decongestants cause vasoconstriction, which reduces swelling and congestion. However, patients with a history of hypertension or heart disease should use any vasoconstrictor with caution. None of the prescribed treatments contain sulfa. None of the prescribed treatments are contraindicated for patients with gastric irritation and reflux.

PTS:

CON: Safety

8. A patient comes to the HCP’s office reporting a serious sore throat that “has lasted for 2 weeks.” A rapid streptococcal antigen test is positive for strep throat. Which is the most important diagnostic test the nurse expects the HCP to order? 1. Identifying the exudate in the throat 2. Culture and sensitivity testing 3. Laboratory tests for renal function 4. Antibiotic allergy testing ANS: 3 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 1. Explain the pathophysiology of disorders of the upper respiratory tract. Page: 564 Heading: Pharyngitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

The patient’s diagnosis is already known. There is no need to identify the exudate in the throat. The HCP will want a culture and sensitivity performed to identify the most effective antibiotic; however, a broad-spectrum antibiotic will be prescribed initially. Untreated strep throat can result in the development of glomerulonephritis, and after 2 weeks of untreated infection, the patient’s renal function should be assessed. The patient is also at risk for rheumatic fever. Antibiotic allergy testing is not routinely performed. Known allergy history will be considered.

PTS:

CON: Patient-Centered Care

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9. The nurse is previewing teaching information for a patient who is diagnosed with noncancerous, chronic laryngitis. Which topic is least useful in addressing modifiable causes of the patient’s condition? 1. History of smoking two packs daily 2. Repeated treatment for alcohol abuse 3. 35 pounds overweight 4. Sensitivity to multiple allergens ANS: 4 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 1. Explain the pathophysiology of disorders of the upper respiratory tract. Page: 564 Heading: Laryngitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Smoking two packs of cigarettes daily can cause chronic laryngitis, but the behavior can be modified. Alcohol abuse can cause chronic laryngitis; the patient needs to continue treatment to modify this behavior. Chronic laryngitis can be caused by gastric reflux related to obesity; however, the behavior is modifiable. Sensitivity to multiple allergens is the least modifiable cause of the patient’s chronic laryngitis.

PTS:

CON: Patient-Centered Care

10. The nurse is providing care for a patient immediately after a tonsillectomy. Which action by the nurse should be avoided? 1. Maintain the patient in a semi-Fowler’s position. 2. Monitor the patient for bleeding and airway maintenance. 3. Provide the patient with warm tea sweetened with honey. 4. Place a humidifier and suction equipment in the patient’s room. ANS: 3 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 4. Plan nursing care for the patient with an upper respiratory disorder. Page: 564 Heading: Tonsillitis/Adenoiditis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback

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1 2 3

The patient is maintained in a semi-Fowler’s position to reduce swelling and promote drainage. The maintenance of a patent airway and the presence of bleeding needs to be closely monitored. Following a tonsillectomy, the patient will be encouraged to prevent dehydration with oral fluids. Cool fluids will be soothing; warm or hot fluids can increase bleeding and should be avoided. Placing a humidifier in the room will prevent drying, and suction equipment is available in case of bleeding.

PTS:

CON: Patient-Centered Care

11. The nurse is providing care for a patient who is hospitalized for complications from West Nile virus. Which data is most indicative that the patient is improving? 1. The patient is alert and oriented. 2. Patient states skin itching has subsided. 3. The patient has completed IV antibiotics. 4. Patient shows no mosquito allergy symptoms. ANS: 1 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 5. Discuss how you will know whether your care has been effective. Page: 570 Heading: Other Respiratory Viruses Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

2 3 4

A complication of West Nile virus is encephalitis, which causes confusion, seizures, loss of sensation, among other manifestations. The patient being alert and orientated is an indication of effective treatment. Itching is not a symptom of West Nile virus. West Nile virus is not responsive to antibiotics; there is no information about a bacterial-related complication. West Nile virus is not caused by a mosquito allergy.

PTS:

CON: Patient-Centered Care

12. The nurse is providing care for a patient diagnosed with influenza. The patient has a fever, chills, sore throat, and a cough. Breath sounds include crackles and wheezes. For which reason will the nurse contact the physician? 1. The antiviral medication appears to be ineffective. 2. The patient needs IV fluids to loosen lung secretions. 3. The breath sounds indicate development of pneumonia. 4. The patient is experiencing bronchial irritation from coughing.

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ANS: 3 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 2. Describe etiologies, signs, and symptoms of disorders of the upper respiratory tract. Page: 565 Heading: Influenza Integrated Process: Communication and Documentation Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Collaboration Difficulty: Moderate Feedback 1 2 3

There is no validation or timeline regarding the use of an antiviral medication. The question does not describe the cough as being either productive or nonproductive. There is no indication that the patient is NPO. The most common complication of influenza is pneumonia, which may be caused by the same virus as the flu or by a secondary bacterial infection. This should be considered if the patient experiences persistent fever and shortness of breath or if the lungs develop crackles or wheezes. It is possible that the patient has bronchial irritation from coughing; however, the presence of crackles and wheezes are most likely related to pneumonia.

PTS:

CON: Collaboration

13. The nurse is preparing to reinforce teaching to a patient scheduled for a laryngectomy due to cancer. Which preoperative teaching review is least necessary for the immediate postoperative period? 1. The loss of the ability to breathe through the nose and mouth. 2. The process of performing tracheostomy care and suctioning. 3. The initial feelings associated with the inability to speak. 4. The reason for performing a dietary consult prior to surgery. ANS: 2 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 6. Identify the special needs of a patient who has undergone a laryngectomy. Page: 565 Heading: Cancer of the Larynx Integrated Process: Teaching/Learning Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 2

It is important to review that the patient will be unable to breathe through the nose and mouth. Understanding will help to defer feelings of panic. The patient will need to learn about performing tracheostomy care and suctioning, but this is the least important information during the immediate

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postoperative period. The nurse needs to review the patient’s inability to speak after a laryngectomy. Understanding will help to defer feelings of panic. Patients with cancer of the larynx may not be able to eat and may be malnourished. Dietary therapy needs to be discussed preoperatively.

PTS:

CON: Patient-Centered Care

14. The nurse is providing care for a patient who is 4 days postoperative for a laryngectomy. Which data about the patient indicates the need to modify the expected outcomes? 1. The patient has clear lung sounds and coughs up secretions. 2. The patient achieves an acceptable pain level with use of a patient-controlled pump. 3. The patient begins to ask about how to perform tracheostomy care. 4. The patient uses both a magic slate and picture board for communication. ANS: 2 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 6. Identify the special needs of a patient who has undergone a laryngectomy. Page: 568 Heading: Cancer of the Larynx Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

3 4

It is expected that the patient will have clear lung sounds and cough up secretions 4 days after surgery. After 3 days, the patient should not need the around-the-clock pain management from a patient-controlled pump, which is usually used for 2 to 3 days. Asking about how to perform tracheostomy care indicates acceptance of the changes related to a laryngectomy. The use of multiple communication devices is acceptable.

PTS:

CON: Patient-Centered Care

15. The nurse is caring for a patient who is malnourished due to throat cancer. During the hospital stay following a laryngectomy, how does the nurse conclude that the patient’s diet is adequate? 1. The patient’s weight is stable postoperatively. 2. The patient’s incision displays complete healing. 3. The patient has active bowel sounds in all quadrants. 4. The patient is tolerating intermittent tube feedings. ANS: 4 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders

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Objective: 6. Identify the special needs of a patient who has undergone a laryngectomy. Page: 566 Heading: Cancer of the Larynx Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 2 3 4

If the malnourished patient’s weight is stable, nutrition therapy is likely to be inadequate. The patient will not experience complete healing during hospitalization. Active bowel sounds are not an indication of adequate nutrition. Monitoring a patient’s nutrition status is important especially if the patient is initially malnourished. After a laryngectomy, the nurse will conclude that nutrition status is adequate if alternate feeding methods are tolerated well.

PTS:

CON: Patient-Centered Care

16. The family of a patient awaiting a laryngectomy for cancer asks how the patient will communicate. Which explanation will the nurse provide to the family? 1. “Classes on sign language will be provided for the patient and family.” 2. “A special valve that diverts air into the trachea allows patients to talk.” 3. “Patients can be taught to swallow air and talk as air is let out of the esophagus.” 4. “I’m sorry, but unfortunately, patients with laryngectomies cannot communicate.” ANS: 3 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 6. Identify the special needs of the patient who has undergone a laryngectomy. Page: 566 Heading: Cancer of the Larynx Integrated Process: Teaching/Learning Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Communication Difficulty: Moderate Feedback 1 2 3 4

The patient will have options for developing a method of speech. Sign language is most effective for patients who are deaf. A valve can divert air into the esophagus, not the trachea. Esophageal speech is one method of communicating with a laryngectomy. Patients with laryngectomies can communicate.

PTS:

CON: Communication

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17. The nurse is reviewing patient teaching with a patient scheduled for a laryngectomy. For which reason will the nurse reinforce careful use of narcotics for postsurgical pain management? 1. To avoid unnecessary incision stress from straining for a bowel movement 2. To decrease the possibility of drug dependency after discharge home 3. To avoid pneumonia from increased respiratory tract secretions 4. To prevent ineffective deep breathing and coughing to clear the airway ANS: 4 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 6. Identify the special needs of the patient who has undergone a laryngectomy. Page: 566 Heading: Cancer of the Larynx Integrated Process: Teaching/Learning Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1

2 3 4

Narcotics can cause constipation, but this is not a reason to withhold them from a postsurgical patient. Straining for a bowel movement will not cause stress on the laryngectomy incision. Narcotics can be addicting, but the length of use should not cause drug dependency after discharge home. Narcotics do not increase respiratory secretions and alone are not a cause of postsurgical pneumonia. It is important for patients with laryngectomies to be able to deep breathe and cough to clear the airway as a method to prevent pneumonia. Narcotics can depress the cough reflex and interfere with deep-breathing compliance.

PTS:

CON: Safety

18. During the postoperative period, the nurse reinforces teaching to a patient recovering from a laryngectomy about how to live with a tracheostomy. Which information will the nurse review? 1. “Avoid suctioning your tracheostomy at home; you could damage your trachea.” 2. “When in public, you should be prepared for people to ask questions about your condition.” 3. “You will be able to return to your normal activities, including showering and swimming.” 4. “Be sure to protect your tracheostomy from pollutants such as powders, hair, and chemicals.” ANS: 4 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 6. Identify the special needs of the patient who has undergone a laryngectomy. Page: 566 Heading: Cancer of the Larynx Integrated Process: Clinical Patient-Centered Process (Nursing Process)

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Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

The patient should be taught to suction the tracheostomy at home; damage to the trachea is unlikely with correct technique. The patient may have some curiosity-driven encounters; however, the nurse has more important teaching to review. Activities that would allow water to enter the tracheostomy, such as showering or swimming, should be avoided. Pollutants, such as powders, chemicals, and hair, can enter the tracheostomy and cause irritation or infection. The nurse needs to reinforce this teaching.

PTS:

CON: Safety

MULTIPLE RESPONSE 1. A patient sees an HCP for symptoms of viral rhinitis. Which treatments does the nurse expect to be prescribed for this patient? (Select all that apply.) 1. Rest 2. Fluids 3. Decongestants 4. Bronchodilators 5. Antibacterial agents ANS: 1, 2, 3 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 3. Describe current therapeutic measures for disorders of the upper respiratory tract. Page: 560 Heading: Viral Rhinitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Collaboration Difficulty: Difficult

1. 2. 3. 4.

Feedback Rest, fluids, and decongestants are helpful for the treatment of viral rhinitis (common cold). Rest, fluids, and decongestants are helpful for the treatment of viral rhinitis (common cold). Rest, fluids, and decongestants are helpful for the treatment of viral rhinitis (common cold). Bronchodilators are used for obstructive airway disease such as asthma. Rhinitis does not affect the lungs.

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5. PTS:

Antibiotics are used for bacterial infections. 1

CON: Collaboration

2. A patient reports having a cold to the nurse in a HCP’s office. Which symptoms does the patient report that causes the nurse to suspect influenza instead? (Select all that apply.) 1. Sore throat 2. Severe muscle aches 3. Runny nose 4. Persistent cough 5. Sudden onset of symptoms ANS: 1, 2, 4, 5 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: Describe the etiologies, signs, and symptoms of disorders of the upper respiratory tract. Page: 564 Heading: Influenza Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

PTS:

Feedback The nurse will suspect influenza instead of a cold if the patient has a sudden onset of symptoms. Severe muscle aches, a sore throat, and persistent cough are also associated with influenza. The nurse will suspect influenza instead of a cold if the patient has a sudden onset of symptoms. Severe muscle aches, a sore throat, and persistent cough are also associated with influenza. A runny nose is less common with influenza, but common with a cold. This symptom alone does not cause the nurse to suspect influenza, especially in the presence of more definitive manifestations. The nurse will suspect influenza instead of a cold if the patient has a sudden onset of symptoms. Severe muscle aches, a sore throat, and persistent cough are also associated with influenza. The nurse will suspect influenza instead of a cold if the patient has a sudden onset of symptoms. Severe muscle aches, a sore throat, and persistent cough are also associated with influenza. 1

CON: Patient-Centered Care

3. A patient is diagnosed with nasal polyps. For which additional health problems should the nurse assess this patient? (Select all that apply.) 1. Asthma 2. Chronic sinusitis 3. Allergy to aspirin 4. Chronic bronchitis

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5. Allergy to pet dander ANS: 1, 3 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: 1. Explain the pathophysiology of disorders of the upper respiratory tract. Page: 563 Heading: Nasal Polyps Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

2. 3.

4. 5.

PTS:

Feedback Some patients with nasal polyps also have asthma and are allergic to aspirin. This is called aspirin triad asthma because the three components often occur together. Nasal polyps are not associated with chronic sinusitis, chronic bronchitis, or an allergy to pet dander. Some patients with nasal polyps also have asthma and are allergic to aspirin. This is called aspirin triad asthma because the three components often occur together. Nasal polyps are not associated with chronic sinusitis, chronic bronchitis, or an allergy to pet dander. Nasal polyps are not associated with chronic sinusitis, chronic bronchitis, or an allergy to pet dander. 1

CON: Patient-Centered Care

4. A patient is demonstrating signs of pharyngitis. Which symptoms will the nurse expect to assess in this patient? (Select all that apply.) 1. Headache 2. Dysphagia 3. Sore throat 4. Extreme thirst 5. Exudate in the throat ANS: 1, 2, 3, 5 Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: Describe the etiologies, signs, and symptoms of disorders of the upper respiratory tract. Page: 561 Heading: Pharyngitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

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1. 2. 3. 4. 5.

PTS:

Feedback Exudate usually signifies bacterial infection and may be accompanied by fever, chills, headache, and generalized malaise. Some patients may also experience dysphagia. The most common symptom of pharyngitis is a sore throat. Extreme thirst is not a symptom of pharyngitis. The throat appears red and swollen and exudate may be present, which may signify an infection. 1

CON: Patient-Centered Care

COMPLETION 1. The release of histamine and other substances causes vasodilation and edema. The resulting inflammation of the nasal mucous membranes is called . ANS: rhinitis Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: Describe the etiologies, signs, and symptoms of disorders of the upper respiratory tract. Page: 561 Heading: Rhinitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback: The presence and cause of histamines will help the nurse to identify conditions and symptoms. In the case of rhinitis, inflammation of the mucous membranes is indicative of some degree of nasal airway obstruction. PTS:

CON: Patient-Centered Care

2. A patient is diagnosed with sinusitis and reports pain over the cheeks and upper teeth in addition to pain between and behind the eyes. The pain locations are indicative of inflammation in the maxillary and sinuses. ANS: ethmoid Chapter: 30. Nursing Care for Patients With Upper Respiratory Tract Disorders Objective: Describe the etiologies, signs, and symptoms of disorders of the upper respiratory tract. Page: 561 Heading: Sinusitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Need: Physiological Integrity—Physiological Adaptation

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Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback: It is important for nurses to have knowledge of anatomy, physiology, and pathophysiology to implement the Clinical Problem-Solving Process (Nursing Process). The type and location of the patient’s pain and condition will assist with nursing care decisions such as positioning and environment management. PTS:

CON: Patient-Centered Care

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Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders MULTIPLE CHOICE 1. A patient is admitted to a respiratory unit with a diagnosis of pneumonia. Assessment data reveal the patient to be febrile and experiencing a weak, congested-sounding cough, with moist crackles throughout the lung fields. Based on the data provided, the nurse will focus care on which issue? 1. Confusion from fever 2. Inadequate oxygen level 3. Difficulty with breathing 4. Inability to clear the airway ANS: 4 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Describe the etiologies, signs, and symptoms of each of the disorders. Page: 577 Heading: Pneumonia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

There is no information indicating the patient is experiencing confusion. There is no information indicating the patient’s oxygen level. The patient may have difficulty breathing due to congestion; airway clearance is the priority. The patient has a weak, congested-sounding cough, which indicates an inability to clear the airway.

PTS:

CON: Patient-Centered Care

2. The nurse is caring for a patient with pneumonia. Which set of laboratory tests will be most helpful to the nurse to monitor the condition of this patient? 1. Electrolytes and serum creatinine 2. Complete blood count (CBC) and urinalysis 3. Partial thromboplastin time (PTT) and serum potassium 4. White blood cell (WBC) count and arterial blood gases (ABGs) ANS: 4 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Identify tests that are used to diagnose lower respiratory disorders. Page: 577 Heading: Pneumonia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation

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Cognitive Level: Physiological Integrity—Physiological Adaptation Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Urinalysis, electrolytes, and creatinine are useful in monitoring kidney and bladder problems. Urinalysis, electrolytes, and creatinine are useful in monitoring kidney and bladder problems. PTT and potassium may be ordered for cardiovascular problems, among other disorders. WBCs are elevated in infection, and ABGs may be abnormal if gas exchange is impaired as with pneumonia. CBC may be helpful, but WBC is more specific.

PTS:

CON: Patient-Centered Care

3. The nurse is reviewing data collected on a patient with a respiratory disorder. Which factors does the nurse identify as placing the patient at risk for lung cancer? 1. Smoking and exposure to radon gas 2. Living in a cold climate and having pets 3. Eating foods high in beta carotene and fiber 4. Living in crowded conditions and a lack of sunlight ANS: 1 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: List data to collect when caring for patients with disorders of the lower respiratory tract. Page: 578 Heading: Lung Cancer Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

Smoking is the biggest risk factor for lung cancer. Radon exposure is also a significant factor. Living in a cold climate, having pets, eating foods high in beta carotene and fiber, living in crowded conditions, and lack of sunlight are not identified risk factors for the development of lung cancer. Living in a cold climate, having pets, eating foods high in beta carotene and fiber, living in crowded conditions, and lack of sunlight are not identified risk factors for the development of lung cancer. Living in a cold climate, having pets, eating foods high in beta carotene and fiber, living in crowded conditions, and lack of sunlight are not identified risk factors for the development of lung cancer.

PTS:

CON: Patient-Centered Care

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4. A patient with lung cancer develops pleural effusion. Which explanation by the nurse would help the patient understand this problem? 1. “Pus has developed in your alveoli that must be removed to improve your breathing.” 2. “You have large amounts of fluid collecting in your airways because of your diagnosis.” 3. “Fluid has collected in the space between your lungs and the sac surrounding your lungs.” 4. “Fluid in your pericardial sac places pressure on your lungs, making it difficult to breathe.” ANS: 3 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Describe the etiologies, signs, and symptoms of each of the disorders. Page: 583 Heading: Lung Cancer Integrated Process: Communication and Documentation Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

Empyema is a collection of pus in the plural space, not the alveoli. Pleural effusion collects in the pleural space and not the airways. When excess fluid collects in the pleural space, it is called a pleural effusion. Fluid normally enters the pleural space from surrounding capillaries and is reabsorbed by the lymphatic system. When a pathological condition causes an increase in fluid production or inadequate reabsorption of fluid, excess fluid collects. Pleural effusion fluid is not in the airways, alveoli, or around the heart.

PTS:

CON: Patient-Centered Care

5. A patient diagnosed with a pleural effusion is experiencing severe dyspnea. With which procedure does the nurse anticipate assisting? 1. Tracheostomy 2. Thoracentesis 3. Bronchoscopy 4. Pericardiocentesis ANS: 2 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Identify interventions for patients experiencing impaired gas exchange, ineffective airway clearance, or ineffective breathing pattern. Page: 543 Heading: Pleural Effusion Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential

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Cognitive Level: Application (Applying) Concept: Collaboration Difficulty: Moderate Feedback 1 2

3 4

Tracheostomy creates a stoma for the placement of an artificial airway. Thoracentesis is done by a physician to remove some of the fluid that has collected in the pleural space and is compressing lung tissue. The nurse can anticipate assisting. Bronchoscopy visualizes the major airways with an endoscope. Pericardiocentesis removes fluid from around the heart.

PTS:

CON: Collaboration

6. A patient who is planning to become pregnant expresses concern about the high incidence of asthma in her family. Which recommendation by the nurse is least helpful? 1. Suggest the patient undergo genetic studies and counseling. 2. Prevent exposure to environmental tobacco smoke during pregnancy. 3. During the first year of life, avoid giving a child acetaminophen. 4. Avoid broad-spectrum antibiotics during the child’s first year of life. ANS: 1 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Describe therapeutic measures used for disorders of the lower respiratory tract. Page: 590 Heading: Asthma Integrated Process: Communication and Documentation Client Need: Patient-Centered Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

It is not confirmed that asthma has a genetic link; however, there is a tendency for the condition to run in families. This is the least helpful recommendation. The mother should avoid environmental tobacco smoke during pregnancy and the child should be protected from exposure during the first year of life. Avoiding the use of acetaminophen with a child during the first year of life is recommended to decrease the incidence of asthma. Not giving a child broad-spectrum antibiotics before the age of 1 year is recommended to decrease the incidence of asthma.

PTS:

CON: Patient-Centered Care

7. A summer camp worker reports shortness of breath and audible wheezing to the camp nurse. Which inhaled medication will the nurse provide? 1. Albuterol 2. Cromolyn sodium 3. Triamcinolone

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4. Nedocromil sodium ANS: 1 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Identify interventions for patients experiencing impaired gas exchange, ineffective airway clearance, or ineffective breathing pattern. Page: 591 Heading: Asthma Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

Albuterol is an adrenergic bronchodilator and would be used to help immediately relieve acute bronchospasm. Cromolyn and nedocromil are mast cell inhibitors. Triamcinolone is a corticosteroid. Cromolyn and nedocromil are mast cell inhibitors.

PTS:

CON: Safety

8. The nurse is providing care for a patient admitted for a lower respiratory infection. On admission, the patient’s vital signs were blood pressure (BP) 140/80 mm Hg, apical pulse (AP) 112 beats/min, respirations (R) 32 breaths/min, and pain level of 8 on a scale of 0 to 10. After assisting the patient to bed and applying the prescribed oxygen, which finding helps the nurse evaluate the effectiveness of nursing care? 1. BP 130/78 mm Hg 2. AP 100 beats/min 3. R 20 breaths/min 4. Pain level of 6/10 ANS: 3 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Explain how you will know whether your nursing interventions have been effective. Page: 589 Heading: Nursing Care Plan for the Patient With a Lower Respiratory Tract Disorder Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

The change in BP does not evaluate nursing care effectiveness. The change in AP is not the best indication of nursing care effectiveness. The patient’s respiratory rate was elevated, indicating shortness of breath

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related to either poor gas exchange or activity intolerance. This improvement is the best evaluation of nursing care effectiveness. The patient’s pain level is still significant.

PTS:

CON: Patient-Centered Care

9. A patient with chronic obstructive pulmonary disease (COPD) is prescribed methylprednisolone. For what reason should the nurse realize that corticosteroids are used in the treatment of this health problem? 1. To dry up respiratory secretions 2. To treat infection from secretion stasis 3. To reduce airway inflammation 4. To improve the blood capacity to carry oxygen ANS: 3 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Describe therapeutic measures used for disorders of the lower respiratory tract. Page: 589 Heading: Obstructive Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

Corticosteroids do not dry secretions. Corticosteroids may mask the manifestations of infection and cause the infection to worsen. Corticosteroids are potent anti-inflammatory agents. Corticosteroids do not directly affect oxygenation or change the function of the blood.

PTS:

CON: Safety

10. The nurse is providing care for a patient admitted with an acute lower respiratory infection. The nurse notices that the patient is stifling the cough reflex and exhibiting shallow respirations due to pain. The nurse will focus nursing care on the prevention of which condition? 1. Atelectasis 2. Pulmonary emboli 3. Chronic airway obstruction 4. Respiratory failure ANS: 1 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Plan nursing care for patients with disorders of the lower respiratory tract. Page: 578 Heading: Atelectasis

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2 3 4

Atelectasis can be caused by any condition that causes hypoventilation, especially pain. Failure to prevent or resolve hypoventilation causes the air sacs to adhere to each other. Pulmonary emboli is the presence of blood clot in the lungs. The question identifies the patient as having an acute, not chronic, condition. Atelectasis can lead to respiratory failure if not effectively treated; however, the patient’s condition is acute and treatable.

PTS:

CON: Patient-Centered Care

11. The nurse is performing a follow up visit with a patient recently diagnosed with a GOLD 1 classification of COPD. Which statement by the patient indicates the most important compliance with previous patient teaching? 1. “I am attending an exercise class three times a week.” 2. “I am including more fresh foods in my daily diet.” 3. “I successfully completed a smoking-cessation program.” 4. “I am wearing a respiratory filter when I work outside.” ANS: 3 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Explain how you will know whether your nursing interventions have been effective. Page: 589 Heading: Obstructive Disorders Integrated Process: Teaching/Learning Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

2 3

The patient’s COPD classification indicates mild airflow limitation; exercise can increase and maintain respiratory function, but smoking cessation is most important. Nutritional status is more important as COPD worsens and interferes with dietary intake. The greatest risk for the development and worsening of COPD is smoking; a patient indicating the completion of a smoking-cessation program indicates important compliance. Preventing exposure to irritants is effective in arresting development of the condition. However, smoking is the greatest risk for worsening COPD.

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PTS:

CON: Patient-Centered Care

12. The nurse enters the room of a patient who is acutely short of breath. Which action should the nurse take first? 1. Assist the patient into Sims’ position. 2. Encourage use of pursed-lip breathing. 3. Ask the patient what caused the dyspnea. 4. Teach the patient use of accessory muscles. ANS: 2 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Identify interventions for patients experiencing impaired gas exchange, ineffective airway clearance, or ineffective breathing pattern. Page: 539 Heading: Obstructive Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Fowler’s, not Sims’, position will help lung expansion. Pursed-lip breathing can help open alveoli and promote excretion of carbon dioxide. Asking the patient the cause is appropriate after the dyspnea is resolved. Accessory muscle use is a sign of respiratory distress, not a therapeutic measure.

PTS:

CON: Patient-Centered Care

13. The nurse is reviewing the medications prescribed by the health care provider (HCP) for a patient with COPD. Which prescription will cause the nurse to verify the ordered medication? 1. Corticosteroid inhaler 2. Antitussive 3. Short-term antibiotic therapy 4. Theophylline bronchodilator ANS: 2 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Describe therapeutic measures used for disorders of the lower respiratory tract. Page: 585 Heading: Obstructive Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Need: Physiological Integrity—Pharmacological and Parenteral Therapies Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate

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Feedback 1 2 3 4

A corticosteroid inhaler is commonly prescribed to decrease inflammation. When a patient has COPD, an antitussive is not prescribed because it interferes with the ability to cough up secretions. Short-term antibiotic therapy is appropriate and is prescribed as needed. While the side effects are significant, theophylline bronchodilators are used as needed.

PTS:

CON: Safety

14. The nurse is providing care for a patient diagnosed with an obstructive respiratory disorder. Which patient finding indicates that nursing interventions may be ineffective? 1. Respiratory secretions are coughed up. 2. Daily care is performed independently. 3. The patient uses oxygen only when active. 4. The patient reports a low level of anxiety. ANS: 3 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Explain how you will know whether your nursing interventions have been effective. Page: 585 Heading: Nursing Process for the Patient With an Obstructive Disorder Integrated Process: Teaching/Learning Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

Nursing interventions are effective if the patient can cough up respiratory secretions. Nursing interventions are effective if the patient can perform daily care independently. A patient with an obstructive respiratory disorder may need to have oxygen when both active and inactive. This finding alone is not an indication of effective nursing interventions. Nursing interventions are effective if the patient reports a decreased or low level of anxiety.

PTS:

CON: Patient-Centered Care

15. The licensed practical nurse/licensed vocational nurse (LPN/LVN) is reviewing laboratory results for a patient with COPD. Which action does the LPN/LVN take if the ABG analysis shows a PaCO2 of 62 mm Hg? 1. Notify the registered nurse (RN) of the high laboratory result. 2. Have the patient breathe into a paper bag. 3. Increase the flow rate of the patient’s nasal oxygen. 4. No action is necessary; this is a normal PaCO2 level.

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ANS: 1 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: List data to collect when caring for patients with disorders of the lower respiratory tract. Page: 586 Heading: Obstructive Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Patient Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Professionalism Difficulty: Moderate Feedback 1

2 3 4

Normal PaCO2 is 35 to 45 mm Hg. The value 62 mm Hg is evidence of hypoventilation and the inability to excrete carbon dioxide (CO2). The RN or physician should be notified. Breathing into a paper bag will increase the CO2 level. Increasing nasal oxygen will not help CO2 excretion. This is not a normal level and action must be taken immediately.

PTS:

CON: Professionalism

16. The nurse is providing care for a patient with a lower respiratory tract infection who is having difficulty expectorating secretions. The patient is weak and easily fatigued. Which action by the nurse will best assist the patient in maintaining a clear airway? 1. Review effective coughing technique. 2. Plan activities with rest periods between. 3. Explain the importance of fluid intake. 4. Encourage abdominal and pursed-lip breathing. ANS: 3 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Identify interventions for patients experiencing impaired gas exchange, ineffective airway clearance, or ineffective breathing pattern. Page: 582 Heading: Obstructive Disorder Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

The patient may or may not need a review of coughing technique. Rest and relaxation can help with activity intolerance and anxiety but will not assist with airway clearance. Fluids help reduce viscosity of secretions and make them easier to expectorate. Breathing exercises help correct impaired gas exchange, but will not assist with

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airway clearance. PTS:

CON: Patient-Centered Care

17. The nurse is researching the dietary recommendations by the American Lung Association for patients with lower respiratory tract disease. Which strategy is not supported by the American Lung Association? 1. Eat more food early in the day if fatigue occurs late in the day. 2. Consume a daily diet high in complex carbohydrates. 3. Consult with the HCP regarding a multivitamin. 4. Maintain a diet that is low in fats and high in carbohydrates. ANS: 4 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Describe therapeutic measures used for disorders of the lower respiratory tract. Page: 582 Heading: Optimizing Nutrition in Patients With Respiratory Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

If a patient routinely is too fatigued to eat well late in the day, he or she is encouraged to eat more food early in the day. Complex carbohydrates are recommended for high-fiber content; simple carbohydrates should be avoided. The HCP should be consulted regarding the use of a multivitamin. The patient with lower respiratory tract disease needs a diet with increased fat and lower carbohydrates (fats produce less CO2 when metabolized).

PTS:

CON: Patient-Centered Care

18. The nurse is providing care for a patient with a suspected pulmonary emboli. Which data will the nurse gather about this patient? 1. BP from both arms 2. Heart sounds and peripheral edema 3. Activity prior to manifestations 4. Side effects of medications ANS: 2 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: List data to collect when caring for patients with disorders of the lower respiratory tract. Page: 576 Heading: Pulmonary Embolism Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential

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Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

There is no need to monitor the BP in both arms for a patient suspected of a pulmonary emboli. Because an emboli in the lungs can cause right-sided heart failure, the nurse should monitor heart sounds and the presence of peripheral edema. Ascertaining the activity prior to the manifestations of a pulmonary emboli will not be useful. It is not necessary to evaluate the side effects of medications.

PTS:

CON: Patient-Centered Care

19. The nurse works in a clinic and is performing tuberculosis (TB) screening with the purified protein derivative (PPD). Which option about PPD screening is correct? 1. The test is positive if reddened area occurs within 48 to 72 hours. 2. If a person is anergic, a larger area of induration will appear. 3. A positive reaction to the test indicates active disease process. 4. A reddened area without induration is considered negative. ANS: 4 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Identify tests that are used to diagnose lower respiratory disorders. Page: 580 Heading: Tuberculosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

An area of induration must appear within 48 to 72 hours for a PPD test to be considered positive. In persons with a limited ability to react to the test due to immune dysfunction (anergic), a smaller area of induration is considered positive. A positive reaction is indicative of exposure to TB and not of active disease process. In regard to PPD testing for TB, a reddened area without induration is considered negative; induration must be present for a positive response.

PTS:

CON: Patient-Centered Care

20. A patient with TB who is in respiratory isolation must go to the x-ray department. Which action will the nurse take? 1. Place a gown and gloves on the patient. 2. Place a mask over the patient’s nose and mouth.

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3. Notify the x-ray department that the test must be cancelled. 4. Call the x-ray department to make sure the waiting room is empty. ANS: 2 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Plan nursing care for patients with disorders of the lower respiratory tract. Page: 580 Heading: Tuberculosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Gown and gloves are not necessary; the patient has a respiratory infection. The patient is in respiratory isolation, so a mask over the nose and mouth is essential when moving the patient into other areas of the facility. The x-ray is an important evaluation test for the patient and should not be cancelled, even if bedside x-ray is not available. It is not necessary that the x-ray waiting room be vacated; however, the patient’s exposure to others should be minimized.

PTS:

CON: Patient-Centered Care

21. The nurse finds a patient gasping for breath and looking very anxious. Based on the patient’s history, the nurse believes the patient may be experiencing a pulmonary embolism (PE). Which action should the nurse take first? 1. Contact the physician. 2. Call for help and start oxygen. 3. Check the patient’s vital signs. 4. Place the patient in a left lateral position. ANS: 2 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Identify interventions for patients experiencing impaired gas exchange, ineffective airway clearance, or ineffective breathing pattern. Page: 582 Heading: Pulmonary Embolism Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

Leaving the patient to call the physician is not appropriate—someone else can contact the physician. Be alert to the presence of risk factors and obtain immediate assistance if the

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3 4

cause of dyspnea might be PE. Death can occur if treatment is not quick and effective. Checking vital signs is important but is not more important than oxygen. The nurse should not assess a patient who is in distress. Left lateral position will not help.

PTS:

CON: Patient-Centered Care

22. The nurse auscultates the lung sounds of a patient with a pneumothorax every 4 hours. Which finding indicates to the nurse that the patient’s condition is improving? 1. Patient anxiety is decreased. 2. Crackles or wheezes are heard. 3. Bilateral lung sounds are present. 4. Symmetry of the chest is noted. ANS: 3 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Explain how you will know whether your nursing interventions have been effective. Page: 599 Heading: Pneumothorax Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Decreased patient anxiety is not an indication that a pneumothorax is improving. Crackles, wheezes, secretions, or obstruction are concerning, but do not provide direct information about pneumothorax. Lung sounds are absent over a pneumothorax. Return of bilateral sounds signifies that the lung is reinflated. Chest symmetry is restored via treatment for a pneumothorax, but alone is not indicative of improvement.

PTS:

CON: Patient-Centered Care

23. A patient is diagnosed with respiratory failure. Which acid-base abnormality should the nurse expect the patient to demonstrate? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis ANS: 3 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders

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Objective: Explain the pathophysiology of each of the disorders of the lower respiratory tract. Page: 528 Heading: Respiratory Failure Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Metabolic imbalances are not caused by respiratory dysfunction. Metabolic imbalances are not caused by respiratory dysfunction. ABGs in respiratory failure show decreasing PaO2 and pH and increasing PaCO2, which lead to respiratory acidosis. Respiratory alkalosis is associated with hyperventilation.

PTS:

CON: Patient-Centered Care

24. The nurse works primarily with patients diagnosed with lung cancer. Which patient with lung cancer does the nurse recognize as having the best prognosis? 1. Small cell lung cancer 2. Large cell carcinoma 3. Adenocarcinoma 4. Squamous cell carcinoma ANS: 4 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Explain the pathophysiology of each of the disorders of the lower respiratory tract. Page: 603 Heading: Lung Cancer/Pathophysiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

Feedback This patient has a poor prognosis. Small cell lung cancer grows rapidly and is often metastasized by the time of diagnosis.

This patient has a poor prognosis. Large cell carcinoma is a rapidly growing cancer that can occur anywhere in the lungs; it also metastasizes early.

This patient has a poor prognosis. Adenocarcinoma occurs most often in women and is most often on the peripheral lung fields. It grows slowly but is often not diagnosed until metastasis occurs.

This patient has the best prognosis. Squamous cell carcinoma usually originates in the

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bronchial lining and metastasizes late in the disease; this type has a better prognosis than the other types of lung cancer.

PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 1. The nurse is providing care for a patient admitted to the hospital for a respiratory disorder. The HCP is prescribing diagnostic tests to rule out bronchiectasis. Which manifestations does the nurse recognize as possible indicators for the diagnosis? (Select all that apply.) 1. Radiographic studies reveal areas of bronchial dilation. 2. Adult patient has a history of cystic fibrosis since birth. 3. Family history reveals multiple members with lung cancer. 4. The patient has recurring episodes of lower extremity edema. 5. Bronchitis occurred three times in the last three years. ANS: 1, 2, 4 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Describe the etiologies, signs, and symptoms of each of the disorders. Page: 582 Heading: Bronchiectasis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback Bronchiectasis involves dilation of the bronchial tree; the radiographic studies support the possibility of the condition. Patients with cystic fibrosis are at greater risk for bronchiectasis. A tumor or cancer in the lungs can be a cause of bronchiectasis; however, family history of lung cancer alone is not specific to the diagnosis. Bronchiectasis can cause right-sided heart failure; recurring episodes of lower extremity edema may be a symptom. If bronchitis occurs three times a year for 2 consecutive years, the diagnosis of bronchiectasis should be ruled out. 1

CON: Patient-Centered Care

2. The nurse is caring for a patient with a suspected PE. Which diagnostic tests or procedures should the nurse expect to be prescribed for this patient? (Select all that apply.) 1. D-dimer 2. Spirometry 3. Angiogram 4. Ventilation-perfusion lung scan 5. Spiral computed tomography (CT) scan

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ANS: 1, 3, 4 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Identify tests that are used to diagnose lower respiratory disorders. Page: 597 Heading: Pulmonary Embolism Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

2. 3. 4.

PTS:

Feedback D-dimer is a fibrin fragment that is found in the blood after any thrombus formation. It can be present in a number of disorders, but if it is negative, PE can be eliminated as a possible cause of the patient’s symptoms. Spirometry is not a diagnostic test. A pulmonary angiogram can outline the pulmonary vessels with a radiopaque dye injected via a cardiac catheter. If a CT scan is not available, a lung scan (ventilation-perfusion scan) is done to assess the extent of ventilation of lung tissue and the areas of blood perfusion. A spiral CT scan is a new and fast type of CT scan that is noninvasive and can diagnose PE quickly. 1

CON: Patient-Centered Care

3. Management of asthma involves avoidance of triggers. Which environmental triggers will the nurse suggest the patient eliminate? 1. Carpet and drapes in the bedroom 2. Exposure to secondhand smoke 3. Pets and foods that cause symptoms 4. Cardiovascular exercise 5. Beta-blocking medications ANS: 1, 2, 3 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Describe therapeutic measures used for disorders of the lower respiratory tract. Page: 582 Heading: Asthma Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3.

Feedback Carpet and drapes harbor dust, which can trigger asthma attacks. Smoking and exposure to secondhand smoke can trigger asthma attacks. Pet dander and certain foods can cause asthma attacks.

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4. 5.

PTS:

Cardiovascular exercise can trigger asthma attacks, but exercise is not an environmental trigger, it is activity. Beta-blocking medications can trigger asthma attacks, but it is not an environmental trigger. 1

CON: Patient-Centered Care

4. A young adult is admitted with manifestations associated with cystic fibrosis. What should the nurse expect to find when collecting data from this patient? (Select all that apply.) 1. Extreme thirst 2. Finger clubbing 3. Body mass index 16 4. Thick sputum production 5. Complaints of frequent foul-smelling stool ANS: 2, 3, 4, 5 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Describe the etiologies, signs, and symptoms of each of the disorders. Page: 594 Heading: Cystic Fibrosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Patient Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

1. 2.

PTS:

Feedback Extreme thirst is not a manifestation of cystic fibrosis. Symptoms of cystic fibrosis usually first appear in infancy or childhood, although a few individuals are not diagnosed until adulthood. Manifestations include finger clubbing. Symptoms of cystic fibrosis usually first appear in infancy or childhood, although a few individuals are not diagnosed until adulthood. Manifestations include malnutrition. Symptoms of cystic fibrosis usually first appear in infancy or childhood, although a few individuals are not diagnosed until adulthood. Manifestations include thick sputum production. Symptoms of cystic fibrosis usually first appear in infancy or childhood, although a few individuals are not diagnosed until adulthood. Manifestations include frequent foul-smelling stools. 1

CON: Patient-Centered Care

5. The nurse works on a pulmonary care unit and provides care for multiple patients with obstructive pulmonary conditions. Which specific symptoms will prompt the nurse to identify a patient’s diagnosis as chronic bronchitis as opposed to other pulmonary diseases? (Select all that apply.) 1. Chronic productive cough 2. Classic barrel-shaped chest

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3. Use of accessory muscles to breath 4. Condition worsening in the winter 5. Clear breath sounds with coughing ANS: 1, 4, 5 Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Describe the etiologies, signs, and symptoms of each of the disorders. Page: 586 Heading: Obstructive Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback The patient with chronic bronchitis will exhibit a chronic productive cough and crackles and wheezing that clears with coughing. The classic barrel-shaped chest is seen in the patient with COPD and is the result of trapped air in the lungs. Patients with emphysema will use the accessory muscles to breathe. The patient will likely notice the condition worsening during the winter months. The patient with chronic bronchitis will exhibit a chronic productive cough and crackles and wheezing that clears with coughing. 1

CON: Patient-Centered Care

COMPLETION 1. Some lung cancers produce

hormones that mimic the body’s own hormones.

ANS: ectopic Chapter: Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders Objective: Describe the etiologies, signs, and symptoms of each of the disorders. Page: 603 Heading: Ectopic Hormone Production Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback: Some lung cancers can produce ectopic hormones, which mimic the body’s hormones. Ectopic production of antidiuretic hormone can produce syndrome of inappropriate antidiuretic hormone production, with resulting fluid retention. Ectopic production of adrenocorticotropic hormone can cause Cushing syndrome. High calcium levels can be caused by ectopic secretion of a parathyroid-like hormone.

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PTS:

CON: Patient-Centered Care

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Chapter 32. Gastrointestinal, Hepatobiliary, and Pancreatic Systems Function, Assessment, and Therapeutic Measures MULTIPLE CHOICE 1. The nurse is inspecting a patient’s oral cavity and notices reddened areas on the gums, several teeth with cavities, and multiple loose teeth. Which finding is of greatest safety concern to the nurse? 1. Reddened area on the gums can be a source of infection. 2. Dental cavities can be painful and a possible source of infection. 3. Loose teeth concern due to possible aspiration and airway blockage. 4. Abnormal findings in the oral cavity can lead to poor nutrition status. ANS: 3 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Differentiate normal and abnormal data collection findings. Page: 612 Heading: Oral Cavity Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Health Promotion Difficulty: Moderate Feedback 1

2 3

Reddened areas on the patient’s gums can be indicative of infection or abscesses. The condition should be evaluated and treated by a dentist. This is not the greatest safety concern. Cavities can be a source of pain and infection. The condition should be evaluated and treated by a dentist. This is not the greatest safety concern. Loose teeth can be aspirated into the airway and become a choking risk or airway blockage. This finding is the nurse’s greatest safety concern. The patient needs to see a dentist as soon as possible. It is true that abnormal oral cavity findings can interfere with the patient’s nutritional status, but this is not the nurse’s greatest safety concern.

PTS:

CON: Health Promotion

2. The nurse is providing care for a patient whose nasogastric (NG) tube is attached to low intermittent suction for decompression of a bowel obstruction. The nurse notes the NG tube is not draining. After checking placement, which action should the nurse take? 1. Advance the NG tube 2 inches. 2. Change the suction setting to high. 3. Reinsert the NG tube into the other nares. 4. Irrigate the NG tube with 30 milliliters of normal saline. ANS: 4

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Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Plan nursing care for the insertion and maintenance of nasogastric tubes. Page: 631 Heading: Gastrointestinal Intubation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

2 3 4

The tube should not be advanced without a health care provider’s (HCP) order unless it has migrated from the initial position. The question does not address the possibility of this issue. Suction should remain on a low setting to prevent damage to the lining of the stomach. The NG tube should not be pulled and reinserted without an HCP’s order. There are a variety of methods to reestablish patency of the NG tube. The nurse should irrigate the NG tube with 30 mL of normal saline to see if the tube is blocked with secretions.

PTS:

CON: Patient-Centered Care

3. During the inspection of a patient’s abdomen, which data finding is most unlikely indicative of a serious disorder? 1. Jaundice 2. Caput medusae 3. Visible mound 4. Silver-colored lines ANS: 4 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Differentiate normal and abnormal data collection findings. Page: 620 Heading: Abdomen Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

Jaundice (icterus) is a yellowing of the skin and is usually associated with liver dysfunction or disease. Caput medusae is the appearance of a bluish-purple, swollen vein pattern extending out from the navel. When found in an adult, it can be indicative of portal hypertension or advanced alcoholic cirrhosis of the liver.

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3 4

A visible mound noted with inspection of the abdomen can be indicative of a tumor or other intra-abdominal issues. Silver or thin red lines on the skin of the abdomen is the finding most unlikely to indicate a serious disorder. Striae can develop during pregnancy or obesity from stretching of the skin.

PTS:

CON: Patient-Centered Care

4. The nurse is auscultating the bowel sounds of a patient who is severely constipated and exhibits a swollen abdomen and pain. Which bowel sounds cause the nurse to suspect a bowel obstruction? 1. A series of soft clicks and gurgles 2. A complete absence of sounds 3. A high-pitched tinkling sound 4. A variety of nearly constant sounds ANS: 3 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Differentiate normal and abnormal data collection findings. Page: 659 Heading: Abdomen Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 2 3

A series of soft clicks and gurgles is considered to be normal bowel sounds. A complete absence of bowel sounds may occur for a period following anesthesia or indicate bowel disease. A high-pitched tinkling sound is commonly associated with a bowel obstruction especially if bowel sounds are absent distal to the area of auscultation. A variety of nearly constant bowel sounds is defined as hyperactive bowel sounds and can occur for a variety of reasons.

PTS:

CON: Patient-Centered Care

5. The nurse is providing care for a patient who has just undergone a needle biopsy to rule out liver disease. Which nursing intervention is most critical following the procedure? 1. Monitor vital signs every 4 hours. 2. Instruct to avoid coughing or straining. 3. Remain positioned on right side for 2 hours. 4. Medicate as needed for pain. ANS: 3

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Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Plan nursing care for patients having diagnostic tests of the gastrointestinal tract. Page: 628 Heading: Percutaneous Liver Biopsy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

Vital signs will be monitored several hours as prescribed. Vital signs are indicative of patient stability or instability following a procedure. The patient will be instructed to avoid coughing or straining, exercise and heavy lifting for a period of 1 week. The most important nursing intervention following a percutaneous liver biopsy is to keep the patient positioned on the right side for 2 hours to apply pressure on the site and prevent bleeding. Risk for bleeding is associated with the vascularity of the liver, and because liver disease can cause reduced clotting ability. The nurse will medicate the patient as needed for postprocedure pain; however, this intervention is not as critical as monitoring for and preventing bleeding from the biopsy site.

PTS:

CON: Patient-Centered Care

6. A patient is being prepared for an upper gastrointestinal (GI) series involving a barium swallow. Which statement indicates that the patient understands the preparation for this test? 1. “I should eat a soft diet the night before the procedure.” 2. “I must not eat or drink for 4 hours after the procedure.” 3. “I’ll be given a clear liquid diet the night after the procedure.” 4. “I can’t have anything to eat or drink for 6 hours before the procedure.” ANS: 4 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Plan nursing care for patients having diagnostic tests of the gastrointestinal tract. Page: 627 Heading: Barium Swallow Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

It is not necessary for the patient to eat a soft diet the night before the test. There is no reason to restrict oral intake following a barium swallow.

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3 4

There is no reason for the client to be on a clear liquid diet following the procedure. An appropriate patient diet preparation for an upper GI series is placing the patient on NPO restriction 6 hours before the procedure for best visualization.

PTS:

CON: Patient-Centered Care

7. The nurse is ready to begin a tube feeding via an NG feeding tube for a patient who is comatose. What action should the nurse take before starting the feeding? 1. Listen to bowel sounds. 2. Check the pH of gastric aspirate. 3. Secure the NG tube with additional tape. 4. Irrigate the tube with 10 mL of sterile water. ANS: 2 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Plan nursing care for insertion and maintenance of nasogastric tubes. Page: 631 Heading: Gastrointestinal Intubation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2

3 4

Bowel sounds can be auscultated at any time and are not specifically indicative of NG tube placement. Prior to instilling anything into the NG tube, it is essential to verify placement of the NG tube; after x-ray is performed, the preferred method of verification is to check the pH of the gastric aspirate. The NG tube should have been secured after insertion. The tube is irrigated with normal saline and not sterile water.

PTS:

CON: Safety

8. The nurse reviews the results of a patient’s stool occult blood test, which tests positive. Which additional data is unlikely to cause a false positive for the testing? 1. If the patient has bleeding gums following a recent dental procedure 2. If the patient ingested red meat within 3 days of testing 3. If the patient took oral laxatives in preparation for the test 4. If the patient ate turnips, fish, or horseradish prior to testing ANS: 3 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Plan nursing care for patients having diagnostic tests of the gastrointestinal tract. Page: 626

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Heading: Stool Tests Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Medium Feedback 1 2 3 4

Bleeding gums from a recent dental procedure can cause a false positive for a stool occult blood test. Ingesting red meat within 3 days of a stool occult blood test can cause a falsepositive result. The use of oral laxatives in preparation for the test is unlikely to cause a falsepositive stool blood occult test. Eating spicy foods can irritate the digestive tract and cause a false-positive result on a stool occult blood test.

PTS:

CON: Patient-Centered Care

9. The nurse is caring for a patient who has a nonvented NG tube. Which suction setting should the nurse select? 1. Low continuous suction 2. High continuous suction 3. Low intermittent suction 4. High intermittent suction ANS: 3 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Plan nursing care for insertion and maintenance of nasogastric tubes. Page: 654 Heading: Gastrointestinal Intubation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Low continuous suction is inappropriate for this type of NG tube. High continuous suction is inappropriate for this type of NG tube. If suction is ordered, low intermittent suction is used with nonvented NG tubes. High intermittent suction is inappropriate for this type of NG tube. PTS:

CON: Patient-Centered Care

10. The nurse is planning to reinforce teaching to a patient regarding the function of the organs in the GI tract. Which information is correct? 1. The presence of food is necessary to trigger the release of gastric juices.

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2. The colon is the last 3 feet of GI tract where digestion is completed. 3. The duodenum is where the common bile and pancreatic duct enters the small intestine. 4. The singular function of the liver is to remove potentially toxic substances from the blood. ANS: 3 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: List the structures of the gastrointestinal tract and of the accessory glands: liver, gallbladder, and pancreas. Pages: 611–612 Heading: Normal Gastrointestinal, Hepatobiliary, and Pancreatic Systems Anatomy and Physiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

The secretion of gastric juices begins with the sight and smell of food; the response is parasympathetic. The colon is 5 feet in length and no additional digestion takes place in this organ. Fluids are reabsorbed and feces are passed along for defecation. The first 10 inches of the small intestine is called the duodenum, which is the location of the ampulla of Vater consisting of the common bile and pancreatic duct. The liver is responsible for removing potentially toxic substances from the blood. However, the liver also aids in digestion through the production of bile.

PTS:

CON: Patient-Centered Care

11. The nurse is performing research to obtain best practice information on the topic of enteral feedings. Which information is least likely to be included in best practice recommendations? 1. Residual checks can cause clogged tubes and the stoppage of feeding. 2. Measurement of residual volumes reflect gastric emptying and aspiration risk. 3. Stopping tube feedings based solely on residual findings can result in malnutrition. 4. Eliminating residual volume checks does not decrease patient safety with enteral feedings. ANS: 2 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Explain types of nasogastric tubes and their uses. Page: 632 Heading: Method of Enteral Feeding Delivery Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing)

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Concept: Evidence-Based Practice Difficulty: Difficult Feedback 1 2 3 4

Research reveals that residual checks can cause clogged tubes and the stoppage of feeding. Research does not support the belief that measurement of residual volumes reflects gastric emptying and aspiration risk. Research supports that stopping tube feedings based solely on residual findings can result in malnutrition of the patient. Research states that eliminating residual volume checks does not decrease patient safety with enteral feedings.

PTS:

CON: Evidence-Based Practice

12. The nurse is providing care for a client who requires gastric irrigation for a medication overdose. The nurse understands the use of an orogastric tube requires which intervention? 1. The abdominal incision requires regular wound care. 2. The patient needs careful observation for a sinus infection. 3. Suction equipment is needed at the bedside for nasal drainage. 4. The tube is temporary and is removed following treatment. ANS: 4 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Describe therapeutic measures used for patients with gastrointestinal disorders. Page: 630 Heading: Therapeutic Measures for the Gastrointestinal, Hepatobiliary, and Pancreatic Systems Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

An orogastric tube is not placed through an abdominal incision. The use of an orogastric tube decreases the possibility of a sinus infection because the tube is not inserted through the nares. There is no reason to place suction equipment at the bedside for nasal drainage. The orogastric tube is placed through the mouth. The orogastric tube is placed through the client’s mouth and is primarily used for short-term interventions such as flushing the stomach and obtaining gastric secretions for diagnostics.

PTS:

CON: Patient-Centered Care

13. The nurse is palpating the abdomen of a patient reporting mild abdominal pain in the upper right quadrant. How deep should the nurse depress this patient’s abdomen?

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1. 2. 3. 4.

1 inch 2 inches 3 inches 4 inches

ANS: 1 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Explain techniques used to conduct a physical examination of the abdomen. Page: 621 Heading: Abdomen Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

2 3 4

When palpating the abdomen of a patient reporting mild abdominal pain in the upper right quadrant, the nurse should depress the abdomen no more than 1 inch. Deep palpation of the abdomen is done only by physicians and highly skilled nurses. Deep palpation of the abdomen is done only by physicians and highly skilled nurses. Deep palpation of the abdomen is done only by physicians and highly skilled nurses.

PTS:

CON: Patient-Centered Care

14. The nurse is gathering data from a client in a physician’s office. The client reports severe diarrhea, nausea, and abdominal pain. Which additional data information will cause the nurse to report possible Clostridium difficile to the HCP? 1. Osteoarthritis treated with anti-inflammatories 2. Currently in outpatient treatment for alcohol abuse 3. Recent hospitalization for treatment of pneumonia 4. History of poorly controlled type 2 diabetes mellitus ANS: 3 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: List data to collect when caring for a patient with a disorder of the gastrointestinal system, liver, gallbladder, or pancreas. Page: 663 Heading: Nursing Assessment of the Gastrointestinal, Hepatobiliary, and Pancreatic Systems Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment—Coordinated Care Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate

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Feedback 1 2 3

Patients treated with anti-inflammatories for osteoarthritis are not likely candidates for C difficile. Patients being treated for alcohol abuse are more likely to have other gastrointestinal disorders rather than C difficile. C difficile is a risk for patients who have been recently hospitalized or treated for an infection. The patient was hospitalized and likely treated with antibiotics for a respiratory infection. A history of poorly controlled type 2 diabetes mellitus is not a reason to suspect C difficile.

PTS:

CON: Patient-Centered Care

15. The nurse is preparing to perform an abdominal examination. For which reason will the nurse perform auscultation before palpation and percussion? 1. Palpation will alter or stimulate bowel sounds. 2. Percussion is painful and makes auscultation difficult. 3. Auscultation is expected and will relax the patient. 4. Inspection is normally followed by auscultation. ANS: 1 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Explain the techniques used to conduct a physical examination of the abdomen. Page: 621 Heading: Physical Examination Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

The nurse will need to listen to current bowel sounds. Palpation is a physical examination of the abdomen and will alter or stimulate bowel sounds. Percussion is not expected to be painful. Auscultation is an expected part of a physical examination of the abdomen, but it does not necessarily relax the patient. Except when examining the abdomen, the routine order of physical examination is inspection, percussion, palpation, and the auscultation.

PTS:

CON: Patient-Centered Care

16. The nurse is providing care for a client 1 day after major abdominal surgery. The client’s abdomen is distended and bowel sounds are absent. Which treatment does the nurse expect the HCP to prescribe? 1. Insertion of a nasointestinal tube to stimulate peristalsis 2. Administration of medication to dissipate abdominal gas

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3. Placement of a NG tube for decompression 4. Use of a rectal tube to clear flatus from the distal colon ANS: 3 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Explain the types of nasogastric tubes and their uses. Page: 672 Heading: Gastrointestinal Decompression Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

2 3

A nasointestinal tube is not used to stimulate peristalsis. This type of tube is rarely used for decompression because it is difficult and slower to place and may be uncomfortable. Medication to dissipate abdominal gas is not an effective way to achieve abdominal decompression. The most common way to achieve abdominal decompression is by the placement of an NG tube. The NG tube will also remove any fluid accumulation related to poor or absent peristalsis. The patient with a distended abdomen 1 day after major abdominal surgery is not likely to benefit from a rectal tube to clear flatus from the colon.

PTS:

CON: Patient-Centered Care

17. The nurse is caring for a patient admitted with malnutrition related to gastric disease. The HCP orders parenteral nutrition (PN). Which information does the nurse consider regarding insulin therapy for this patient? 1. The PN will likely cause diabetes mellitus. 2. A combination of insulins is used for control. 3. The patient was identified as a prediabetic. 4. Temporary insulin coverage uses regular insulin. ANS: 4 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Describe therapeutic measures used for patients with gastrointestinal diseases. Page: 673 Heading: Parenteral Nutrition Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback

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PN therapy causes elevated glucose levels as a response to the glucose in the PN; the condition is temporary and glucose levels will return to normal after the therapy is discontinued. A combination of insulins is not used to control elevated glucose levels for a client on PN therapy. Regular insulin is rapid acting and reduces the current blood glucose level. Elevated glucose blood levels with PN therapy do not occur because the patient is identified as being prediabetic. PN related hyperglycemia is a temporary condition that is treated with regular insulin coverage.

PTS:

CON: Patient-Centered Care

18. A patient is being scheduled for a barium swallow test to rule out esophageal strictures and gastric ulcer. Which pretesting information will the nurse provide for the patient? 1. Remain NPO for 12 hours prior to the procedure. 2. Increased fluid intake afterward should be water. 3. Do not smoke on the morning of the testing. 4. Notify the HCP if stools are abnormal in color. ANS: 3 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Describe therapeutic measures used for patients with gastrointestinal diseases. Page: 612 Heading: Barium Swallow Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Medium Feedback 1 2 3 4

The patient having a barium swallow needs to be NPO for 6 hours before the test. After the barium swallow, the client will need to increase fluid intake, but the liquid is not restricted to water. The patient is encouraged not to smoke the morning of the barium swallow because smoking can stimulate gastric motility. There is no reason to notify the HCP if the patient’s stools are an abnormal color after a barium swallow; stools are expected to be white in appearance for 2 to 3 days.

PTS:

CON: Patient-Centered Care

19. The nurse is providing care for a client prescribed to undergo a basal cell secretion test. Which nursing action is incorrect? 1. An NG tube is inserted. 2. A syringe is used to suction specimens.

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3. The NG tube is left unconnected between specimens. 4. Specimens are labeled in order of obtainment. ANS: 3 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Plan nursing care for patients having diagnostic tests of the gastrointestinal tract. Page: 652 Heading: Gastric Analysis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

An NG tube is inserted to obtain gastric secretions every 15 minutes for a period of 1 hour. A syringe is used to suction specimens from the stomach. This method of obtaining the specimens assures that no contamination occurs. Between obtainment of the specimens, the NG tube is connected to wall suction. The amount of gastric acid is also measured; too much hydrochloric acid may indicate a peptic ulcer, and too little can indicate cancer or pernicious anemia. Collected specimens are labeled in the order by which they are obtained.

PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 1. The nurse is providing care for a client with gallbladder disease. The client states, “What good is a gallbladder anyway?” The nurse is aware that which digestive processes are a function of the gallbladder? (Select all that apply.) 1. Bile causes emulsification of large globules of fats into small globules. 2. Bile carries bilirubin and excess cholesterol through the intestines. 3. Bile secretion by the gallbladder is stimulated by the hormone secretin. 4. The solitary function of the gallbladder is to produce bile. 5. The liver ceases to produce bile if the gallbladder is diseased. ANS: 1, 2, 3 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Describe the function of each organ of the gastrointestinal tract and the accessory glands: liver, gallbladder, and pancreas. Page: 615 Heading: Liver Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing)

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Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback Bile is primarily responsible for the digestion of fats by a process called emulsification, which breaks large fat globules into small globules. Bile is responsible for carrying bilirubin and excess cholesterol through the intestines to be excreted in the feces. Bile secretion is stimulated by the hormone secretin. Ejection of bile from the gallbladder is stimulated by cholecystokinin. Bile is produced by the liver and stored in the gallbladder until secretion is stimulated by secretin to aid in the digestion of fats. When the gallbladder is diseased or removed, the liver will continue to produce bile. However, without the stored bile in the gallbladder, fat digestion is affected. 1

CON: Patient-Centered Care

2. The nurse is contributing to a patient’s plan of care. Which patients does the nurse recommend as benefiting from PN? (Select all that apply.) 1. A patient who has esophageal cancer 2. A patient scheduled for leg amputation 3. A patient who is NPO for esophageal varices 4. A patient who is postoperative for an appendectomy 5. A patient with severe burns across the face and chest ANS: 1, 3, 5 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Describe therapeutic measures used for patients with gastrointestinal diseases. Pages: 634–635 Heading: Enteral Nutrition Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3.

4. 5.

Feedback The patient with esophageal cancer may have difficulty swallowing and need nutritional support via PN. Surgery for the amputation of a limb does not routinely require PN nutrition. The patient being treated with esophageal varices is at risk for bleeding if food passes through the esophagus. The client will benefit from nutrition via PN. A client who is postoperative for an appendectomy is not likely to benefit from nutrition via PN. The patient with burns across the face and chest may have difficulty swallowing and need nutritional support via PN.

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PTS:

CON: Patient-Centered Care

3. The nurse is providing care for an older adult client. The client states, “I don’t eat much anymore and I have terrible problems with my bowels.” Which information does the nurse share with the patient to explain the changes as related to age? (Select all that apply.) 1. Decreased GI peristalsis contributes to constipation. 2. Constipation requires an increased intake of fluids and roughage. 3. Decreased sense of taste can cause a loss of desire to eat. 4. Periodontal disease can interfere with eating and healthy nutrition. 5. Decline of eating habits and nutrition is an expected part of aging. ANS: 1, 2, 3, 4 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Discuss how age affects the gastrointestinal tract and accessory glands. Page: 630 Heading: Aging and the Gastrointestinal, Hepatobiliary, and Pancreatic Systems Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3.

PTS:

Feedback Constipation is compounded by decreased GI peristalsis, which is an expected manifestation of aging. Older clients need information about how to increase fluids and dietary roughage to improve bowel function. An expected decrease in the sense of taste is a contribution to loss of appetite in older adult clients. Information of how to healthfully improve the taste of food may be helpful. With aging, periodontal disease can contribute to the inability to maintain healthy nutrition. Dental care is encouraged and soft food preparation is suggested. A decline in eating habits and healthy nutrition is not considered an expected part of aging. 1

CON: Patient-Centered Care

4. The nurse is providing care for a patient with an NG tube for PN, an IV line for fluids and medications, and a nasal cannula for oxygen therapy. Which safety interventions does the nurse implement during care for this patient? (Select all that apply.) 1. Label or color-code feeding tubes and connectors. 2. Physically arrange the tubes for quick identification. 3. Write “Alert! For enteral use only” on all tube feeding bags. 4. Mark enteral tubes with a black marker for quick recognition. 5. During the handoff process, check tube origins and connections.

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ANS: 1, 3, 4 Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Describe therapeutic measures used for patients with gastrointestinal diseases. Page: 630 Heading: Method of Enteral Feeding Delivery Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment—Safety and Infection Control Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Difficult

2. 3. 4.

5. PTS:

Feedback When caring for a client with multiple tubes, all tubes should be labeled as to use. Color-coded tubes and connectors will assure that tubes are connected correctly. Arranging various tubes for quick identification is not fail-safe. If the patient is repositioned, the tubes can be moved or displaced. A warning needs to be written on all enteral feeding bags to prevent infusion into the wrong tubes. Marking the enteral tubes with a black marker is not safe unless it is part of facility policy; other health care members may not recognize the meaning of the marks. At handoff, all tubes need to be checked for correct origins and connections. 1

CON: Safety

COMPLETION 1.

is the procedure performed via a GI intubation to remove a toxic substance that has been ingested. ANS: Lavage Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Explain types of nasogastric tubes and their uses. Page: 629 Heading: Gastrointestinal Intubation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis Concept: Patient-Centered Care Difficulty: Moderate Feedback: Lavage is the process used to remove toxic substances ingested, either accidently or intentionally, in a timely manner. An NG tube can be placed quickly and the stomach “flushed” as often as needed to remove the ingested substance.

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PTS:

CON: Patient-Centered Care

2. The digestive enzymes are involved in the digestion of all four of the organic molecule categories. ANS: pancreatic Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems Function Assessment, and Therapeutic Measures Objective: Describe the functions of each organ of the gastrointestinal tract and of the accessory glands: liver, gallbladder, and pancreas. Page: 625 Heading: Pancreas Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis Concept: Patient-Centered Care Difficulty: Moderate Feedback: The enzyme pancreatic amylase digests starch to maltose. Pancreatic lipase converts emulsified fats to fatty acids and monoglycerides. Trypsinogen is an inactive enzyme that is changed to active trypsin in the duodenum. Trypsin digests polypeptides to shorter chains of amino acids. PTS:

CON: Patient-Centered Care

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Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders MULTIPLE CHOICE 1. The nurse is providing care for a client who had surgical repair of a paraesophageal hernia. The nurse observes that the patient exhibits signs of dysphagia during the first postoperative meal. Which action does the nurse take? 1. Offer the patient fluids. 2. Cut the food into small pieces. 3. Report observation to the health care provider (HCP). 4. Assure patient the problem is temporary. ANS: 3 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Plan nursing care for patients with hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Page: 644 Heading: Hiatal Hernia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

If a patient is having difficulty swallowing, fluids may increase the problem and result in aspiration. Cutting food into small pieces may improve the situation, but is considered an attempt to correct the problem without addressing the cause. After the repair of a paraesophageal hernia, dysphagia should be reported to the HCP. The corrective fundoplication surgery may have the stomach fundus wrapped too tight around the esophagus, causing food obstruction. Food obstruction following repair of a paraesophageal hernia is not a temporary or self-correcting condition.

PTS:

CON: Patient-Centered Care

2. The nurse is teaching a patient with gastroesophageal reflux related to a hiatal hernia about body position for management of the disease process. Which patient statement indicates that teaching has been effective? 1. “I elevate the head of the bed 4 to 6 inches on blocks.” 2. “I elevate the foot of the bed 12 to 16 inches on blocks.” 3. “I sleep on my back with several pillows under my head.” 4. “I sleep in a recliner to elevate my head correctly.” ANS: 1 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders

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Objective: Plan nursing care for patients with hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Page: 646 Heading: Gastroesophageal Reflux Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

2 3

The patient with gastroesophageal reflux needs to keep the head elevated during sleep or when prone to rest. The head of the bed needs to be solidly elevated with blocks to a height of 4 to 6 inches. Elevating the foot of the bed to any height will place the patient with gastroesophageal reflux at risk for aspiration of gastric contents. Ideally, the client with gastroesophageal reflux should sleep on the back with the head elevated. However, pillows are not adequate to maintain a solid, permanent elevation. Not all patients have a recliner or will be able to sleep comfortably in one.

PTS:

CON: Patient-Centered Care

3. The nurse is collecting health information from a patient. Which patient statement will cause the nurse the most concern? 1. “My stool has been dark green and hard to pass lately.” 2. “Lately, I’ve had two or three loose, sticky, black stools every day.” 3. “Usually I move my bowels every day and the stool is light brown.” 4. “My stool is soft and dark brown; I usually move my bowels twice a day.” ANS: 2 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Explain the pathophysiology, signs and symptoms, and diagnostic testing for hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Page: 647 Heading: Gastric Bleeding Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

Stool that is dark green and hard to pass can indicate constipation caused by an iron preparation. The nurse is most concerned from the patient’s description, which is indicative of blood loss causing black tarry stools (melena) caused by slow bleeding from the upper gastrointestinal (GI) area. The patient’s description describes normal bowel function for many persons.

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More information is needed before becoming concerned about these descriptions. The patient’s description describes normal bowel function for many persons. More information is needed before becoming concerned about these descriptions.

PTS:

CON: Patient-Centered Care

4. The nurse is reinforcing teaching with a patient who had a large portion of the stomach surgically removed. For which condition related to the surgery will the patient need to receive vitamin B12 for life? 1. Sickle cell anemia 2. Pernicious anemia 3. Iron-deficiency anemia 4. Acquired hemolytic anemia ANS: 2 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Explain the pathophysiology, signs and symptoms, and diagnostic testing for hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Page: 655 Heading: Nursing Process for the Patient Having Gastric Surgery Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Nutrition Difficulty: Moderate Feedback 1 2

3 4

Sickle cell anemia is an inherited blood disorder. Vitamin B12 deficiency can occur after some or all of the stomach is removed because intrinsic factor secretion is reduced or gone. Normally, vitamin B12 combines with intrinsic factor to prevent its digestion in the stomach and promote its absorption in the intestines. Lifelong administration of vitamin B12 is required to prevent the development of pernicious anemia. Iron deficiency anemia is caused by a low dietary intake of iron-rich foods. Acquired hemolytic anemia is not related to gastric surgery.

PTS:

CON: Nutrition

5. The nurse reviews the laboratory results for a patient during a routine office visit. The results indicate a low hemoglobin level. The client denies any obvious signs of illness. For which primary reason does the nurse suspect the HCP will order gastric studies? 1. The condition can be related to low intrinsic factor. 2. Gastric bleeding is the likely cause of the anemia. 3. Type A chronic gastritis is asymptomatic. 4. The laboratory results have been noted previously. ANS: 1

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Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Plan nursing care for patients with acute and chronic gastritis. Page: 655 Heading: Chronic Gastritis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction in Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1

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Chronic type A gastritis is often symptomatic except for anemia. In this condition there is usually a deficiency of intrinsic factor secreted from the stomach cells, which results in difficulty absorbing vitamin B12, resulting in pernicious anemia. Endoscopy and upper GI x-ray studies will be performed; however, gastric aspirate analysis for the intrinsic factor will confirm the diagnosis in the absence of bleeding. Type A chronic gastritis is symptomatic; however, gastric studies will be ordered to rule out type A or B gastritis as the cause of the patient’s anemia. If the patient’s laboratory results have been noted previously, the HCP may suspect a chronic condition. There is a need to rule out both type A and B gastritis.

PTS:

CON: Patient-Centered Care

6. The nurse is providing care for a client with a body mass index (BMI) of 44, type 2 diabetes mellitus, sleep apnea, and was recently hospitalized for congestive heart failure. The patient is short of breath and ambulates with difficulty. Which therapeutic management does the nurse suspect the HCP will initially recommend? 1. Psychiatric treatment for poor self-esteem 2. Enrollment in an exercise program for the obese 3. Attendance at a weight-loss support group 4. Initiation of the process for bariatric surgery ANS: 4 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Describe medical, surgical, and nursing management for obesity. Page: 653 Heading: Obesity Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1

The patient is likely to have poor self-esteem and may benefit from psychiatric treatment. However, the patient needs immediate attention to the manifestations

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of obesity. The patient may benefit from an exercise program tailored to the needs of a person who is obese. However, the patient’s current condition and abilities do not support this as an initial response by the HCP. Once the patient’s condition is stabilized, continued weight loss can be achieved by attending a weight-loss support group. The patient is exhibiting medical and physical indications that bariatric surgery is essential. The nurse should suspect this as the HCP’s initial recommendation.

PTS:

CON: Patient-Centered Care

7. The nurse is providing care to a patient 3 days after a Billroth I procedure. About which observation should the nurse be most concerned? 1. Pulse 58 beats per minute 2. Incisional pain score of 4 on a 1-to-10 scale 3. Patient tearful while viewing the incision 4. Reports of abdominal cramping shortly after eating ANS: 4 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Plan nursing care for patients with hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Page: 654 Heading: Gastric Surgery Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

A pulse of 58 beats per minute could be within the patient’s normal pulse range. Pain and the emotional reaction to the incision are psychosocial concerns and are not the highest priority at this time. Pain and the emotional reaction to the incision are psychosocial concerns and are not the highest priority at this time. Dumping syndrome is a complication of Billroth I procedure and occurs 5 to 30 minutes after eating. Symptoms include dizziness, tachycardia, fainting, sweating, nausea, diarrhea, a feeling of fullness, and abdominal cramping.

PTS:

CON: Patient-Centered Care

8. The nurse is reinforcing teaching provided to a patient with a peptic ulcer. Which patient statement indicates understanding of the medication ranitidine? 1. “It clings to the ulcer.” 2. “It coats your stomach.” 3. “It neutralizes stomach acid.” 4. “It reduces production of gastric acid.”

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ANS: 4 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: List current pharmacological treatments used for peptic ulcer disease. Page: 647 Heading: Peptic Ulcer Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

This statement does not explain the purpose or mechanism of ranitidine. This statement does not explain the purpose or mechanism of ranitidine. This statement does not explain the purpose or mechanism of ranitidine. Ranitidine reduces production of gastric acid, which aids in healing the ulcer.

2 3 4

PTS:

CON: Patient-Centered Care

9. The nurse is asking about the type of bariatric surgery the patient had. The patient states, “They folded my stomach inward and sutured the folds in place.” Which surgery description does the nurse recognize? 1. Sleeve gastrectomy 2. Gastric plication 3. Roux-en-Y bypass 4. Gastric banding ANS: 2 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Describe medical, surgical, and nursing management for obesity. Page: 655 Heading: Gastric Bypass Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

A sleeve gastrectomy is a bariatric surgery that removes approximately 75 percent of the stomach, leaving a slim, narrow tube. The gastric plication is a bariatric surgery that folds the stomach inward and sutures the folds together. The Roux-en-Y bypass is a bariatric surgery that reduces the stomach size and bypasses some of the small intestine. Gastric banding involves the placement of an inflatable silicone band around the upper portion of the stomach. The pouch can be made bigger or smaller by injecting saline into the band through a skin port. The procedure is reversible.

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PTS:

CON: Patient-Centered Care

10. The nurse is caring for a patient who has developed esophagitis from gastroesophageal reflux disease (GERD). For which additional complication should the nurse anticipate providing care to this patient? 1. Laryngospasm 2. Bronchospasm 3. Barrett’s esophagus 4. Aspiration pneumonia ANS: 3 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Explain the pathophysiology, signs and symptoms, and diagnostic testing for hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Page: 645 Heading: Gastroesophageal Reflux Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

Laryngospasm is not a complication typically associated with GERD. Bronchospasm is not a complication typically associated with GERD. Complications of GERD can result in esophagitis. Over time, this can lead to changes in the epithelium of the esophagus and lead to Barrett’s esophagus, a precancerous lesion. Aspiration pneumonia is not a complication typically associated with GERD.

PTS:

CON: Patient-Centered Care

11. The nurse is collecting data for a patient who is taking lansoprazole for peptic ulcer disease. Which data collection finding requires immediate intervention? 1. A rash 2. Tarry stools 3. Constipation 4. Changes in mental status ANS: 2 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: List current pharmacological treatments used for peptic ulcer disease. Page: 647 Heading: Peptic Ulcer Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate

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Feedback 1 2

3 4

A rash is not identified as an adverse effect of lansoprazole. With lansoprazole administration, the nurse should assess for epigastric or abdominal pain and for blood in stool (tarry stools), emesis, or gastric aspirate. Notify the physician if any evidence of bleeding has occurred. Constipation is not identified as an adverse effect of lansoprazole. Changes in mental status is not identified as an adverse effect of lansoprazole.

PTS:

CON: Safety

12. The nurse is providing care for a patient who is experiencing nausea and vomiting. Which pathological manifestation is unlikely to occur with prolonged vomiting? 1. Anemia 2. Dehydration 3. Metabolic alkalosis 4. Electrolyte imbalance ANS: 1 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Explain anorexia, nausea, and vomiting. Page: 651 Heading: Anorexia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

The patient is unlikely to experience anemia with prolonged vomiting. However, vomiting of blood in any form can be a cause of anemia. Dehydration is a risk related to prolonged vomiting due to the loss of body fluids. Metabolic alkalosis can occur with prolonged vomiting due to the loss of hydrochloric acid from the stomach. When there is a loss of fluid, there is also the risk for electrolyte imbalance with prolonged vomiting.

PTS:

CON: Patient-Centered Care

13. The nurse is providing care for a patient who reports nausea following chemotherapy. Which nursing intervention is unlikely to effectively manage the patient’s nausea? 1. Provide a quiet, odor-free, visually clean environment. 2. Give an antiemetic as needed and prescribed by the HCP. 3. Bring the patient a small, bland meal to ease any hunger. 4. Provide frequent mouth care to remove noxious tastes. ANS: 3

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Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Describe therapeutic measures and nursing care for anorexia, nausea, and vomiting. Page: 645 Heading: Anorexia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

The nurse needs to provide an environment that removes any triggering stimuli for nausea. An antiemetic medication is given to alleviate the sensation of nausea and prevent vomiting. Even a small, bland meal can trigger nausea and vomiting. The patient may be able to tolerate clear liquids, preferably water or ice chips. If liquids are tolerated, crackers or dry toast may also be tolerated. When patients have sensations of nausea, it may be compounded by noxious tastes in the mouth. Frequent mouth care is effective for eliminating this trigger, especially if the client has vomited.

PTS:

CON: Patient-Centered Care

14. A patient who had bariatric surgery presents at the HCP’s office and is diagnosed with aphthous stomatitis. Given the patient’s medical history, the nurse recognizes which cause of the condition is most likely? 1. Vitamin B12 deficiency 2. Emotional stress 3. Recent dental work 4. Menstruation ANS: 1 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Describe medical, surgical, and nursing management for obesity. Page: 642 Heading: Oral Inflammatory Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

The patient has oral inflammation. Given the medical history of bariatric surgery, the most likely cause of the condition is the lack of vitamin B12. The patient may or may not have emotional stress. There is no specific information in the question to support this cause.

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Oral inflammation may occur after recent dental work; however, there is no specific information in the question to support this cause. Menstruation can be a trigger for oral inflammation; however, there is no specific information in the question to support this cause.

PTS:

CON: Patient-Centered Care

15. The nurse is providing care for a patient who underwent a Billroth I surgery for stomach cancer. Which nursing care is most important during the postoperative period for this patient? 1. Medicating for pain to promote coughing and deep breathing 2. Assisting the patient out of bed to prevent clot formation 3. Observing the surgical dressing to recognize excessive bleeding 4. Monitoring the amount and type of drainage from the NG tube ANS: 1 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Plan care for patients with hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Page: 643 Heading: Gastric Cancer Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction in Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1

After any surgery with general anesthesia, the most important issue is the establishment and maintenance of a patent airway. The location of this patient’s surgery will make it difficult to cough and deep breathe; adequate pain management is essential. All surgical patients need to be out of bed and/or ambulating as soon as possible to prevent the formation of blood clots. However, airway maintenance and oxygenation are the most important postoperative care. Surgical patients always need to be monitored for bleeding or hemorrhage; in this situation, airway management and oxygenation is the most important concern. It is likely that this client will have an NG tube. The nurse will need to monitor for patency and drainage characteristics. However, airway maintenance and oxygenation are still the most important.

PTS:

CON: Patient-Centered Care

16. The nurse is providing care for a patient who is receiving chemotherapy and radiation as treatment for esophageal cancer. Which factor in the care of this patient is the nurse’s least concern? 1. Risk of choking 2. The ability to speak

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3. Meeting nutritional needs 4. Effective pain management ANS: 2 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Plan care for patients with hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Page: 643 Heading: Esophageal Cancer Integrated Process: Clinical Problem-Solving Process (Nursing Process) Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1

2 3

With esophageal cancer, it is possible for the esophagus to become narrow; the condition is exacerbated by the radiation therapy. The risk for choking and/or aspiration is high and of great concern. The patient may or may not be able to speak. Alternate methods of communication make this the least concern for the nurse. Due to the disease process and treatments, the client may have difficulty meeting nutritional needs. Nutritional deficiency is of great concern to the nurse. Pain related to the diagnosis and treatment of esophageal cancer can be intense. Management of pain is more important than concern about the ability to speak.

PTS:

CON: Patient-Centered Care

17. The nurse works with cancer patients. Which factor does the nurse identify as a cause of gastric cancer? 1. The female gender 2. Oxidants in fruit and vegetables 3. High intake of smoked fish and meats 4. Medical history of iron deficiency anemia ANS: 3 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Explain the pathophysiology, signs and symptoms, and diagnostic testing for hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Page: 652 Heading: Gastric Cancer Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

The male gender has a higher incidence of gastric cancer does than the female

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gender. Fruits and vegetables are a high source of antioxidants, which help prevent cancer. Patients with a diet high in smoked fish and meats have an increased risk for gastric cancer. A medical history of pernicious anemia, not iron deficiency anemia, is a cause of gastric cancer.

PTS:

CON: Patient-Centered Care

18. The nurse is preparing to provide care for a client diagnosed with peptic ulcer disease. Which pathophysiological characteristic will the nurse correctly associate with the patient’s diagnosis? 1. Erosion is confined to the stomach and esophagus. 2. A common cause is an infection from Helicobacter pylori. 3. Surgery to increase mucus will heal the ulcerations. 4. Gastric ulcers occur more frequently than do peptic ulcers. ANS: 2 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Explain the pathophysiology, signs and symptoms, and diagnostic testing for hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Page: 647 Heading: Peptic Ulcer Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

With peptic ulcer disease, the stomach, esophagus, pylorus, and duodenum can all be involved. The most common cause of peptic ulcer disease is infection from H pylori. Surgery for peptic ulcer disease is not performed to increase mucous secretion. Peptic ulcers occur more frequently than gastric ulcers.

PTS:

CON: Patient-Centered Care

19. The nurse is providing care for a patient who is diagnosed with a Mallory-Weiss tear (MWT). Which treatment for the condition is the nurse expecting? 1. Immediate emergency surgery 2. Ice lavage to the damaged esophagus 3. Positioning in reverse Trendelenburg’s 4. An injection of epinephrine ANS: 4 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders

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Objective: Explain the pathophysiology, signs and symptoms, and diagnostic testing for hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Page: 646 Heading: Mallory-Weiss Tear Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1

2 3

An MWT does not require immediate emergency surgery. The tear is usually self-healing without intervention and bleeding stops within a few hours. During endoscopy, endoclips may be placed to stop bleeding. Ice lavage is not used in the treatment of MWT. Ice lavage is likely to be used to stop the bleeding of esophageal varices. Positioning the patient in reverse Trendelenburg’s is contraindicated with a MWT. The position will cause blood to move upward in the esophagus and increase the risk for aspiration. The patient with MWT may receive an injection of epinephrine, which is a vasoconstrictor, to control bleeding.

PTS:

CON: Patient-Centered Care

20. The nurse is providing care for a client with multiple injuries from a serious car accident. The HCP prescribes a diet as tolerated and administration of sucralfate orally. Which condition and goal does the nurse associate with the HCP’s prescriptions? 1. Prevention of peptic ulcer disease 2. Decreased healing from malnutrition 3. Management of causes of shock 4. Formation of stress ulcers ANS: 4 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Plan care for patients with hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Page: 652 Heading: Stress-Induced Gastritis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

The HCP’s prescriptions are aimed at the prevention of stress ulcers. The HCP is attempting to prevent the formation of stress ulcers by making an effort to keep food in the stomach and reduce gastric erosion. Neither of the HCP’s prescriptions will manage shock.

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The stress response to illness causes decreased blood flow to the stomach and small intestine, which can result in damage to the gastric mucosa. The goal of the HCP’s prescription is to reduce stress ulcers. Feeding the patient within 24 hours and giving prophylactic sucralfate (to form a gel that binds to the base of the ulcer) are appropriate treatments. Antacids and histamine can also be prescribed.

PTS:

CON: Patient-Centered Care

21. The nurse is planning care for a patient admitted for gastric bleeding, which is presently controlled. If the patient experiences a recurrence of bleeding, which manifestation will indicate to the nurse that the patient is experiencing hypovolemic shock? 1. Tachycardia and tachypnea 2. Dry mucous membranes 3. Change in level of consciousness 4. Reports of fatigue and thirst ANS: 1 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Plan care for patients with hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Page: 651 Heading: Gastric Bleeding Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Tachycardia and tachypnea, along with hypotension, chills, palpations, and diaphoresis, are all signs of hypovolemic shock. Dry mucous membranes are indicative of a decrease in circulating blood volume. A change in the level of consciousness is indicative of a decrease in circulating blood volume. Patient reports of fatigue and thirst are indicative of a decrease in circulating blood volume.

PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 1. The nurse is contributing to the care plan of a patient admitted after a massive gastric bleed. Which goals will the nurse consider during this process of planning care? (Select all that apply.) 1. Recognize and treat hypovolemic shock. 2. Reassess for pain and medicate as needed.

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3. Monitor and report signs of stress-induced ulcers. 4. Reassess for indications of electrolyte imbalances. 5. Implement measures to prevent or treat dehydration. ANS: 1, 4, 5 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Plan care for patients with hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Page: 651 Heading: Gastric Bleeding Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

1. 2.

3. 4. 5.

PTS:

Feedback The patient who experiences a massive gastric bleed is susceptible to hypovolemic shock, which can be fatal. The patient who experiences a massive gastric bleed is not likely to have pain (the question does not provide information to support the presence of pain). Stress-induced ulcers usually occur from serious illness or trauma. There is no indication that the patient is at risk for this development. Because the patient is likely to be hypovolemic due to a massive gastric bleed, the nurse should be alert to signs of electrolyte imbalances. After a massive gastric bleed, the patient is likely to be dehydrated due to the loss of blood. The option includes measures to correct the condition. 1

CON: Patient-Centered Care

2. The nurse instructs a patient prescribed omeprazole for peptic ulcer disease about the use of the medication. Which patient statements indicate understanding of the instructions? (Select all that apply.) 1. “I should not take antacids while I’m on this medication.” 2. “If I wish, I can open the capsule and sprinkle it on food.” 3. “I will take the capsule before eating a meal in the morning.” 4. “I will need to take this drug for 3 weeks for my ulcer to heal.” 5. “I will report any abdominal pain, diarrhea, or bleeding that occurs.” ANS: 3, 5 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: List current pharmacological treatments used for peptic ulcer disease. Page: 647 Heading: Peptic Ulcer Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Safety

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Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback Antacids are not contraindicated when omeprazole is prescribed; instructions are not understood. Omeprazole is a time-released medication and the capsule should not be opened, or the contents sprinkled on food; instructions are not understood. The patient is instructed to take omeprazole in the morning before a meal; instructions are understood. The patient will need to take omeprazole for 4 to 8 weeks for ulcer healing to occur; instructions are not understood. The patient needs to report abdominal pain, diarrhea, or bleeding to the HCP during the medication therapy; instructions are understood. 1

CON: Safety

3. A patient who had extensive gastric surgery for stomach cancer reports feeling sick and diaphoretic with abdominal cramping about 20 minutes after eating. The nurse is providing information about dumping syndrome. Which information is correct? (Select all that apply.) 1. The patient is experiencing one of the most common complications. 2. Food enters the jejunum without adequate amounts of digestive juices. 3. The condition is lifelong and may require treatment with insulin. 4. High concentrations of electrolytes and sugar draws fluid into the bowel. 5. The patient will need to eat some candy or drink juice containing sugar. ANS: 1, 2, 4, 5 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Plan care for patients with hiatal hernia, peptic ulcer disease, gastric bleeding, and gastric cancer. Page: 653 Heading: Dumping Syndrome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3. 4.

Feedback Dumping syndrome is one of the most common complications following extensive gastric surgery. Dumping syndrome occurs when food rapidly enters the jejunum without being thoroughly mixed with digestive juices. The dumping syndrome may last up to 6 months after gastric surgery and will gradually decrease over time. The concentration of electrolytes and sugar is diluted when the body draws fluid into the bowel and from the circulating blood volume. The rapid drop in circulating fluid volume causes many of the symptoms of dumping syndrome. In addition, high sugar concentrations trigger the release of insulin, which

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results in hypoglycemia about 2 hours after eating. The patient needs a rapid source of oral sugar to alleviate the symptoms. PTS:

CON: Patient-Centered Care

COMPLETION 1. A patient’s ideal body weight is 150 lb. At which weight would the patient be considered obese? Enter the numeral only. ANS: 180 Chapter: Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders Objective: Describe medical, surgical, and nursing management of obesity. Page: 655 Heading: Obesity Integrated Process: Clinical Problem-Solving Process Client Need: Physical Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Difficult Feedback: A weight that is 20 percent over ideal weight is considered obese. Calculate this by multiplying the current weight by 20 percent, or 150 × 0.20 = 30. Then add this value of 30 to the current weight of 150 lb. The patient would need to weigh 180 lb to be considered obese PTS:

CON: Patient-Centered Care

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Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders MULTIPLE CHOICE 1. The nurse is providing care for a patient diagnosed with obstipation. Which condition is the nurse aware as being unrelated to the patient’s diagnosis? 1. History of repeatedly ignoring the urge to defecate 2. Colon and rectal tissue insensitive to presence of feces 3. Medical history of obesity and cardiovascular disorders 4. Stronger stimulation needed to produce a peristaltic rush ANS: 3 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Identify the causes, signs and symptoms, and therapeutic measures of constipation and diarrhea. Page: 659 Heading: Constipation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1 2 3 4

Obstipation is the term for long-standing constipation. A patient history of repeatedly ignoring the urge to defecate is a strong contributor to the condition. The musculature of the bowel and rectal mucous membrane become insensitive to the presence of feces. A medical history of obesity and cardiovascular disorders are unrelated to intermittent or long-standing constipation. Once obstipation occurs, stronger stimulation is needed to produce the peristaltic rush required for defecation.

PTS:

CON: Elimination

2. The nurse is providing care for a patient who reports feeling constipated, yet passes frequent small liquid stools. The nurse suspects an impaction. Which statement by the patient causes the nurse concern? 1. “I took some medication to stop the diarrhea.” 2. “I have strained but cannot have a good bowel movement.” 3. “When I do pass feces, they are small, hard, and dry.” 4. “My stomach is so bloated that I am uncomfortable.” ANS: 1 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Identify the causes, signs and symptoms, and therapeutic measures of constipation and diarrhea. Page: 659

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Heading: Constipation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1

3 4

Fecal impaction results when the fecal mass is so dry it cannot be passed. Small amounts of liquid stool ooze around the fecal mass and cause incontinence of liquid stools. The nurse is concerned if the patient takes antidiarrheal medication, which can make the condition worse. Straining is not uncommon by a patient who has constipation or a bowel impaction. There is no information in the question to indicate a cardiac, neurologic, or respiratory concern. The patient is describing the expected appearance of feces during constipation; the passage of some stool does not support the presence of an impaction. With constipation or impaction, the patient will frequently experience bloating and pain.

PTS:

CON: Elimination

3. The nurse notes that a patient with a history of a myocardial infarction is straining during defecation. Which response by the nurse is best? 1. “Be careful, you might get a headache when you push so hard.” 2. “It is important that you not strain because it could cause damage to your heart.” 3. “Your blood pressure gets very low when you strain like that and you could faint.” 4. “Chronic constipation often causes a dilated colon, it is good that you are staying empty.” ANS: 2 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Plan nursing care and teaching for patients with constipation or diarrhea. Page: 659 Heading: Constipation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1 2

The nurse’s response does not address the greatest concern for the patient. Straining to have a bowel movement (Valsalva’s maneuver) can result in cardiac, neurologic, and respiratory complications. If the patient has a history of heart failure, hypertension, or recent myocardial infarction, straining can lead to cardiac rupture and death. When straining, Valsalva’s maneuver can actually cause the patient’s blood pressure to rise.

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Chronic constipation can cause a dilated colon (megacolon) proximal to the dry fecal mass and obstruct the colon. However, this is not the greatest concern for this patient.

PTS:

CON: Elimination

4. The nurse is providing care for a client postoperative for the placement of a colostomy for colon cancer. When examining the stoma, which finding causes the nurse to immediately contact the health care provider (HCP)? 1. Large, beefy-red in color 2. Small in size and pink color 3. Large and seeping drainage 4. Dusky color, dryness noted ANS: 4 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Plan nursing care and teaching for a patient with an ostomy. Page: 679 Heading: Colostomy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

The colostomy stoma appears large and beefy-red in color after surgery and during a period of healing. The colostomy stoma will eventually appear small and pink in color. The initial appearance of a colostomy stoma is large and may exhibit some seeping drainage. A dusky-colored stoma that appears dry needs to be reported immediately to the HCP. The finding is indicative of compromised circulation to the stoma and additional surgery may be necessary.

PTS:

CON: Patient-Centered Care

5. The nurse is gathering data on a patient with severe diarrhea for 3 days. The patient reports being out of the country for 2 weeks. Laboratory results indicate the presence of red blood cells (RBCs) and mucus in a stool sample. For which conditions does the nurse expect further testing? 1. Cholera, typhoid, typhus, or amebiasis 2. Shigellosis, salmonellosis, or reginal enteritis 3. Large bowel cancer or intestinal tuberculosis 4. Celiac disease, or irritable bowel syndrome ANS: 1 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders

NURSING TEST BANK

Objective: Describe pathophysiology, therapeutic measures, nursing care, and teaching for patients with inflammatory and infectious disorders of the lower gastrointestinal tract. Page: 662 Heading: Diarrhea Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Difficult Feedback 1

2 3

The presence of diarrhea after traveling out of the country and the patient’s manifestations and laboratory test results indicate possible cholera, typhoid, typhus, or amebiasis. The most applicable information is the presence of RBCs and mucus in the stool sample. Shigellosis, salmonellosis, or reginal enteritis would manifest with the presence of white blood cells (WBCs) and mucus in the stool sample. Intestinal tuberculosis would test with WBCs in the stool; large bowel cancer would cause RBCs in the stool. The most significant clue to the patient’s condition is travel outside the country. Celiac disease and irritable bowel syndrome may cause some of the same laboratory results, but are not linked to travel outside of the country.

PTS:

CON: Elimination

6. The nurse is providing discharge teaching to a patient with diarrhea. Which patient statement indicates that teaching has been effective? 1. “It is important that I increase fluid intake to prevent dehydration.” 2. “I am at increased risk for a ruptured bowel, so I must remain on bedrest.” 3. “I should tell future health care workers that I’ve been diagnosed with obstipation.” 4. “My risk for a urinary tract infection is very high, so I should call the doctor if I have pain.” ANS: 1 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Plan nursing care and teaching for patients with constipation or diarrhea. Page: 662 Heading: Diarrhea Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1 2 3

Weakness and dehydration from fluid loss may occur with diarrhea. A ruptured bowel is not an adverse effect of diarrhea. Obstipation is a term for chronic constipation.

NURSING TEST BANK

The patient’s risk for urinary tract infection is not high because of diarrhea.

PTS:

CON: Elimination

7. The nurse is contributing to the plan of care for a patient with gluten enteropathy (celiac disease). Which food(s) does the nurse recommend be eliminated from the diet of the patient? 1. Red meats 2. Milk and milk products 3. Fresh fruits and vegetables 4. Wheat, rye, oats, and barley ANS: 4 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Plan nursing care and teaching for patients with absorption disorders. Page: 675 Heading: Absorption Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Elimination Difficulty: Moderate Feedback 1 2 3 4

Gluten is not found in red meats. Gluten is not found in milk and milk products. Gluten is not found in fresh fruits and vegetables. Gluten is a protein found in wheat, barley, oats, and rye. In celiac disease, a high-calorie, high-protein, gluten-free diet is ordered to relieve symptoms and improve nutritional status.

PTS:

CON: Elimination

8. The nurse is collecting data from a patient who is reporting abdominal pain. Which symptom suggests that the patient is experiencing appendicitis? 1. Suprapubic pain 2. Midepigastric pain 3. Substernal pain that radiates to the back 4. Pain in the right lower abdominal quadrant ANS: 4 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: List data to collect when caring for patients with lower gastrointestinal disorders. Page: 663 Heading: Inflammatory and Infectious Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Inflammation

NURSING TEST BANK

Difficulty: Moderate Feedback 1 2 3 4

Appendicitis pain is not located in the suprapubic area. Appendicitis pain is not located in the midepigastric area. Appendicitis pain is not located in the substernal area with radiation to the back. Signs and symptoms of appendicitis include fever, increased white blood cells, and generalized pain in the upper abdomen. Within hours of onset, the pain usually becomes localized to the right lower quadrant at McBurney’s point.

PTS:

CON: Inflammation

9. The nurse is monitoring a patient recovering from an emergency appendectomy. Which finding does the nurse report immediately to the HCP? 1. Pain at the operative site 2. Absence of bowel sounds 3. Abdomen rigid on palpation 4. 3-cm spot of bloody drainage on dressing ANS: 3 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and teaching for patients with inflammatory and infectious disorders of the lower gastrointestinal tract. Page: 663 Heading: Inflammatory and Infectious Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Inflammatory and Infectious Disorders Difficulty: Moderate Feedback 1 2 3 4

The patient is expected to experience postoperative pain. Absence of bowel sounds is expected after anesthesia. With peritonitis, a life-threatening complication, abdominal rigidity is present. The physician should be notified promptly for treatment orders. Some bleeding is expected after surgery.

PTS:

CON: Inflammatory and Infectious Disorders

10. A patient is informed, after a colonoscopy, of diverticulosis. The patient asks the nurse about the causes and management of the condition. Which information shared by the nurse is inaccurate? 1. Chronic constipation is a common precursor to the condition. 2. A major management intervention is an increase in dietary fiber. 3. Nuts and foods with seeds and hulls are avoided to prevent infection. 4. Weight control, a healthy diet, and exercise are good management interventions.

NURSING TEST BANK

ANS: 3 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and teaching for inflammatory bowel disease. Page: 664 Heading: Diverticulosis and Diverticulitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1

2 3 4

Diverticulosis is most common in patients who have had chronic constipation, which increases the pressure in the bowel and causes outpouching in weaker/weakened areas. Patients with diverticulosis are encouraged to increase dietary fiber to help promote healthy bowel function and prevent diverticulitis. Some HCPs will recommend avoidance of nuts, seeds, and hulls with a diagnosis of diverticulosis; however, this is not proven to prevent diverticulitis. Weight control, a healthy diet, and exercise will all promote healthy bowel function.

PTS:

CON: Elimination

11. The nurse is reinforcing teaching to a patient with diverticulosis about how to avoid complications. Which patient statement indicates that teaching has been effective? 1. “I will avoid milk and milk products.” 2. “I should avoid very hot and spicy foods.” 3. “I will increase fluids and fiber in my diet.” 4. “I should cook vegetables thoroughly before eating.” ANS: 3 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and teaching for patients with inflammatory and infectious disorders of the lower gastrointestinal tract. Page: 664 Heading: Diverticulosis and Diverticulitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Inflammatory and Infectious Disorders Difficulty: Moderate Feedback 1 2

Avoiding milk products will not prevent the development of complications from diverticulosis. Avoiding hot and spicy foods will not prevent the development of complications from diverticulosis.

NURSING TEST BANK

Diverticulosis is managed by preventing constipation. Diverticulitis can be prevented by increasing dietary fiber to prevent constipation and onset of diverticulosis. Cooking vegetables will not prevent the development of complications from diverticulosis. However, it does decrease the fiber content of the vegetables.

PTS:

CON: Inflammatory and Infectious Disorders

12. A patient receives a diagnosis of Crohn disease and states, “I don’t understand anything about this disease.” Which information provided by the nurse is most helpful at this time? 1. The condition is an autoimmune inflammatory bowel disease. 2. Treatment will focus on symptom management and medications. 3. Inflamed areas are not continuous lesions along the intestine. 4. Connections between organs called fistulas and fissures may develop. ANS: 2 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and teaching for patients with inflammatory and infectious disorders of the lower gastrointestinal tract. Page: 667 Heading: Inflammatory Bowel Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Elimination Difficulty: Difficult Feedback 1

2 3

The patient will eventually want to know more about the pathology of the disease; however, initially the greatest interest or concern will be focused on treatment and management. The most helpful information for the patient at this time will be that treatment will focus on symptom management and medications. The patient will eventually want to know more about the pathology of the disease. The most helpful information at this time is focused on management and treatment. Informing the patient about the formation of fistulas and fissures at this time is likely to cause client distress and/or confusion.

PTS:

CON: Elimination

13. The nurse is providing care for a client with advanced Crohn disease who has developed multiple complications of the disease and no longer responds to treatment. The HCP is recommending surgery. Which detail about the patient’s surgery does the nurse comprehend? 1. The patient is not a candidate for a Kock pouch. 2. The patient will be considered cured after the surgery. 3. The narrowed parts of the colon will be removed. 4. The formation of a colostomy is the surgical goal.

NURSING TEST BANK

ANS: 1 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and teaching for patients with inflammatory and infectious disorders of the lower gastrointestinal tract. Page: 667 Heading: Crohn Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Difficult Feedback 1

The patient is not a candidate for the formation of a Kock pouch, which is formed from part of the patient’s ileum. With Crohn disease, there is a high risk that the pouch will also become diseased. There is no cure for Crohn disease; the goal of care is for the management of symptoms and medication therapy. When the disease no longer responds to treatment, surgery is recommended. Because Crohn disease is a progressive condition with lesions intermittently located throughout the length of the intestine (skip-lesions), removing the narrowed parts of the colon will not arrest the manifestations. The surgery for this patient is likely to involve removal of the colon. The ostomy will be either an ileostomy or an ileorectal anastomosis.

PTS:

CON: Elimination

14. The nurse is monitoring a patient and finds a bulging area in the patient’s groin. Which additional finding causes the nurse the most concern? 1. The bulging disappears at times. 2. The WBC count is 10,000/mm3. 3. The patient develops pain at the site and vomiting. 4. The bulging occurs when the patient coughs or strains. ANS: 3 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Plan nursing care for an abdominal hernia. Page: 644 Heading: Abdominal Hernias Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

The disappearance of the bulge means the hernia can be reduced. An elevated WBC count means an infection is present, which is not expected or common with a hernia.

NURSING TEST BANK

An incarcerated hernia may become strangulated if the blood and intestinal flows are completely cut off. Symptoms are pain at the site of the strangulation, nausea and vomiting, and colicky abdominal pain. Bulging with coughing or straining is an indication that a hernia is present.

PTS:

CON: Patient-Centered Care

15. The nurse is providing care for a patient diagnosed with celiac disease. The patient initially presented with a skin rash with severe pruritus and blistering. Which additional manifestation is the nurse unlikely to associate with the patient’s condition? 1. Gas and abdominal bloating 2. Frequent loose bulky stools 3. Moderate amount of weight gain 4. Foul-smelling, gray-colored stool ANS: 3 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Planning nursing care and teaching for patients with absorption disorders. Page: 675 Heading: Absorption Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1 2 3 4

The nurse will associate gas and abdominal bloating with celiac disease. The nurse will associate frequent loose bulky stools with celiac disease, related to passage of underdigested food. The patient with celiac disease is likely to exhibit signs of malnutrition; weight gain is not expected. Foul-smelling, gray-colored stool (steatorrhea) is caused by increased fat due to malabsorption.

PTS:

CON: Elimination

16. The nurse is caring for a patient admitted with a possible bowel obstruction. Which patient symptom should cause the nurse the most concern? 1. Flank pain 2. Fecal vomiting 3. Watery diarrhea 4. Occult blood in the stool ANS: 2 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Describe causes, signs and symptoms, therapeutic measures, and nursing care for intestinal obstruction. Page: 676

NURSING TEST BANK

Heading: Intestinal Obstruction Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1 2

3 4

Flank pain is not associated with a bowel obstruction. As a bowel obstruction becomes more extreme, peristaltic waves reverse, propelling the intestinal contents toward the mouth, eventually leading to fecal vomiting. Watery diarrhea would not be present with a bowel obstruction. Occult blood in the stool is not present with a bowel obstruction.

PTS:

CON: Elimination

17. A patient with ulcerative colitis is scheduled for a colectomy with formation of an ileoanal pouch. The patient is reviewing information presented by the HCP regarding possible surgical complications. Which statement by the patient causes the nurse to report a misunderstanding to the HCP? 1. “I will defecate in a normal manner after healing with the pouch.” 2. “I will still need to watch for obstruction or pouch inflammation.” 3. “The placement of an ileostomy is temporary until healing is complete.” 4. “Formation of the pouch is part of the cure of my condition.” ANS: 4 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and teaching for patients with inflammatory and infectious disorders of the lower gastrointestinal tract. Page: 682 Heading: Ulcerative Colitis Integrated Process: Communication and Documentation Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Collaboration Difficulty: Difficult Feedback 1

2 3 4

The patient will be able to defecate normally with the formation of an ileoanal pouch, which will hold stool and preserve the function of the retained anal sphincter. With the described surgery, the patient will need to be aware of the symptoms of a bowel obstruction or pouch inflammation (pouchitis). An ileostomy will be temporarily placed until the ileoanal pouch is healed. The nurse needs to report a patient misunderstanding to the HCP about the planned surgery being curative. A colectomy is curative for ulcerative colitis; however, the placement of an ileoanal pouch is not curative. The retained tissue is still subject to the disease process.

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PTS:

CON: Collaboration

18. On admission, a patient with gastrointestinal bleeding had the following vital signs: blood pressure (BP) 140/80 mm Hg, pulse 72 beats/min, respirations 14 breaths/min, and temperature 98.8°F (37.1°C) orally. Which finding does the licensed practical nurse/licensed vocational nurse (LPN/LVN) report immediately to the registered nurse (RN) or HCP? 1. Pulse 78 beats/min 2. Crampy abdominal pain 3. Occult blood in the stool 4. BP 104/68 mm Hg ANS: 4 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Describe causes, signs and symptoms, therapeutic measures, and nursing care for lower gastrointestinal bleeding. Page: 679 Heading: Inflammatory Bowel Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Collaboration Difficulty: Moderate Feedback 1 2 3 4

The patient’s pulse remains within normal range. Crampy abdominal pain does not indicate acute distress. Occult blood in the stool would be expected in the patient with gastrointestinal bleeding. A BP of 104/68 mm Hg is a significant drop from the patient’s prior pressure and may indicate that the patient is going into shock. Prompt treatment is needed.

PTS:

CON: Collaboration

19. The nurse is providing care for a patient admitted with a complete, nonmechanical small bowel obstruction. Which manifestation indicates to the nurse that the patient’s condition is improving? 1. Flatus and feces are passed. 2. Peristaltic waves are visible. 3. Patient verbally reports thirst. 4. Abdominal circumference decreases. ANS: 4 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Describe causes, signs and symptoms, therapeutic measures, and nursing care for intestinal obstruction. Page: 676 Heading: Intestinal Obstruction Integrated Process: Clinical Problem-Solving Process (Nursing Process)

NURSING TEST BANK

Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 2

3 4

Initially, flatus and feces already in the distal part of the colon may be passed. This is not an indication of improvement. When peristaltic waves are visible through the abdominal wall, it indicates that the obstruction remains and the bowel is attempting to move bowel contents. This is not an indication of improvement. When the patient verbally reports thirst, it is indicative of dehydration and not an indication of improvement. When the abdominal circumference decreases, it is a sign that the obstruction is resolved or resolving.

PTS:

CON: Patient-Centered Care

20. The spouse of a patient with an ascending ostomy asks if the patient will always have to wear an ostomy bag. Which is the correct response by the nurse? 1. “An ostomy bag will be needed all of the time.” 2. “An ostomy bag will be needed only during the night.” 3. “An ostomy bag will be needed only to protect the stoma.” 4. “An ostomy bag will be needed until discharge from the hospital.” ANS: 1 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Plan nursing care and teaching for a patient with an ostomy. Page: 682 Heading: Ostomy and Continent Ostomy Management Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Elimination Difficulty: Medium Feedback 1 2 3 4

An ostomy bag will be needed all of the time as the stool will be liquid to mushy. The drainage from an ostomy at the ascending colon will pass as needed and not only at night. Ostomy bags are not used to protect the stoma; they are applied to manage the passage of feces. An ostomy bag will be needed all of the time, even after discharge from the hospital.

PTS:

CON: Elimination

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21. The nurse provides care to older adult residents in an extended-care facility. One resident is experiencing diarrhea. The resident reports loss of appetite, weakness, and drowsiness. Which body system is most important for the nurse examine? 1. Respiratory system 2. Skin condition 3. Cardiovascular system 4. Gastrointestinal system ANS: 3 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: List data to collect when caring for patients with lower gastrointestinal disorders. Page: 661 Heading: Diarrhea Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1 2 3

The highest risk for an older adult with diarrhea is for dehydration and hypokalemia. The respiratory system is not a priority. Older adults with diarrhea are at risk for skin breakdown; however, this is not the most important body system for the nurse to examine. Older adults with diarrhea are at great risk to quickly develop dehydration and hypokalemia, which can cause the listed symptoms along with life-threatening cardiac manifestations. Both fluid and potassium are lost through the stools. The gastrointestinal system is involved when a patient has diarrhea. Monitoring is necessary, but this is not the most important system to examine.

PTS:

CON: Elimination

22. The nurse is reviewing teaching with a patient scheduled for an ileostomy and placement of a continent ostomy reservoir. Which teaching is most important for the nurse to review? 1. The selected surgery takes longer than conventional surgery. 2. The pouch must be emptied regularly to prevent rupture. 3. The management of a continent pouch requires extra teaching. 4. Valve slipping or leakage will require additional surgery. ANS: 2 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Plan nursing care and teaching for a patient with an ostomy. Page: 682 Heading: Ostomy and Continent Ostomy Management Integrated Process: Teaching/Learning Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Difficult

NURSING TEST BANK

Feedback 1

The patient needs to be aware that the surgical procedure and recovery with a continent ileostomy is longer than with a conventional ileostomy. However, this is not the most important information to review. The most important information for the nurse to review is that failure to empty the continent ileostomy on a regular basis can result in rupture of the internal pouch. Preservation of the pouch is of great importance. It is important that the nurse remind the patient that the management of a continent pouch requires additional patient teaching; however, this is not the most important information to review. The patient needs to be aware that valve slipping or leakage will require additional surgery for correction. This is not the most important information to review.

PTS:

CON: Patient-Centered Care

23. A patient is scheduled for colon surgery that will require the placement of a colostomy. The wound, ostomy, and continence nurse (WOCN) will evaluate the patient for correct stoma placement. Which consideration by the nurse will directly impact skin integrity? 1. The placement that will prevent interference with clothing 2. The placement that promotes visibility and easy care 3. The placement that will prevent leaking or poor appliance fit 4. The placement that promotes comfort when sitting ANS: 3 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Plan nursing care and teaching for a patient with an ostomy. Page: 682 Heading: Ostomy and Continent Ostomy Management Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

It is important for the WOCN to consider placement that will not interfere with clothing, but the consideration does not directly impact skin integrity. The patient must be able to have stoma placement that is easy to view and care for, but the consideration does not directly impact skin integrity. The consideration about placement that will prevent leaking or poor appliance fit directly impacts skin integrity. Maintenance of skin integrity is crucial for a patient with a colostomy. Skin breakdown from stool and/or moisture can interfere with the ability to place or use a colostomy appliance. The patient needs to be comfortable when sitting, but the consideration does not directly impact skin integrity.

PTS:

CON: Patient-Centered Care

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24. The nurse is gathering data on a patient who was recently treated for colon cancer with the endoscopic removal of a small tumor. Which data will the nurse determine most important to relay to the HCP? 1. Ecchymosis and tenderness in the groin 2. Mild discomfort during palpation of the abdomen 3. A 4-pound weight loss over a period of a month 4. Auscultation of active bowel sounds in all quadrants ANS: 1 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Describe the causes, signs and symptoms, therapeutic measures, and nursing care of colon cancer. Page: 684 Heading: Colorectal Cancer Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1

Metastasis from colon cancer is commonly to the lymphatic system and the liver. Ecchymosis (bruising) can indicate liver dysfunction, and tenderness in the groin can be related to swollen lymph nodes. This is the most important information to relay to the HCP. Mild discomfort in the abdomen can be from a variety of causes and should be investigated further. The nurse should consider the passage of time from the removal of the tumor in the colon. A 4-pound weight loss is not significant. The nurse should gather data regarding the intention to lose weight, dietary changes, activity levels, and so forth. Active bowel sounds in all abdominal quadrants is a normal finding.

PTS:

CON: Patient-Centered Care

25. The nurse is gathering information from a patient who reports anal pain. Which finding upon physical examination supports the presence of an anal abscess? 1. Thrombosed vessels 2. Pain with defecation 3. Fever and drainage 4. Pain-induced constipation ANS: 3 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Plan nursing care for anorectal problems. Page: 678 Heading: Anorectal Problems Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing)

NURSING TEST BANK

Concept: Inflammation Difficulty: Moderate Feedback 1 2 3 4

Thrombosed vessels of the anal area are indicative of external hemorrhoids. Pain with defecation is present with hemorrhoids, anal fissures, or an anal abscess. However, pain is subjective and not objective information. If a client exhibits a fever and drainage with rectal pain, the nurse recognizes the possibility of an anal abscess. Pain-induced constipation can be caused by any condition or treatment of anorectal problems. However, constipation is subjective and not objective information.

PTS:

CON: Inflammation

26. The nurse is providing care for a patient diagnosed with an obstructed colon related to colon cancer. The client receives endoscopic treatment prior to surgical intervention to remove the obstructing tumor. Which observation will the nurse expect? 1. Decrease in pain level 2. Increased rectal bleeding 3. Rectal passage of stool 4. Improved dietary intake ANS: 3 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Describe the causes, signs and symptoms, therapeutic measures, and nursing care for colon cancer. Page: 676 Heading: Colorectal Cancer Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Difficult Feedback 1 2 3

The placement of a colon stint may or may not decrease the patient’s pain. The placement of a colon stint is not expected to increase rectal bleeding. The patient who is obstructed by a cancerous colon tumor cannot defecate. Endoscopically, a stent will be placed in the colon to allow the passage of stool until surgery is performed. The nurse can expect to see the passage of feces. The placement of a colon stint is not expected to improve the patient’s dietary intake.

PTS:

CON: Cellular Regulation

MULTIPLE RESPONSE

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1. The nurse is reinforcing teaching with a patient about appropriate diet modifications to help prevent exacerbations of inflammatory bowel disease. Which patient statements indicate that teaching has been effective? (Select all that apply.) 1. “I should avoid caffeine and spicy fiber foods.” 2. “I should avoid concentrated sweets and starches.” 3. “It is important to eat more whole grains and bran.” 4. “High-fiber foods should not be included in my diet.” 5. “Milk and other dairy products should be limited in my diet.” ANS: 1, 4, 5 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and teaching for inflammatory bowel disease. Page: 671 Heading: Inflammatory Bowel Disease Integrated Process: Teaching/Learning Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback High-fiber foods, caffeine, spicy foods, and milk products are avoided with inflammatory bowel disease. The patient with inflammatory bowel disease needs to avoid concentrated sweets and starches. The patient with inflammatory bowel disease needs to avoid high-fiber foods. High-fiber foods, caffeine, spicy foods, and milk products are avoided with inflammatory bowel disease. High-fiber foods, caffeine, spicy foods, and milk products are avoided with inflammatory bowel disease. 1

CON: Elimination

2. The nurse is reinforcing teaching to a patient who is being discharged with a new colostomy. Which comments by the patient indicate understanding of the discharge teaching? (Select all that apply.) 1. “I will empty the pouch when it is less than half full.” 2. “I can spray deodorant into the pouch after I clean it.” 3. “I will not be concerned if there is no stool for several days.” 4. “I always check the seal and tape around the stoma after I shower.” 5. “I should change the pouch each morning and evening to prevent infection.” ANS: 1, 2, 4 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and teaching for inflammatory bowel disease. Page: 684

NURSING TEST BANK

Heading: Ostomy and Ostomy Management Integrated Process: Teaching/Learning Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback The patient should empty the pouch before it is less than half full, use a deodorant spray in the pouch, and check the stoma seal after showering. The patient should empty the pouch before it is less than half full, use a deodorant spray in the pouch, and check the stoma seal after showering. Lack of stool could indicate a blockage and should be reported. The patient should empty the pouch before it is less than half full, use a deodorant spray in the pouch, and check the stoma seal after showering. Pouches are changed as needed, from every 3 days to every 14 days. Daily changing can cause a breakdown in skin integrity. 1

CON: Patient-Centered Care

3. The nurse reinforces teaching to a patient prescribed budesonide for Crohn disease inflammation. Which patient statements indicate that additional teaching is necessary? (Select all that apply.) 1. “I should avoid grapefruit juice.” 2. “I must avoid the sun while taking this drug.” 3. “I should swallow the pill whole, not crushed.” 4. “I will take the pill each evening before going to bed.” 5. “I can stop taking the medication once I feel better.” ANS: 2, 4, 5 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and teaching for inflammatory bowel disease. Page: 667 Heading: Inflammatory Bowel Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Teaching/Learning Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3. 4. 5.

Feedback Grapefruit juice should be avoided. This medication does not cause photosensitivity. The medication should be swallowed whole. The medication should be taken as prescribed in the morning and not stopped when the patient feels better. The medication should be taken as prescribed in the morning and not stopped when the patient feels better.

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PTS:

CON: Patient-Centered Care

4. The nurse is reinforcing teaching to a patient newly diagnosed with ulcerative colitis about triggers for exacerbation of the disease. Which recommendation does the nurse make to the patient to prevent a future exacerbation? (Select all that apply.) 1. Do not use tobacco. 2. Reduce exposure to stress. 3. Restrict fluids to 2 liters per day. 4. Read food labels to avoid food additives. 5. Avoid ingesting foods sprayed with pesticides. ANS: 1, 2, 4, 5 Chapter: Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders Objective: Describe pathophysiology, therapeutic measures, nursing care, and teaching for patients with inflammatory and infectious disorders of the lower gastrointestinal tract. Page: 667 Heading: Ulcerative Colitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

3. 4.

PTS:

Feedback Environmental agents such as pesticides, tobacco, radiation, and food additives may precipitate an exacerbation. Diet or psychological stress may trigger or worsen an attack of symptoms. Environmental agents such as pesticides, tobacco, radiation, and food additives may precipitate an exacerbation. Diet or psychological stress may trigger or worsen an attack of symptoms. There is no need for the patient to restrict fluids. Environmental agents such as pesticides, tobacco, radiation, and food additives may precipitate an exacerbation. Diet or psychological stress may trigger or worsen an attack of symptoms. Environmental agents such as pesticides, tobacco, radiation, and food additives may precipitate an exacerbation. Diet or psychological stress may trigger or worsen an attack of symptoms. 1

CON: Patient-Centered Care

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Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders MULTIPLE CHOICE 1. A patient reports that a family member is diagnosed with hepatitis and asks the nurse the best way to prevent becoming infected. Which is the best information for the nurse to provide? 1. Expose fabric or unwashable items to ultraviolet light. 2. Thoroughly scrub hard surfaces with a strong bleach solution. 3. Perform frequent hand washing and do not share personal items. 4. Immediately start and complete a prophylactic antibiotic regimen. ANS: 3 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Explain the causes, risk factors, and pathophysiology of the various types of liver disease. Page: 693 Heading: Hepatitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

Hepatitis viruses are very resistant to a wide range of anti-infective measures, including exposure to ultraviolet light. Hepatitis viruses are very resistant to a wide range of anti-infective measures, including exposure to bleach and other disinfectants. The best information the nurse can provide is the correct way to perform hand hygiene and to not share personal items. If personal items are contaminated, they are to be discarded if possible; boiling in water for 30 minutes is also effective. Hepatitis is a virus and is not responsive to antibiotic therapy. Prevention is dependent on minimizing or avoiding exposure to the causative pathogen.

PTS:

CON: Patient-Centered Care

2. The nurse is providing care for a patient admitted with acute liver failure related to an acetaminophen overdose. Which goal is associated with care for the patient? 1. Maintain functional ability of the liver. 2. Keep the patient on complete bed rest. 3. Monitor for the need to initiate intubation. 4. Provide a diet high in vitamins and protein. ANS: 1

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Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Describe therapeutic measures for patients with liver disease. Page: 700 Heading: Acute Liver Failure Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 2 3 4

The overall goal when caring for a patient in acute liver failure is to attempt to put the liver completely at rest to maintain functional ability. The client will be placed on complete bedrest in a quiet environment to decrease stimulation; however, this is an intervention and not a goal. Protection and maintenance of a patent airway is important in the care of a patient in acute liver failure. However, this is an intervention and not a goal. The patient in acute liver failure will be NPO; food will stimulate the liver and initiate the digestive process.

PTS:

CON: Patient-Centered Care

3. A patient with liver failure and esophageal varices is prescribed to receive vasopressin. For which purpose does the nurse recognize the need for this medication? 1. To promote portal circulation 2. To reduce ammonia buildup and encephalopathy 3. To constrict vessel dilation to the esophageal varices 4. To maintain hypotension related to bleeding varices ANS: 3 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Describe therapeutic measures for patients with liver disease. Page: 700 Heading: Liver Failure Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

Vasopressin does not promote circulation. Vasopressin does not affect ammonia levels. Vasopressin is a vasoconstrictor and will reduce the possibility or help manage bleeding related to esophageal varices. Vasopressin can maintain blood pressure, but it is not the primary reason the drug is given to patients with esophageal varices. There is no information

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confirming that the esophageal varices are bleeding. PTS:

CON: Safety

4. The nurse is obtaining information from a patient who is obese and has diabetes mellitus (DM). Upon physical examination, the nurse notes generalized ecchymosis, an enlarged and tender liver with palpation, and evidence of ascites with percussion. Which possible disease condition does the nurse identify from the findings? 1. Diabetic complications 2. Liver dysfunction 3. Acute kidney disorder 4. Deficient blood clotting ANS: 2 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Explain the causes, risk factors, and pathophysiology of the various types of liver disease. Page: 700 Heading: Chronic Liver Disease and Cirrhosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1

The patient’s diabetes mellitus is a likely contributor to the current disease process. DM can cause a fatty liver, which can lead to cirrhosis, but the symptoms are related to liver disease and not diabetes. The manifestations and medical history are common for the development of liver dysfunction. The patient is likely to be diagnosed with cirrhosis of the liver. The patient may be experiencing acute kidney disorder related to the portal hypertension related to liver dysfunction/cirrhosis. However, this is not the primary cause of the patient’s condition. Deficient blood clotting is related to generalized ecchymosis. Liver disease/cirrhosis causes deficiency in clotting.

PTS:

CON: Patient-Centered Care

5. The nurse is reinforcing teaching provided to a patient with esophageal varices. Which suggestion is the least important? 1. Avoid lifting heavy objects. 2. Bleeding is a reason to call 911. 3. Keep appointments with the health care provider (HCP). 4. Maintain low physical activity. ANS: 4

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Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Plan nursing care for a patient with liver disease. Page: 703 Heading: Esophageal Varices Integrated Process: Clinical Problem-Solving Process Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Lifting heavy objects should be avoided to prevent straining that will put pressure on esophageal varices and cause bleeding. If esophageal varices begin to bleed, it is a medical emergency and 911 needs to be called immediately. Esophageal varices is a serious complication of liver disease/cirrhosis; the patient needs to be closely monitored by the HCP. There is no indication that the patient needs to maintain a low physical activity; however, any activity that increases the blood pressure or intraabdominal pressure should be avoided.

PTS:

CON: Patient-Centered Care

6. The nurse is collecting data from a patient with liver failure to detect hepatic encephalopathy. Which instruction does the nurse give to the patient to collect the data? 1. “Stand with your eyes closed.” 2. “Hold out your arms and hands.” 3. “Kneel on your hands and knees.” 4. “Perform a Valsalva’s maneuver.” ANS: 2 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Plan nursing care for a patient with liver disease. Page: 703 Heading: Hepatic Encephalopathy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

Standing with the eyes closed is not part of the process of identifying hepatic encephalopathy. Neuromuscular function is monitored by asking the patient to hold his or her arms out straight in front and steady. If asterixis, or liver flap, is present, the patient’s hands will unwillingly dip and return to the horizontal position in a

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3 4

flapping motion. Kneeling on the hands and knees is not part of the process of identifying hepatic encephalopathy. Performing the Valsalva’s maneuver is not part of the process of identifying hepatic encephalopathy.

PTS:

CON: Patient-Centered Care

7. The nurse is collecting data from a patient with acute pancreatitis. Which symptoms should the nurse anticipate? 1. Low abdominal pain, bradycardia, and confusion 2. Shortness of breath, hypotension, and restlessness 3. Fever, tachycardia, right upper quadrant pain, and jaundice 4. Abdominal distention, respiratory distress, and midepigastric pain ANS: 4 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Explain the causes, risk factors, and pathophysiology of the various pancreatic disorders. Page: 706 Heading: Disorders of the Pancreas Integrated Process: Clinical Problem-Saving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 2

Low abdominal pain, bradycardia, and confusion are not associated with acute pancreatitis. Shortness of breath, hypotension, and restlessness are not together associated with acute pancreatitis. Shortness of breath may be expected with fluid accumulation in the retroperitoneal space. Fever, tachycardia, right upper quadrant pain, and jaundice are not together associated with acute pancreatitis. Right upper quadrant pain and fever is expected. Patients with acute pancreatitis are very ill, with dull abdominal pain, guarding, a rigid abdomen, hypotension or shock, and respiratory distress from accumulation of fluid in the retroperitoneal space. The abdominal pain is generally located in the midline just below the sternum, with radiation to the spine, back, and flank.

PTS:

CON: Patient-Centered Care

8. The nurse is providing care for a patient diagnosed with chronic pancreatitis. The patient’s vital signs are blood pressure 130/78 mm Hg, respirations 28 breaths/min and labored with O2 saturation rate of 90%, pulse 102 beats/min, and pain level of 7 on a 0-to-10 scale. Which immediate nursing action is appropriate?

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1. 2. 3. 4.

Observe for use of accessory or intercostal muscles. Validate when the last pain medication was administered. Place in an upright or slightly leaning forward position. Seek approval to begin or increase delivery of oxygen therapy.

ANS: 3 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Plan nursing care for a patient with a pancreatic disorder. Page: 708 Heading: Chronic Pancreatitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 2 3

The nurse can observe for the use of respiratory or intercostal muscles, but this is not the immediate nursing intervention. The most obvious issue for the client is related to respiratory problems. The nurse can address the level of pain when oxygenation is improved. The nurse should immediately ascertain that the patient is experiencing breathing and oxygenation issues. The patient should be immediately placed upright or slightly leaning forward to promote lung expansion and oxygenation. Beginning or increasing the delivery of oxygen therapy is not effective if the patient’s breathing is affected by the presence of fluid in the retroperitoneal space.

PTS:

CON: Patient-Centered Care

9. A patient just receives a diagnosis of pancreatic cancer with metastasis to the liver, gallbladder, and stomach. The nurse is informed that the patient has agreed to palliative care. Which intervention seems unexpected to the nurse? 1. Performance of a Whipple procedure 2. Surgery to bypass a blocked bile duct 3. Chemotherapy and radiation therapy 4. Surgical placement of a bile duct stent ANS: 1 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Describe therapeutic measures used for patients with pancreatic disorders. Page: 706 Heading: Cancer of the Pancreas Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

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Feedback 1 2 3

An unexpected intervention would be for performance of a Whipple procedure that is aimed at curing pancreatic cancer. The patient receiving palliative care for pancreatic cancer may undergo surgery to bypass a blocked bile duct. The procedure decreases pain. The patient receiving palliative care for pancreatic cancer may receive chemotherapy and/or radiation therapy to shrink the pancreatic tumors and promote comfort. If the bile duct is blocked, pain will increase. The patient receiving palliative care may have a surgical placement of a bile duct stent to promote comfort.

PTS:

CON: Patient-Centered Care

10. The nurse is assisting with the care of a patient following a liver transplant for cirrhosis. Which finding will the nurse report immediately to the RN or HCP? 1. Surgical pain greater than 4 on a 0-to-10 scale 2. Decrease in the amount of bile in the T-tube 3. Difficulty with taking deep breaths or coughing 4. A regular apical pulse rate of 98 beats/min ANS: 2 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Plan nursing care for the patient experiencing a liver disorder. Page: 706 Heading: Liver Transplantation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1

3 4

Following surgery for a liver transplant, the nurse expects the patient to have pain. The patient may or may not want or need pain medication at the level rating of 4. A decrease in the amount of bile in the T-tube drainage system is an indication of impending rejection of the newly transplanted liver. The nurse needs to inform the RN or HCP immediately. Difficulty with deep breathing or coughing is expected after abdominal surgery. Liver transplant surgery is performed in close proximity to the diaphragm. The nurse will report a pulse rate greater than 100 beats/min to the RN or HCP as an indication of impending rejection. The pulse rate of 98 will be closely monitored.

PTS:

CON: Patient-Centered Care

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11. The nurse is reinforcing patient teaching regarding the causes of gallbladder disorders. Which condition does the nurse present as being a common cause? 1. Metastasis of cancer from the liver 2. Obesity and high dietary intake of fats 3. Gallstones and inflammations 4. History of excessive alcohol intake ANS: 3 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Explain the causes, risk factors, and pathophysiology of gallbladder disorders. Page: 713 Heading: Disorders of the Gallbladder Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Gallbladder disorders are not commonly caused by metastasis of cancer from the liver. Obesity and high dietary intake of fats are contributing factors but are not alone a common cause of gallbladder disorders. The presence of gallstones and inflammations are the most common cause of gallbladder disorders. A history of excessive alcohol intake is most likely to contribute to liver disorders.

PTS:

CON: Patient-Centered Care

12. A patient presents at the HCP’s office with epigastric pain. The patient’s temperature and pulse and respiration rates are all elevated. Which additional symptom will the nurse associate as a possible sign of cholelithiasis? 1. Jaundice 2. Vomiting 3. Heartburn 4. Flatulence ANS: 1 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Explain the causes, risk factors, and pathophysiology of gallbladder disorders. Page: 713 Heading: Cholelithiasis Integrated Process: Clinical Problem-Solving Process Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate

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Feedback 1 2 3 4

Jaundice is most commonly indicative of cholelithiasis because the common bile duct is either inflamed or blocked by a gallstone. Vomiting can occur with gallbladder disorders, but is not exclusive to cholelithiasis. Heartburn is not commonly associated with cholelithiasis and is seen with cholecystitis. Flatulence is not commonly associated with cholelithiasis and is seen with cholecystitis.

PTS:

CON: Patient-Centered Care

13. A patient is being treated for acute cholecystitis. The patient is instructed on dietary measures to reduce the possibility of recurrent episodes. Which patient comment indicates a need to reinforce teaching? 1. “I will need to limit the amount of fat in my diet.” 2. “I can increase my intake of nuts and avocados.” 3. “While I am having an attack, I may need to be NPO.” 4. “I need to get my extra weight off as quick as possible.” ANS: 4 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Describe therapeutic measures used for patients with gallbladder disorders. Page: 713 Heading: Cholecystitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Inflammation Difficulty: Moderate Feedback 1 2 3 4

The patient with cholecystitis needs to limit the amount of fat in the diet to avoid a recurrence of the condition. The patient can consume healthy fats, such as nuts and avocados, which supply monosaturated fats. Acute attacks of cholecystitis may require the patient to be NPO. Fasting or strict weight-loss diets can trigger cholecystitis; the patient needs to aim for a slow, steady weight loss. This comment warrants additional teaching.

PTS:

CON: Inflammation

14. A patient with biliary colic is prescribed an anticholinergic medication to help treat the condition. For which medical diagnosis should the nurse question the administration of this medication? 1. Asthma 2. Psoriasis

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3. DM 4. Prostatic hypertrophy ANS: 4 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Describe therapeutic measures used for patients with gallbladder disorders. Page: 716 Heading: Cholelithiasis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Difficult Feedback 1 2 3 4

Anticholinergic medications are not contraindicated in diabetes, asthma, or psoriasis. Anticholinergic medications are not contraindicated in diabetes, asthma, or psoriasis. Anticholinergic medications are not contraindicated in diabetes, asthma, or psoriasis. Anticholinergic medications are contraindicated in patients with prostatic hypertrophy; there is a high risk for urinary retention.

PTS:

CON: Safety

15. The nurse is providing care for a client following an open cholecystectomy involving the removal of large gallstones and placement of a T-tube. Which third day postsurgical manifestation will cause the nurse to report the finding? 1. Deep breathing and coughing improves with incisional splinting. 2. Pain level remains between 3 and 5 depending on patient activity. 3. T-tube drainage is 600 mL over the past 24-hour period. 4. Patient complains about receiving a soft, low-fat diet. ANS: 3 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Plan nursing care for the patient with a gallbladder disorder. Page: 715 Heading: Disorders of the Gallbladder Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physical Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

The nurse should expect deep breathing and coughing to improve with

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incisional splinting. This is not a concern. It is not unexpected for some patients to have a pain level between 3 and 5 on the third postoperative day. However, by this time, pain will be affected by patient activity. By the third postoperative day, the patient’s T-tube drainage should not be more than 200 mL; an amount of 600 mL is a matter of concern and should be reported. The nurse is not concerned when a patient complains about dietary restrictions; the nurse should use this opportunity to reinforce patient dietary teaching.

PTS:

CON: Patient-Centered Care

16. The nurse is providing care for an older adult patient with a diagnosis of small noncalcified gallstones. The HCP prefers to avoid surgery on the patient due to age and a medical history of cardiac disorders. Which medical treatment does the nurse most likely expect the HCP to prescribe? 1. Dietary alterations and limitations 2. Management of cholecystitis flare-ups 3. Routine anti-inflammatory medications 4. Long-term treatment with a dissolution drug ANS: 4 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Describe therapeutic measures used for patients with gallbladder disorders. Page: 715 Heading: Medication Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

Dietary alterations and limitations may or may not be effective for the patient who already has gallstones. The HCP will medically manage cholecystitis flare-ups but will most likely focus on resolution and prevention. The routine use of anti-inflammatory medications have side effects that are undesirable and more likely to occur in the older adult. Gastric irritation and bleeding is the main concern. Due the fact that the patient is considered a high surgical risk, the HCP is likely to use long-term treatment with a dissolution drug to get rid of the gallstones. However, the treatment may take up to 2 years, and the gallstones are apt to return.

PTS:

CON: Patient-Centered Care

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17. The nurse is gathering information about a new patient in an adult clinic. The patient states, “I have severe arthritis, but I control the pain with two 650-mg acetaminophen tablets four times a day.” Which condition does the nurse associate with the patient’s medication regimen? 1. Urinary retention 2. Gastric bleeding 3. Liver failure 4. Kidney disease ANS: 3 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Explain the causes, risk factors, and pathophysiology of the various types of liver disease. Page: 704 Heading: Chronic Liver Disease and Cirrhosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

There is no connection between the patient’s medication regimen and urinary retention. Anticholinergic medications would cause this condition. There is no connection between the patient’s medication regimen and gastric bleeding. Aspirin or NSAIDs would cause gastric bleeding. Liver failure is frequently connected to the overuse of acetaminophen. The patient’s medication regimen is not connected to kidney failure; acetaminophen is cleared by the liver and not the kidneys.

PTS:

CON: Patient-Centered Care

18. The nurse is providing care for a patient admitted with serious acute pancreatitis. The patient is in guarded condition and exhibits multiple manifestations of pancreatitis complications. The nurse is aware that which body system is unlikely to lead to patient death? 1. Neurologic 2. Cardiovascular 3. Respiratory 4. Renal/kidney ANS: 1 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Explain the causes, risk factors, and pathophysiology of the various pancreatic disorders. Page: 706 Heading: Acute Pancreatitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation

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Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

Any involvement of the neurologic system is unlikely to occur with acute pancreatitis. Acute pancreatitis causes cardiovascular manifestations such as hemorrhage and peripheral vascular collapse that can cause death. Acute pancreatitis causes respiratory manifestations, such as hypoxia, from compromised function related to ascites. Respiratory complications can cause death. Acute pancreatitis causes renal/kidney manifestations such as electrolyte imbalances that can cause death.

PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 1. A patient recovering from hepatitis is concerned about liver damage from the infection. Which instructions does the nurse provide the patient to prevent long-term liver damage? (Select all that apply.) 1. Get adequate rest. 2. Ingest nutritious foods. 3. Abstain from all alcohol. 4. Restrict physical activity. 5. Limit the intake of dairy products. ANS: 1, 2, 3 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Describe therapeutic measures used for patients with liver disease. Page: 702 Heading: Disorders of the Liver Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

Feedback Recovery varies and depends on the type of hepatitis. Full recovery is measured by the return to normal of all liver function tests and may take as long as 1 year. The effects of hepatitis can be considered reversible if the patient complies with a medical regimen of adequate rest, proper nutrition, and abstinence from alcohol or other liver-toxic agents for at least 1 year after liver function laboratory values return to normal. Recovery varies and depends on the type of hepatitis. Full recovery is

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4. 5.

PTS:

measured by the return to normal of all liver function tests and may take as long as 1 year. The effects of hepatitis can be considered reversible if the patient complies with a medical regimen of adequate rest, proper nutrition, and abstinence from alcohol or other liver-toxic agents for at least 1 year after liver function laboratory values return to normal. Recovery varies and depends on the type of hepatitis. Full recovery is measured by the return to normal of all liver function tests and may take as long as 1 year. The effects of hepatitis can be considered reversible if the patient complies with a medical regimen of adequate rest, proper nutrition, and abstinence from alcohol or other liver-toxic agents for at least 1 year after liver function laboratory values return to normal. Restricting physical activity does not prevent the development of long-term liver damage. Limiting the intake of dairy products does not prevent the development of long-term liver damage. 1

CON: Patient-Centered Care

2. The nurse is preparing to reinforce discharge teaching for a patient who underwent a cholecystectomy. Which information does the nurse plan to cover? (Select all that apply.) 1. Increase high-quality protein to promote healing. 2. Avoid dietary fats to prevent postoperative nausea or pain. 3. Call the HCP if fever, redness, or drainage indicates infection. 4. Increase fluid intake to flush excess bilirubin from the system. 5. Reintroduce fats slowly back into the diet to prevent rebound effects. ANS: 1, 2, 3, 5 Chapter: Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders Objective: Plan care for the patient with a gallbladder disorder. Page: 715 Heading: Disorders of the Gallbladder Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

1. 2.

3. 4.

Feedback The nurse needs to reinforce the importance of dietary protein to promote healing. Initially, the patient should avoid dietary fats to prevent postoperative intolerance. The duodenum needs to become accustomed to the constant infusion of bile from the liver. All surgical patients need to be aware of the signs of infection and when to call the HCP. Changes in the color of urine and stool are not related to cholecystectomy where the gallbladder is completely removed. The mentioned changes are more likely to occur with pancreatic or liver disorders.

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PTS:

Fats need to be reintroduced in small amounts and over a period of time to allow the duodenum to become accustomed to the constant infusion of bile from the liver. 1

CON: Patient-Centered Care

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Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures MULTIPLE CHOICE 1. The nurse understands that a major function of the kidneys is to remove potentially toxic waste products from the blood. Which function is inaccurate? 1. Regulate blood pressure through the conservation of fluids. 2. Regulate minerals to maintain electrolyte balance. 3. Manage hydrogen or bicarbonate for acid-base balance. 4. Manage erythrocyte production in the bone marrow. ANS: 1 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Describe the normal function of the urinary system. Page: 719 Heading: Normal Urinary System Anatomy and Physiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 2 3 4

The kidneys regulate blood pressure through the excretion or conservation of water. The kidneys regulate electrolyte balance of the blood through the excretion or conservation of minerals. The kidneys maintain the acid-base balance of the blood through the excretion or conservation of ions such as hydrogen and bicarbonate. The kidneys produce erythropoietin, which stimulates erythrocyte production in the bone marrow.

PTS:

CON: Patient-Centered Care

2. The nurse is providing care for a patient admitted for a suspected kidney infection. Which area of the body does the nurse expect the patient to identify as a source of pain? 1. Lower abdomen 2. Bilateral flanks 3. Midepigastric 4. Pelvic floor ANS: 2 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Identify the normal anatomy of the urinary system. Page: 742 Heading: Normal Urinary System Anatomy and Physiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation

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Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

The kidneys are located in the retroperitoneal cavity; pain would not be expected in the lower abdomen. The kidneys are located in the retroperitoneal cavity; pain would be located in the bilateral flank areas. The kidneys are located in the retroperitoneal cavity; pain would not be expected in the midepigastric area of the abdomen. The kidneys are located in the retroperitoneal cavity; pain would not be expected in the pelvic floor area.

PTS:

CON: Patient-Centered Care

3. A patient’s urinalysis results are white blood cells (WBCs) 100+/hpf; red blood cells (RBC) 4/hpf; bacteria, moderate amount; nitrite, positive; specific gravity, 1.025; and urine, cloudy. What should the nurse recognize these findings indicate? 1. Dehydration 2. Urinary tract infection 3. Contamination from menstruation 4. Presence of bacteria from the perineum ANS: 2 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Explain data to collect when caring for a patient with a disorder of the urinary system. Page: 741 Heading: Diagnostic Tests for the Urinary System Integrated Process: Clinical Problem-Solving Process Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 2 3 4

The laboratory findings do not indicate dehydration. Elevated WBCs, bacteria, nitrites, and cloudy urine indicate an infection. There is no information in the question to indicate menstruation. There is no information regarding the preparation of the perineum.

PTS:

CON: Patient-Centered Care

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4. The nurse is collecting data on a patient who experienced a sport injury to the lower back area. Which finding will cause the nurse greatest concern? 1. Report of nausea and anxiety 2. Ecchymosis and pain in area of injury 3. Flank edema and bloody urine 4. Pain in the lower abdomen ANS: 3 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Identify the normal anatomy of the urinary system. Page: 742 Heading: Blood Vessels of the Kidney Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

It is expected that a patient may experience nausea and anxiety following an injury. Ecchymosis and pain in the area of the injury is expected, but require additional monitoring. Ecchymosis is most likely associated with soft tissue injury. The nurse’s greatest concern is the presence of flank edema and bloody urine. The kidneys are highly vascular and major vessels include a renal artery and a renal vein. Both findings are indicative of blood vessel damage. The kidneys are located in the retroperitoneal cavity; pain in the lower abdomen is not expected with this injury.

PTS:

CON: Patient-Centered Care

5. The formation of urine is a critical physiological function. The nurse is aware that multiple processes are involved. Which process does the nurse recognize as not part of the formation of urine? 1. Micturition 2. Glomerular filtration 3. Tubular excretion 4. Tubular reabsorption ANS: 1 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Describe the normal function of the urinary system. Page: 723 Heading: Formation of Urine Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care

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Difficulty: Moderate Feedback 1 2

Micturition is the terminology for the process of urinating, which is not involved in the process of urine production. Glomerular filtration is the initial process of urine formation. Blood pressure forces water and small solutes out of the glomeruli and into Bowman capsules. The fluid is then called renal filtrate. Tubular excretion is the final process of urine formation. In excretion, substances are actively secreted from the blood in the peritubular capillaries into the filtrate in the renal tubules. Tubular reabsorption is the second process of urine formation. Tubular reabsorption is the recovery of useful materials from the renal filtrate and their return into the blood in the peritubular capillaries.

PTS:

CON: Patient-Centered Care

6. The nurse is providing care for a patient with a diagnosis of kidney disease. The patient’s last laboratory result indicates metabolic acidosis. Which kidney activity does the nurse recognize for the condition? 1. The kidneys are absorbing more bicarbonate. 2. The kidneys are unable to excrete hydrogen ions. 3. The kidneys are compensating for respiratory function. 4. The kidneys are responding to vomiting related to disease. ANS: 2 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Describe the normal function of the urinary system. Page: 728 Heading: The Kidneys and Acid-Base Balance Integrated Process: Clinical Problem-Solving Process Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Difficult Feedback 1 2

3 4

If the kidneys were absorbing more bicarbonate into the blood, the laboratory test would not indicate metabolic acidosis. When the kidneys are unable to excrete hydrogen ions into the blood, the laboratory test indicates metabolic acidosis. The process is related to kidney disease. If the kidneys were compensating for respiratory function, the pH would be balanced when the kidneys reabsorbed bicarbonate. Vomiting can cause metabolic alkalosis when hydrochloric acid is lost. However, there is no indication that the patient’s renal disease is causing vomiting.

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PTS:

CON: Elimination

7. The nurse is providing care for a patient with a thoracic spinal cord injury. For which reason does the nurse understand the presence of a suprapubic catheter? 1. The patient is unable to stand to void. 2. The patient is less likely to have bladder infections. 3. The patient is unable to detect the need to urinate. 4. The patient is at risk for skin breakdown from incontinence. ANS: 3 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Plan preparation and postprocedure care for patients undergoing diagnostic tests of the urinary system. Page: 738 Heading: Elimination of Urine Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

2 3

The inability to stand to void is not alone the reason to place a suprapubic catheter. Patients with any type of catheter are a high risk for developing bladder infections. The patient with a thoracic spinal cord injury will have lost the sensation of urinary reflex over which urinary control may be exerted. The detrusor muscles of the bladder wall and two urethral sphincters will all be involved. Incontinence and the risk for skin breakdown are not reasons alone to place a suprapubic catheter.

PTS:

CON: Patient-Centered Care

8. The nurse is testing the urine pH for a patient in the HCP’s office. The test indicates a pH of 7.0. Which question does the nurse ask the client? 1. “Do you have pain when you urinate?” 2. “Are you following a vegetarian diet?” 3. “How much aspirin do you take daily?” 4. “Is there a family history of renal disease?” ANS: 2 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Describe the normal function of the urinary system. Page: 728 Heading: pH Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation

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Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

3 4

The patient’s urine pH is within normal limits; there is no reason to suspect a bladder infection. Diet has the greatest influence over urine pH. The patient’s urine pH is normal, but is in the higher range. Vegetarians are likely to have a more alkaline urine, which makes the pH higher. Diet has the greatest influence over urine pH. There is no reason for the nurse to inquire about aspirin use. The urine pH is within normal limits. There is no reason to ask if the patient has a family history of renal disease. The urine pH is within normal limits.

PTS:

CON: Patient-Centered Care

9. The nurse is reviewing the laboratory results for a patient. Which question does the nurse ask the patient if the creatinine level is elevated? 1. “Have you been sick lately?” 2. “Are you lactose intolerant?” 3. “Do you have flank pain?” 4. “How much do you exercise?” ANS: 4 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Describe the normal function of the urinary system. Page: 728 Heading: Constituents Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Illness does not affect the creatinine level in urine. Being lactose intolerant does not affect the creatinine level in urine. The nurse should not expect flank pain in a patient with an elevated creatinine level. Creatinine is a product of metabolism of creatine phosphate, which is an energy source in muscles. The amount and type of exercise can affect creatinine levels.

PTS:

CON: Patient-Centered Care

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10. A patient with pneumonia has a blood urea nitrogen (BUN) of 32 mg/dL and creatinine of 0.8 mg/dL. What should the nurse realize is the most probable explanation for this finding? 1. The patient is dehydrated. 2. The patient has septicemia. 3. The patient is malnourished. 4. The patient has kidney damage. ANS: 1 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Explain data to collect when caring for a patient with a disorder of the urinary system. Page: 728 Heading: Constituents. Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

2 3 4

BUN elevates with dehydration, because the loss of water makes the blood more concentrated. Creatinine levels are a very good indicator of kidney function. There is not enough information to determine if the patient is septic. There is not enough information to determine if the patient is malnourished. There is not enough information to determine if the patient has kidney damage.

PTS:

CON: Patient-Centered Care

11. The nurse is collecting information from an older adult patient in the health care provider’s (HCP) office. The patient reports frequent urination. Which effect of aging does the nurse recognize? 1. A decrease in glomerular filtration 2. The presence of an early bladder infection 3. Decreased bladder size and muscle tone 4. General decrease in renal functioning ANS: 3 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Discuss the effects of aging on the urinary system. Page: 722 Heading: Aging and the Urinary System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate

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Feedback 1 2

Older adult patients do have a decrease in glomerular filtration; however, this change does not cause frequent urination. The older adult patient’s need for frequent urination is likely associated with physical functioning. There are no other indications of a bladder infection such as fever or painful urination. Older adult patients normally experience a decrease in bladder size and a decrease in the tone of the detrusor muscle. The result is frequent urination or the presence of residual urine after voiding. Older adult patients do have a decrease in renal function; up to half of the original nephrons can be lost by age 70 or 80. However, this is not related to frequent urination.

PTS:

CON: Patient-Centered Care

12. The nurse is providing care for a patient who is on fluid restrictions due to renal failure. The patient’s intake & output (I&O) should be carefully measured. Which substance does the nurse exclude from the intake total? 1. Mashed potatoes and creamed corn 2. All oral and IV fluids 3. Water, coffee, juices, and gelatin 4. Any tube feeding administered ANS: 1 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Explain data to collect when caring for a patient with a disorder of the urinary system. Page: 726 Heading: Nursing Assessment of the Urinary System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Elimination Difficulty: Moderate Feedback 1

2 3 4

The nurse does not need to include foods that are not either a liquid form or liquefy at body temperature. Mashed potatoes and creamed corn are not considered liquids. All oral and IV fluids are counted as fluid intake. Water, coffee, juices, and gelatin are considered liquids. The gelatin will become a liquid at body temperature. Tube feedings are considered liquids when the patient’s I&O is being measured.

PTS:

CON: Elimination

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13. The nurse is providing care for a patient scheduled for diagnostic studies of the gastrointestinal system using contrast medium. Which finding in the patient’s medical history warrants the nurse contacting the HCP? 1. The patient reports an allergy to shellfish. 2. The patient recently had pneumonia. 3. The patient had food intake 12 hours previous. 4. The patient has a history of renal dysfunction. ANS: 4 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Plan preparation and postprocedure care for patients undergoing diagnostic tests of the urinary system. Page: 728 Heading: Contrast-Induced Nephropathy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

Contrast media does not always contain radioactive isotopes, which are given with caution to patients with iodine allergies. A recent incidence of pneumonia will not warrant the nurse contacting the HCP. A gastrointestinal study with contrast medium is performed after the patient has been NPO; 12 hours without food does not warrant the nurse contacting the HCP. The use of contrast media can nephrotoxic and cause contrast-induced nephropathy. The nurse needs to contact the HCP regarding the patient’s history of renal dysfunction, which places the patient at high risk for nephropathy.

PTS:

CON: Patient-Centered Care

14. The nurse is catheterizing a patient after voiding to determine the amount of residual urine in the bladder. What should the nurse consider as being the normal amount of urine within the bladder after urination? 1. 25 mL 2. 75 mL 3. 100 mL 4. 150 mL ANS: 1 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Explain data to collect when caring for a patient with a disorder of the urinary system. Page: 737 Heading: Management of Urinary Retention

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Normally the bladder contains less than 50 mL after urination. This represents excessive amounts of residual urine after voiding. This represents excessive amounts of residual urine after voiding. This represents excessive amounts of residual urine after voiding.

PTS:

CON: Patient-Centered Care

15. An older male patient expresses frustration at need to urinate often, dribbling of urine, and feelings of inability to empty his bladder. Which suggestion by the nurse is most helpful to the patient? 1. Obtain and wear incontinence pads. 2. Encourage an appointment with a urologist. 3. Review medications with the primary HCP. 4. Set up a schedule for regular voiding. ANS: 2 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Plan nursing care for patients with incontinence. Page: 725 Heading: Overflow Incontinence Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1

3 4

The patient is likely to be experiencing overflow incontinence and the suggestion to obtain and use incontinence pads is helpful in managing the manifestations. However, the most helpful suggestion will address the cause. Older men commonly experience overflow incontinence related to an enlarged prostate. The most helpful suggestion is to encourage an appointment with a urologist for treatment of the condition. Medication is sometimes a cause for incontinence; however, medications and their effects can be reviewed during a visit with a urologist. Setting a schedule for regular voiding is appropriate for bladder training, but overflow incontinence will not improve with this intervention.

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PTS:

CON: Elimination

16. The nurse is reinforcing teaching to a client who is preparing to perform intermittent selfcatheterization at home. Which information by the nurse is inappropriate? 1. The bladder should be emptied every 3 hours. 2. An overfilled bladder can be a source of infection. 3. Catheters can be washed and reused repeatedly. 4. Wear a urinary incontinence pad if away from home. ANS: 4 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Discuss nursing actions to decrease the risk of infection in urinary catheterized patients. Page: 728 Heading: Intermittent Catheterization Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integration—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1 2 3

It is appropriate for the nurse to inform the patient to empty the bladder every 3 hours when performing intermittent self-catheterization. It is important for the patient to understand that an overfilled urinary bladder is a source of infection. Urine is a good medium for bacteria growth. When in the home environment, urinary catheters used for self-catheterization can be washed and reused. All types of catheterizations in the clinical environment require sterile technique. When away from home, the patient can still perform intermittent selfcatheterization and there is no need to wear an incontinence pad. However, the patient is taught to use appropriate hand washing and to be particularly careful to avoid touching the catheter to places or items in surrounding area.

PTS:

CON: Elimination

17. The nurse is making a visit to the home of a patient with functional incontinence. Which observation indicates that teaching about the disorder has been effective? 1. Patient wearing sweat pants 2. Patient drinking a cup of coffee 3. Patient sitting with the legs elevated 4. Patient restricting fluid intake after 6 p.m. ANS: 1 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Plan nursing care for patients with incontinence. Page: 725 Heading: Management of Urinary Incontinence Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

2 3 4

If clothing is inhibiting timely voiding for the patient with functional incontinence, the patient should be instructed to wear clothing with Velcro fasteners or sweat pants. Coffee with caffeine is a bladder stimulant and increases the need to void. Elevating the legs is not an action appropriate for functional incontinence. Restricting fluids after 6 p.m. is not an appropriate action for functional incontinence.

PTS:

CON: Patient-Centered Care

18. The nurse is providing care for a patient who has undergone placement of a suprapubic catheter. Which postprocedure nursing care is avoided? 1. Change the surgical dressing as needed. 2. Tape the catheter in place to avoid tension. 3. Change the catheter with sterile technique daily. 4. Apply a skin barrier to prevent skin breakdown. ANS: 3 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Discuss nursing actions to decrease the risk of infection in urinary catheterized patients. Page: 728 Heading: Suprapubic Catheter Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

Postprocedure for the placement of a suprapubic catheter, it is correct for the nurse to change the surgical dressing as needed. The suprapubic catheter will need to be taped in a manner that prevents tension on the catheter. Postprocedure, the nurse will not be changing the suprapubic catheter, which may result in closure of the abdominal incision. After healing, the patient will learn when and how the catheter will be changed. Because of a likelihood of urine leakage, a skin barrier can be applied to prevent skin irritation or breakdown from exposure to urine.

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PTS:

CON: Patient-Centered Care

19. A patient shares a long-standing problem of urinary incontinence with the nurse. Which intervention does the nurse recognize as taking priority? 1. Referring the patient to a urologist 2. Providing caring support to the patient 3. Recommending a continence clinic 4. Keeping a voiding diary for evaluation ANS: 2 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures Objective: Plan nursing care for patients with incontinence. Page: 725 Heading: Management of Urinary Incontinence Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1

3 4

The nurse is likely to refer the patient to a urologist for evaluation of the condition and proposed treatment. However, this is not the priority nursing intervention. Because the patient reveals a long-standing problem, the nurse is aware that the patient has possibly delayed reporting the condition due to embarrassment. The nurse’s priority intervention is to provide caring support to the patient. The patient may need to be recommended to a continence clinic; however, this is not the priority nursing intervention. Keeping a voiding diary is helpful in determining when incontinence occurs and identifying of predisposing events. However, this is not the priority nursing intervention.

PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 1. The nurse is reviewing the results of a patient’s urinalysis. Which components does the nurse identify as being abnormal in urine? (Select all that apply.) 1. Urea 2. Hormones 3. Protein 4. RBCs 5. Water ANS: 3, 4 Chapter: Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures

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Objective: Explain data to collect when caring for a patient with a disorder of the urinary system. Page: 728 Heading: Constituents Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback Urea is present in normal urine and is formed by liver cells when excess amino acids are metabolized. Hormones, in small quantities, are normally present in urine. Proteins are not normally found in urine and can indicate renal dysfunction from injury or disease. RBCs are not normally found in urine and can indicate renal dysfunction from injury or disease. Water makes up 95 percent of urine and is a solvent for waste products and salts. 1

CON: Patient-Centered Care

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Chapter 37. Nursing Care of Patients With Disorders of the Urinary System MULTIPLE CHOICE 1. A female patient with a history of diabetes mellitus presents at the health care provider’s (HCP) office with chills, a high fever, and flank pain. The nurse notes that a collected urine specimen appears cloudy. Which condition does the nurse expect? 1. Diabetic related sepsis 2. Infection from hepatitis 3. Urethritis and bladder infection 4. Complicated pyelonephritis ANS: 4 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Explain the predisposing causes, symptoms, laboratory abnormalities, and treatment of urinary tract infections. Page: 742 Heading: Urinary Tract Infections Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1

2 3 4

The patient’s symptoms support a diagnosis involving the urinary tract. Diabetic related sepsis is too broad of a term to apply to the patient’s manifestations. There is no information in the question to support the presence of infection from hepatitis. The symptoms presented indicate an involvement of upper urinary tract rather than the urethra and bladder. The patient is exhibiting the symptoms of complicated pyelonephritis, which includes a high fever, flank pain, and existing diabetes mellitus.

PTS:

CON: Elimination

2. The nurse is collecting data from a male patient who reports hematuria and bladder cramping. The patient’s history indicates a 20-year history of smoking and long-term employment in a tool factory. Which specific test does the nurse expect the HCP to order? 1. Complete blood count 2. Urine test for telomerase 3. Urinalysis for bladder infection 4. Urine culture for presence of bacteria ANS: 2 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: List risk factors and signs and symptoms of cancer of the bladder.

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Page: 747 Heading: Cancer of the Bladder Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Difficult Feedback 1 2

3 4

Routinely, the HCP may order a complete blood count. A urine test for the presence of the enzyme telomerase is 90 percent accurate for the diagnosis of early or late bladder cancer. Given the patient’s symptoms and history, this is the most specific test that the HCP can order. The patient does not exhibit the symptoms of a bladder infection. Urine for cytology can be obtained to determine the presence of cancer cells. A urine culture can be done because the symptoms of a bladder infection can be similar to the symptoms of bladder cancer. However, this is not the most specific test.

PTS:

CON: Cellular Regulation

3. The nurse is providing postoperative care for a patient with a newly formed ileal conduit for a diagnosis of cancer. Which factor regarding the patient’s surgery does the nurse identify as incorrect? 1. The nurse can expect the urine to contain mucus. 2. Urine will drain continuously from the reservoir. 3. Bladder continence will develop after healing. 4. The surgery includes the formation of an ileostomy. ANS: 3 Chapter: Nursing Care of Patients With Disorders of the Urinary System Objective: Discuss nursing care for a patient with an ileal conduit or continent reservoir. Page: 751 Heading: Incontinent Urinary Diversion Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 2 3 4

The nurse will expect mucus in the patient’s urine because the diversionary pouch is created from part of the bowel, which is mucus producing. With an ileal conduit, the urine will drain continuously from the reservoir. Bladder continence is never obtained with an ileal conduit, the reservoir continuously drains from the stoma into a collection bag. The surgery for an ileal conduit always includes the formation of an ileostomy through which the urine is drained.

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PTS:

CON: Cellular Regulation

4. The nurse is providing care for a patient admitted with severe flank pain identified as renal colic. Urinalysis is positive for microscopic hematuria. Which nursing intervention is most important for the nurse to implement? 1. Administer prescribed narcotic medication. 2. Maintain IV fluids and encourage oral fluids. 3. Promote assisted ambulation as tolerated. 4. Strain urinary output and observe for stones. ANS: 4 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Explain the predisposing causes, symptoms, treatment, and teaching for kidney stones. Page: 747 Heading: Renal Calculi (Urolithiasis) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1

The patient with severe flank pain described as renal colic is frequently prescribed narcotic medication for pain control. However, this is not the most important intervention. The nurse is aware that an increase in fluids will assist in flushing the kidney stone through the urinary system. However, this is not the most important intervention. Ambulation can be effective in moving a renal stone through the urinary system. If the patient is in extreme pain or medicated with a narcotic, assistance is warranted. The most important intervention for the nurse to implement involves straining all urinary output for the collection of any passed stones. The stones are then sent to the laboratory where the type can be identified and appropriate treatment implemented.

PTS:

CON: Elimination

5. The nurse is preparing a patient for a cystectomy and the creation of a continent urinary diversion. For which reason does the nurse identify creation of this type of diversion? 1. Convenience for the patient 2. Extensive bladder destruction exists 3. Prevention of skin breakdown 4. Failed previous incontinent diversion ANS: 1 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Discuss nursing care for a patient with an ileal conduit or continent reservoir. Pages: 751–752

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Heading: Continent Urinary Diversion Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Applying (Application) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

2 3

Continent urinary diversion, of either a Kock or Indiana pouch, is created for the convenience of the patient. An incontinent diversion requires the formation of a stoma and constant use of a collection pouch as opposed to intermittent catheterization through a valve opening. If the bladder is destroyed by disease, either a continent or incontinent diversion can be considered. The possibility of skin breakdown is more likely with an incontinent diversion; however, this reason alone is not a determination for formation of a continent diversion. The failure of an incontinent urinary diversion is not necessarily a reason to form a continent urinary diversion.

PTS:

CON: Patient-Centered Care

6. The nurse is providing care for older adult clients in an extended care facility. Which patient will the nurse monitor most closely for symptoms of urosepsis? 1. The patient with continuous urinary incontinence 2. The patient who is unable to obtain fluids independently 3. The patient who has an indwelling catheter for a urinary tract infection (UTI) 4. The patient who has surgery for placement of an ileostomy ANS: 3 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Explain the predisposing causes, symptoms, laboratory abnormalities, and treatment of urinary tract infections. Page: 742 Heading: Types of Urinary Tract Infections Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Continuous incontinence places the patient at risk for skin breakdown and not for urosepsis. The patient who is unable to independently obtain fluids is at risk for dehydration or for a UTI. The patient with an indwelling urinary catheter is at high risk for urosepsis; the possibility is increased by an already existing UTI. The patient who had surgery for the placement of an ileostomy may be at risk

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for urosepsis; however, the patient with an indwelling catheter and a UTI is at greatest risk. PTS:

CON: Patient-Centered Care

7. The nurse is providing care for a patient who is diagnosed with urinary obstruction from a blockage of the urethra. An emergency surgery is scheduled. The nurse is aware of which complication occurring without resolution of the condition? 1. Bilateral hydronephrosis 2. Urinary bladder rupture 3. Irreparable kidney damage 4. Dilation of the ureters ANS: 3 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Explain the pathophysiology and nursing care for diabetic nephropathy, nephrosclerosis, hydronephrosis, and glomerulonephritis. Page: 744 Heading: Hydronephrosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1

Bilateral hydronephrosis will occur from a blocked urethra when the urine backs up to the kidneys. The condition is reversible with surgical resolution of the blockage. With a blockage of the urethra, urine will back up into the bladder, but the bladder is not at risk for rupture. The urine will continue to back up past the bladder. Irreparable damage to the kidneys can occur with the formation of hydronephrosis. Within hours, the blood vessels and renal tubules can be extensively damaged. Both kidneys are at risk with a urethral blockage. With blockage of the urethra, it is possible for the urine to back up to the point of dilating the ureters. However, this condition is reversible with resolution of the blockage.

PTS:

CON: Elimination

8. The nurse is providing support for a client who just finished a hemodialysis session. Which patient symptom is considered to be a complication of hemodialysis? 1. Headache from a drop-in blood pressure 2. Increased clotting time from dialysate 3. Cardiac arrhythmias and angina from fluid loss 4. High energy level related to loss of toxins ANS: 3

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Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Plan nursing care for patients on hemodialysis. Page: 766 Heading: Hemodialysis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

The patient is likely to experience low blood pressure causing weakness, dizziness, and nausea. The patient is likely to experience increased clotting time related to the use of heparin to prevent blood clotting during dialysis. Cardiac arrhythmias and angina can occur after dialysis because of a sudden fluid drop. After dialysis, the patient is more likely to feel weak and fatigued, and possibly unable to even eat.

PTS:

CON: Patient-Centered Care

9. The nurse is reinforcing teaching about the most serious side effect of peritoneal dialysis with a patient scheduled for the first treatment. Which side effect stated by the patient indicates correct understanding? 1. Peritonitis 2. Paralytic ileus 3. Respiratory distress 4. Cramps in the abdomen ANS: 1 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Planning care for patients on peritoneal dialysis. Page: 766 Heading: Peritoneal Dialysis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

2 3

A major complication of peritoneal dialysis is peritonitis, which can be life threatening. The major cause of peritonitis is poor technique when connecting the bag of dialyzing solution to the peritoneal catheter. Paralytic ileus and respiratory distress are not associated with peritoneal dialysis. Paralytic ileus and respiratory distress are not associated with peritoneal dialysis.

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Abdominal cramps can occur with this type of dialysis; however, they are not the most serious side effect of this treatment.

PTS:

CON: Patient-Centered Care

10. The nurse is providing care for a patient with glomerulonephritis. Which form of kidney injury should the nurse realize has occurred with this patient? 1. Prerenal 2. Postrenal 3. Intrarenal 4. Suprabladder ANS: 3 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Explain the pathophysiology and nursing care for diabetic nephropathy, nephrosclerosis, hydronephrosis, and glomerulonephritis. Page: 755 Heading: Intrarenal Injury Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

This patient’s kidney injury is not caused by a pre- or postrenal injury. This patient’s kidney injury is not caused by a pre- or postrenal injury. Intrarenal kidney injury occurs when there is damage to the nephrons inside the kidney. Causes are ischemia, reduced blood flow, toxins, infectious processes leading to glomerulonephritis, trauma to the kidney, allergic reactions to radiograph dyes, and severe muscle injury. Suprabladder is not a type of kidney injury.

PTS:

CON: Patient-Centered Care

11. A 19-year-old patient reports flank pain and scanty urination. The nurse notices periorbital edema, and the urinalysis reveals white blood cells, red blood cells, albumin, and casts. Which question will provide important information for the nurse to include in data collection? 1. “Have you noticed changes in your vision?” 2. “Have you ever had unprotected sex?” 3. “Have you had any gastrointestinal problems lately?” 4. “Have you had any type of strep infection recently?” ANS: 4 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Explain the pathophysiology and nursing care for diabetic nephropathy, nephrosclerosis, hydronephrosis, and glomerulonephritis. Page: 741

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Heading: Acute Poststreptococcal Glomerulonephritis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1 2 3 4

Asking about blurred vision, sexual activity, and gastrointestinal problems will not provide important information regarding the patient’s condition. Asking about blurred vision, sexual activity, and gastrointestinal problems will not provide important information regarding the patient’s condition. Asking about blurred vision, sexual activity, and gastrointestinal problems will not provide important information regarding the patient’s condition. The patient has symptoms of glomerulonephritis, which can be caused by a variety of factors, but is most commonly associated with a beta-hemolytic streptococcus infection following a streptococcal infection of the throat or skin.

PTS:

CON: Elimination

12. The nurse is providing care for a patient scheduled for surgery for the formation of an orthotopic bladder substitution. Which patient teaching is important for the nurse to review during the patient’s recovery? 1. How to monitor the stoma 2. How to prevent skin injury 3. How to perform catheterization 4. How to apply an ostomy appliance ANS: 3 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Discuss nursing care for a patient with an ileal conduit or continent reservoir. Page: 770 Heading: Orthotopic Bladder Substitution Integrated Process: Teaching/Learning Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

2 3

The patient who has orthotopic bladder substitution does not have a stoma. A “new” bladder is surgically formed and both the ureters and urethra are implanted. The patient who has orthotopic bladder substitution is not prone to skin breakdown even though incontinence is sometimes a problem. The patient who has orthotopic bladder substitution may need to perform intermittent catheterization as needed. The nurse needs to review this procedure during the recovery period. The patient who has orthotopic bladder substitution will not need to wear an

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appliance. The patient will be able to urinate through the urethra normally. PTS:

CON: Patient-Centered Care

13. Which patient will the nurse consider to be at greatest risk for cancer of the kidney? 1. A 30-year-old male who smokes a pack a day and is treated for hypertension 2. A 46-year-old female who is obese and works full time as an x-ray technician 3. A 55-year-old female who has undergone dialysis for 6 years for renal disease 4. A 50-year-old male with a 20-year history of smoking and works in a chemical laboratory ANS: 4 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: List risk factors and signs and symptoms of cancer of the kidneys. Page: 750 Heading: Cancer of the Kidney Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integration—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Difficult Feedback 1

2 3 4

Men are more likely to develop cancer of the kidney, but rarely under the age of 45; smoking is a high risk for the disease; and hypertension can be caused by multiple conditions. This patient has two possible risks, smoking and gender. This client has three risks for kidney cancer: age, obesity, and radiation exposure. This client has two risks for kidney cancer: age and long-term kidney dialysis. This client has four risks for kidney cancer: gender, age, smoking history, and chemical exposure.

PTS:

CON: Cellular Regulation

14. The nurse is collecting data on a patient admitted for symptoms of renal insufficiency. Which factor will cause the nurse to suspect prerenal injury? 1. A family history of polycystic kidney disease (PKD) 2. Medications for chronic joint pain and hypertension 3. Laboratory results indicating a high level of an aminoglycoside 4. A tumor obstruction diagnosed as being present in the right ureter ANS: 2 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Plan nursing care for a patient with an acute kidney injury. Page: 730 Heading: Prerenal Injury Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing)

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Concept: Elimination Difficulty: Difficult Feedback 1 2

3 4

The patient may or may not have PKD; however, the condition is an intrarenal injury. Medications such as NSAIDs for joint pain and cyclooxygenase-2 inhibitors for hypertension can cause prerenal injury by impairing the autoregulatory responses of the kidney by blocking prostaglandin, which is needed for renal perfusion. An aminoglycoside is an antibiotic that is cleared by the kidneys and is nephrotoxic. However, nephrotoxicity from any cause is an intrarenal injury. Any obstruction to the outflow of urine is considered to be a postrenal injury.

PTS:

CON: Elimination

15. The nurse is planning care for a patient diagnosed with chronic renal failure. The nurse notes that the patient’s output is 620 mL for the last 24 hours. The patient has periorbital edema and crackles in all lung fields upon auscultation. Which intervention is most important for the nurse to implement during care of this patient? 1. Administer oxygen therapy. 2. Measure abdominal girth. 3. Obtain daily weights. 4. Maintain fluid restrictions. ANS: 3 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Plan nursing care for patients with chronic kidney disease. Page: 753 Heading: Nursing Care for the Patient With Chronic Kidney Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1 2

The patient may or may not need oxygen therapy; this intervention requires a prescription by the HCP. Measurement of abdominal girth provides information about ascites. Patients with renal failure may not initially exhibit abdominal ascites. There is a better nursing intervention. Patients with acute or chronic renal failure must be weighed daily at the same time, on the same scale, wearing the same type of clothing. Any weight gain of 2 pounds or more indicates fluid retention. This is the most important nursing intervention. Fluids may or may not need to be restricted; this intervention requires a prescription by the HCP.

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PTS:

CON: Elimination

16. The nurse is visiting a patient who performs peritoneal dialysis at home. The nurse is evaluating the patient’s technique and environment. Which situation is least likely to cause the nurse concern? 1. The patient has several pets who roam around the house. 2. The patient verbally expresses symptoms to report to the HCP. 3. The patient uses clean technique when instilling the dialysate. 4. The patient voices the reasons for limiting dietary protein intake. ANS: 2 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Plan nursing care for patients on peritoneal dialysis. Page: 765 Heading: Peritoneal Dialysis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

The patient on peritoneal dialysis needs to perform the procedure in a clean environment. The nurse needs to be concerned about the cleanliness with several pets roaming around in the house. It is important that the patient understands the symptoms that need to be reported to the HCP. The symptoms of infection or peritonitis must have immediate treatment. This is the nurse’s least concern. The patient must use sterile technique when attaching and instilling the dialysate to prevent the introduction of pathogens or microbes into the abdominal cavity. Clean technique is a matter of concern. The nurse is concerned if the patient limits dietary protein intake. The patient on peritoneal dialysis loses proteins through the peritoneal membrane. Increased protein is needed. This is a matter of concern for the nurse.

PTS:

CON: Patient-Centered Care

17. The nurse is providing care for a patient who is scheduled for the formation of access for hemodialysis. Which important action does the nurse take with this patient? 1. Refrains from drawing blood or placing IV lines in the nondominate arm 2. Prepares the patient for permanent placement of a central venous catheter 3. Instructs the patient about the need for showering with antimicrobial soap 4. Reviews the type of underclothing that will be worn to protect the access ANS: 1 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Discuss nursing care for a vascular access site. Page: 763 Heading: Vascular Access Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

3 4

The patient will have an arteriovenous (AV) fistula formed; placement is in the nondominate arm. Therefore, all needle sticks and blood pressures should be avoided in this arm to prevent damage to the veins. A central venous catheter may be placed temporarily until the AV fistula is healed and developed. Long use of a central catheter should be avoided due to the risk for infection. There is no need for the patient to shower with antimicrobial soap before or after the establishment of an AV fistula. The AV fistula is most commonly placed on the patient’s arm. Tight clothing on the arm needs to be avoided, but there are no restrictions about under clothing.

PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 1. The nurse is reinforcing teaching provided to a patient with a history of calcium oxalate kidney stones. The nurse recognizes that teaching has been effective if the patient avoids which foods? (Select all that apply.) 1. Bread 2. Cocoa 3. Lettuce 4. Spinach 5. Instant coffee ANS: 2, 4, 5 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Plan nursing care for a patient with acute kidney injury. Page: 744 Heading: Urological Obstructions Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Difficult

1. 2. 3. 4.

Feedback Bread does not need to be restricted on a low-oxalate diet. A low-oxalate diet restricts foods such as beets, rhubarb, spinach, cocoa, and instant coffee. Lettuce does not need to be restricted on a low-oxalate diet. A low-oxalate diet restricts foods such as beets, rhubarb, spinach, cocoa, and instant coffee.

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PTS:

A low-oxalate diet restricts foods such as beets, rhubarb, spinach, cocoa, and instant coffee. 1

CON: Elimination

2. The nurse is reinforcing teaching provided to a patient about caring for a new arteriovenous (AV) fistula in the left arm for dialysis. Which patient statements indicate correct understanding? (Select all that apply.) 1. “Do not sleep on my arm.” 2. “Keep my arm elevated at all times.” 3. “Keep a firm bandage on my arm.” 4. “Wear loose clothing on my left arm.” 5. “Avoid carrying heavy things with my left arm.” ANS: 1, 4, 5 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Discuss nursing care for a vascular access site. Page: 764 Heading: Vascular Access Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback The fistula must be protected from anything causing pressure or restriction of blood flow. The patient should not sleep on the left arm. The left arm does not need to be elevated at all times. A firm bandage does not need to be on the left arm. The fistula must be protected by anything causing pressure or restriction of blood flow. Loose clothing should be worn on the left arm. The fistula must be protected by anything causing pressure or restriction of blood flow. Heavy objects should not be carried with the left arm. 1

CON: Elimination

3. The nurse is preparing to reinforce teaching to a patient newly diagnosed with PKD. Which information does the nurse include? (Select all that apply.) 1. Typically, first signs of the disease appear during late childhood. 2. Grape-like cysts will replace normal, functioning structures. 3. Initial symptoms are dull heaviness in the flank area and hematuria. 4. Patients are at risk for brain aneurysms and diverticulosis in the colon. 5. Disease is likely to require additional treatment for hypertension and UTIs. ANS: 2, 3, 4, 5 Chapter: Chapter 37. Nursing Care of Patients With Disorders of the Urinary System Objective: Plan nursing care for patients with chronic kidney disease. Page: 760

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Heading: Polycystic Kidney Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback The first signs of PKD occur in adulthood. Grape-like structures do replace normal, functioning kidney structures. The cysts contain serous fluid, blood, or urine. The initial symptoms will include a dull heaviness in the flank or lumbar region, accompanied by hematuria. Persons with inherited PKD are at risk for brain aneurysms and diverticulosis in the colon. Persons diagnosed with PKD are likely to have hypertension and UTIs that require treatment. 1

CON: Elimination

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Chapter 38. Endocrine System Function and Assessment MULTIPLE CHOICE 1. The nurse is reviewing information with a patient about the normal anatomy and physiology of the endocrine system. Which factor is inaccurate? 1. All endocrine glands are anatomically separate in location. 2. All endocrine glands function independently of each other. 3. Most hormone levels are regulated by a negative feedback system. 4. Each hormone is secreted in response to a specific stimulus. ANS: 2 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Identify the glands of the endocrine system. Pages: 773–778 Heading: Normal Endocrine System Anatomy and Physiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Unlike other organ systems, all endocrine glands are anatomically separate in location. Endocrine glands may function separately, but some hormones are secreted in response to hormones secreted by other endocrine glands. Most hormone levels are regulated by a negative feedback system, as when hormone levels are low or body functions are not normal. Each specific hormone is secreted in response to a specific stimulus and affects target cells for that specific hormone.

PTS:

CON: Patient-Centered Care

2. The nurse is researching information for a patient newly diagnosed with diabetes mellitus. The nurse wants to present the responses by hormones other than insulin. Which information does the nurse avoid? 1. Growth hormones (GHs) secreted by the anterior pituitary play a part in glucose regulation. 2. Growth hormone-releasing hormone (GHRH) is secreted during hypoglycemia or when there is a high blood level of amino acids. 3. GH and growth hormone-inhibiting hormone (GHIH) are secreted to maintain blood glucose levels and metabolism rates are normal. 4. GHIH is secreted during hyperglycemia when carbohydrates are available for energy production. ANS: 3 Chapter: Chapter 38. Endocrine System Function and Assessment

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Objective: Explain the function of each of the hormones in the endocrine system. Page: 782 Heading: Anterior Pituitary Gland Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3

The anterior pituitary hormones play a part in blood glucose regulation with the secretion of GHRH and GHIH. The option correctly explains the function of GHRH during hypoglycemia and high blood level of amino acids. GH and GHIH are growth hormones secreted by the anterior pituitary gland, but GH has no influence on the regulation of blood glucose levels. GH stimulates growth and GHIH inhibits growth. However, GHIH also plays a part in glucose regulation. This correctly explains the function of GHIH during hyperglycemia when adequate carbohydrates are available for energy production and fat mobilization is not necessary.

PTS:

CON: Metabolism

3. An older adult patient is experiencing a reduction in energy. Which comment by the nurse is most appropriate? 1. “Mild diabetes often develops with age; I’ll see about checking your blood sugar.” 2. “Your tiredness is because your body increases the release of growth hormone as you age.” 3. “Aging causes the basal metabolic rate to change, and it’s often normal to have less energy.” 4. “A decrease in parathyroid hormone secretion occurs with age, and that can make you feel tired.” ANS: 3 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Describe the effects of aging on endocrine system function. Page: 795 Heading: Aging and the Endocrine System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

Most of the endocrine glands decrease their secretions with age, but normal aging usually does not lead to serious hormone deficiencies or illness. Unless specific pathological conditions develop, the endocrine system usually

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continues to function adequately in old age. Most of the endocrine glands decrease their secretions with age, but normal aging usually does not lead to serious hormone deficiencies or illness. Unless specific pathological conditions develop, the endocrine system usually continues to function adequately in old age. Decreases in thyroid-stimulating hormone (TSH) and thyroid hormone cause a decrease in the basal metabolic rate and may result in decreased energy. The decrease in secretion is normal with aging. Low parathyroid hormone is not a common cause of tiredness.

PTS:

CON: Patient-Centered Care

4. After reviewing the patient’s medical record, the nurse plans to perform a physical examination. Which finding will change the usual process of physical examination? 1. The patient had surgery for a goiter. 2. The patient is being treated for diabetes mellitus. 3. The patient has elevated thyroid hormones. 4. The patient is diagnosed with a posterior pituitary tumor ANS: 3 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: List data to collect when caring for a patient with a disorder of the endocrine system. Page: 796 Heading: Thyroid Gland Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physical Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

The finding that the patient had surgery for a goiter will not alone change the nurse’s process of physical examination. The finding that the patient is being treated for diabetes mellitus will not change the nurse’s process of physical examination. Elevated thyroid hormones are indicative of a hyperactive thyroid gland. The nurse will not assist the health care provider (HCP) during thyroid examination. The HCP will avoid palpating the thyroid to avoid stimulation. Because the nurse would be unable to perform a physical examination on the posterior pituitary gland, this finding alone is not going to change the nurse’s process of physical examination.

PTS:

CON: Patient-Centered Care

5. The HCP prescribes a 24-hour urine specimen for cortisol. The patient is incontinent. Which method will the nurse use to collect the specimen? 1. Place the patient on a bedpan every half hour during the test. 2. Obtain an order for an indwelling catheter for the duration of the test.

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3. Review the use of the nurse call light and have the patient indicate a need to void. 4. Place a bedside commode in a position to enable the patient to make a safe transfer. ANS: 2 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Plan nursing care for patients undergoing testing for an endocrine disorder. Page: 780 Heading: Adrenal Cortex Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment—Safety and Infection Control Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

Placing the patient on a bedpan every half hour is not going assure that all urine is collected; the patient may have continuous incontinence. If the patient is incontinent or otherwise unable to participate in the test, a catheter may need to be inserted. If the patient already has an indwelling catheter, a new bag and tubing should be attached before the start of the test. Reviewing the use of the call light may not be effective. The patient may or may not be able to determine the need to void or may not be able to wait for help without voiding. There is not enough information to determine if the patient is able to use a bedside commode safely. Functional incontinence would not support this method of collection.

PTS:

CON: Patient-Centered Care

6. The nurse is providing care for a patient diagnosed with posterior pituitary tumor resulting in oversecretion of hormones. Which manifestation of this disorder will the nurse expect? 1. Significant increase in urinary output 2. Notable increase in blood pressure 3. Physical indications of dehydration 4. Severe blood loss associated with injury ANS: 2 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: List data to collect when caring for a patient with a disorder of the endocrine system. Page: 790 Heading: Posterior Pituitary Gland Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Difficult Feedback

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1 2 3 4

Oversecretion of antidiuretic hormone (ADH) will result in a decrease, not increase, in urinary output related to fluid reabsorption. Oversecretion of antidiuretic hormone (ADH) will result in a significant increase in blood pressure related to increased fluid reabsorption. With the oversecretion of antidiuretic hormone (ADH), fluid will be retained and the patient will not exhibit signs of dehydration. ADH normally constricts blood vessels and prevents blood loss in the case of injury. Oversecretion of antidiuretic hormone (ADH) will not cause severe blood loss with injury.

PTS:

CON: Metabolism

7. The nurse is providing care for a patient diagnosed with type 2 diabetes mellitus. Which information will the nurse give the patient about the response of the pancreas to hypoglycemia? 1. Pancreatic alpha cells are stimulated to inhibit insulin. 2. Pancreatic beta cells are stimulated to move glucose from cells. 3. Pancreatic alpha cells are stimulated to release glucagon. 4. Pancreatic beta cells are stimulated to decrease insulin. ANS: 3 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Explain the function of each of the hormones in the endocrine system. Page: 816 Heading: Pancreas Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback 1

Pancreatic alpha cells will stimulate the release of glucagon to raise glucose blood levels in response to hypoglycemia. Alpha cells do not inhibit the release of insulin. Hyperglycemia stimulates pancreatic beta cells to release insulin; the beta cells do not move glucose from the cells and into the blood in the event of hypoglycemia. Pancreatic alpha cells will stimulate the release of glucagon in response to hypoglycemia. Glucagon raises blood glucose levels and makes it available to body cells. Pancreatic beta cells are stimulated to increase the secretion of insulin with hyperglycemia. The beta cells do not have a role with hypoglycemia.

PTS:

CON: Metabolism

8. The nurse is assisting with care to a patient who underwent surgery for removal of the thyroid gland. Which symptom contradicts a possible complication of the surgery? 1. Decreased calcium in blood

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2. Prolonged clotting time 3. Decreased calcitonin levels 4. Hyperactive bowel sounds ANS: 4 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Explain the function of each of the hormones in the endocrine system. Page: 800 Heading: Parathyroid Glands Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1

A possible complication related to removal of the thyroid is accidental removal or damage to the parathyroid glands, which secrete parathyroid hormone (PTH). A complication of thyroid surgery is hypocalcemia, or a decrease in calcium in the blood. Parathyroid hormone (PTH) is necessary to assist in blood clotting. With the accidental removal or damage to the parathyroid glands, blood clotting will be prolonged. Calcitonin is an antagonist to parathyroid hormone (PTH). If the secretion of PTH is decreased by the accidental removal or damage to the parathyroid glands, the level of calcitonin is also decreased. The delivery of calcium ions is essential for normal excitability of neurons and muscle cells and blood clotting. A decrease or lack of parathyroid hormone (PTH) will affect bone, the small intestine, and kidneys. Hyperactive bowels sound are a contraindication.

PTS:

CON: Metabolism

9. The licensed practical nurse/licensed vocational nurse (LPN/LVN) is assisting with the physical examination of a patient in the HCP’s office. Which physical examination does the LPN/LVN perform? 1. Observe for abnormal physical characteristics. 2. Palpation of the flank for adrenal gland disorders. 3. Gently palpate the thyroid gland for enlargement. 4. Percuss the abdomen to validate normal pancreas size. ANS: 1 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: List data to collect when caring for a patient with a disorder of the endocrine system. Page: 790 Heading: Nursing Assessment of the Endocrine System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying)

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Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

2 3 4

The LPN/LVN is able to observe the patient for abnormal physical characteristics during a physical examination. The nurse will note the presence of exophthalmos, buffalo hump, and dry and thin hair as an example. The adrenal glands cannot be palpated; the only palpable gland is the thyroid. The LPN/LVN may assist the HCP with palpation of the thyroid gland by positioning the patient and providing water to sip and swallow. Auscultation and percussion are not part of the physical assessment of the endocrine system.

PTS:

CON: Patient-Centered Care

10. A client is identified with a thyroid disorder resulting in hormone deficiency. The HCP prescribes a stimulation test. Which process does the nurse expect for the test? 1. The patient will drink a contrast medium. 2. Hormone measurements will occur after a meal. 3. A substance will be injected into the patient. 4. The patient is evaluated after monitored exercise. ANS: 3 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Plan nursing care for patients undergoing testing for an endocrine disorder. Page: 780 Heading: Stimulation Tests Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3 4

A contrast medium is not used for a stimulation test. Contrast medium is used for radiographic studies. The function of the thyroid is not measured after a meal. The function of the pancreas is often stimulated by the ingestion of food or nutrients. A substance will be injected into the patient to stimulate the thyroid gland; reactions and hormone measurements will be noted. Exercise is not an element used to stimulate thyroid function; cardiac and respiratory assessment may involve exercise.

PTS:

CON: Metabolism

11. A patient is diagnosed with adrenal gland dysfunction and is scheduled for a 24-hour urine test. Which action by the nurse in regard to the test is incorrect? 1. The test is complete when the last voiding is collected. 2. The first morning urine sample is retained for testing.

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3. The test will need to be restarted if a urine sample is missed. 4. Urine samples are collected immediately after voiding. ANS: 2 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Plan nursing care for patients undergoing testing for an endocrine disorder. Page: 780 Heading: Urine Tests Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment—Coordinated Care Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

The test is complete when the last voiding is collected at the end of the 24-hour period. The nurse needs to ask the patient to void at the time the test ends. The first morning sample of urine is discarded because it is a product of a time period before the test began. The urine collection is a continuous collection during a designated 24-hour period. If a sample is missed, the test is restarted. Urine samples for a 24-hour urine collection should be collected immediately to prevent deterioration of the sample. Most collections are refrigerated and may have added preservatives.

PTS:

CON: Patient-Centered Care

12. The nurse is preparing a patient to undergo a suppression test to verify adrenal cortex dysfunction. Which reply will the nurse make when the client asks about the expected test procedure? 1. “You will be injected with an adrenal stimulant to see how the adrenal glands work.” 2. “You will be injected with a steroid hormone that should suppress cortisol release.” 3. “A failure of adrenal cortex function is indicated by a low blood cortisol level.” 4. “You will be injected with epinephrine to stimulate your metabolic functions.” ANS: 2 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Plan nursing care for patients undergoing testing for an endocrine disorder. Page: 807 Heading: Suppression Tests Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Integrity Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback

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1 2

3 4

A suppression test does not stimulate organ activity; this would result from a stimulation test. A suppression test for adrenal cortex function incudes the injection of a steroid hormone, which should result in a suppression of cortisol release. If the cortisol level is not suppressed, it is indicative of adrenal cortex dysfunction and verifies the patient’s diagnosis. The indicator of adrenal cortex dysfunction is a high blood cortisol level even after the administration of a suppressor. The patient will not be injected with epinephrine as part of a suppression test. Epinephrine is a metabolic stimulant.

PTS:

CON: Patient-Centered Care

13. The nurse is preparing a patient for a thyroid scan to rule out thyroid cancer. Which instruction does the nurse give the patient prior to the testing? 1. Do not leave the area after the radioactive material is injected. 2. Collect all urine for 4 hours so it can be evaluated for radiation. 3. Use the bathroom before the scanning part of the test is performed. 4. Multiple series of x-rays will be taken over a period of 2 hours. ANS: 3 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Plan nursing care for patients undergoing testing for an endocrine disorder. Page: 800 Heading: Thyroid Scan Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

2 3

There is no reason for the patient to remain in a specific area after radioactive material is injected or ingested. The amount of radioactive material is small and unlikely to cause harm to the patient or others. After a thyroid scan, the patient does not need to collect urine for any period of time to be evaluated for radiation. The patient does need to go to the bathroom prior to the scanning part of the test; the scanning can take approximately 30 minutes to complete. The test should not be interrupted for the patient to void. The scanning is performed by a scintillation camera and is completed in 30 minutes. Hot spots are indicative of healthy thyroid tissue, and cold spots are indicative of malignancies.

PTS:

CON: Patient-Centered Care

14. The nurse receives information that an assigned patient is scheduled for an ultrasound of an endocrine gland. Which instruction does the nurse give the patient? 1. Wear clothing with an elastic waistband.

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2. Remain NPO for 12 hours prior to testing. 3. Do not wear a tight or high-necked shirt. 4. Wash hair with antimicrobial shampoo. ANS: 1 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Plan nursing care for patients undergoing testing for an endocrine disorder. Page: 800 Heading: Ultrasound Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

Ultrasound is not performed to examine the adrenal glands, which would require elastic waistband clothing. Other testing methods will provide more definitive results. Even with ultrasound of the abdominal cavity, it is not necessary to remain NPO for 12 hours. The only endocrine gland in the abdomen is the pancreas and other more definitive testing is available. The thyroid and parathyroid glands are easily examined by ultrasound. The location and accessibility will result in definitive results. The ultrasound is able to detect enlargement or masses. However, the patient is instructed not to wear clothing with a tight or high neckline. The only endocrine gland in the head is the pituitary. The pituitary gland is encased in the skull and would not be an appropriate area to examine with ultrasound.

PTS:

CON: Patient-Centered Care

15. A patient has returned to the unit after a needle biopsy of the thyroid gland to rule out cancer. Which observation is expected by the nurse following the procedure? 1. Pain level of 2 on a 0-to-10 scale 2. Moderate amount of bleeding on the bandage 3. Inability to swallow or speak clearly 4. An oxygen saturation level of 90 percent ANS: 1 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Plan nursing care for patients undergoing testing for an endocrine disorder. Page: 803 Heading: Biopsy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

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Feedback 1 2

3 4

After a needle biopsy of the thyroid, the patient may express a low level of pain; this observation is expected. It is unlikely that a needle biopsy will produce a moderate amount of bleeding on the bandage used to cover the puncture site. This is an unexpected observation. The inability to swallow or speak after a thyroid needle biopsy is unexpected. The throat is not involved in the procedure. An oxygen saturation level of 90 percent is unexpected after a needle biopsy of the thyroid. The procedure is not likely to interfere with the patient’s airway.

PTS:

CON: Patient-Centered Care

16. The nurse is aware that a 12-year-old male client is at the fifth percentile on the growth chart for height. Which medical intervention does the nurse expect the HCP to prescribe? 1. Surgery to lengthen the long bones and increase height 2. Administration of GH therapy for added height 3. Maintaining a wait-and-see approach until the patient is age 18 4. Diagnostic testing to identify any adrenal gland dysfunction ANS: 2 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Explain the function of each of the hormones in the endocrine system. Page: 794 Heading: Anterior Pituitary Gland Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult Feedback 1

3 4

Surgery to lengthen the long bones and increase height is a long and painful process, which is usually not performed on adolescent clients when growth can be promoted in less invasive ways. It is expected for an adolescent to experience notable increases in height. When height lags behind, the patient may be treated with GH to stimulate height increase. By the age of 18 years, the most responsive time for growth stimulation may have passed. Growth hormones are secreted by the hypothalamus; testing of the adrenal glands is not needed.

PTS:

CON: Patient-Centered Care

17. The nurse is aware that the pancreas is the only gland that is both endocrine and exocrine. Which secretion is related to the endocrine function of the pancreas? 1. Insulin 2. Bile

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3. Amylase 4. Lipase ANS: 1 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Explain the function of each of the hormones in the endocrine system. Page: 820 Heading: Pancreas Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

An endocrine function of the pancreas is to excrete insulin in response to blood glucose levels. Bile is excreted by the liver to aid in digestion; the liver is not a gland. Amylase is secreted by the pancreas to assist in the digestion of carbohydrates; the excretion is an exocrine function. Lipase is secreted by the pancreas to assist in the digestion of fats; the excretion is an exocrine function.

PTS:

CON: Patient-Centered Care

18. The nurse is aware that the adrenal cortex secretes a variety of hormones. Which is an incorrect function of glucocorticoids? 1. In both genders, they contribute to libido. 2. They are small amounts of male androgens. 3. In females, they counterbalance estrogen effects. 4. They are the only source of estrogen after menopause. ANS: 3 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Explain the function of each of the hormones in the endocrine system. Page: 807 Heading: Adrenal Cortex Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

In both genders, glucocorticoids contribute to sexual desire, known as libido. Glucocorticoids are small amounts of male androgens. Glucocorticoids do not counterbalance estrogen effects in females. Male androgens are converted to estrogen in females. After menopause, the only source of estrogen for females is from

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glucocorticoids. PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE 1. A patient is prescribed a dose of epinephrine. Which effects does the nurse expect the patient to exhibit after receiving this medication? (Select all that apply.) 1. Decreases peristalsis 2. Constricts bronchioles 3. Increases heart rate and force of contraction 4. Stimulates the liver to convert glycogen to glucose 5. Stimulates vasoconstriction in skin and most viscera ANS: 1, 3, 4, 5 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Explain the function of each of the hormones in the endocrine system. Page: 819 Heading: Adrenal Medulla Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

2. 3.

Feedback Epinephrine increases the heart rate and force of contraction, stimulates vasoconstriction in skin and most viscera and vasodilation in skeletal muscles, dilates the bronchioles, decreases peristalsis, stimulates the liver to convert glycogen to glucose, increases the use of fats for energy, and increases the rate of cell respiration. Epinephrine does not constrict the bronchioles. Epinephrine increases the heart rate and force of contraction, stimulates vasoconstriction in skin and most viscera and vasodilation in skeletal muscles, dilates the bronchioles, decreases peristalsis, stimulates the liver to convert glycogen to glucose, increases the use of fats for energy, and increases the rate of cell respiration. Epinephrine increases the heart rate and force of contraction, stimulates vasoconstriction in skin and most viscera and vasodilation in skeletal muscles, dilates the bronchioles, decreases peristalsis, stimulates the liver to convert glycogen to glucose, increases the use of fats for energy, and increases the rate of cell respiration. Epinephrine increases the heart rate and force of contraction, stimulates vasoconstriction in skin and most viscera and vasodilation in skeletal muscles, dilates the bronchioles, decreases peristalsis, stimulates the liver to convert glycogen to glucose, increases the use of fats for energy, and increases the rate of cell respiration.

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PTS:

CON: Patient-Centered Care

2. A patient is experiencing an increased level of corticotropin-releasing hormone (CRH). What should the nurse consider is occurring with this patient? (Select all that apply.) 1. Body stressed 2. Low blood volume 3. Presence of an injury 4. Low blood glucose level 5. Elevated blood glucose level ANS: 1, 3, 4 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: Explain the function of each of the hormones in the endocrine system. Page: 781 Heading: Adrenal Cortex Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3. 4. 5. PTS:

Feedback CRH is produced during any type of stress such as injury, disease, exercise, or hypoglycemia. Antidiuretic hormone is released in response to low blood volume. CRH is produced during any type of stress such as injury, disease, exercise, or hypoglycemia. CRH is produced during any type of stress such as injury, disease, exercise, or hypoglycemia. Growth hormone–inhibiting hormone is secreted during hyperglycemia. 1

CON: Patient-Centered Care

3. While collecting data, the nurse suspects that a patient is experiencing Cushing syndrome. Which findings does the nurse use to come to this conclusion? (Select all that apply.) 1. Bulging eyes 2. Mood swings 3. Buffalo hump 4. Water weight gain 5. Round “moon” face ANS: 2, 3, 4, 5 Chapter: Chapter 38. Endocrine System Function and Assessment Objective: List data to collect when caring for a patient with a disorder of the endocrine system. Page: 808 Heading: Adrenal Glands Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation

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Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Difficult

1. 2.

PTS:

Feedback Bulging eyes are a manifestation of Graves disease. Manifestations of Cushing syndrome include water weight gain, mood swings, fat pads on neck and shoulders (“buffalo hump”), and a round “moon” face. Manifestations of Cushing syndrome include water weight gain, mood swings, fat pads on neck and shoulders (“buffalo hump”), and a round “moon” face. Manifestations of Cushing syndrome include water weight gain, mood swings, fat pads on neck and shoulders (“buffalo hump”), and a round “moon” face. Manifestations of Cushing syndrome include water weight gain, mood swings, fat pads on neck and shoulders (“buffalo hump”), and a round “moon” face. 1

CON: Metabolism

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Chapter 39. Nursing Care of Patients With Endocrine Disorders MULTIPLE CHOICE 1. A patient is scheduled for diagnostic tests for hypothyroidism. Which symptoms does the nurse expect to observe in a patient with this disorder? 1. Tremor and oily skin 2. Anxiety and tachycardia 3. Dry skin and slowed heart rate 4. Increase in appetite and diarrhea ANS: 3 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Describe the etiologies, signs, and symptoms of each of the endocrine orders. Page: 795 Heading: Hypothyroidism Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3

Tremor and oily skin are not related to hypothyroidism. Anxiety and tachycardia are not related to hypothyroidism. Symptoms of hypothyroidism are related to the reduced metabolic rate and include fatigue, weight gain, bradycardia, constipation, mental dullness, feeling cold, shortness of breath, decreased sweating, and dry skin and hair. Increase in appetite and diarrhea are not related to hypothyroidism.

PTS:

CON: Metabolism

2. The nurse is monitoring a patient admitted for testing of diabetes insipidus. Which observation by the nurse is unexpected? 1. Low specific gravity of urine 2. Expressions of extreme thirst 3. Elevated blood glucose levels 4. Large amounts of clear urine ANS: 3 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Describe the etiologies, signs, and symptoms of each of the endocrine orders. Page: 790 Heading: Disorders Related to Antidiuretic Hormone Imbalance Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism

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Difficulty: Moderate Feedback 1 2 3 4

Low specific gravity of urine (<1.005) is indicative of diabetes insipidus. When a patient has diabetes insipidus, dehydration occurs, which results in feelings of extreme thirst. Diabetes insipidus is not to be confused with diabetes mellitus, which is a condition related to insulin and blood glucose levels. A client with diabetes insipidus may void 3 to 15 liters of urine daily. This is a classic manifestation of the disorder.

PTS:

CON: Metabolism

3. A patient who is 1 day postoperative thyroidectomy reports feeling numb around the mouth and is experiencing random muscle twitches. Which IV medication does the nurse anticipate being prescribed by the health care provider (HCP)? 1. Iodine 2. Calcium gluconate 3. Potassium chloride 4. Sodium bicarbonate ANS: 2 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Describe current therapeutic measures used for each of the selected endocrine disorders. Page: 800 Heading: Nursing Process for the Patient Undergoing Thyroidectomy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3 4

The patient is exhibiting symptoms of hypocalcemia; iodine will not help to restore the calcium level. In the absence of parathyroid hormone, serum calcium levels drop and tetany results. IV calcium gluconate is given to treat acute tetany. Potassium chloride will not help to restore the calcium level. Sodium bicarbonate will not help to restore the calcium level.

PTS:

CON: Metabolism

4. The nurse is providing care for a patient with syndrome of inappropriate antidiuretic hormone (SIADH). Which additional diagnosis does the nurse need to identify as a contributor to the patient’s disorder? 1. Diabetes insipidus 2. History of renal calculi 3. Ulcerative colitis

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4. Mental health disorder ANS: 4 Chapter: Nursing Care of Patients With Endocrine Disorders Objective: Identify disorders caused by variations in the hormones of the pituitary, thyroid, parathyroid, and adrenal glands. Pages: 791–792 Heading: Syndrome of Inappropriate Antidiuretic Hormone Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3 4

Diabetes insipidus is the result of too much antidiuretic hormone (ADH) causing fluid deficit, and not SIADH, which causes fluid retention. A history of renal calculi is not a current diagnosis and does not provide information related to the patient’s diagnosis of SIADH. Ulcerative colitis is not a condition that contributes to the patient’s diagnosis of SIADH. Mental health disorders treated with antipsychotics is a condition that can contribute to or cause the patient’s diagnosis of SIADH.

PTS:

CON: Metabolism

5. The nurse is monitoring a patient 6 hours after a thyroidectomy for cancer. Vital signs are temperature 104°F, pulse 144 beats/min, respirations 24/min, and blood pressure 184/108 mm Hg. Which prescription does the nurse anticipate from the HCP? 1. Aspirin and bedrest 2. Beta blockers and a cooling blanket 3. Epinephrine and compression dressings 4. Diphenhydramine and Fowler’s position ANS: 2 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Describe current therapeutic measures used for each of the selected endocrine disorders. Page: 800 Heading: Thyrotoxic Crisis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1

Aspirin is avoided because it binds with the same serum protein as T4, freeing additional T4 into the circulation.

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If thyrotoxic crisis occurs, treatment is first directed toward relieving the lifethreatening symptoms. Acetaminophen is given for the fever. IV fluids and a cooling blanket may be ordered to cool the patient. A beta-adrenergic blocker, such as propranolol, is given for tachycardia. Epinephrine will make symptoms worse. Compression dressing on the thyroid could compromise the airway. Diphenhydramine and Fowler’s position do not address the problem.

PTS:

CON: Metabolism

6. The nurse is gathering information from a patient in a HCP’s office. The patient reports difficulty speaking and swallowing and, recently, frequent headaches. Which additional manifestation does the nurse observe that indicates a possible glandular dysfunction? 1. Large fleshy hands 2. Sleep apnea 3. Visual disturbances 4. Carbohydrate intolerance ANS: 1 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Describe the etiologies, signs, and symptoms of each of the endocrine disorders. Page: 810 Heading: Acromegaly Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Difficult Feedback 1

2 3 4

The question is asking for an objective manifestation. The nurse will be able to observe large fleshy hands, which in addition to the patient’s report, can be an indication of acromegaly. Sleep apnea is a manifestation that can be associated with acromegaly; however, the information is subjective. Visual disturbances can occur with acromegaly from pressure in the brain from a tumor; however, the information is subjective. Patients with acromegaly can develop diabetes mellitus. Carbohydrate intolerance does not necessarily indicate this disorder; this information is subjective.

PTS:

CON: Metabolism

7. The nurse is contributing to the plan of care for an adult patient diagnosed with growth hormone (GH) deficiency. Which nursing intervention is appropriate for this patient? 1. Teach the importance of weight reduction. 2. Monitor and report blood cholesterol levels. 3. Reassess for cardio- and cerebrovascular changes. 4. Promote a caring, supportive relationship.

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ANS: 4 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Plan nursing care for patients with each of the disorders. Page: 811 Heading: Growth Hormone Deficiency Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Difficult Feedback 1

2 3

The adult patient with GH deficiency may have excess body fat, which may or may not respond to dietary changes. Teaching should focus on healthy dietary practices. If the HCP prescribes cholesterol testing, the nurse is always responsible to report results. The question is asking for a nursing intervention. Adult patients with GH deficiency may develop cardio- or cerebrovascular changes. Assessment and reassessment of these body systems is routine nursing care. The adult patient with GH deficiency may exhibit mental slowness and/or psychological disturbances. The nurse needs to promote a caring, supportive relationship so that a trusting patient-nurse relationship can be established.

PTS:

CON: Metabolism

8. The nurse determines that treatment has been effective for a patient with diabetes insipidus. Which laboratory value did the nurse use to come to this conclusion? 1. Urine ketones 2. Serum potassium 3. Fasting blood glucose 4. Urine specific gravity ANS: 4 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Explain how you will know if nursing interventions have been effective. Page: 790 Heading: Diabetes Insipidus Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2

Blood glucose and urine ketones are monitored in diabetes mellitus, not diabetes insipidus. Diabetes insipidus does not directly affect potassium level.

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3 4

Blood glucose and urine ketones are monitored in diabetes mellitus, not diabetes insipidus. Urine specific gravity is a good measure of urine concentration and ADH function.

PTS:

CON: Metabolism

9. The nurse is providing care for a patient who is postoperative for a transsphenoidal surgery for the removal of a pituitary tumor. Which nursing care is inappropriate in the postsurgical period? 1. Promote use of spirometer and deep breathing. 2. Change nasal packing and moustache dressing. 3. Obtain and report results of urine specific gravity. 4. Monitor for signs of cerebrospinal fluid drainage. ANS: 2 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Plan nursing care for patients with each of the disorders. Page: 795 Heading: Nursing Care for Patients Undergoing Hypophysectomy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1

The patient needs to be reminded to use spirometry and to take deep breaths to improve respiratory status. However, coughing is prohibited to avoid increasing pressure on the surgical site. The patient’s method of surgery will require nasal packing and a moustache dressing to absorb any drainage. The packing and dressing is not to be changed without a HCP’s order. After pituitary gland surgery, the patient is at risk for diabetes insipidus. The most effective manner for monitoring for this complication is by monitoring urine specific gravity. The transsphenoidal surgical approach for pituitary surgery can cause a leakage of cerebrospinal fluid through the nares. Due to the presence of glucose in the fluid, a glucose dip stick is used to check for the source of the drainage.

PTS:

CON: Metabolism

10. A patient arrives at the emergency department and states, “I was outside shoveling snow and suddenly started to feel really bad.” The patient’s medical history indicates treatment for hypothyroidism for the past 10 years. Which possible condition causes the nurse the greatest concern? 1. Cardiac failure 2. Myxedema coma 3. Thyrotoxic crisis

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4. Respiratory failure ANS: 2 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Describe the etiologies, signs, and symptoms of each of the endocrine disorders. Page: 795 Heading: Disorders of the Thyroid Gland Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2

3 4

The possibility of cardiac failure can occur as result of the complication myxedema coma. The nurse’s greatest concern is for the development of myxedema coma, which includes the complications of cardiac or respiratory failure, reduced kidney perfusion, and hypoglycemia. Thyrotoxic crisis occurs with hyperthyroidism. The possibility of respiratory failure can occur as a result of the complication myxedema coma.

PTS:

CON: Metabolism

11. A patient enters the emergency department in adrenal crisis. The patient is lethargic and vital signs are blood pressure 85/52 mm Hg and pulse 88 beats/min. Which event in the patient’s week most likely precipitated this crisis? 1. Eating a high-fat diet 2. Being laid off from a job 3. Taking Tylenol for a headache 4. Nightly walking exercise ANS: 2 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Identify disorders caused by variations in the hormones of the pituitary, thyroid, parathyroid, and adrenal glands. Page: 799 Heading: Disorders of the Adrenal Glands Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2

Consuming a high-fat diet is not a source of stress. Stress causes a need for an increase in cortisol, the body’s stress hormone. Being laid off is a stressor and can preclude adrenal crisis.

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3 4

Taking Tylenol for a headache is not a source of stress. Walking for exercise is not a source of stress, and, in fact, can be a stress reliever.

PTS:

CON: Metabolism

12. The nurse is reinforcing teaching to a patient who is diagnosed with genetically related hypoparathyroidism. Which comment by the patient indicates that patient teaching is successful? 1. “I will immediately report numbness and tingling of the fingers, tongue, and lips.” 2. “I understand that muscle spasms and twitching mean I need more calcium in my diet.” 3. “If I make funny noises when I breathe, I will drink more fluids and get a humidifier.” 4. “I will switch to whole milk instead of skim milk and increase my intake of cheese.” ANS: 1 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Explain how you will know if nursing interventions have been effective. Page: 801 Heading: Hypoparathyroidism Integrated Process: Teaching/Learning Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1

2 3 4

Numbness and tingling of the fingers, tongue, and lips are signs of impending tetany and should be reported immediately. The statement indicates understanding of teaching. Muscle spasms and twitching are signs of impending tetany, which is a medical emergency. Eating more calcium will not solve the problem quickly enough. Laryngospasms are an indication of tetany; drinking more fluids and using a humidifier are not appropriate actions for this medical emergency. Whole and skim milk have nearly the same calcium content. Cheese is a source of calcium, but the patient needs a better understanding of alternate sources of calcium in addition to dairy products.

PTS:

CON: Metabolism

13. The licensed practical nurse/licensed vocational nurse (LPN/LVN) is assisting in the care of a 51-year-old patient recovering from a hypophysectomy. Which observation should the nurse identify as needing immediate intervention? 1. Urine specific gravity of 1.19 2. Hemoglobin level of 13.2 g/dL 3. Urinary output of 800 mL in 4 hours 4. Complaints of pain at a 5 on a scale of 0 to 10

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ANS: 3 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Identify disorders caused by variations in the hormones of the pituitary, thyroid, parathyroid, and adrenal glands. Page: 795 Heading: Nursing Process for the Patient With Diabetes Insipidus Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3

The listed urine specific gravity is within normal limits for the patient. The listed hemoglobin is within normal limits for the patient. Tumors, trauma, or other problems to the hypothalamus or pituitary gland can lead to decreased production or release of ADH, causing diabetes insipidus and resulting in excess urinary output. Pain is not the highest priority in this scenario.

PTS:

CON: Metabolism

14. The nurse is providing care for a patient scheduled to receive radioactive iodine as treatment for thyroid cancer. Which care intervention for this patient is inappropriate? 1. All urine, vomitus, and body secretions are handled as contaminated. 2. Hospital policy and the radiation safety officer are consulted for instructions. 3. Pregnant caretakers will wear a lead apron during patient contact. 4. The toilet is flushed twice after disposing of contaminated body products. ANS: 3 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Plan nursing care for patients with each of the disorders. Page: 801 Heading: Nursing Care for the Patient Receiving Radioactive Iodine Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3 4

When the patient is hospitalized for treatment with radioactive iodine, the dose is high. All urine, vomitus, and body secretions are considered contaminated. Because of radioactive contamination, the nurse needs to consult the hospital policy and radiation safety officer for specific instructions. Pregnant caretakers need to avoid all contact with the patient receiving radioactive iodine. When disposing of contaminated body products, the toilet needs to be flushed

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twice to be sure that radioactive residue is removed. PTS:

CON: Metabolism

15. The LPN/LVN is monitoring a patient with a goiter who is scheduled for surgery. Physical inspection reveals only slight swelling in the anterior base of the neck. Which manifestation will prompt the LPN/LVN to notify the registered nurse (RN)? 1. Patient expresses difficulty with swallowing. 2. Patient reports sensation of heaviness in the neck. 3. Patient expresses a fear of choking on food. 4. A whistling sound is heard with breathing. ANS: 4 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Explain the pathophysiology of each of the endocrine disorders presented. Pages: 801–802 Heading: Goiter Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3

The lack of swelling in the anterior base of the neck indicates that the patient is likely to have posterior swelling, which causes difficulty with swallowing. Patients with goiters will frequently express feelings of heaviness in the neck with a goiter. However, the sensation is more likely with anterior swelling. The patient is likely to have posterior goiter swelling, which will create problems with swallowing food. The nurse will consult with the RN about a soft diet along with a swallowing consult. The manifestation of greatest concern, which requires immediate reporting to the RN, is stridor (whistling sound during breathing). The presence of stridor is an ominous indication that the airway is compromised.

PTS:

CON: Metabolism

16. The nurse is assigned to provide care for a patient diagnosed with diabetes insipidus. While reviewing the nursing care planned for the patient, which intervention will the nurse recognize as being least important? 1. Monitoring daily weight, intake and output, vital signs, and urine specific gravity 2. Providing free access of the patient to oral fluids as desired 3. Reporting a significant drop in blood pressure and increase in pulse 4. Determining the patient’s understanding of her condition ANS: 4 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Plan nursing care for patients with each of the disorders presented. Pages: 790–791

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Heading: Nursing Process for the Patient With Diabetes Insipidus Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3

Because of the symptoms and manifestations of diabetes insipidus, the nurse will carefully monitor all indicators of the patient’s fluid status. When caring for a patient with diabetes insipidus, it is important to replenish the patient’s fluid volume to prevent hypovolemic shock. The nurse needs to report any significant drop in blood pressure and increase in pulse rate to the RN or HCP. These changes are indicative of hypovolemic shock. The least important intervention by the nurse with a patient diagnosed with diabetes insipidus is the determination of the patient’s understanding of her condition. The patient needs careful monitoring and care to prevent a crisis.

PTS:

CON: Metabolism

17. The nurse is monitoring the effects of a water deprivation test on a patient suspected of diabetes insipidus related to pituitary dysfunction. Which test result supports the diagnosis? 1. Body weight and urine osmolality remains unchanged. 2. The patient is unable to void after 6 hours of deprivation. 3. Urine continues to be diluted with a high specific gravity. 4. Weight loss occurs due to the large amount of urine voided. ANS: 4 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: List data to collect when caring for patients with each of the endocrine disorders discussed. Page: 790 Heading: Diabetes Insipidus Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1

During a water deprivation test, the urine osmolality may or may not change; however, the patient is expected to lose weight related to dehydration and lack of fluid replacement. After 6 hours of fluid deprivation, an inability to void indicates that the client does not have diabetes insipidus; the client will continue to void large amounts of dilute urine if the test is positive. With positive results to a water deprivation test, the patient will continue to void diluted urine, but the specific gravity will be low.

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During a water deprivation test for diabetes insipidus, the patient will continue to lose weight because of the large volume of urine that is passed. This is the option that supports the diagnosis.

PTS:

CON: Metabolism

18. The nurse is providing care for a patient diagnosed with complications related to Cushing syndrome. Which situation indicates a need for a change in nursing intervention? 1. Insulin for high blood glucose is administered by the nurse. 2. The patient’s skin has remained intact during hospitalization. 3. Complications of fluid overload are recognized and treated early. 4. The patient is receptive to and appreciative of help with personal care. ANS: 1 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Explain how you will know if nursing interventions have been effective. Page: 808 Heading: Disorders of the Adrenal Glands Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1

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The patient needs to demonstrate an ability to perform self-care for the management of diabetes mellitus. This situation indicates a need for change in nursing intervention. Patients with Cushing syndrome are susceptible to skin breakdown; maintenance of skin integrity indicates appropriate nursing intervention. The early recognition and treatment for complications related to fluid retention indicates appropriate nursing intervention. When the patient is receptive and appreciative of help with personal care, the indication is that the nurse has established a caring relationship with the patient. The patient responses are also an indication of self-acceptance.

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19. The nurse is gathering data from a patient who voices concerns about feeling dizzy upon standing, fatigue, and recent weight loss. Which additional information will most likely cause the nurse to suspect a problem with adrenal insufficiency? 1. Periods of tachycardia 2. Bronzed skin coloration 3. Low blood pressure reading 4. Indications of dehydration ANS: 2 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Describe the etiologies, signs, and symptoms of each of the endocrine disorders.

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Page: 806 Heading: Adrenal Insufficiency/Addison Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1

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With adrenal deficiency and the development of Addison disease, the client can have periods of tachycardia due to electrolyte imbalance and dehydration. However, this symptom also occurs with multiple other causes. Bronzed skin coloration is a classic sign for primary adrenal gland deficiency, which results in the development of Addison disease. Patients with adrenal deficiency or Addison disease will exhibit low blood pressure related to fluid loss. However, this symptom also occurs with multiple other causes. Indications of dehydration such as poor skin turgor and sticky membranes can occur with Addison disease and multiple other medical conditions.

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20. The nurse is reviewing information with a patient about endocrine gland disorders. The patient asks, “I have pituitary insufficiency, what is happening?” Which information from the nurse is incorrect? 1. “You may have an ectopic growth on the pituitary secreting hormones.” 2. “There are a variety of tests that will help distinguish the cause.” 3. “Too little hormone is secreted when a gland does not work properly.” 4. “Target tissue insensitivity results in too little hormone activity.” ANS: 1 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Explain the pathophysiology of each of the endocrine disorders presented. Page: 790 Heading: Introduction Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Teaching/Learning Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

When an ectopic growth on a gland is secreting hormones, the result is an excess of the hormone, not an insufficiency. This statement is incorrect. The statement about a variety of tests that can identify the cause of a gland insufficiency is a true statement. The statement about a gland secreting an insufficient amount of hormone when it is not functioning correctly is a true statement. The statement that hormone insufficiency can be related to target tissue

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insensitivity is a true statement. PTS:

CON: Patient-Centered Care

21. The nurse is attending to patients in an assisted-living facility. For which reason is the nurse aware that the recognition of hyperthyroidism is difficult in older patients? 1. The manic and psychotic behavior mimics dementia. 2. The presenting symptoms tend to mimic cardiac concerns. 3. Nervousness and tremor are common in this population. 4. This age category has difficulty describing signs and symptoms. ANS: 2 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Describe the etiologies, signs, and symptoms of each of the endocrine disorders. Page: 799 Heading: Hyperthyroidism Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2

Manic and psychotic behavior is typical in younger clients; older clients may not have typical signs and symptoms of hyperthyroidism. In older patients, the signs and symptoms of hyperthyroidism are atypical. This population may experience heart failure, atrial fibrillation, fatigue, apathy, and depression; all signs are also indicative of other disorders, making diagnosis difficult. Nervousness and tremor are typical symptoms of hyperthyroidism in younger patients; older patients exhibit more atypical symptoms, which make diagnosis difficult. It is not true that older patients have difficulty describing signs and symptoms; this statement is an example of ageism.

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22. The nurse is assisting with discharge of a patient with Addison disease following an adrenal crisis. Which instruction is most important for the nurse to reinforce? 1. The need for a well-balanced diet 2. How to monitor blood glucose levels 3. The importance of 30 minutes of exercise each day 4. The importance of taking steroid replacements as prescribed ANS: 4 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Describe current therapeutic measures used for each of the selected endocrine disorders. Page: 807

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Heading: Adrenal Insufficiency/Addison Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1

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The patient with Addison disease may be placed on a high-sodium diet due to the loss of sodium and water associated with hyposecretion of adrenal gland hormones. Because patients with Addison disease are prone to hypoglycemia, the patient needs to understand how and when to test blood glucose levels. However, this is not as important as appropriate hormone replacement. There is no particular reason why a patient with Addison disease needs 30 minutes of exercise daily. Hormone replacement for the patient with Addison disease is lifelong therapy. Hormones are given in divided doses; 2/3 in the morning and 1/3 in the evening to mimic the body’s own diurnal rhythm. This is the most important teaching to reinforce.

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MULTIPLE RESPONSE 1. A patient is being discharged with prescribed treatment for long-term hypoparathyroidism. Which does the nurse include in discharge teaching? (Select all that apply.) 1. Eat a diet high in calcium. 2. Limit dietary phosphates. 3. Have regular eye examinations. 4. Add iron-rich foods to your diet. 5. Follow up with regular laboratory tests. ANS: 1 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Describe current therapeutic measures used for each of the selected endocrine disorders. Page: 804 Heading: Hypothyroidism Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Difficult

Feedback A high calcium diet with calcium supplements is necessary to maintain serum calcium levels.

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2. 3. 4. 5.

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A high-phosphate diet may lower serum calcium levels, which are already low. Eye examinations are important because calcifications can occur in the eyes and cataracts can develop. Hypoparathyroidism will not alter iron stores; increased intake of iron-rich foods is not necessary. Follow-up laboratory tests are important to be sure the calcium level is normal. 1

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2. A patient with suspected hyperthyroidism is scheduled for a radioactive iodine uptake test. Which symptoms of hyperthyroidism does the nurse note on the medical record? (Select all that apply.) 1. Fatigue 2. Tremor 3. Weight loss 4. Constipation 5. Buffalo hump ANS: 1 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Describe the etiologies, signs, and symptoms of each of the endocrine disorders. Page: 799 Heading: Hypothyroidism Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Difficult

1. 2. 3. 4. 5. PTS:

Feedback Weight loss, fatigue, heat intolerance, tremor, increased pulse and blood pressure, and agitation or nervousness may be seen with hyperthyroidism. Weight loss, fatigue, heat intolerance, tremor, increased pulse and blood pressure, and agitation or nervousness may be seen with hyperthyroidism. Weight loss, fatigue, heat intolerance, tremor, increased pulse and blood pressure, and agitation or nervousness may be seen with hyperthyroidism. Constipation is seen with hypothyroidism. Buffalo hump is seen in Cushing syndrome. 1

CON: Metabolism

3. A patient diagnosed with SIADH is scheduled for surgery in a few days. Which does the nurse expect to be prescribed for this patient to help manage the symptoms until surgery? (Select all that apply.) 1. Salt restriction 2. Fluid restriction 3. Furosemide

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4. Conivaptan 5. Hypertonic saline infusion ANS: 2, 3, 4, 5 Chapter: Chapter 39. Nursing Care of Patients With Endocrine Disorders Objective: Describe current therapeutic measures used for each of the selected endocrine disorders. Page: 791 Heading: Pituitary Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Difficult

1. 2. 3. 4. 5. PTS:

Feedback Oral salt may be encouraged to maintain the serum sodium level. Symptoms of SIADH can be alleviated by restricting fluids to 800 to 1,000 mL per 24 hours. A loop diuretic such as furosemide increases water excretion. A vasopressin receptor antagonist such as conivaptan may be used to block the action of ADH in the kidney. Hypertonic saline fluids may be administered intravenously. 1

CON: Metabolism

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Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas MULTIPLE CHOICE 1. The nurse is providing information to a patient recently diagnosed with type 1 diabetes mellitus (DM). The patient expresses a desire to understand the disease. Which information provided by the nurse is accurate? 1. Insulin is released into the gastrointestinal tract to aid in the digestion process. 2. Glucose is carried into cells when glucose transporters are activated in the membrane. 3. Diabetes is most frequently caused by the inability of the pancreas to release insulin. 4. Type 1 and type 2 DM are reversible with dietary, weight loss, and exercise programs. ANS: 2 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Describe causes, signs and symptoms, and treatment of high and low blood glucose levels. Page: 817 Heading: Pathophysiology and Etiology Integrated Process: Teaching/Learning Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback 1

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Insulin is destroyed by gastric juices, which is the reason why insulin is not taken orally. The pancreas does release other hormones such as lipase and amylase to aid in digestion. When blood glucose (BG) touches a cell membrane, glucose transporters are activated and move the glucose into the cell for energy. The inability of the pancreas to produce insulin is type 1 DM; type 2 DM is the most common. In type 2 DM, the pancreas is able to produce insulin. Type 2 DM can be reversed with dietary, weight loss, and exercise programs. Type 1 DM is irreversible.

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2. The nurse is evaluating the knowledge of a patient recently diagnosed with type 1 DM. Which statement by the patient indicates a need for additional information? 1. “My pancreas may have started to attack itself after a childhood viral infection” 2. “I may be genetically prone since diabetes goes back for several generations.” 3. “I will learn to carefully check my BG since I am prone to ketoacidosis.” 4. “I know that I am obese and can reduce my need for insulin with weight loss.” ANS: 4

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Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Explain the pathophysiologies of type 1 and type 2 diabetes mellitus. Page: 817 Heading: Type 1 Diabetes Integrated Process: Teaching/Learning Client Need: Pathological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3 4

When the patient understands that type 1 DM may have been caused by a viral infection, additional teaching is not necessary. It is a true statement that patients with type 1 DM may be genetically prone to the disease; no additional teaching is necessary. Patients with type 1 DM are prone to developing ketoacidosis; the patient’s statement is correct and does not require additional teaching. Type 2 DM can be caused by obesity and may respond positively to weight loss. However, the pancreas of a patient with type 1 DM cannot trigger insulin production with weight loss.

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3. The nurse is assisting with nutrition teaching for a patient who voices concern over coping with a diabetic diet. Which response by the nurse about medical nutrition therapy is correct? 1. “Your diet will be a well-balanced, individualized meal plan that is healthy for your whole family.” 2. “Sugars and fats need to be avoided, but the dietitian will help you find acceptable alternatives.” 3. “You will require special foods, but stores now stock a variety of choices for people with diabetes.” 4. “The diet stresses high-protein and low-carbohydrate intake, but people adapt to the restrictions.” ANS: 1 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Identify therapeutic measures to help patients with diabetes mellitus control blood glucose levels. Page: 821 Heading: Nutrition Therapy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback

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1 2 3 4

Because all diabetic nutrition recommendations emphasize low-fat intake and balanced intake of other food groups, it is healthy for the whole family. Patients with diabetes do not have to avoid all sugars and fats. Special foods are not necessary. High protein is not recommended; low protein may be necessary if nephropathy occurs.

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CON: Metabolism

4. The nurse is providing care for a marathon runner who is recently diagnosed with DM. Which explanation regarding exercise is best for the nurse to provide? 1. “You will need to avoid regular exercise since it will lower your blood sugar.” 2. “You can still exercise, but running is too strenuous for someone with diabetes.” 3. “You always need to take some emergency glucose with you when you are running.” 4. “Exercise needs to be coordinated with the time your insulin is peaking.” ANS: 3 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Identify therapeutic measures to help patients with diabetes mellitus control blood glucose levels. Page: 820 Heading: Exercise Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3 4

Exercising at similar times each day also helps prevent BG fluctuations. Running is not too strenuous for someone who is used to doing it, but patients with neuropathy or foot problems should consult with a physician first. Persons with diabetes should always carry a quick source of sugar when exercising in case the BG drops too low. Individuals on intermediate-acting insulin are taught to avoid exercising at the time of day when their BG is at its lowest point (i.e., when insulin or medication is peaking) and to have a carbohydrate snack before exercising if BG is less than 100 mg/dL.

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5. The nurse is reinforcing teaching for a patient who is on four injections of regular insulin daily. About how many hours after each injection of insulin does the nurse teach the patient to be alert for symptoms of hypoglycemia? 1. 1/2 hour 2. 3 hours

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3. 8 hours 4. 12 hours ANS: 2 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Identify therapeutic measures to help patients with diabetes mellitus control blood glucose levels. Page: 823 Heading: Medication: Onset, Peak, Duration Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3 4

Onset is a half hour, and duration is 5 to 8 hours. Regular insulin peaks in 2 to 5 hours, so blood sugar will be lowest at this time. Onset is a half hour, and duration is 5 to 8 hours. Onset is a half hour, and duration is 5 to 8 hours.

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CON: Metabolism

6. The nurse is providing information to a patient recently diagnosed with type 2 DM. The health care provider (HCP) prescribes an oral hypoglycemic medication for BG control. Which information is the best comparison the nurse can give the patient between insulin and an oral hypoglycemic? 1. Oral hypoglycemic agents act as an insulin replacement. 2. Oral hypoglycemic agents stimulate a partially working pancreas. 3. Insulin is used for a type 2 diabetic with a history of ketoacidosis. 4. Insulin is used by a type 2 diabetic to control BG levels. ANS: 2 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Differentiate the action of insulin and oral hypoglycemic agents in lowering blood glucose levels. Page: 817 Heading: Oral Hypoglycemic Medication Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1

Oral hypoglycemic agents are not an insulin replacement; they work to

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stimulate the pancreas to make more insulin or to make tissues more sensitive to insulin. Oral hypoglycemic agents are prescribed for type 2 DM because there is a partially working pancreas. This is the best comparison the nurse can present about the difference between insulin and oral hypoglycemic agents. Type 2 diabetics do not experience ketoacidosis, which is a serious complication for type 1 diabetics related to an inability for the body to produce insulin. With a type 2 diabetic, insulin is prescribed when the patient is having difficulty controlling BG levels. In contrast, the type 1 diabetic uses insulin to sustain life.

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CON: Metabolism

7. The nurse is providing care for a patient with type 2 DM who has been treated with an oral hypoglycemic agent. The HCP prescribes for the addition of insulin. Which situation does the nurse recognize as being the least valid reason for giving this patient insulin? 1. The patient is unable to effectively follow a diabetic diet. 2. The patient’s pancreas is unable to produce adequate insulin. 3. The amount of insulin is high, but the body cells are resistant. 4. The pancreas has worn out leading to little or no insulin production. ANS: 1 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Explain the pathophysiologies for type 1 and type 2 diabetes mellitus. Page: 823 Heading: Type 2 Diabetes Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback 1

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The HCP may need to eventually prescribe insulin to a patient who cannot effectively follow a diabetic diet to promote BG control. However, other interventions such as education and support would be considered before adding insulin to the therapy. When a patient’s pancreas is unable to produce adequate insulin, the HCP will prescribe insulin in addition to an oral hypoglycemic agent. When a patient’s pancreas is producing a normal or high amount of insulin, but the BG level remains elevated, the patient is likely to have body cells that are resistant. The HCP will prescribe insulin in addition to an oral hypoglycemic agent. If the patient’s pancreas wears out and little or deficient amounts of insulin are produced, the HCP will prescribe insulin to be added to the oral hypoglycemic regimen.

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CON: Metabolism

8. A patient is admitted to the hospital with hyperosmolar hyperglycemia. The patient is 40 percent overweight and has a BG value of 987 mg/dL. Which is the priority focus while planning nursing care for this patient? 1. BG level 2. Hydration status 3. Presence of an illness 4. Age-related changes ANS: 2 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Describe causes, signs and symptoms, and treatment of high and low blood glucose levels. Page: 829 Heading: Hyperosmolar Hyperglycemic State Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2

The BG level can be elevated as high as 1,500 mg/dL in a client with hyperosmolar hyperglycemia. BG level is not the nurse’s priority focus. The nurse’s priority focus for a patient with hyperosmolar hyperglycemia is the state of hydration. A reduced fluid intake is often a contributing factor; however, as BG levels rise, polyuria can cause profound dehydration. The presence of an illness can contribute to the patient’s condition, but the nurse’s priority focus is on stabilizing the patient to avoid shock, coma, or death. Older clients with type 2 DM are more inclined to experience hyperosmolar hyperglycemia, but patient’s age is not the nurse’s focus.

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CON: Metabolism

9. The nurse is collecting data on a new patient in a HCP’s office. Data includes the following: 65-year-old male, abdominal obesity with waist circumference of 42 inches, blood pressure 140/88 mm Hg, and fasting glucose of 120 mg/dL. Which health concerns by the HCP is least expected? 1. Probability of type 2 diabetes 2. Risk of cardiovascular issues 3. Damage to weight bearing joints 4. History of family health issues ANS: 3 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Discuss how diabetes mellitus increases risk of complications such as heart disease, blindness, and kidney failure.

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Page: 830 Heading: Metabolic Syndrome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3 4

The patient is exhibiting risk factors related to metabolic syndrome; the patient is at high risk for type 2 DM. The patient is exhibiting risk factors related to metabolic syndrome; the patient is at high risk for cardiovascular issues. The patient may be at risk for damage to weight-bearing joints, due to age and weight; however, this is not likely to be the HCP’s greatest concern. The HCP will be concerned about the patient’s family medical history; a genetic predisposition for type 2 DM puts the patient at greater risk.

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10. The nurse is monitoring laboratory BG levels for a patient diagnosed with type 2 DM. Which test result does the nurse use to evaluate the patient’s compliance with treatment? 1. Fasting BG test 2. Random BG testing 3. Oral glucose tolerance test 4. Glycohemoglobin testing ANS: 4 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Identify diagnostic tests used to diagnose and monitor diabetes mellitus and its complications. Page: 827 Heading: Diagnostic Tests Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2

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Fasting BG test is effective for diagnosing diabetes; however, this is not a test to indicate compliance with treatment. Random BG testing is most effective in diagnosing diabetes; however, this is not a test to indicate compliance with treatment. An oral glucose tolerance test is effective in diagnosing diabetes; however, this is not a test to indicate compliance with treatment. The glycohemoglobin test (HbA1c) measures the glucose attached to red blood

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cells (RBCs), which have a lifespan of about 3 months. The test provides a good analysis of the average BG level for the previous 2 to 3 months, which indicates compliance with treatment regimen. PTS:

CON: Metabolism

11. A female patient is prescribed glyburide for control of BG. What precaution does the nurse teach the patient about this medication? 1. “Avoid drinking alcohol.” 2. “Do not take it if you skip a meal.” 3. “You will need to use two forms of birth control.” 4. “Be sure it is discontinued before any tests involving contrast dye.” ANS: 1 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Plan nursing care and education for the patient with diabetes mellitus. Page: 824 Heading: Oral Hypoglycemic Medication Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3 4

Sulfonylureas, such as glyburide, interact with alcohol and can make the patient very ill. This action should be taken for meglitinides and alpha-glucosidase inhibitors. Glitazones may interfere with birth control. This action should be taken for metformin.

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CON: Metabolism

12. A patient with type 1 diabetes has frequent episodes of hypoglycemia, even with multiple daily BG self-monitoring throughout the day. Which method of self-monitoring does the nurse recognize as being more effective for this patient? 1. The patient needs a pocket-sized glucose monitor. 2. The patient will benefit from continuous monitoring. 3. The patient needs to check for urine ketones regularly. 4. The patient is a good candidate for a therapy pet. ANS: 2 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Identify diagnostic tests used to diagnose and monitor diabetes mellitus and its complications. Page: 827 Heading: Self-Monitoring of Blood Glucose

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Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2

3 4

The patient has two issues, multiple monitoring needs and frequent hypoglycemia; this suggestion does not effectively or efficiently address either. This patient will benefit from continuous monitoring. This newer type of device monitors BG via a small catheter inserted into the abdomen. The device monitors BG regularly and can be set to alarm if BG drops too low. Checking for urine ketones on a regular basis does not effectively address either patient issue. Some patients with either hyper- or hypoglycemia can benefit from a therapy pet trained to identify either condition. However, this would not address the issue of multiple BG checks throughout the day.

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CON: Metabolism

13. The nurse is providing care for a patient with diabetes who experiences frequent periods of hyperglycemia. Which comment by the patient is indicative to the nurse of a major cause of this BG imbalance? 1. “My job is really busy in tax season.” 2. “My diet never seems to fill me up.” 3. “I have increased my daily exercise.” 4. “I frequently substitute cookies for bread.” ANS: 1 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Describe causes, signs and symptoms, and treatment of high and low blood glucose levels. Page: 827 Heading: Hyperglycemia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3 4

A major cause of hyperglycemia for a diabetic is stress; the patient is expressing a cause of stress. A common cause of hyperglycemia for a diabetic is eating more than the meal plan prescribes. Without further assessment, stress is still the major cause. Increasing a daily exercise plan is more likely to cause hypoglycemia. Mismanagement of the prescribed meal plan can cause hyperglycemia. Cookies

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are not a good substitute for bread. PTS:

CON: Metabolism

14. A patient being treated with rosiglitazone for type 2 DM is receiving a routine follow-up assessment. In addition to HbA1c and a fasting plasma glucose test, which other laboratory test should the nurse expect to be monitored in this patient? 1. Blood lipids 2. Liver function tests 3. Urine for microalbumin 4. Complete blood count (CBC) ANS: 2 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Plan nursing care and education for the patient with diabetes mellitus. Page: 827 Heading: Oral Hypoglycemic Medication Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3 4

Lipids are important to monitor in any diabetic patient, but are not unique to glitazones. Liver function must be monitored in patients taking glitazones. Microalbumin is important to monitor in any diabetic patient but, is not unique to glitazones. A CBC test would supply nonspecific information.

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15. The nurse is discussing the management of an older adult client recently diagnosed with type 2 DM. Which information is least helpful? 1. An emergency call system should be placed in the home. 2. The family can promote healthy eating by supplying meals. 3. If hyperglycemia is controlled, BG levels can be relaxed. 4. A week’s supply of insulin can be drawn up and refrigerated. ANS: 2 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Identify therapeutic measures to help patients with diabetes mellitus control blood glucose levels. Page: 817 Heading: Gerontological Issues Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential

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Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2

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Especially if the older adult lives alone, an emergency call system should be placed in the home. Food delivery services have become common and are a good source for the patient living alone. The family cannot always be depended on to deliver the patient’s meals. This information is the least helpful. The BG parameters can be relaxed for the older adult patient, especially if hyperglycemia is controlled and incidents are rare. Having a week’s supply of insulin drawn up and stored in the refrigerator can be helpful for the older adult who is diabetic.

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16. The nurse is researching the current information available regarding the long-term complications for patients diagnosed with diabetes. Which finding is accurate? 1. Chronic hypoglycemia causes a variety of serious complications. 2. Most complications involve either the large or tiny vessels of the body. 3. Type 1 diabetics are at greatest risk for complications even with tight control. 4. Patients with HbA1c levels below 6 percent are less likely to experience complications. ANS: 2 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Identify therapeutic measures to help patients with diabetes mellitus control blood glucose levels. Pages: 830–832 Heading: Long-Term Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction in Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1 2

It is chronic hyperglycemia, not hypoglycemia, which causes a variety of serious complications for the patient with diabetes. It is a factual statement that most complications for the patient with diabetes involves either the large vessels (macrovascular complications) or the tiny vessels (microvascular complications) in the body. Tiny vessels found in the eyes and kidneys are commonly effected. In general, type 2 diabetics are at greater risk for complications. However, type 1 diabetics decrease the likelihood of having complications if tight control is maintained on BG levels.

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Patients with an HbA1c below 7 percent are less likely to develop complications related to diabetes.

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17. The nurse is preparing a patient with type 2 DM for surgery. The patient expresses concern about the use of insulin at this time. Which reason does the nurse understand that insulin therapy is appropriate in regard to surgery? 1. Surgery is a stressor causing counter-regulatory hormones to increase BG. 2. Insulin promotes healing and eliminates the common causes of infection. 3. Critically ill patients with diabetes require a lower BG from insulin therapy. 4. Ongoing insulin therapy is required for the type 2 diabetic after having surgery. ANS: 1 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: List measures to increase the safety of the patient with diabetes mellitus who is undergoing surgery. Page: 832 Heading: Special Consideration for the Patient Undergoing Surgery Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1

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Surgery is a stressor that causes an elevation in BG even if the patient is fasting. Insulin is an effective and efficient method of controlling BG levels for the surgical patient. Insulin does not promote healing or eliminate the common causes of infection. Insulin prevents high BG, which can interfere with these processes. Critically ill patients with diabetes require a higher level of BG; a range of 140 to 180 mg/dL is recommended. The type 2 diabetic will revert to presurgical management after the stress of surgery has passed.

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18. A patient with diabetes has peripheral neuropathy. What should the nurse do to prevent related complications? 1. Wash, dry, and inspect feet daily. 2. Use a lubricating lotion on feet daily. 3. Wear loose comfortable shoes in the house. 4. Soak feet in soap and water for 20 minutes daily. ANS: 1 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Plan nursing care and education for the patient with diabetes mellitus. Page: 830

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Heading: Foot Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3 4

The feet must be washed, dried, and inspected daily to recognize pressure points or red areas before they turn into wounds that are difficult to treat. Lubricating lotion can be a medium for bacterial or fungal growth and should be avoided, especially between the toes. Sturdy, well-fitting shoes should be worn all the time to protect the feet from injury. Soaking the feet can cause maceration of the skin, increasing the risk for sores.

PTS:

CON: Metabolism

19. The nurse is planning to review information with a patient diagnosed with diabetes. Which information does the nurse include regarding an increased risk for and treatment of infection? 1. IV antibiotics are the preferable for effective treatment of infection. 2. White blood cells (WBCs) become sluggish and ineffective against infection with hypoglycemia. 3. Circulation may not be adequate to heal a wound or fight infection. 4. Routine vaccinations to prevent infection are not effective with diabetes. ANS: 3 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Plan nursing care and education for the patient with diabetes mellitus. Page: 830 Heading: Infection Integrated Process: Clinical Problem-Solving (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback 1

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A patient with diabetes is at risk for poor circulation, which decreases the effectiveness of IV antibiotic treatment. Topical antibiotics may be more effective. WBCs become sluggish and ineffective against infections in the presence of hyperglycemia, not hypoglycemia. Patients with diabetes are at risk for poor circulation, which slows down the ability to heal a wound or fight an infection. Patients with diabetes are encouraged to receive routine vaccinations against

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flu, pneumonia, and hepatitis; prevention of illness or infection is crucial. PTS:

CON: Metabolism

20. A patient with type 1 DM expresses concern about developing retinopathy due to a chronic disease. Which information does the nurse provide to give the patient the best reassurance? 1. Newer laser surgery can improve sight after retinal hemorrhage. 2. The high incidence of cataracts can be surgically corrected. 3. Diabetes is low as a cause for blindness in the United States. 4. Good control of BG and blood pressure can reduce the risk. ANS: 4 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Plan nursing care and education for the patient with diabetes mellitus. Page: 831 Heading: Eyes Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Moderate Feedback 1

3 4

If the patient experiences retinal hemorrhage, information about newer laser surgery that can improve sight may be reassuring; however, information about prevention is the most reassuring. Patients with diabetes are at greater risk for developing cataracts and it may be reassuring to know that the condition can be surgically corrected. However, the patient is more likely interested in prevention. Diabetes is the leading cause of blindness in adults in the United States. The presented information is untrue. Good control of BG and blood pressure can reduce the risk of vision complications in the patient who is diabetic. Prevention is always preferred over treatment when possible.

PTS:

CON: Metabolism

21. The nurse is employed at a clinic for patients diagnosed with diabetes. Which patient does the nurse identify as being at greatest risk for needing dialysis? 1. The non-Hispanic adult with type 1 DM since early childhood 2. The older adult with type 2 DM, unstable BG, and hypertension 3. The patient who is African American with type 2 DM and hypertension 4. The patient who is Asian with type 1 DM and well-controlled BG ANS: 2 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Discuss how diabetes mellitus increases risk of complications such as heart disease, blindness, and kidney failure. Page: 834

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Heading: Kidneys Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Difficult Feedback 1 2

The non-Hispanic patient with type 1 DM since childhood does not exhibit any risks other than longevity of the disease process. The older adult with type 2 DM, unstable BG, and hypertension is at greatest risk for needing dialysis. Four risk factors exist: diabetes, age, uncontrolled BG, and hypertension. The patient with diabetes who is African American with type 2 DM and hypertension exhibits three risk factors for needing dialysis: ethnicity, diabetes, and hypertension. The patient who is Asian with type 1 DM and well-controlled BG does not exhibit any risks other than the disease process. Duration of the disease is not included.

PTS:

CON: Metabolism

22. The nurse is contributing to a dietary presentation for patients in a multicultural community with diabetes. Which intervention will be least likely to meet the needs of the attendees? 1. Suggestions for culture sensitive substitutes 2. Presentation of the standard diabetic diet 3. Opportunity for patients to ask questions privately 4. Advance preparation regarding culturally preferred foods ANS: 2 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Plan nursing care and education for patients with diabetes mellitus. Page: 829 Heading: Cultural Considerations Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Teaching/Learning Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Moderate Feedback 1 2 3

Suggestions for culture-sensitive food substitutes will be likely to meet the needs of patients with diabetes in a multicultural community. Due to the expected multicultural attendees, the presentation of the standard diabetic diet is least likely to meet the needs of the attendees. It is important for the nurse to provide the opportunity for patients to ask questions privately. The patients may not be comfortable asking group questions due to language, culture, and dietary differences.

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The nurse will be able to meet the needs of multicultural attendees if advance preparation is made regarding culturally preferred foods.

PTS:

CON: Metabolism

MULTIPLE RESPONSE 1. The nurse is providing teaching to a patient with reactive hypoglycemia. Which instructions related to glucose monitoring should the nurse provide? (Select all that apply.) 1. “It is important to check your BG at bedtime.” 2. “It is important to check your BG 1 hour before meals.” 3. “You will need to check your BG 2 hours after meals.” 4. “You should check your BG when you get up in the morning.” 5. “Checking your BG once a day, at the same time each day, is sufficient.” ANS: 1, 3, 4 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Explain reactive hypoglycemia and its treatment. Page: 836 Heading: Reactive Hypoglycemia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Difficult

2. 3.

PTS:

Feedback Low BG may occur as an overreaction of the pancreas to eating. The pancreas senses a rising BG and produces more insulin than is necessary for the use of that glucose. As a result, the BG drops to below normal. Readings should be taken in the morning on arising, 2 hours after each meal, at bedtime, and during symptoms of hypoglycemia. Checking BG levels 1 hour before meals will not help the patient control reactive hypoglycemia. Low BG may occur as an overreaction of the pancreas to eating. The pancreas senses a rising BG and produces more insulin than is necessary for the use of that glucose. As a result, the BG drops to below normal. Readings should be taken in the morning on arising, 2 hours after each meal, at bedtime, and during symptoms of hypoglycemia. Low BG may occur as an overreaction of the pancreas to eating. The pancreas senses a rising BG and produces more insulin than is necessary for the use of that glucose. As a result, the BG drops to below normal. Readings should be taken in the morning on arising, 2 hours after each meal, at bedtime, and during symptoms of hypoglycemia. Checking BG once daily at the same time will not help the patient control reactive hypoglycemia. 1

CON: Metabolism

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2. A patient is diagnosed with diabetic ketoacidosis. Which manifestations should the nurse expect to observe in this patient? (Select all that apply.) 1. Dehydration 2. Hypertension 3. Flulike symptoms 4. Kussmaul’s respirations 5. Edema associated with fluid overload ANS: 1, 3, 4 Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Describe causes, signs and symptoms, and treatment of high and low blood glucose levels. Page: 829 Heading: Diabetic Ketoacidosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Metabolism Difficulty: Difficult

1. 2. 3.

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Feedback With such high BG and the accompanying polyuria, the body becomes dehydrated very quickly. Tachycardia, hypotension, and shock can result. The combination of dehydration, potassium imbalance, and acidosis causes the patient to develop flu-like symptoms, including abdominal pain and vomiting. The body attempts to compensate for acidosis by deepening respirations, thereby blowing off excess carbon dioxide. The deep, sighing respiratory pattern is called Kussmaul’s respirations. With such high BG and the accompanying polyuria, the body becomes dehydrated quickly. 1

CON: Metabolism

COMPLETION 1. A patient is upset to learn that a recent HbA1c level is 10.3 percent. Which average BG level does the nurse provide based upon this percentage if the equation 28.7 × HbA1c - 46.7 is used? (Round to the nearest whole number.) ANS: 249 mg/dL Chapter: Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas Objective: Identify therapeutic measures to help patients with diabetes mellitus control blood glucose levels. Page: 826 Heading: Estimated Average Glucose

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Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Metabolism Difficulty: Difficult Feedback: When using this equation, the patient’s average BG level is calculated as: 28.7 × 10.3 - 46.7 = 248.91. With rounding, it would be 249 mg/dL. PTS:

CON: Metabolism

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Chapter 41. Genitourinary and Reproductive System Function and Assessment MULTIPLE CHOICE 1. The nurse is preparing a presentation about the normal reproductive system of the female. Which condition is incorrect? 1. Females have a definite limit to reproductive capability. 2. The mammary glands are considered part of the reproductive system. 3. Normal pH of the vagina is alkaline to prevent microbial growth. 4. Internal structures include paired ovaries and fallopian tubes, a vagina, and uterus. ANS: 3 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Explain the normal structures and functions of the reproductive system. Pages: 839–840 Heading: Female Reproductive System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Sexuality Difficulty: Moderate Feedback 1 2 3

Females do have a definite limit to reproductive capability, which ends when ovulation stops (menopause). Mammary glands are considered accessory organs to the reproductive system. The normal pH of the vagina is acidic, not alkaline, which helps retard microbial growth. After puberty, the vagina mucosa is relatively resistant to infection. Internal structures of the female reproductive system include paired ovaries and fallopian tubes, a vagina, and a uterus.

PTS:

CON: Sexuality

2. The nurse is preparing a presentation about the normal reproductive system of the male. Which statement is incorrect? 1. The scrotum keeps the testes at a temperature slightly lower than the body. 2. Spermatogenesis is constant after puberty and usually continues through life. 3. Alkaline secretions ensure sperm viability in the acidic environment of the vagina. 4. The arterioles of the penis constrict to hold blood in the penis for an erection. ANS: 4 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Explain the normal structures and functions of the reproductive system. Page: 841 Heading: Male Reproductive System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation

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Cognitive Level: Application (Applying) Concept: Sexuality Difficulty: Moderate Feedback 1

2 3 4

The testes are located in the scrotum, which is located between the thighs. The temperature of the scrotum is slightly lower than the body, which is necessary for the production of viable sperm. The male begins to produce sperm after puberty, a process that usually continues throughout the male’s lifetime. The gland secretions in the ejaculate are alkaline to ensure sperm viability in the acidic environment of the female vagina. During sexual arousal, the arterioles of the penis dilate, the penile sinuses become filled with blood, and the penis becomes firm and erect.

PTS:

CON: Sexuality

3. A female patient who is 40 years of age is scheduled for a baseline mammography. The patient becomes concerned when she learns a digital mammography is planned. The client states, “I thought that test was for high risk women.” Which answer by the nurse is most appropriate? 1. “This type of testing is more effective in detecting cancer in younger women.” 2. “The test is more expensive, but the cost is offset by the benefits of earlier detection.” 3. “The image is computerized, allowing the radiologist to look more closely at specific areas.” 4. “This method of testing is much quicker, easier, and with less discomfort for the woman.” ANS: 3 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Identify commonly performed tests used to diagnose disorders of the reproductive system. Page: 849 Heading: Mammography Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Sexuality Difficulty: Moderate Feedback 1

Digital mammography is more effective in detecting breast cancer in younger women who have denser breast tissue. This is an accurate statement, but there is another statement that more closely addresses the patient’s concern. It is inappropriate for the nurse to make a reference to the cost of the test in relation to the benefit. The patient may feel compelled to make a decision about the type of test based on cost. The most appropriate statement by the nurse is the one that provides a benefit

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and rationale for the selected method of testing. The computerized imagery is clearer and allows the radiologist to closely examine any specific area. The routine for digital mammography is the same as for previous methods. The time frame is unchanged. The comfort level is unchanged because the breast tissue is still compressed as much as possible.

PTS:

CON: Sexuality

4. The nurse is providing information on breast self-examination to a female patient. Which palpation pattern does the nurse instruct the patient to use when performing this examination? 1. Spiral pattern 2. Parallel lines 3. Wheel-spoke pattern 4. Any pattern that is consistent and thorough ANS: 4 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Identify commonly performed tests used to diagnose disorders of the reproductive system. Page: 848 Heading: Breast Self-Examination Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Sexuality Difficulty: Moderate Feedback 1 2 3 4

Spiral pattern is an accepted method of breast self-examination. Parallel lines is an accepted method of breast self-examination. Wheel-spoke pattern is an accepted method of breast self-examination. Whether the breasts are examined in parallel lines, a spiral formation, or a wedge pattern is probably insignificant. It is important, however, to encourage that the examination be methodical and cover all areas of the breast, the tail of Spence, and the axilla.

PTS:

CON: Sexuality

5. The nurse is collecting information from a female patient who is 55 years of age. The patient is postmenopausal for 8 years. The patient is also small boned, Caucasian, and has never been pregnant. Which type of bone testing does the nurse suggest to the patient? 1. A heel scan that is performed at the local pharmacy 2. A dual energy x-ray absorptiometry (DEXA) scan 3. A laboratory test to determine estrogen levels 4. A blood test to determine circulating calcium levels ANS: 2 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment

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Objective: Identify commonly performed tests used to diagnose disorders of the reproductive system. Page: 850 Heading: Bone Health Assessment Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1

2 3

The patient has numerous risk factors for osteoporosis. A heel scan at the local drug store may serve as a good screening option; however, it is not the most conclusive test for bone density in this client. The DEXA scan measures bone density at the hip or spine, which are areas that are prone to bone loss leading to injuries or joint damage. A laboratory test for estrogen levels is not necessary; the patient is past menopause and estrogen levels are expected to be low unless the patient is on hormone replacement therapy. A blood test for the levels of circulating calcium levels is not effective in determining bone density.

PTS:

CON: Sexuality

6. The nurse is discussing menstruation with a patient who is present for her yearly physical. The patient is 11 years of age and states, “I have not had a period yet and I hear so much at school it is confusing.” Which detail about the function is unnecessary at this time? 1. Normally, a cycle will occur approximately every 28 days. 2. A period usually lasts about 5 days and bleeding is not excessive. 3. The process is related to fluctuating estrogen and progesterone hormones. 4. Cramping can occur, but is not usually severe and can be managed fairly easy. ANS: 3 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Explain the normal structures and functions of the reproductive system. Page: 845 Heading: The Ovarian and Menstrual Cycles Integrated Process: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1 2 3

The frequency of menstruation is appropriate information for this patient. The length and characteristics of the menstrual cycle is appropriate information for this patient. At this point in time and at the patient’s age, information about the function of hormones is unnecessary. The patient is most likely seeking information about

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the actual manifestations and related expectations. It is appropriate for the nurse to mention the possibility of cramping and including that it is a manageable condition.

PTS:

CON: Sexuality

7. A 60-year-old patient receives information that a prostate-specific antigen (PSA) laboratory value is 11 ng/mL. Which intervention by the health care provider (HCP) does the nurse expect? 1. Needle biopsy of the prostate 2. A prostatic acid phosphatase test 3. Retesting as usual in 1 year 4. Informing the patient of cancer ANS: 2 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Identify commonly performed tests used to diagnose disorders of the reproductive system. Page: 901 Heading: Male Reproductive System Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1 2 3

The HCP provider will defer a needle biopsy until additional laboratory tests are performed. The HCP is most likely to prescribe for a prostatic acid phosphatase test, which will confirm or rule out the presence of prostate cancer. The normal PSA level is less than 4 ng/mL. The patient’s PSA level is significantly elevated and requires intervention. Waiting a year may put the patient at risk for disease or complications related to an enlarged prostate. It is too early to inform the patient of having cancer; additional testing is needed to either confirm or rule out the condition.

PTS:

CON: Sexuality

8. The nurse is collecting data from a female patient regarding normal function baselines of the reproductive system. Which question is appropriate for the nurse to ask? 1. “Do you have any questions about sex?” 2. “How many sexual partners have you had?” 3. “Have you ever been treated for a sexually transmitted infection, or STI?” 4. “Has sexual functioning and desire changed?” ANS: 4 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Explain the normal structures and functions of the reproductive system.

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Page: 840 Heading: Female Reproductive System Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1 2

3 4

The question is closed ended and will not provide adequate information to add to a function baseline. The question is also very broad. When gathering data for a normal function baseline, it is not necessary to ascertain the number of sexual partners. The question is inappropriate because it also insinuates the client has had more than one sexual partner. Obtaining a normal function baseline is not the time to ask about treatment of STIs. Asking about changes in sexual functioning and desire is appropriate as deviations from the normal function baseline may be indicative of a hormone imbalance. The expected functioning of the reproductive system changes throughout the process of aging, so the normal function baseline will depend on the patient’s age.

PTS:

CON: Sexuality

9. After finding a mass in the scrotum of a male patient, the nurse provides the HCP with a flashlight and turns off the lights. For which reason did the nurse perform these actions? 1. Preparation for identifying a varicocele 2. Preparation for a digital rectal examination 3. Preparation for transillumination of the testes 4. Preparation for a PSA to be drawn ANS: 3 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Identify commonly performed tests used to diagnose disorders of the reproductive system. Page: 911 Heading: Male Reproductive System Data Collection Integrated Process: Clinical Problem-Solving Problems (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Sexuality Difficulty: Moderate Feedback 1 2 3

Identification of a varicocele is done by palpating the spermatic cord. A flashlight and darkened room are not needed for a digital rectal examination and PSA blood test. A simple noninvasive test called transillumination is used to determine if a mass is fluid filled or solid. With the room lights out, a flashlight is held behind the scrotum. If the mass is fluid, a red glow appears; if it is solid, it appears

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opaque. A flashlight and darkened room are not needed for a digital rectal examination and PSA blood test.

PTS:

CON: Sexuality

10. The nurse reviews laboratory values for a male patient with an elevated PSA level and notes that the alkaline phosphatase and serum calcium levels are also elevated. Which condition do these findings suggest to the nurse? 1. The patient has a fulminating bladder infection. 2. The patient has a sexually transmitted infection. 3. The patient has an obstruction of the spermatic cord. 4. The patient has cancer that has metastasized to the bone. ANS: 4 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Identify commonly performed tests used to diagnose disorders of the reproductive system. Page: 909 Heading: Male Reproductive System Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1 2 3 4

Elevated alkaline phosphatase and serum calcium levels are not associated with a bladder infection. Elevated alkaline phosphatase and serum calcium levels are not associated with an STI. Elevated alkaline phosphatase and serum calcium levels are not associated with an obstruction of the spermatic cord. If prostate cancer is suspected or diagnosed, additional tests may be done. Alkaline phosphatase and serum calcium levels may be elevated if metastasis to the bone has occurred.

PTS:

CON: Sexuality

11. A patient is scheduled for a surgical biopsy for removal of a lesion suspected to be breast cancer. Which care by the nurse is most important? 1. Presenting a calm and understanding attitude 2. Explaining the reasons for the surgical biopsy 3. Sharing that most breast biopsies are benign 4. Providing the patient with antianxiety medication ANS: 1 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Plan nursing care for patients undergoing each of the diagnostic tests.

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Page: 865 Heading: Diagnostic Tests of the Breast Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Sexuality Difficulty: Moderate Feedback 1

3 4

Any concern about breast cancer can cause the patient extreme anxiety; the most important care the nurse can provide at this time is presenting a caring and understanding attitude. The HCP has likely provided the reasons for surgical biopsy at the time of obtaining surgical consent; there is no need for the nurse to explain further at this time. It is inappropriate for the nurse to share that most breast biopsies are benign; this is giving the patient false hope. The patient may need some antianxiety medication; however, this is not the most important care the nurse can provide.

PTS:

CON: Sexuality

12. A female patient is scheduled for her first pelvic examination. Which action by the nurse will provide the patient with physical comfort? 1. Offer to allow the patient to squeeze the nurse’s hand during the procedure. 2. Allow the patient to remain in a sitting position until the HCP is present. 3. Instruct the patient to blow out a deep breath as the speculum is inserted. 4. Explain the details of the examination as the procedure is performed. ANS: 3 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Plan nursing care for patients undergoing each of the diagnostic tests. Page: 850 Heading: Pelvic Examination Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Sexuality Difficulty: Moderate Feedback 1

Offering to allow the patient to squeeze the nurse’s hand through the examination is not likely to provide the greatest comfort. In addition, the nurse’s assistance is needed by the HCP. Allowing the patient to remain in a sitting position until the HCP enters the room may or may not provide the patient with comfort. This action can also delay the start of the examination. The suggestion that will provide the patient with the most comfort during a pelvic examination is to instruct the patient to take a deep breath and blow it

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out as the speculum is inserted. Explaining the details of the examination as it is performed is most commonly done by the HCP. Performance by the nurse is not likely to provide a better sense of comfort.

PTS:

CON: Sexuality

13. A female patient has not achieved pregnancy after 8 months of attempting to do so and is undergoing hormone testing. Which additional reason other than infertility does the nurse identify for hormone testing? 1. To confirm a patient’s stage of puberty 2. To assess hormone-producing tumors 3. To verify the achievement of pregnancy 4. To identify bone loss after menopause ANS: 2 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Identify commonly performed tests used to diagnose disorders of the reproductive system. Page: 860 Heading: Additional Diagnostic Tests of the Female Reproductive System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Sexuality Difficulty: Moderate Feedback 1 2

3 4

Hormone testing is not done to confirm a patient’s stage of puberty. One of the reasons for performing hormone testing is to assess hormoneproducing tumors. In addition, the testing is performed to measure potential infertility, find reasons for abnormal menses, and to evaluate the effectiveness of hormone therapy. Hormone testing is not performed to verify the achievement of pregnancy. Hormone testing is not performed to identify bone loss after menopause.

PTS:

CON: Sexuality

14. A female patient is scheduled for laparoscopy for determination of endometriosis. Following the procedure, which nursing care will the nurse perform? 1. Place the patient on the left side to centralize carbon dioxide. 2. Keep the patient in a supine position for 8 hours postoperative. 3. Monitor the patient for pain in the neck, shoulders, and upper back. 4. Check the surgical dressing for signs of infectious drainage. ANS: 3 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Plan nursing care for patients undergoing each of the diagnostic tests. Page: 873

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Heading: Endoscopic Examinations Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1 2

There is no need to place the patient on the left side to centralize carbon dioxide. The gas, if used, will be absorbed by the body. There is no need to keep a patient in a supine position, for any amount of time, following a laparoscopy unless the patient had a spinal anesthesia, which was not indicated in this scenario. The patient may experience pain in the neck, shoulders, and upper back following a laparoscopy if carbon dioxide was pumped into the body cavity being examined. The “insufflation” increases the distance between structures for better visualization. The patient will likely have a small dressing on the small incisions that are made in the abdominal wall for the insertion of the endoscope. The procedure is often referred to as “Band Aid” surgery. The presence of infectious drainage would require, at minimum, the use of a wound drainage system.

PTS:

CON: Sexuality

15. The nurse is assisting the HCP in a procedure used for cytology of the surface of the cervix. Which procedure does the nurse understand is being performed? 1. Conization 2. Endometrial biopsy 3. Lesion extraction 4. Papanicolaou ANS: 4 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Identify commonly performed tests used to diagnose disorders of the reproductive system. Page: 875 Heading: Cytology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Sexuality Difficulty: Moderate Feedback 1 2 3

Conization is a procedure performed to obtain cells from the cervical canal for cytology. An endometrial biopsy involves taking cells from the lining of the uterus using a small spoon-shaped tool called a curet. Extraction of small parts of or an entire lesion is a process to obtain cells for

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cytology. This procedure can be used at multiple locations. Papanicolaou (PAP) tests are done by gently scraping the cervix to obtain cells from the surface of the cervical canal. The cells are then affixed to a glass slide for cytology.

PTS:

CON: Sexuality

16. A male client is scheduled for an outpatient cystourethrography to evaluate the degree of obstruction by an enlarged prostate. Which nursing care will the nurse provide after the procedure? 1. Maintain strict input and output until discharge 2. Place a warm moist cloth over the urethra for pain 3. Perform intermittent catheterization for urine retention 4. Monitor for effects of analgesics before allowing to drive ANS: 2 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Plan nursing care for patients undergoing each of the diagnostic tests. Page: 902 Heading: Cystourethrography Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Sexuality Difficulty: Moderate Feedback 1 2 3

The patient is actually maintained on input and output for 24 hours following the procedure. The nurse can apply a warm moist cloth over the urethra for reduction of pain. If the patient has alterations in the normal voiding pattern, bleeding, or the absence of urination, the nurse contacts the HCP. Intermittent catheterization is performed only with a HCP’s prescription. If analgesics are used during the procedure, the patient must have someone who can drive the patient home.

PTS:

CON: Sexuality

17. The nurse is collecting health history on a female client who is considered a high-risk pregnancy. Which information will the nurse record if the patient has had four pregnancies, a miscarriage at 16 weeks, one 22-week stillborn delivery, and delivery at term to a set of twins and a single birth? 1. G4P4A1 2. G4P2A2 3. G4P2A1 4. G4P3A2 ANS: 3 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment

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Objective: List data you should collect when caring for a patient with a disorder of the reproductive system. Page: 845 Heading: Female Reproductive System Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1 2 3

The patient has not had four live births. The patient has not had two abortions, either spontaneous or therapeutic. The patient has four pregnancies (G), two deliveries resulting in live births (P), and one spontaneous abortion (A). The birth at 22 weeks is not considered an abortion, but is also not a live birth. The patient has three children from two pregnancies. The patient has not delivered live fetuses from three pregnancies and had only one spontaneous abortion.

PTS:

CON: Sexuality

18. The nurse is in the initial stage of physical examination with a male patient. Which observation by the nurse is most likely unrelated to a hormone imbalance? 1. Gynecomastia 2. Absence of facial hair 3. Lack of pubic hair 4. Short stature ANS: 4 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: List data you should collect when caring for a patient with a disorder of the reproductive system. Page: 856 Heading: Male Reproductive System Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1 2 3 4

Gynecomastia is a male condition where there is an excess of breast tissue related to excess female hormones. An absence of facial hair is considered to be unexpected in a male patient. Abnormal hair patterns are frequently an indication of hormone imbalance. A lack of pubic hair is an abnormal hair pattern that frequently indicates a hormone imbalance. Short stature may be related to genetics and is not commonly associated with

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hormone imbalances. PTS:

CON: Sexuality

MULTIPLE RESPONSE 1. The nurse is reviewing the anatomy of the reproductive tract with a female patient. Which structures do the nurse identify as being part of the vulva? (Select all that apply.) 1. Mons pubis 2. Bartholin’s glands 3. Cervix 4. Clitoris 5. Vagina ANS: 1, 2, 4 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Explain the normal structures and functions of the reproductive system. Page: 840 Heading: Female Reproductive System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Difficult

1. 2. 3. 4. 5. PTS:

Feedback Also called the vulva, the female external genital structures are the clitoris, mons pubis, labia majora and minora, and Bartholin’s glands. Also called the vulva, the female external genital structures are the clitoris, mons pubis, labia majora and minora, and Bartholin’s glands. The cervix is not part of the vulva. Also called the vulva, the female external genital structures are the clitoris, mons pubis, labia majora and minora, and Bartholin’s glands. The vagina is not part of the vulva. 1

CON: Sexuality

2. The licensed practical nurse is providing instructions on testicular self-examination. Which statements do the nurse include in this teaching? (Select all that apply.) 1. “The testicles should be examined monthly while in the shower.” 2. “The spermatic cord generally cannot be felt without deep palpation.” 3. “The left side of the scrotum usually hangs a little lower than the right.” 4. “If you notice any lumps or unusual changes, you should call your doctor.” 5. “Hold the scrotum in one hand and massage gently to note any tenderness.” ANS: 1, 3, 4 Chapter: Chapter 41. Genitourinary and Reproductive System Function and Assessment Objective: Explain the normal structures and functions of the reproductive system. Page: 860

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Heading: Male Reproductive System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Difficult

2. 3. 4. 5.

PTS:

Feedback Testicular self-examination is to be performed monthly and while in the shower. When the skin is wet, the patient’s hand will glide more smoothly across the testicles, and the warm water will facilitate relaxation of the scrotum. The spermatic cord usually feels firm, smooth, and movable and can be readily identified. The left side of the scrotum usually hangs a little lower than the right. Testicular self-examination should be done monthly and lumps or unusual changes should be communicated to the physician. Both hands are used to hold the scrotum and gently roll each testicle between the thumb and first three fingers, feeling for any lumps or hard spots. 1

CON: Sexuality

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Chapter 42. Nursing Care of Women With Reproductive System Disorders MULTIPLE CHOICE 1. The nurse is contributing to information for women in a fibrocystic breast disease support group. Which information does the nurse suggest including? 1. The manifestations of the condition usually subside with menopause. 2. One cause is related to the use of hormonal birth control medications. 3. The disease process frequently results in the development of cancer. 4. Women between the ages of 20 and 30 years are most susceptible. ANS: 1 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Explain the pathophysiology of each of the disorders of the female reproductive system. Page: 865 Heading: Fibrocystic Breast Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

Fibrocystic breast disease is due to a hormonal response, primarily to estrogen. Because estrogen levels decrease after menopause, the symptoms are likely to subside at that time. Limitation of dietary fats and caffeine, along with the addition of oral contraceptives may help control hormonal changes associated with the condition. Fibrocystic breast disease is not related to the development of breast cancer. However, the presence of fibrous tissue in the breasts make it more difficult to diagnose breast cancer should it develop. Fibrocystic disease is most common in women between the ages of 30 and 50 years.

PTS:

CON: Patient-Centered Care

2. The nurse is providing care for a patient who had a mastectomy for breast cancer 2 days ago and is now developing pulmonary congestion. For which reason is a mastectomy patient at risk for pulmonary complications? 1. Breast cancer often metastasizes to the lungs prior to diagnosis. 2. Pathogens may have been introduced during the surgical procedure. 3. The chest incision makes the patient hesitant to deep-breathe and cough. 4. Mastectomy patients are on bedrest for the first 48 to 72 hours postoperatively. ANS: 3 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders

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Objective: Explain the pathophysiology of each of the disorders of the female reproductive system. Page: 867 Heading: Malignant Breast Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Breast cancer does not often spread to the lungs before the diagnosis of breast cancer. Pathogens should not be introduced during surgery and the mastectomy site is not the same as the lungs. Patients can have ineffective breathing patterns and difficulty coughing because of pain with chest movement. Bedrest is not necessary and may actually contribute to postsurgical complications.

PTS:

CON: Patient-Centered Care

3. A patient at age 23 reports severe pelvic and back pain, which increases during her menses. After testing, she is diagnosed with endometriosis. Which information provided by the nurse is likely to be considered premature? 1. “The condition is called retrograde menstruation.” 2. “Removal of the ovaries is the most effective treatment.” 3. “Migrated endometrium cells attach to the abdominal organs.” 4. “The cells in the abdomen will build up and slough like the uterus.” ANS: 2 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Explain the pathophysiology of each of the disorders of the female reproductive system. Page: 874 Heading: Endometriosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Teaching/Learning Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

Endometriosis is considered to be retrograde menstruation because of the backward leakage of blood and tissue into the fallopian tubes and pelvic cavity. The management of endometriosis is related to the management of hormones involved in menstruation. Reduction of ovulation via medications or surgical removal of the ovaries can be effective. However, the treatment results in infertility; this information can be premature to a young patient newly

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diagnosed with the condition. The migrated endometrium cells will attach to or grow into tissues such as the intestinal walls, ovaries, and other abdominal structures/organs. On a cyclic basis mediated by ovarian hormones, the endometrial cells in the abdomen will buildup and slough like those in the uterus. The difference is that the bleeding occurs within the abdominal cavity, causing pain, swelling, and damage to abdominal organs and structures. The scar tissue will result in infertility.

PTS:

CON: Patient-Centered Care

4. A 50-year-old woman states, “It is such a relief not to need birth control any more. I haven’t had a period in 3 months.” Which response by the nurse is correct? 1. “Birth control is usually unnecessary after age 50, even if you are still having periods.” 2. “It is still possible for you to get pregnant and you should consider having a tubal ligation.” 3. “You should continue to use birth control for at least 6 months after cessation of your periods.” 4. “Without confirmation, you are still considered to be perimenopausal and should continue birth control.” ANS: 4 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Describe the etiologies, signs, and symptoms of each disorder. Page: 875 Heading: Menopause Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

2 3 4

To prevent conception, the patient needs to continue to practice birth control until she receives confirmation from her health care provider (HCP) that menopause is complete. A tubal ligation is not necessary because only a brief time of needing protection remains. Six months is not a magic number; menopause needs to be confirmed by an HCP. It is important to remind perimenopausal women that they may still be fertile even after several months of amenorrhea.

PTS:

CON: Patient-Centered Care

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5. The nurse is collecting data from a female client who is having difficulty conceiving. The nurse notes that the client has increased amounts of body and facial hair, is moderately overweight, and has acne-like lesions on the face. Which medical condition is the nurse likely to suspect? 1. Polycystic ovary syndrome (PCOS) 2. Decreased estrogen hormone 3. Severe endometriosis 4. Immature ovaries ANS: 1 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Describe the etiologies, signs, and symptoms of each disorder. Page: 881 Heading: Polycystic Ovary Syndrome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

3 4

The patient is exhibiting and reporting the classic manifestations of PCOS. With PCOS, many symptoms are a result of insulin resistance with excessive levels of insulin in the blood, which in turn stimulates the secretion of androgens. Severe endometriosis does not exhibit the listed manifestations and is not related to PCOS. PCOS is not related to immature ovaries.

PTS:

CON: Patient-Centered Care

6. The nurse is providing care for a female patent diagnosed with displacement disorders currently being treated with placement of a pessary. Which nursing care is the most important for the nurse implement? 1. Provide information about weight management. 2. Suggest methods to avoid constipation. 3. Discuss how to perform Kegel exercises. 4. Inform of symptoms to report to the HCP. ANS: 3 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Plan nursing care for females with reproductive disorders. Page: 879 Heading: Displacement Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

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Feedback 1

2 3

It is important for a patient with displacement disorders to maintain a healthy weight because obesity will worsen the condition. However, there is another consideration that is more important. Constipation can increase the manifestations of displacement disorders; however, another nursing action is more important. The most important action by the nurse for a patient with displacement disorders is to discuss the importance and performance of Kegel exercises, which keep the pubococcygeus muscles strong and able to support pelvic organs. With a pessary, the patient needs to report pink, bloody, or purulent drainage from the vagina to the HCP. This is important if it occurs. Kegel exercises are more important because they address an existing condition.

PTS:

CON: Patient-Centered Care

7. The nurse is assisting with teaching to a woman who is having difficulty conceiving. Which instruction does the nurse provide about keeping a basal body temperature chart? 1. “Record your temperature in the late afternoon each day for 3 months.” 2. “Record your temperature every 4 hours, starting the first day of each month.” 3. “Record your temperature three times each day of your period, then once a day thereafter.” 4. “Starting with the first day of your period, record your temperature first thing each morning.” ANS: 4 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Compare different forms of contraceptives and their effectiveness. Page: 884 Heading: Natural Family Planning Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Teaching/Learning Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

The method described is incorrect to measure basal body temperature. The method described is incorrect to measure basal body temperature. The method described is incorrect to measure basal body temperature. The nurse teaches the patient to keep a precise record of her oral temperatures with a basal thermometer each morning on awakening, before any other activity. The first day of her menses is day 1 on the temperature chart. Changing levels of hormones result in slight temperature changes, which can be used to identify when ovulation seems to be occurring and when particular hormone levels should be tested.

PTS:

CON: Patient-Centered Care

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8. A patient is inquiring about the insertion of an intrauterine device (IUD) for contraception. Which information from the nurse is incorrect? 1. Perforation of the vaginal wall is common. 2. Effectiveness ranges between 5 to 10 years. 3. Insertion is best during the first 7 days of menses. 4. Procedure is performed in the HCP’s office. ANS: 1 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Compare different forms of contraceptives and their effectiveness. Page: 884 Heading: Intrauterine Devices Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Teaching/Learning Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Perforation of the vaginal wall with an IUD rarely occurs. The effectiveness of an IUD is between 5 to 10 years, depending on the specific product. It is best to insert an IUD during the first 7 days of menses because the cervix is slightly open at this time. The procedure is commonly performed in the HCP’s office.

PTS:

CON: Patient-Centered Care

9. A female reports being conflicted between the effectiveness of a condom versus a diaphragm for contraception. Which information does the nurse provide regarding effectiveness? 1. Diaphragms are more expensive. 2. Condoms can be part of foreplay. 3. Spermicide is a good addition to both. 4. A female condom is more effective. ANS: 3 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Compare different forms of contraceptives and their effectiveness. Page: 885 Heading: Barrier Methods Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

It is true that a diaphragm is more expensive and may need to be refitted and

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replaced for a variety of reasons. However, this does not address effectiveness. Male condoms can be applied as part of sexual foreplay; however, this does not address effectiveness. The addition of spermicide with the use of any barrier contraception device improves the effectiveness. There is no evidence that female condoms are more effective; they are more expensive and may break or be defective.

PTS:

CON: Patient-Centered Care

10. A female patient who is in the last trimester of pregnancy is considering sterilization as a permanent method of birth control. The patient states, “I know this is what I want, but I don’t want to do this until the baby is a little older.” Which information does the nurse provide? 1. Removal of the uterus can be performed later. 2. The patient’s partner can opt for a vasectomy. 3. Tiny implants can be nonsurgically placed later. 4. The procedure is best performed after birth. ANS: 3 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Compare different forms of contraceptives and their effectiveness. Page: 886 Heading: Sterilization Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Teaching/Learning Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

Removal of the uterus is a hysterectomy; there are effective methods of sterilization that are less invasive and with fewer possible complications. The male partner of the patient can opt for a vasectomy; however, this statement does not specifically address the patient’s wishes. A nonsurgical procedure (Essure) uses an endoscope to place tiny implants into each fallopian tube to block tube patency. The procedure can be performed at any time. There is no indication that the procedure is best performed after child birth unless the patient delivers via cesarean.

PTS:

CON: Patient-Centered Care

11. The nurse is providing care for a female patient diagnosed with stage II breast cancer. The patient states, “I have done some research about targeted therapies and I’m not sure it is the best option.” Which information does the nurse provide? 1. They will decrease positive body responses for some patients. 2. They are still experimental and are not available for stage II cancer. 3. They require positive testing for HER2 protein on the cancer cells.

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4. They target cancer cells and are less toxic to normal body cells. ANS: 4 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Describe current therapeutic management for each disorder. Page: 885 Heading: Targeted Therapies Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Pharmacological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3 4

Some targeted therapies will intensify positive body responses and decrease negative body responses. Many targeted therapies are beyond the experimental stage and can be used when appropriate for treatment of cancer. Three drugs target the protein HER2, which is found on the surface of some breast cancer cells. The drugs are trastuzumab, pertuzumab, and lapatinib. Because targeted therapy targets cancer cells specifically, they are less toxic to normal body cells.

PTS:

CON: Patient-Centered Care

12. The nurse is providing care to a female patient who just received a diagnosis of agenesis of the ovaries. Which nursing care is most appropriate for the patient? 1. Monitor for physical pain related to testing. 2. Express a willingness to listen if the patient wishes. 3. Check surgical dressings for signs of bleeding. 4. Provide for privacy so the patient can consider options. ANS: 2 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Plan nursing care for female patients with reproductive disorders. Page: 878 Heading: Disorders Related to the Development of Genital Organs Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

The patient may have been diagnosed by testing procedures that do not cause pain, such as ultrasound. The nurse needs to express a willingness to listen if the patient wishes to talk. The information can be emotionally devastating and cause intense feelings. There is no indication that the patient has experienced surgery.

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The patient will need privacy to deal with emotions and the meaning of the diagnosis. However, the most important nursing action is to project a caring and supportive attitude toward the patient.

PTS:

CON: Patient-Centered Care

13. A female patient who is experiencing symptoms related to menopause is denied hormone replacement therapy by the HCP because of a family history of breast cancer and heart disease. Which suggestion does the nurse make for management of symptoms that is likely to be ineffective? 1. Initiate a calcium and vitamin regimen. 2. Increase weight-bearing exercise and activity. 3. Discuss the benefit of including dietary phytoestrogens. 4. Dress in layers to promote comfort during hot flashes. ANS: 1 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Describe current therapeutic management for each disorder. Page: 874 Heading: Hormone Replacement Therapy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

To be effective, calcium and vitamin D therapy should begin in early adulthood. This suggestion is likely to be ineffective. Increasing weight-bearing exercise and activity is appropriate to promote bone health, which is no longer protected by estrogen. Phytoestrogens can provide the benefits of estrogen without hormone replacement therapy. However, phytoestrogens do carry some risks; food and supplement additions should be discussed with the HCP. The suggestion to dress in layers so that clothing can be removed easily during hot flashes is an effective intervention during menopause.

PTS:

CON: Patient-Centered Care

14. The nurse is collecting data from a female patient with a possible Bartholin gland cyst. Which data does the nurse need to validate? 1. Lack of pain with intercourse 2. Difficulty when attempting to sit 3. Foul odor drainage from perineum 4. Inability to void related to pain ANS: 2 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders

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Objective: List data to collect when caring for patients with disorders of the female reproductive system. Page: 890 Heading: Bartholin Cysts Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1

The patient with a Bartholin cyst is expected to have pain with intercourse. The patient with a Bartholin cyst will express pain and difficulty with sitting. Foul odor drainage is not expected with a Bartholin cyst. The patient with a Bartholin cyst is not expected to have difficulty voiding.

2 3 4

PTS:

CON: Patient-Centered Care

15. The nurse is reviewing discharge teaching for a patient who has undergone laparoscopic surgery. Which patient statement indicates that discharge teaching is effective? 1. “I will report feelings of dizziness to my physician.” 2. “I will call for a refill prescription if pain is intense.” 3. “I will maintain a full liquid diet until nausea passes.” 4. “I will refrain from showering until the staples are removed.” ANS: 1 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Explain how you will know whether nursing interventions have been effective. Page: 891 Heading: Gynecological Surgery Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2

3 4

The nurse can determine that teaching is effective if the patient understands the necessity of reporting dizziness, which can be indicative of internal bleeding. Teaching has not necessarily been effective if the patient feels that a need to manage pain requires additional prescription pain medication. Most laparoscopic surgery does not require long-term use of pain medications. Dietary restrictions are not commonly required after discharge for laparoscopic surgery. Showering is not prohibited until staples are removed. The patient needs to follow the HCP’s directions.

PTS:

CON: Patient-Centered Care

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16. A female patient is diagnosed with premenstrual dysphoric disorder (PMDD). The HCP prescribes, along with hormonal contraceptives, supplements of calcium, magnesium, and vitamins E and B6. Which information is most important for the nurse to provide to the patient? 1. Food sources high in calcium and magnesium 2. Side effects of hormonal contraceptives 3. Instructions that vitamin increases need HCP approval 4. Natural sources of vitamins E and B6 ANS: 3 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Plan nursing care for female patients with reproductive disorders. Page: 874 Heading: Premenstrual Syndrome and Premenstrual Dysphoric Disorder Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

The nurse does not need to provide information about foods high in calcium and magnesium. The patient needs a healthy, balanced diet. The nurse can provide information regarding the side effects of hormonal contraceptives; however, this is not the most important information. The nurse needs to give the patient instructions not to increase vitamin doses without HCP approval because vitamins are medications as well as nutrients. High doses of some vitamins can cause physiological damage. The nurse does not need to provide information about foods high in vitamins E and B6.

PTS:

CON: Patient-Centered Care

17. The nurse works in the office of an HCP specializing in female health. Which patient does the nurse identify as being at greatest risk due to prescribed oral contraceptives? 1. A 20-year-old patient with a family history of cardiovascular disease 2. A 45-year-old patient who smokes and is treated for diabetes and hypertension 3. A 30-year-old patient with a history of thrombophlebitis and high cholesterol 4. A 38-year-old patient with a high-stress job who is being treated for anxiety ANS: 2 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Compare different forms of contraceptives and their effectiveness. Page: 876 Heading: Oral Contraceptives Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

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Feedback 1 2

3 4

The 20-year-old patient has only one risk related to oral contraceptives, and that is a family history of cardiovascular disease. The 45-year-old patient has three risk factors related to oral contraceptives: smoking, treatment for diabetes, and treatment for hypertension. This is the patient at greatest risk. The 30-year-old patient with a history of thrombophlebitis is considered at high risk. However, having high cholesterol is not alone considered a risk. The 38-year-old patient with a high-stress job who is being treated for anxiety has no risk factors directly related to the use of oral contraceptives.

PTS:

CON: Patient-Centered Care

18. The nurse is providing care and support to a female client who tested positive for the BRCA 1 and BRCA 2 genes. Which statement by the patient indicates that additional information from the nurse is necessary? 1. “I think this requires that I be closely monitored for breast cancer.” 2. “The only choice I have at this point is to have a bilateral mastectomy.” 3. “This may explain why there is such a high incidence of family breast cancer.” 4. “I feel blessed to have this information, it may save my female family members.” ANS: 2 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Explain how you will know whether nursing interventions have been effective. Page: 866 Heading: Malignant Breast Disorders Integrated Process: Clinical Problem-Solving Process Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 2 3

The recognition that close monitoring is necessary does not indicate a need for additional information. If the patient thinks that a bilateral mastectomy is her only option, the nurse may need to provide additional information. The patient is making a correct connection between the genetics and family incidence of breast cancer. This does not indicate a need for additional information. If the patient realizes that early identification of genetic tendencies to have breast cancer can be a blessing for future female family members, no additional information is needed.

PTS:

CON: Patient-Centered Care

MULTIPLE RESPONSE

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1. The nurse is caring for a woman who has just had a spontaneous abortion. Which instructions do the nurse provide? (Select all that apply.) 1. “Call if you experience bleeding for more than 3 days.” 2. “Call if there is more bleeding than during a heavy period.” 3. “The discharge often has a foul odor due to the procedure.” 4. “You can expect to pass large clots the size of golf balls.” 5. “Abstain from sexual intercourse as directed by your physician.” ANS: 1, 2, 5 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Plan nursing care for female patients with reproductive disorders. Page: 888 Heading: Pregnancy Termination Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback The patient should be instructed to notify the physician if bleeding lasts longer than 3 days. Bleeding should not exceed that of a heavy period. The discharge should not have a foul odor. Clots larger than a golf ball should be reported. The patient should abstain from sexual intercourse for the time specified by the HCP, usually 3 weeks. 1

CON: Patient-Centered Care

2. After reviewing data, the nurse suspects that a young female patient is experiencing manifestations of toxic shock syndrome. Which findings does the nurse use to make this decision? (Select all that apply.) 1. Sore throat 2. Peeling skin 3. Fluid retention 4. Red palms and soles of feet 5. Muscle pain and weakness ANS: 1, 2, 4, 5 Chapter: Chapter 42. Nursing Care of Women With Reproductive System Disorders Objective: Describe the etiologies, signs, and symptoms of each disorder. Page: 877 Heading: Toxic Shock Syndrome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care

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Difficulty: Difficult

3. 4.

PTS:

Feedback Individuals with toxic shock syndrome may experience a sore throat, rash, blisters, and petechiae, followed by peeling of the skin, redness of the palms and soles of the feet, and muscle pain and weakness. Individuals with toxic shock syndrome may experience a sore throat, rash, blisters, and petechiae, followed by peeling of the skin, redness of the palms and soles of the feet, and muscle pain and weakness. Fluid retention is not a manifestation of toxic shock syndrome. Individuals with toxic shock syndrome may experience a sore throat, rash, blisters, and petechiae, followed by peeling of the skin, redness of the palms and soles of the feet, and muscle pain and weakness. Individuals with toxic shock syndrome may experience a sore throat, rash, blisters, and petechiae, followed by peeling of the skin, redness of the palms and soles of the feet, and muscle pain and weakness. 1

CON: Patient-Centered Care

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Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders MULTIPLE CHOICE 1. The nurse is providing care for a male patient diagnosed with acute prostatitis. Which intervention is unnecessary for the nurse to discuss with this patient? 1. Methods of pain management 2. Need for surgery intervention 3. Monitoring of ability to void 4. Information about prevention ANS: 2 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Plan nursing care for men with genitourinary and reproductive disorders. Page: 899 Heading: Prostatitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1

The nurse needs to be sure the patient understands the methods of pain management, which will include both medication and nonmedication interventions. At this point, it is likely to be unnecessary to discuss the need for surgery. If the condition persists and is unresponsive to treatment or becomes chronic, surgery is considered to rule out other conditions. The nurse needs to explain the necessity and process for monitoring the ability to void. The patient will need to keep a diary with times and amounts of urination. Information about prevention is important. The nurse will discuss all measures that can cause prostatitis and how to prevent reinfection.

PTS:

CON: Sexuality

2. A patient diagnosed with benign prostatic hyperplasia is prescribed the alpha-blocking medication tamsulosin to reduce symptoms. For which side effect does the nurse monitor this patient? 1. Dry mouth 2. Headaches 3. Hypotension 4. Urinary frequency ANS: 3 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders

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Objective: Describe the etiologies, signs and symptoms, and treatments of prostate disorders. Page: 902 Heading: Benign Prostatic Hyperplasia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Safety Difficulty: Moderate Feedback 1 2 3

Headache, dry mouth, and urinary frequency are also possible but are not life or health threatening. Headache, dry mouth, and urinary frequency are also possible but are not life or health threatening. Alpha-blocking medications dilate vessels, so the nurse should monitor the patient for hypotension, which under some circumstances can be life or health threatening. Headache, dry mouth, and urinary frequency are also possible but are not life or health threatening.

PTS:

CON: Safety

3. A 70-year-old male arrives in the emergency department and says, “I haven’t urinated in 24 hours. I feel like I have to go, but I can’t.” Which care does the nurse anticipate providing first? 1. STAT administration of IV fluids 2. Emergency preparation for a cystoscopy 3. STAT insertion of an indwelling catheter 4. Emergency preparation for an intravenous pyelogram (IVP) ANS: 3 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Plan nursing care for men with genitourinary and reproductive disorders. Page: 903 Heading: Prostate Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1 2 3 4

IV fluids will further add to his need to urinate. Preparation for tests would wait until he is safe from immediate harm. First, the patient must be assisted to empty his bladder to avoid rupture or other complications. Preparation for tests would wait until he is safe from immediate harm.

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PTS:

CON: Elimination

4. The nurse is providing preoperative care for an 80-year-old patient who is scheduled to have prostate surgery. The patient says, “I know a man who was impotent after this surgery. Will that happen to me?” Which response by the nurse is most appropriate? 1. “There are many treatments available if it does occur.” 2. “Most men your age learn to deal with erectile dysfunction if it does occur.” 3. “Impotence should not be a problem; sperm production is not affected by this surgery.” 4. “Prostate surgery can cause erectile dysfunction. I’ll ask your surgeon to explain the risks to you.” ANS: 4 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Describe the etiologies, signs and symptoms, and treatments of prostate disorders. Page: 903 Heading: Prostate Disorders Integrated Process: Clinical Problem-Solving Process Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Elimination Difficulty: Moderate Feedback 1

2 3

It is inappropriate for the nurse to talk about treatments. It is not known from the information given if the patient is having a high-risk procedure. There is no reason to alarm the patient unnecessarily. This reply is inappropriate because it makes an assumption about the patient’s sexual function based on age. It is inappropriate for the nurse to talk about treatments. It is not known from the information given if the patient is having a high-risk procedure. There is no reason to alarm the patient unnecessarily. Some types of prostate procedures can lead to erectile dysfunction. The physician needs to address this risk with the patient.

PTS:

CON: Elimination

5. A patient has just returned from a transurethral resection of the prostate (TURP). Which explanation does the nurse provide if the patient asks why he needs a urinary catheter? 1. “The catheter keeps your bladder empty to reduce risk for infection” 2. “The catheter is keeping pressure on the surgery area to prevent bleeding.” 3. “We can take the catheter out when you are able to urinate on your own.” 4. “The catheter is being used to irrigate your bladder with antibiotics.” ANS: 2 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Describe the etiologies, signs and symptoms, and treatments of prostate disorders. Page: 903

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Heading: Transurethral Resection of the Prostate Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Moderate Feedback 1 2

3 4

Antibiotics are not routine. As the tissue is removed during TURP, bleeding occurs. A Foley catheter is left in place with 30 to 60 mL of sterile water inflating the balloon. The balloon is overfilled and may be secured tightly to the leg or abdomen to tamponade (compress) the prostate area and stop the bleeding. The health care provider (HCP) will remove the Foley catheter after the danger of hemorrhage has passed. Irrigation solution generally flows continuously; manual irrigation may be done for the first 24 hours to help maintain catheter patency by removing clots and tissue shreds.

PTS:

CON: Elimination

6. A male patient who is 60 years old is diagnosed with prostate cancer. Which condition does the nurse recognize as the best indication for a radical prostatectomy? 1. The cytology tests indicate slow-growing cells. 2. A digital examination locates a small prostate nodule. 3. The patient is experiencing bone pain. 4. Age indicates lack of the need for fertility. ANS: 3 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Describe the etiologies, signs and symptoms, and treatments of prostate disorders. Page: 907 Heading: Cancer of the Prostate Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 2

When prostate cancers are determined to be slow growing, treatment does not always indicate the need for a radical prostatectomy. A digital examination of the prostate will reveal a small hardened lump or lobe. The decision to perform a radical prostatectomy will depend on the type of cancer and whether metastases has occurred. Metastases of prostate cancer frequently involves pain in bone tissue, most often of the back or hip. Bone pain may be an indication for a radical prostatectomy.

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The decision for a radical prostatectomy is made based on physiological indications. Age is not a determining factor, and the patient’s age is not necessarily an indication of sexual or reproductive functioning.

PTS:

CON: Cellular Regulation

7. The nurse in the emergency department is providing care for a male client with priapism, which has lasted for 6 hours. For which serious condition will the nurse monitor the patient? 1. The ability to urinate 2. The current level of pain 3. The inability for an erection 4. The signs of necrotic tissue ANS: 1 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Plan nursing care for men with genitourinary and reproductive disorders. Page: 910 Heading: Priapism Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1

2 3

Prolonged priapism can result in the inability to urinate, which can lead to bladder distention, dilation of the ureters, and hydronephrosis. This condition is considered serious. The patient’s pain level is to be monitored, but the presence of pain is expected and not considered to be serious. After priapism, the patient may have an inability to have an erection. However, the nurse will not be monitoring for this condition. Diagnosis will occur after recovery from the episode. The patient with prolonged priapism is at risk for penile tissue necrosis due to a lack of oxygen. However, the condition is not likely to occur during emergency care.

PTS:

CON: Sexuality

8. A male patient has been diagnosed with acute epididymitis. The HCP has prescribed bedrest, elevation of the scrotum on ice packs, and antibiotics. The nurse is aware that which complication is least likely to develop with the patient’s diagnosis? 1. Abscess 2. Orchitis 3. Sterility 4. Chronic epididymitis ANS: 2 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders

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Objective: Explain the pathophysiology associated with each male genitourinary and reproductive disorder discussed in this chapter. Page: 910 Heading: Epididymitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1 2

3 4

With the diagnosis of epididymitis, it is possible for the patient to develop an abscess as a complication. Orchitis is inflammation/infection of the testicles; it can be caused by trauma or infection from epididymitis, urinary tract infections (UTIs), sexually transmitted infections (STIs), or systemic diseases. However, because orchitis is a rare condition, it is the least likely complication. It is possible for the patient with epididymitis to develop sterility. Acute epididymitis can become a chronic condition if not treated or not responsive to treatment.

PTS:

CON: Sexuality

9. A 30-year-old male patient has just received a diagnosis of testicular cancer. He appears sad and states, “I always wanted to have children. Now it will be impossible.” Which information does the nurse provide to assist the patient? 1. Contact information for a support group. 2. Provide the patient with literature about adoption. 3. Validate the impossibility of the patient fathering a child. 4. Share that it is possible to bank sperm before treatment. ANS: 4 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Plan nursing care for men with genitourinary and reproductive disorders. Page: 910 Heading: Cancer of the Testicles Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Moderate Feedback 1 2 3 4

The patient may benefit from a support group; however, the patient’s current concern is the possibility of having children. Providing adoption literature is inappropriate at this time. Having children is possible even with the diagnosis of testicular cancer. If the patient wants to have children, he should be encouraged to make deposits in a sperm bank before any surgery or treatment is started.

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PTS:

CON: Cellular Regulation

10. The nurse is reviewing a patient’s understanding about a scheduled vasectomy. Which statement by the patient indicates the need for additional teaching? 1. “There is no change in the way an ejaculation looks or feels.” 2. “Another kind of birth control should be used for 3 months.” 3. “Sperm will no longer be produced once healing is completed.” 4. “A semen sample evaluation will confirm success of the surgery.” ANS: 3 Chapter: Nursing Care of Male Patients With Genitourinary Disorders Objective: Plan nursing care for men with genitourinary and reproductive disorders. Page: 910 Heading: Vasectomy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1 2 3 4

When the patient states no change in the way an ejaculation looks or feels, there is no need for additional teaching. Three months of additional birth control provides protection until the lack of sperm passage is validated. This statement indicates a need for additional teaching. Sperm will continue to be produced by the testes, but they will be absorbed by the body. The evaluation of a semen sample is the most effective way to confirm the success of a vasectomy. Unprotected intercourse should not be experienced before this confirmation.

PTS:

CON: Sexuality

11. A male patient in an HCP’s office, tells the nurse, “I am impotent and cannot have a fulfilling sex life with my spouse.” In which way can the nurse support the patient? 1. “We see many patients with your condition and it is usually emotional.” 2. “You should discuss the problem with your spouse and share feelings.” 3. “We no longer use negative terms as reference to erectile dysfunction.” 4. “The problem is usually related to fatigue and stress and can be managed.” ANS: 3 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Discuss the nurse’s role in helping men cope with loss of sexual function. Page: 912 Heading: Sexual Functioning Integrated Process: Caring Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sexuality

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Difficulty: Difficult Feedback 1

2 3

Before the 1980s, 90 percent of erectile dysfunction was thought to be caused by emotional issues. Researchers now believe that 80 to 90 percennt are caused by physical problems. This statement does not provide the patient with support. Also, the nurse does not know if the patient and spouse have already discussed the issue. The nurse can support the patient by replacing the client’s negative terminology with the term of erectile dysfunction. The term impotence carries a negative meaning of “powerlessness.” The problem may be related to fatigue and stress, but there is no indication that the patient is experiencing either outside the problem itself. This does not provide the patient with the best support.

PTS:

CON: Sexuality

12. A patient has just received a new prescription for a transurethral suppository for erectile dysfunction. Which instruction should the nurse provide regarding the use of this medication? 1. “Urinate before you insert the suppository into your urethra.” 2. “Remove the suppository after you are finished having intercourse.” 3. “Lubricate the suppository well and insert it into your rectum before intercourse.” 4. “Insert the suppository into the urethra at least 2 hours before anticipated intercourse.” ANS: 1 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Discuss the nurse’s role in helping men cope with loss of sexual function. Page: 912 Heading: Transurethral Suppository Integrated Process: Teaching/Learning Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Sexuality Difficulty: Moderate Feedback 1 2 3

The patient is instructed to urinate before use of the suppository. The suppository will be absorbed and is not removable. A tiny pellet (microsuppository) is inserted into the urethra using a specialized single-dose applicator. The medication usually begins to work in 5 to 10 minutes, and the effects last for approximately 30 to 60 minutes. Two hours is too long to insert before having intercourse.

PTS:

CON: Sexuality

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13. The nurse is reviewing the report on fertility testing for a male patient who is 28 years of age. The report designates the cause of infertility as a low sperm count with no other identified physiological disorders. Which type of infertility does the nurse recognize? 1. Pretesticular 2. Testicular 3. Posttesticular 4. Hormonal ANS: 2 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Identify disorders of the male reproductive system that interfere with fertility. Page: 913 Heading: Infertility Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Difficult Feedback 1

Pretesticular infertility is usually associated with pituitary or adrenal tumors, thyroid problems, or uncontrolled diabetes mellitus. The report notes no physiological disorders. Testicular infertility is caused by two factors: varicoceles and idiopathic. The report notes no physiological disorder, which would include varicoceles. However, idiopathic causes are numerous: A common cause is anything that raises the temperature of the testes or causes damage or injury. Posttesticular infertility is caused by any surgery or injury along the path of the sperm from the testes to the outside of the body, such as vasectomy or any other surgery that can cause retrograde ejaculation. Hormonal infertility by definition is considered pretesticular.

PTS:

CON: Sexuality

14. The nurse is participating in the care of a male patient in the emergency department for a severe episode of hypotension. The patient takes sildenafil for erectile dysfunction. Medical history indicates management of hypertension and diabetes. Which information does the nurse provide related to meeting this patient’s needs? 1. The need to have antihypertensive medication adjusted 2. Testing to determine compromised penile circulation 3. The effectiveness of herbs for erectile dysfunction 4. Testing to validate an adequate testosterone level ANS: 3 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: List treatment options available for treatment of male infertility. Page: 913 Heading: Erectile Dysfunction Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies

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Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1

If the patient is being treated for hypertension, adjustment of the medication can be considered, but may not be possible. Any antihypertensive medication will likely cause a hypotensive episode when sildenafil is used. The patient is a diabetic and may very well have compromised penile circulation. Acquisition of this knowledge does not alone meet the patient’s need. Several herbal remedies may be effective in resolving erectile dysfunction, such as yohimbine, ginseng, gingko, and others. The patient needs to understand that herbal therapies can have side effects and the HCP should be aware of the therapy. Testing to validate an adequate testosterone level will not alone meet the patient’s need.

PTS:

CON: Sexuality

15. The nurse is told during a physical examination that a male patient has a curved penis during erection. Which term does the nurse use to document this observation? 1. Priapism 2. Phimosis 3. Paraphimosis 4. Peyronie disease ANS: 4 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Describe disorders of the testicles and penis and how they affect sexual function. Page: 916 Heading: Penile Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Sexuality Difficulty: Moderate Feedback 1 2

Priapism is a painful erection that lasts too long. Phimosis describes a condition in which the foreskin of an uncircumcised male becomes so tight it is difficult or impossible to pull back, away from the head of the penis. Paraphimosis occurs when the uncircumcised foreskin is pulled back, during intercourse or bathing, and not immediately replaced in a forward position. This causes constriction of the dorsal veins, which leads to edema and pain. Peyronie disease often gives the penis a curved or crooked look when it is erect.

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CON: Sexuality

16. The nurse is contributing to patient teaching for a patient who is not circumcised and diagnosed with penile cancer. The small red lesion was removed by laser surgery. Which postprocedure information does the nurse recognize as being least beneficial? 1. Refraining from unprotected sexual activity 2. Maintaining good hygiene due to being uncircumcised 3. The importance of early reporting of additional lesions 4. The benefits and complications related to adult circumcision ANS: 4 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Describe disorders of the testicles and penis and how they affect sexual function. Page: 910 Heading: Penile Cancer Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Cellular Regulation Difficulty: Moderate Feedback 1

2 3 4

Penile cancer can be spread to a sexual partner. Because the patient is at risk for additional lesions, the patient and the patient’s partner may benefit by having protected sex. It is important for the patient to understand the importance of good hygiene, especially when uncircumcised. The patient is at risk for reoccurrence of penile cancer. Monitoring for lesions regularly allows for early treatment. If a male patient has had penile cancer, he may want to consider being circumcised to decrease the risk of reoccurrence of the disease. However, this is the least beneficial information at this time.

PTS:

CON: Cellular Regulation

17. The parent of a newborn male is informed of a condition called cryptorchidism. The HCP states if the condition does not resolve within a few months, surgery will be required before the age of 1 year. The parent asks the nurse why surgery is so important. Which reason does the nurse provide in support of the surgery? 1. The child will be teased for looking different. 2. Formation of sexual characteristics are delayed. 3. Lack of correction can result in infertility. 4. Normal sexual functioning will not be possible. ANS: 3 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Identify disorders of the male reproductive system that interfere with fertility. Page: 910 Heading: Testicular Disorders Integrated Process: Teaching/Learning

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Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Difficult Feedback 1 2 3 4

The reason that the child will be teased for looking different is not necessarily supportive of surgery. Cryptorchidism does not delay the formation of sexual characteristics if surgery is not performed. The nurse should inform the parent that not having the surgery can result in the development of infertility. This factor is strongly supportive of surgery. Cryptorchidism does not interfere with normal sexual functioning.

PTS:

CON: Sexuality

18. A male patient expresses the desire to have a vasectomy reversed that was performed 5 years ago. Which information about vasectomy reversal does the nurse recognize as the most likely cause of an unsuccessful surgery? 1. Sections of the vas deferens were removed. 2. Testing will be needed to confirm sperm production. 3. The period of time passed may be too long. 4. It may be necessary to reconnect at the epididymis. ANS: 3 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: List treatment options available for male infertility. Page: 912 Heading: Vasectomy Reversal Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1

When a section of the vas deferens is removed during a vasectomy, the HCP may not be able to reconnect the ends. However, another type of surgery is available. It is true that sperm production may be limited or absent, depending on the time lapse for the vasectomy. However, this fact alone does not reflect the success of the surgery. Reversed vasectomy is more likely to be successful if the time span from the vasectomy is short. The reconstruction process and sperm production both decline with the passage of time. When the ends of the vas deferens are too short or are unable to be reconnected, the vas deferens can be connected directly to the epididymis.

PTS:

CON: Sexuality

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19. A male patient is unable to achieve or maintain a penile erection long enough for ejaculation. The erectile dysfunction is considered the reason for the patient’s infertility. Which treatment does the nurse expect the HCP to prescribe initially? 1. Dehydroepiandrosterone 2. Oral doses of tadalafil 3. Testosterone replacement 4. Penile injections ANS: 2 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Identify disorders of the male reproductive system that interfere with fertility. Page: 912 Heading: Erectile Dysfunction Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Difficult Feedback 1

2 3

Dehydroepiandrosterone (DHEA) is a steroid hormone that is listed under herbal remedies in this book. Treatment from this category may or may not be effective. This is unlikely to be the HCP’s initial prescription. Oral medications such as tadalafil, sildenafil, and vardenafil are now the first line of therapy used to treat erectile dysfunction. Testosterone replacement can be prescribed if a deficiency is identified. The HCP must assure that the patient does not have contraindications such as prostate cancer. This is not likely to be the HCP’s first approach. Penile injections are a possible treatment for erectile dysfunction; however, it requires careful evaluation of the patient and the patient’s partner to determine their ability to perform the injections. This is not likely the HCP’s first approach.

PTS:

CON: Sexuality

20. A male patient reports that he is uncircumcised and has been having a problem retracting his foreskin for several months. The penis now looks reddened with a noticeable discharge. Which is the most likely reason the patient has delayed reporting the condition? 1. Fear of a serious disease such as cancer 2. Not wanting a circumcision as an adult 3. Confident about success with self-treatment 4. Embarrassment about such a personal issue ANS: 4 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Describe disorders of the testicles and penis and how they affect sexual function. Page: 910 Heading: Phimosis Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Sexuality Difficulty: Moderate Feedback 1 2 3

Fear of a serious disease may cause some patients to report phimosis, but this is not the most likely reason to delay seeking medical help. Not wanting a circumcision as an adult is not likely to be the reason to delay seeking medical help. Being confident about success with self-treatment may be motivated by embarrassment, but alone it is not the likely reason to delay seeking medical help. Many male patients have difficulty reporting penile disorders to HCPs because of embarrassment about reporting such a personal problem.

PTS:

CON: Sexuality

21. A male patient seeks medical advice about intermittent erectile dysfunction. Which comment by the patient prompts the nurse to collect additional information? 1. “After a few drinks, I always ask my partner for sex.” 2. “I have a very busy job, but feel up to the challenge.” 3. “I function well with 7 hours of sleep each night.” 4. “I have been really healthy except for the flu last year.” ANS: 1 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: List selected physical and emotional causes of erectile dysfunction. Page: 912 Heading: Erectile Dysfunction Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1

2 3

Excessive use of drugs or alcohol can cause erectile dysfunction. The nurse needs to collect more specific information about how much alcohol the patient consumes, especially before a sexual encounter. Stress can be a cause of erectile dysfunction. The patient’s comment about his job does not indicate a source of stress. Many adults function well with 7 hours of nightly sleep; this comment does not prompt the need to seek additional information. The patient has not reported fatigue. Illness can be a cause for penile dysfunction; however, the patient reports good health during the past year.

PTS:

CON: Sexuality

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22. A patient arrives in the emergency department with pain in the scrotum. The scrotal skin is tender, red, and warm to the touch. Which information will cause the nurse to suspect the patient has epididymitis? 1. The patient is single but has a monogamous sexual relationship. 2. The patient has not traveled out of the country before. 3. The patient started a new task on his job using a jack hammer. 4. The patient has not been treated for any illness for 6 months. ANS: 3 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Describe disorders of the testicles and penis and how they affect sexual function. Page: 910 Heading: Epididymitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Moderate Feedback 1 2 3 4

One source of epididymitis can be an STI; the patient is in a monogamous relationship, which does not indicate the likelihood of an STI infection. Travel outside the country can sometimes expose a patient to illnesses or diseases from parasites. This is not a likely source for this patient’s symptoms. Epididymitis can be caused by trauma. The patient’s new job task, using a jack hammer, is a likely source of epididymitis. Bacterial or viral infections can cause epididymitis; however, the patient has not been ill for 6 months.

PTS:

CON: Sexuality

MULTIPLE RESPONSE 1. The nurse is collecting a medication history from a man with erectile dysfunction. For which class of medication and lifestyle substances should the nurse focus because they can cause erectile dysfunction? (Select all that apply.) 1. Alcohol 2. Caffeine 3. Antibiotics 4. Antihistamines 5. Beta-blocking agents ANS: 1, 2, 4, 5 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: List selected physical and emotional causes of erectile dysfunction. Page: 912 Heading: Erectile Dysfunction Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sexuality Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback Beta blockers, alcohol, antihistamines, and caffeine can all contribute to erectile dysfunction. Beta blockers, alcohol, antihistamines, and caffeine can all contribute to erectile dysfunction. Antibiotics do not cause erectile dysfunction. Beta blockers, alcohol, antihistamines, and caffeine can all contribute to erectile dysfunction. Beta blockers, alcohol, antihistamines, and caffeine can all contribute to erectile dysfunction. 1

CON: Sexuality

2. A male patient reports that manifestations of benign prostatic hyperplasia (BPH) have been occurring for several years. On which problems related to this condition does the nurse focus when collecting health information? (Select all that apply.) 1. Urosepsis 2. Bladder cancer 3. Renal insufficiency 4. Evidence of hydronephrosis 5. Recurrent urinary tract infections ANS: 1, 3, 4, 5 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Describe the etiologies, signs and symptoms, and treatments of prostate disorders. Page: 902 Heading: Benign Prostatic Hyperplasia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Difficult

2. 3.

Feedback When BPH is untreated and obstruction is prolonged, serious complications can occur. Urine that sits in the bladder for too long can back up into the kidneys, causing hydronephrosis, renal insufficiency, or urosepsis; it can also damage the bladder walls, leading to bladder dysfunction and recurrent urinary tract infections. Bladder cancer is not an adverse effect of untreated BPH. When BPH is untreated and obstruction is prolonged, serious complications can occur. Urine that sits in the bladder for too long can back up into the kidneys, causing hydronephrosis, renal insufficiency, or urosepsis; it can also

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PTS:

damage the bladder walls, leading to bladder dysfunction and recurrent urinary tract infections. When BPH is untreated and obstruction is prolonged, serious complications can occur. Urine that sits in the bladder for too long can back up into the kidneys, causing hydronephrosis, renal insufficiency, or urosepsis; it can also damage the bladder walls, leading to bladder dysfunction and recurrent urinary tract infections. When BPH is untreated and obstruction is prolonged, serious complications can occur. Urine that sits in the bladder for too long can back up into the kidneys, causing hydronephrosis, renal insufficiency, or urosepsis; it can also damage the bladder walls, leading to bladder dysfunction and recurrent urinary tract infections. 1

CON: Elimination

3. The nurse reviews orders from the HCP for a patient recovering from a TURP. The patient is prescribed for bladder irrigation, antispasmodic medication, and IV antibiotics every 6 hours. Which potential complications are these orders specifically addressing? (Select all that apply.) 1. Infection 2. Blood clots 3. Bladder spasms 4. Urinary retention 5. Nausea and vomiting ANS: 1, 2, 3 Chapter: Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders Objective: Describe the etiologies, signs and symptoms, and treatments of prostate disorders. Page: 903 Heading: Transurethral Resection of the Prostate Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Elimination Difficulty: Difficult

Feedback Complications associated with prostate surgery depend on the type and extent of the procedure performed. The main medical complications include clot formation, bladder spasms, and infection. Complications associated with prostate surgery depend on the type and extent of the procedure performed. The main medical complications include clot formation, bladder spasms, and infection. Complications associated with prostate surgery depend on the type and extent of the procedure performed. The main medical complications include clot formation, bladder spasms, and infection. Bladder irrigation, antispasmodic medication and IV antibiotics are not prescribed to prevent urinary retention or nausea and vomiting.

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PTS:

Bladder irrigation, antispasmodic medication and IV antibiotics are not prescribed to prevent urinary retention or nausea and vomiting. 1

CON: Elimination

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Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections MULTIPLE CHOICE 1. The nurse is providing care for a patient who presents with redness, itching, pain, and burning of the vulva and vagina. Which additional manifestation will support the nurse’s suspicion of vulvovaginitis? 1. A thin watery vaginal discharge 2. History of treatment for multiple sexually transmitted infections (STIs) 3. Presence of Bartholin gland abscesses 4. Nausea, vomiting, and loss of appetite ANS: 2 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Describe the signs and symptoms of each of the common STIs. Page: 920 Heading: Vulvovaginitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1 2

3 4

A thin watery vaginal discharge does not support the presence of vulvovaginitis. A patient can have vulvovaginitis with or without sexual contact. A variety of sexually and nonsexually transmitted infectious agents can cause vulvovaginitis. Bartholin glands can develop abscesses as a result of infection with nonsexually transmitted microbes or STIs such as gonorrhea and Chlamydia. Nausea, vomiting, and loss of appetite can present for a variety of reasons and is not a manifestation exclusively of vulvovaginitis.

PTS:

CON: Infection

2. The nurse is collecting health information from a client who has presented with penile condyloma. Which comment by the patient indicates the greatest need for additional information from the nurse? 1. “I am glad that I received Gardasil as a teen.” 2. “I only have oral sex with my sexual partner.” 3. “I received two vaccinations before the age of 14.” 4. “I know I am still at risk for some types of human papilloma virus (HPV).” ANS: 2 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Plan teaching to promote STI prevention. Page: 920

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Heading: Human Papillomavirus Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1

Being vaccinated with Gardasil before the age of 15 years does not protect the patient against all types of high- and low-risk HPVs. The patient needs this information, but it is not the greatest need. High-risk HPV can cause cancer of the cervix, vagina, and vulva in women. Men can develop cancer of the penis. Both genders are at risk for anal and oropharyngeal cancers. This is the greatest need for information for this patient. The Gardasil vaccine is effective in two doses if they are received before the age of 15; after 15, three doses are required. There is no need for additional information. The patient is correct about still being at risk for types of HPV. Additional information may be helpful, but it is not the greatest need for this patient.

PTS:

CON: Infection

3. The nurse is collecting data on a patient with Chlamydia. Which assessment finding should be reported immediately to the registered nurse (RN) or physician? 1. Painful urination 2. Red conjunctivae 3. Vaginal discharge 4. Sharp pain at the base of the ribs ANS: 4 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Describe the signs and symptoms of each of the common STIs. Page: 921 Heading: Chlamydia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1 2 3 4

Painful urination is a concern, but is not as health threatening as liver inflammation. Conjunctivitis is a concern but is not as health threatening as liver inflammation. Vaginal discharge is a concern but is not as health threatening as liver inflammation. Fitz-Hugh-Curtis syndrome, a surface inflammation of the liver, can also be caused by Chlamydia trachomatis. This inflammation may cause nausea,

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vomiting, and sharp pain at the base of the ribs that sometimes refers to the right shoulder and arm. PTS:

CON: Infection

4. The nurse is gathering information from a male patient who is presenting with difficult, painful, and frequent urination and a clear penile discharge. Which additional information supports urethritis? 1. “My partner also has some of the same symptoms.” 2. “I could have gotten something from swimming in a river.” 3. “I don’t have tenderness anywhere else in my genitals.” 4. “I drank cranberry juice in case it was my bladder.” ANS: 1 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Describe the signs and symptoms of each of the common STIs. Page: 920 Heading: Urethritis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1 2

Female partners of men with urethritis can also exhibit the symptoms of urethritis. This information supports the diagnosis. Urethritis is caused by a variety of microorganisms such as Neisseria gonorrhoeae, C trachomatis, Ureaplasma urealyticum, Trichomonas vaginalis, Candida albicans, and herpes simplex virus. These are all microorganisms that are sexually transmitted. The patient is not likely to become infected by swimming in a river. Urethritis can also cause epididymitis in the male patient, which accounts for tenderness on the testicles. The lack of genital tenderness may or may not support the diagnosis. The patient’s statement about drinking cranberry juice does not support urethritis. The patient suspected and responded to a possible bladder infection.

PTS:

CON: Infection

5. The nurse is providing care for a patient admitted for pneumonia. Which discovery made during admission will cause the nurse to notify the RN or HCP immediately? 1. Shortness of breath and coughing 2. Poor intake of food and liquids 3. An open, but painless ulcer on the penis 4. Low output via an indwelling catheter ANS: 3 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections

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Objective: Describe the signs and symptoms of each of the common STIs. Page: 920 Heading: Genital Ulcers Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1 2 3

It is expected for a patient admitted with pneumonia to experience shortness of breath and coughing. It is not unexpected for a patient admitted with pneumonia to have a poor intake of food and liquids. The nurse will encourage intake as tolerated. The nurse will report the presence of an open ulcer on the patient’s penis immediately to the RN or HCP. Genital ulcers can be caused by syphilis, herpes, and HIV. The absence of pain is most indicative of a syphilic ulcer. Because of the poor fluid intake, it is expected that the patient may have a low urinary output. However, the nurse will monitor this finding carefully.

PTS:

CON: Infection

6. A patient with hepatitis B virus (HBV) delivers a 6-pound, 2-ounce baby. Which action does the nurse anticipate will be needed for the infant? 1. IV antibiotics for 12 hours 2. Antiviral eye medication less than 2 hours after birth 3. There is no treatment that is safe and effective for infants. 4. HBV-immune globulin before 12 hours and HBV vaccine series ANS: 4 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Identify the pathogens involved with each of the common sexually transmitted infections (STIs). Page: 928 Heading: Hepatitis B Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 2 3 4

Antibiotics are not effective against viruses. Eye medication may be necessary for gonorrhea or Chlamydia. The infant needs to receive the HBV vaccination. It is recommended that all babies of HBV-positive mothers receive HBV immune globulin less than 12 hours after birth and then be immunized with HBV vaccine 1 week, 1 month, and 6 months after birth.

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PTS:

CON: Infection

7. The nurse is providing care for a female patient who is pregnant and tests positive for genital HSV-2 (herpes simplex virus type 2). Which comment by the patient indicates to the nurse that patient teaching is effective? 1. “At least I have the least serious type of herpes virus.” 2. “I know that an active lesion will mean a cesarean section.” 3. “At least the baby is at low risk for having serious effects.” 4. “I will decline antiviral medications to avoid birth defects.” ANS: 2 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Explain how you will know whether your nursing interventions have been effective. Page: 926 Heading: Herpes Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1 2 3

Herpes simplex virus type 2 (HSV-2) is more serious than HSV-I. Nursing teaching has been effective if the patient understands that an active lesion close to the time of birth will result in a cesarean section. Babies born to women with genital herpes always carry a risk for skin, eye, mucous membrane, and nervous system involvement. If the newborn develops a disseminated herpes infection, it can be life threatening. If the patient declines prophylactic antiviral medications at 36 weeks gestation, teaching has not been effective. The patient needs to know that medication at this point in pregnancy will not cause birth defects.

PTS:

CON: Infection

8. The nurse is collecting data on a patient in a HCP’s office. The patient tells the nurse he or she has the flu. The nurse notices a skin rash on the palms of the hands and soles of the feet, mouth sores, and lymphadenopathy. Which question is most important for the nurse to ask? 1. “Do you ever have unprotected sex?” 2. “Have you had any painless sores lately?” 3. “Does your hair appear to be thinning?” 4. “Is your activity hindered by joint pain?” ANS: 2 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Describe the signs and symptoms of each of the common STIs. Page: 925 Heading: Syphilis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation

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Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1

3 4

The patient may be exhibiting manifestations of secondary syphilis. Inquiring about unprotected sex may provide a source of an STI, but the nurse needs additional information before drawing any conclusions about the patient’s condition. The initial sign of syphilis is a painless, red, ulcerated area called a chancre, which can appear anywhere on the patient’s body. Chancres are the only manifestation of the primary stage of syphilis. This question is most important in determining if the patient is experiencing the secondary stage of syphilis. During the secondary stage of syphilis, the hair may thin; however, this is not a manifestation specific to syphilis. Joint pain may occur during the second stage of syphilis; however, this is not a manifestation specific to syphilis.

PTS:

CON: Infection

9. The nurse reviews the medical record for a patient who is diagnosed with genital warts. Which method of treatment is unexpected if the patient is pregnant? 1. Cryotherapy 2. Immunity stimulation 3. Laser 4. Electrocautery ANS: 2 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Describe treatment options for common STIs. Page: 927 Heading: Genital Warts (Low-Risk HPV) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1

3 4

Cryotherapy is a safe treatment of genital warts during pregnancy. The freezing of the wart is performed by touching it with a cryoprobe or with a liquidnitrogen soaked swab. Immunity stimulation treatment is not considered safe during pregnancy. The therapy uses medications to manipulate the patient’s immunity system into attacking the virus. The cytotoxic effects can damage the fetus. Laser treatment on genital warts is safe during pregnancy. The laser causes destruction of the wart tissue. Electrocautery is a safe treatment of genital warts during pregnancy. The process produces heat that causes proteins to coagulate, resulting in death of

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the wart tissue. PTS:

CON: Infection

10. The nurse is involved with a follow up visit for a female patient who contracted and had been self-treating for pubic lice. Which comment by the patient indicates that patient teaching is effective? 1. “I read the instructions for oral permethrin very carefully.” 2. “I have not seen any new red tracks in my external genital area.” 3. “I plan to have a serious talk to the guy who gave me an STI.” 4. “I plan to be much more discriminate about who I have sex with.” ANS: 4 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Explain how you will know whether your nursing interventions have been effective. Page: 928 Heading: Genital Parasites Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1 2

3 4

Permethrin is a topical medication used for the treatment of scabies, not pubic lice. All medications for scabies or pubic lice are topical. The lack of new red tracts under the skin is an indication that the patient does not have scabies. Resolution of pulic lice is supported by a lack of itching, redness, or visualization of the parasites. The patient needs to understand that pubic lice or scabies are not true STIs. Teaching is determined to be effective when the patient states a new cautious attitude about sexual partners.

PTS:

CON: Infection

11. The nurse is providing care for residents in an extended-care facility. An oriented, older adult female states to the nurse, “I think my boyfriend made me sick. My private parts itch and hurt.” Which action by the nurse is appropriate? 1. Ask permission for the RN to do a physical examination. 2. Inquire if the male who was involved forced her to have sex. 3. Request immediate STI testing for the male counterpart. 4. Understand the female resident is likely confused about the event. ANS: 1 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Plan nursing care for patients with STIs. Page: 920 Heading: Gerontological Issues

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The nurse needs to immediately inform the RN, who will ask for permission to perform a physical examination. Before asking if the male forced the female to have sex, data must be gathered to support or rule out the event. It is possible that geriatric residents may have consensual sex. If the female exhibits the manifestations indicative of an STI, the male will need to be tested. Older adults who engage in high-risk sexual behaviors are also at risk for STIs. However, the situation must be validated. It states in the question that the female resident is oriented. The nurse needs to understand that older adults may have consensual sex. However, the condition of the female must be assessed.

PTS:

CON: Infection

12. The nurse is teaching a patient the importance of completing treatment for gonorrhea. On which information is the nurse basing this teaching? 1. Gonorrhea is not treatable. 2. Only men experience symptoms; women are usually asymptomatic. 3. Men and women may be asymptomatic and still transmit the infection. 4. Treatment is associated with many serious side effects, so compliance is low. ANS: 3 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Plan nursing care for patients with STIs. Page: 921 Heading: Gonorrhea Integrated Process: Teaching/Learning Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Comprehension (Understanding) Concept: Infection Difficulty: Moderate Feedback 1 2 3

Gonorrhea is treatable with antibiotics, which have side effects, but not such serious side effects that compliance is affected. Men may be asymptomatic or may have urethritis with a yellow urethral discharge. Women who have gonorrhea may have either no noticeable symptoms or have a sore throat, mucopurulent cervicitis (MPC), urethritis, or abnormal menstrual symptoms such as bleeding between periods. The antibiotics used to treat gonorrhea do not have side effects so serious that compliance is affected.

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PTS:

CON: Infection

13. A patient who is pregnant is being treated for MPC. Which information is correct when the patient asks the nurse about the cause of the condition? 1. Imbalanced flora of the vagina 2. Presence of organisms that cause STIs 3. Risks of antibiotics during gestation 4. Continued sexual activity during pregnancy ANS: 2 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Identify the pathogens involved with each of the common sexually transmitted infections (STIs). Page: 920 Heading: Mucopurulent Cervicitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 2

3 4

MPC is not caused by an imbalance of the vaginal flora. MPC is caused by the same organisms that cause urethritis. Some causative agents include N gonorrhoeae, C trachomatis, U urealyticum, T vaginalis, C albicans, and herpes simplex virus, which are associated with STIs. Needing or receiving antibiotics during gestation does not cause MPC. Sexual activity during pregnancy, either prolonged absence or frequent activity, does not cause MPC.

PTS:

CON: Infection

14. A female client has been hospitalized multiple times requiring IV antibiotics for the treatment of pelvic inflammatory disease (PID). The nurse provides information to the patient emphasizing the potential for infertility from PID. Which statement by the patient indicates effectiveness of the presented information? 1. The patient understands the importance of antibiotic therapy. 2. The patient cries when learning about possible infertility. 3. The patient asks about the available surgery to restore fertility. 4. The patient promises to work on a monogamous relationship. ANS: 1 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Explain how you will know whether your nursing interventions have been effective. Page: 920 Heading: Pelvic Inflammatory Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential

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Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1

2 3

It is extremely important for the patient with PID to complete both the IV and oral antibiotics regimens to cure the infection. When the patient states an understanding, teaching is considered successful. Compliance is evaluated later. The patient may be upset about the possibility of infertility, but without a specific plan, the nurse cannot be certain the information has been effective. Asking about surgery to restore fertility does not indicate that information has been effective. The patient is seeking a resolution and not deciding on a change. Becoming monogamous may or may not indicate the information was effective. A promise to change is not an indicator of change.

PTS:

CON: Infection

15. A patient with frequent recurrent episodes of proctitis is diagnosed with rectal cancer. The patient is distraught and asks how cancer could develop. Which answer by the nurse is best? 1. Frequent inflammation of the anus and rectum causes cellular changes. 2. The patient is likely to have a family history of gastrointestinal cancer. 3. Cancer could have been prevented if the patient had followed medical advice. 4. The patient could have avoided the disease with dietary and vitamin therapy. ANS: 1 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Identify the pathogens involved with each of the common sexually transmitted infections (STIs). Page: 928 Heading: Cellular Changes Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1

2 3 4

Cellular changes can be related to STIs and result in precancerous or cancerous changes. Herpes viruses, HIV, and human papilloma have all been linked to the development of cancer. Proctitis is especially prevalent among persons who engage in anal intercourse. The patient may or may not have a family history of gastrointestinal cancer. Given the patient’s medical history, proctitis is the most likely cause. There is no information regarding medical advice given to the patient by the HCP. Dietary and vitamin therapy are not always the best preventions of cancer; the patient has a history of a precancerous or cancerous condition related to

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cellular changes caused by inflammation. PTS:

CON: Infection

16. A female patient is at the HCP’s office for an annual gynecological examination. When a bimanual examination is performed, the patient reports significant pain. Which medical condition is the patient likely to have? 1. Cystic ovaries 2. Ectopic pregnancy 3. PID 4. MPC ANS: 3 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Describe the signs and symptoms of each of the common STIs. Page: 926 Heading: Pelvic Inflammatory Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1 2 3 4

Cystic ovaries are not diagnosed from pain during a bimanual examination. An ectopic pregnancy is not diagnosed from pain during a bimanual examination. PID can be asymptomatic until the performance of a bimanual examination, which causes pain. MPC is not diagnosed from pain during a bimanual examination. It may produce mucopurulent yellow exudate on the cervix or be asymptomatic.

PTS:

CON: Infection

17. The nurse is visited by a teenage neighbor who asks, “I have a friend who thinks she has an STI and she is afraid to ask anyone about it. Can you give me some information for her?” Which reply does the nurse make? 1. “Are you sure that the ‘friend’ isn’t you?” 2. “Tell me some of the symptoms so I can help.” 3. “Would it help if I approached her mother with her?” 4. “Delayed treatment can result in serious lifelong complications.” ANS: 4 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Describe treatment options for common STIs. Page: 920 Heading: Nursing Care Tip Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential

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Cognitive Level: Application (Applying) Concept: Infection Difficulty: Moderate Feedback 1 2 3 4

Probing about the identity of the “friend” may keep the teenager from getting needed advice. With or without symptoms, the nurse should encourage medical care. It is not within the nurse’s scope of practice to diagnose a condition. The nurse needs to make sure the teenage friend gets appropriate help. Offering to approach the teenager’s mother may interfere with getting medical help. It is most important for the nurse to explain why the teenager needs to seek medical attention for a possible STI. The nurse’s goal is to provide information and encourage early treatment to prevent complications.

PTS:

CON: Infection

18. The nurse is presenting information about preventing STIs to a group of female students. The nurse identifies that teaching is ineffective if which statement is made by a student? 1. “I don’t know why I need all this information, I don’t have sex.” 2. “I know my boyfriend loves me and will always keep me safe.” 3. “It sounds like serious things can happen after getting an STI.” 4. “I feel better knowing there are people and places to help me.” ANS: 2 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Explain how you will know whether your nursing interventions have been effective. Page: 920 Heading: Nursing Diagnosis, Planning, and Implementation Integrated Process: Teaching/Learning Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Moderate Feedback 1 2

3 4

Teaching can be valuable for future reference; just because the student is not sexually active does not mean that teaching is ineffective. The prevention of STIs has nothing to do with how a boyfriend feels; the desire to have sex can prompt irresponsible behaviors. This comment indicates that teaching is ineffective for this student. Understanding and voicing the seriousness of an STI indicate that teaching has been effective. Teaching is effective if the student is aware of available resources, and how and where they can be accessed.

PTS:

CON: Infection

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MULTIPLE RESPONSE 1. The nurse is providing care for a patient recently diagnosed with Chlamydia. Which information does the nurse recommend be included in patient teaching? (Select all that apply.) 1. “Women with Chlamydia may complain of a sore throat.” 2. “Chlamydia is characterized by the development of chancres.” 3. “Ophthalmia neonatorum is seen in infants born to women with Chlamydia.” 4. “Chlamydia can be transmitted sexually and by blood and body fluid contact.” 5. “The risk of ectopic pregnancy is increased in women with a history of Chlamydia.” ANS: 4, 5 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Describe the signs and symptoms of each of the common STIs. Page: 921 Heading: Chlamydia Integrated Process: Clinical Problem-Solving Process Client Need: Clinical Problem-Solving Process (Nursing Process) Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Difficult

1. 2. 3. 4.

PTS:

Feedback Women who have gonorrhea may have either no noticeable symptoms or have a sore throat. Chancres can develop with syphilis. Newborns born to mothers who have gonorrhea can develop ophthalmia neonatorum. Chlamydia is the most commonly diagnosed STI in the United States. It can be transmitted sexually and by blood and body fluid contact. Chlamydia is a frequent cause of PID and infertility, and it increases the risk of ectopic pregnancy. Chlamydia is the most commonly diagnosed STI in the United States. It can be transmitted sexually and by blood and body fluid contact. Chlamydia is a frequent cause of PID and infertility, and it increases the risk of ectopic pregnancy. 1

CON: Infection

2. A patient in labor is diagnosed with MPC. For which health problems does the nurse anticipate providing care to the newborn? (Select all that apply.) 1. Pneumonia 2. Conjunctivitis 3. Irregular heart rate 4. Flaccid extremities 5. Cyanotic extremities

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ANS: 1, 2 Chapter: Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections Objective: Describe the signs and symptoms of each of the common STIs. Page: 921 Heading: Mucopurulent Cervicitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback MPC during pregnancy can result in conjunctivitis and pneumonia in newborn infants. MPC during pregnancy can result in conjunctivitis and pneumonia in newborn infants. MPC does not cause irregular heart rate or flaccid or cyanotic extremities in the newborn. MPC does not cause irregular heart rate or flaccid or cyanotic extremities in the newborn. MPC does not cause irregular heart rate or flaccid or cyanotic extremities in the newborn. 1

CON: Infection

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Chapter 45. Musculoskeletal Function and Assessment MULTIPLE CHOICE 1. The nurse is preparing material for a presentation about the musculoskeletal system. Which information is inaccurate in regard to the functioning of this system? 1. Voluntary muscles require nerve impulses to contract. 2. A continuous supply of blood is needed from the circulatory system. 3. Joint articulations are maintained by moisture from the lymph system. 4. Adequate oxygenation is supplied by respiratory system functioning. ANS: 3 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Explain the anatomy and function of the musculoskeletal system. Pages: 934–936 Heading: Musculoskeletal System Anatomy and Physiology Integrated Process: Teaching/Learning Client Need: Physiological Integrity/Physiological Adaptation Cognitive Level: Application (Applying) Concept: Mobility Difficulty: Moderate Feedback 1 2 3 4

Voluntary muscles do require nerve impulses to contract and create movement. A continuous supply of blood to maintain muscle health and promote functionality is needed from the circulatory system. Joint articulations are not maintained by moisture from the lymph system; joint capsules are lined with membranes that create synovial fluid. Oxygen is needed for muscle function, which is supplied by the respiratory system.

PTS:

CON: Mobility

2. The nurse is helping a patient understand all of the functions of the skeleton. Which function is incorrect? 1. It protects organs and tissues from mechanical injury. 2. It is the main system responsible for body movement. 3. Long, flat, and irregular bones store blood-forming tissue. 4. The entire system is responsible for the storage of excess calcium. ANS: 2 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Explain the anatomy and function of the musculoskeletal system. Pages: 934–936 Heading: Musculoskeletal Tissues and Their Functions Integrated Process: Teaching/Learning Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying)

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Concept: Mobility Difficulty: Moderate Feedback 1 2

The brain is protected by the skull, and the heart and lungs are protected by the thoracic cage. The skeletal system is not the main system responsible for movement. The skeletal system supports the muscles of the body; muscles are responsible for movement. Bone marrow (hematopoietic tissue) is stored in the ends of long bones of the arms and legs, in flat bones such as the ribs, and in irregular bones such as vertebrae and the pelvis. The bones store excess calcium, a process to maintain blood homeostasis. Calcium is also used for clotting and proper functioning of nerves and muscles.

PTS:

CON: Mobility

3. The nurse is caring for a patient with a suspected bone tumor. Which serum laboratory result indicates to the nurse that this health problem is present? 1. Decreased calcium 2. Increased magnesium 3. Increased creatine kinase (CK) 4. Elevated alkaline phosphatase (ALP) ANS: 4 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Identify diagnostic tests for musculoskeletal problems. Page: 962 Heading: Laboratory Tests Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Moderate Feedback 1

2 3 4

Serum calcium tends to decrease in patients with osteoporosis or in people who consume inadequate amounts of calcium in their diets. Serum calcium levels increase in patients with bone cancer. Magnesium is not an identified laboratory test to monitor for this patient. CK is monitored for muscle disease. ALP is an enzyme that increases when bone or liver tissue is damaged. In metabolic bone diseases and bone cancer, ALP increases to reflect osteoblast or bone-forming cell activity.

PTS:

CON: Mobility

4. The nurse is collecting data on an older adult patient. Which finding is indicative of normal changes in the musculoskeletal system of this patient?

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1. 2. 3. 4.

Presence of pain in knees joints in the morning Flaccid muscle tone in major muscle groups A notable “S” curve of the spinal column A recent history of falls and accidents

ANS: 1 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Describe the effects of aging on the musculoskeletal system. Pages: 934–936 Heading: Aging and the Musculoskeletal System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Moderate Feedback 1

3 4

Weight-bearing joints, such as the knees, are subject to damage over many years. The articular cartilage will wear down, which becomes rough and causes pain and stiffness. This is a normal change with aging. Muscle strength will decline with age due to a decrease in protein synthesis. Flaccid muscle tone in major muscle groups is not a normal change in the older patient. A notable “S” curve of the spinal column is most often associated with osteoporosis in the older patient. This is not a normal change. Recent history of falls and accidents for an older patient is a result of failure to maintain muscle strength through exercise. This is not a normal change.

PTS:

CON: Mobility

5. The nurse is collecting data on a patient who is experiencing hip pain. Which data does the nurse consider to be subjective? 1. The presence of a notable limp 2. Limited range of motion in the hip 3. A pain level of 7 on a 0-to-10 scale 4. Wincing when the hip joint is moved ANS: 3 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: List subjective data that are collected when caring for a patient with a disorder of the musculoskeletal system. Page: 962 Heading: Musculoskeletal System Data Collection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Mobility Difficulty: Moderate Feedback

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1 2 3 4

The presence of a notable limp is objective data; the nurse observes the manifestation. Limited range of motion of the hip is objective data; the nurse observes the manifestation. A pain level of 7 on a scale of 0-to-10 is subjective data; the nurse is relying on the patient’s evaluation. When the patient winces when the hip joint is moved, the nurse is able to observe the patient’s reaction. This is objective information.

PTS:

CON: Mobility

6. The nurse is providing care for a patient scheduled for an arthrography. Which explanation about pain during the procedure does the nurse provide? 1. “There is no pain during the procedure.” 2. “There is pain while the x-ray is taken.” 3. “There is temporary pain during dye injection.” 4. “The procedure will be uncomfortable until it is completed.” ANS: 3 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Identify diagnostic tests for musculoskeletal problems. Page: 944 Heading: Radiographs (X-Rays) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Teaching/Learning Cognitive Level: Application (Applying) Concept: Mobility Difficulty: Moderate Feedback 1 2 3 4

There is pain during the injection so this statement would not be true. The pain will be diminished by the time the x-ray is taken. Inform the patient that the test is uncomfortable during injection. The entire procedure will not be uncomfortable. PTS:

CON: Mobility

7. A patient diagnosed with curvature of the spine asks the nurse why breathing is so much more difficult. Which answer by the nurse best answers the question? 1. “The spine curvature is caused by a respiratory problem.” 2. “The curvature is caused by leaning over to breathe.” 3. “The thoracic cage expands with a spinal curvature.” 4. “The thoracic cage has lost some flexibility.” ANS: 4 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Explain the anatomy and function of the musculoskeletal system. Page: 935 Heading: Bone Tissue and Bone Growth

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Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Mobility Difficulty: Moderate Feedback 1

2 3 4

The spinal curvature is not caused by a respiratory problem. Some respiratory disorders will remodel the thoracic cage. An example is a barrel chest caused by chronic obstructive pulmonary disease. The spinal curvature is not caused from leaning over to breathe because of a respiratory disorder. A spinal curvature decreases the space of the thoracic cage and causes difficulty with breathing. Spinal curvatures cause the thoracic cage to lose some flexibility, which makes breathing more difficult.

PTS:

CON: Mobility

8. The nurse is collecting data for a patient with osteoporosis. Which serum calcium result indicates the typical changes that occur in serum calcium levels with osteoporosis? 1. 6.5 mg/dL 2. 8.9 mg/dL 3. 9.7 mg/dL 4. 11.2 mg/dL ANS: 1 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Identify diagnostic tests for musculoskeletal problems. Page: 940 Heading: Laboratory Tests Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Moderate Feedback 1

2 3 4

Serum calcium tends to decrease in patients with osteoporosis or in people who consume inadequate amounts of calcium in their diets. Normal serum calcium levels are 8.5 to 10.5 mg/dL. Normal serum calcium levels are 8.5 to 10.5 mg/dL. Normal serum calcium levels are 8.5 to 10.5 mg/dL. Calcium levels greater than 10.5 mg/dL indicate hypercalcemia, which may be related to metastatic bone disease or extended immobilization.

PTS:

CON: Mobility

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9. The nurse is collecting data on a patient with manifestations of osteoarthritis. Which method of physical examination is unnecessary? 1. Auscultating for joint deformity 2. General visual inspection 3. Palpating for abnormal conditions 4. Observing ability to perform range of motion (ROM) ANS: 1 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: List the objective data that are collected when caring for a patient with a disorder of the musculoskeletal system. Page: 963 Heading: Physical Examination Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Moderate Feedback 1 2 3 4

The nurse does not auscultate for joint deformity, which is usually identified with visual inspection. If the joint has crepitus, it can be heard and palpated. General visual inspection allows the nurse to identify joint deformities, the use of assistive devices, and mobility. Palpating allows the nurse to identify pain, tenderness, temperature, and edema. Observing the patient’s ability to perform ROM allows the nurse to determine the ability for the patient to be mobile and perform self-care.

PTS:

CON: Mobility

10. The nurse is providing care for a patient who is diagnosed with rhabdomyolysis from a crushing injury. Laboratory results indicate elevated levels of CK, myoglobin, and serum potassium. Which nursing care is most important for the nurse implement? 1. Alternate heat and cold applications. 2. Observe the color and amount of urine. 3. Perform passive ROM hourly. 4. Monitor for signs of muscle deterioration. ANS: 2 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Describe the nursing care provided for patients undergoing diagnostic tests of the musculoskeletal system. Page: 956 Heading: Rhabdomyolysis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Moderate

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Feedback 1 2

3 4

The patient will experience myalgia from this very serious and life-threatening condition; however, alternating heat and cold therapy is not commonly used. The most important care for the nurse to implement is close monitoring of the color and amount of urine. Typically, the urine will appear dark in color. The goal is to restore normal fluid balance. The patient with this diagnosis experiences muscle weakness and pain; however, there is no specific reason to perform passive ROM hourly. The diagnosis is indicative of muscle destruction, which is validated by laboratory levels.

PTS:

CON: Mobility

11. A patient arrives at a clinic with a knee joint that is noticeably swollen, warm to the touch, and painful. The HCP plans to perform an arthrocentesis. Given the patient’s symptoms, which is the least likely reason for the procedure? 1. To aspirate synovial fluid from the joint and relieve pressure 2. To inject corticosteroids or anti-inflammatories into the joint 3. To mechanically inhibit the production of synovial fluid 4. To visually inspect the withdrawn fluid for the presence to hemarthrosis ANS: 3 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Identify diagnostic tests for musculoskeletal problems. Page: 943 Heading: Arthrocentesis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Moderate Feedback 1 2

3 4

One reason for arthrocentesis is to aspirate synovial fluid from a swollen joint to decrease pressure and pain. When arthrocentesis is performed, the HCP can inject corticosteroids or antiinflammatories into the joint to promote comfort. Antibiotics can also be injected if necessary. Performance of an arthrocentesis in not done to mechanically inhibit the production of synovial fluid. When synovial fluid is withdrawn, it can be visually inspected or analyzed microscopically for the presence of hemarthrosis (blood in the joint cavity), noninflammatory conditions, or septic arthritis.

PTS:

CON: Mobility

12. The nurse is reviewing the laboratory results for a patient with severe bone pain. Which condition does the nurse suspect if the ALP level is elevated?

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1. 2. 3. 4.

Osteoarthritis Bone cancer Unhealed fracture Osteoporosis

ANS: 2 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Identify diagnostic tests for musculoskeletal disorders. Page: 943 Heading: Alkaline Phosphatase Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Moderate Feedback 1 2 3 4

Elevated ALP levels are not indicative of osteoarthritis. Elevated ALP levels are indicative of bone cancer; the presence of bone pain is an additional manifestation of the disease. Elevated ALP levels are not indicative of an unhealed fracture. Elevated ALP levels are not indicative of osteoporosis.

PTS:

CON: Mobility

13. A patient is scheduled for arthroscopic surgery on a knee. The patient is to receive light general anesthesia and will be discharged home. Which action will cause the nurse to contact the HCP or registered nurse (RN)? 1. Small amount of blood noted on the elastic wrap 2. A pain level of 8 on a 0-to-10 scale after mild analgesia 3. Assistance of two are needed to get into bedside chair 4. Grogginess lingers for several hours after the procedure ANS: 2 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Describe the nursing care provided for patients undergoing diagnostic tests of the musculoskeletal system. Page: 971 Heading: Arthroscopy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Difficult Feedback 1 2

A small amount of bleeding is expected from the surgical site after an arthroscopy; this finding does not warrant contacting the HCP or RN. After arthroscopy, the pain is usually managed effectively with a mild

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analgesic; a pain level of 8 on a 0-to-10 scale is unexpected. The nurse needs to contact the HCP or the RN. It is not unusual or unexpected for the patient to need assistance into a bedside chair following arthroscopy. The number of assistants is dependent on the size and condition of the patient. Every patient will respond to anesthesia differently. There is no reason to contact the HCP or RN if the patient remains groggy after several hours of light general anesthesia.

PTS:

CON: Mobility

14. The nurse is providing care for a patient before a myelography for diagnosis of a spinal column condition. Which statement regarding nursing care related to this procedure is correct? 1. “I will check your vital signs throughout the procedure.” 2. “I will stay close during the magnetic resonance imaging (MRI) portion of the testing.” 3. “You will be head down in bed so the medium flows to the neck.” 4. “You will receive medication for nausea before the testing starts.” ANS: 3 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Describe the nursing care provided for patients undergoing diagnostic tests of the musculoskeletal system. Page: 944 Heading: Myelography Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Teaching/Learning Cognitive Level: Application (Applying) Concept: Mobility Difficulty: Moderate Feedback 1 2

3 4

There is no reason for the nurse to be monitoring vital signs throughout a myelogram. A myelogram involves x-rays after the administration of a contrast medium. The test is usually performed on patients who are not good candidates for computerized tomography (CT) or MRI tests. The patient will be placed head down for a short period of time so that the contrast medium will flow upward into the area of the neck. There is no indication that the contrast medium used for myelography will cause nausea; the patient should not need medication.

PTS:

CON: Mobility

15. A patient is receiving care for a torn ligament at the insertion site of an upper arm muscle. The patient asks the nurse how this condition will affect movement. Which information will the nurse correctly share? 1. The lower arm can no longer be flexed.

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2. The upper arm will become disabled. 3. The movement of the arm will seem normal. 4. The lower arm will tend to hyperextend. ANS: 3 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Explain the anatomy and function of the musculoskeletal system. Page: 935 Heading: Muscle Structure and Arrangements Integrated Process: Clinical Problem-Solving Process (Nursing Process) Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Difficult Feedback 1

2 3 4

The body extremities have groups of muscles to provide movement. If the insertion site of an upper arm muscle is interrupted, movement is still possible via other group muscles. The upper arm is not disabled by interruption of the insertion site of an upper arm muscle. When a muscle of the upper arm is torn away from the insertion site, the arm will seem to function normally after a period of healing. The lower arm will not hyperextend if the tendon at the insertion site of an upper arm is interrupted.

PTS:

CON: Mobility

16. A female patient arrives at the HCP’s office for a routine checkup. The nurse notes that the patient is thin, of Asian descent, and experienced a surgery-induced menopause. Which test does the nurse expect the HCP to prescribe? 1. An anterior x-ray of the thoracic area 2. A bone scan of the ankle and wrist 3. A test to determine blood calcium levels 4. A dual-energy x-ray absorptiometry (DEXA) ANS: 4 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Identify diagnostic tests for musculoskeletal disorders. Page: 935 Heading: Bone Density Scan Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Moderate Feedback 1

An anterior x-ray of the thoracic area is not done to measure bone density; the x-ray will provide visualization of thoracic bones, and to some extent the heart

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and lungs. A bone scan of the wrist and ankle will provide some information regarding bone density, but the DEXA is more accurate for a high-risk patient. A blood test for blood calcium levels is not an effective way to diagnose osteoporosis. The test is a DEXA scan, which measures the spine, hip, and total body bone density. This is the test the HCP is most likely to order for this high-risk patient.

PTS:

CON: Mobility

17. A patient is prepared for a nuclear medicine scan of the skeleton, using gallium and thallium as the radioisotopes. Which nursing care will the nurse provide if the scan reveals high thallium concentrations? 1. Encourage fluid intake to neutralize radioisotopes. 2. Extend a willingness to sit and talk with the patient. 3. Medicate the patient as needed for pain from testing. 4. Support patient during episodes of vomiting and nausea. ANS: 2 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Describe the nursing care provided for patients undergoing diagnostic tests of the musculoskeletal system. Page: 944 Heading: Nuclear Medicine Scans Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Difficult Feedback 1 2

3 4

Fluid intake is encouraged regardless of the diagnostic outcome. When a bone scan is performed using gallium and thallium, the radioisotopes are drawn to the bone. High concentrations of gallium are indicative of tumors, inflammation, and infection. High concentrations of thallium are indicative of bone cancer, especially osteosarcoma. The best nursing care will involve emotional and psychological support. It is not likely the patient will have pain related to the bone scan; however, pain from bone cancer will be managed. It is not likely that the patient will experience nausea or vomiting after the bone scan.

PTS:

CON: Mobility

18. A patient just had an arthrogram performed for pain in a synovial joint. Which nursing care is inappropriate following this procedure? 1. Elevate the limb that was tested. 2. Apply ice to the affected area.

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3. Discuss the need for 12 to 24 hours of rest. 4. Apply an elastic wrap for swelling. ANS: 1 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Describe the nursing care provided for patients undergoing diagnostic tests of the musculoskeletal system. Page: 962 Heading: Arthrogram Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Moderate Feedback 1 2 3 4

After arthrogram, the involved limb needs to be elevated to decrease edema. Ice is applied to the affected limb after an arthrogram to decrease edema and pain. After an arthrogram, the patient is encouraged to rest for 12 to 24 hours to reduce discomfort and/or for safety. Swelling is expected following an arthrogram. Applying an elastic wrap after a procedure is not within the scope of practice for the nurse.

PTS:

CON: Mobility

MULTIPLE RESPONSE 1. A patient is recovering from a biopsy of the right femur and was given pain medication 1 hour ago. Which symptom does the nurse report and closely monitor in this patient? (Select all that apply.) 1. Temperature 98.4°F 2. Hematoma formation 3. Capillary refill of 3 seconds 4. Pain reported as 7 on a 0-to-10 scale 5. ROM of the ankle and knee present ANS: 2, 4 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Describe the nursing care provided for patients undergoing diagnostic tests of the musculoskeletal system. Page: 942 Heading: Bone or Muscle Biopsy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Difficult

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1. 2.

3. 4.

5. PTS:

Feedback This is a normal body temperature. The nurse inspects the biopsy site for bleeding, swelling, and hematoma formation. Increased pain that is unresponsive to analgesic medication may indicate bleeding in the soft tissue. This is a normal capillary refill. The nurse inspects the biopsy site for bleeding, swelling, and hematoma formation. Increased pain that is unresponsive to analgesic medication may indicate bleeding in the soft tissue. Full ROM is an expected finding. 1

CON: Mobility

2. A patient was an unrestrained passenger in a motor vehicle accident and hit the windshield. In addition, the patient’s leg was fractured. Which areas should be included in this patient’s neurovascular checks? (Select all that apply.) 1. Pulses 2. Sensation 3. Movement 4. Orientation 5. Pupil reaction ANS: 1, 2, 3 Chapter: Chapter 45. Musculoskeletal Function and Assessment Objective: Describe the nursing care provided for patients undergoing diagnostic tests of the musculoskeletal system. Page: 940 Heading: Role of the Nervous System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Difficult

4. 5.

Feedback Neurovascular checks for an extremity include movement, sensation (numbness/tingling), presence of pulses, skin temperature, color, and capillary refill. Neurovascular checks for an extremity include movement, sensation (numbness/tingling), presence of pulses, skin temperature, color, and capillary refill. Neurovascular checks for an extremity include movement, sensation (numbness/tingling), presence of pulses, skin temperature, color, and capillary refill. Orientation and pupil reaction are neurologic checks that are done to monitor the central nervous system. Orientation and pupil reaction are neurologic checks that are done to monitor the central nervous system.

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PTS:

CON: Mobility

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Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders MULTIPLE CHOICE 1. The nurse is preparing for a home visit to a patient after surgery for a compound fracture. Which specific care does the nurse anticipate for this patient? 1. Monitoring circulatory status 2. Changing wound dressings 3. Checking skin integrity 4. Validating immobilization ANS: 2 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Plan nursing care for a patient in a splint, cast, traction, or external fixation. Page: 950 Heading: Splints Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2

3 4

Routine care for any patient following a fracture is to perform circulatory status. Specific care for a patient following a compound fracture is to perform wound care. The patient with an open wound is likely to be in a splint and have an elastic bandage around the fracture location. This type of immobilization makes it possible to monitor and care for a wound. Routine care for any patient following a fracture is to check for skin integrity. Routine care for any patient following a fracture is to validate immobilization regardless of the type used.

PTS:

CON: Tissue Integrity

2. A patient experiences a fracture of the lower leg and undergoes a closed reduction and placement of a fiberglass cast. The patient is 65 years old and has a medical 30-year history of diabetes mellitus. Which condition does the nurse recognize as a possible complication for this patient? 1. Delay or absence of healing 2. Malalignment of healed bones 3. Development of bone infection 4. Impaired mobility function ANS: 1

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Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Explain the pathophysiology, signs and symptoms, and complications of fractures. Page: 951 Heading: Non-Union Modalities Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Moderate Feedback 1

3 4

The possibility of non-union (delayed or absence of healing) is a higher risk for some patients. Contributing factors are age and diseases that alter the healing process, such as diabetes mellitus. Malunion (malalignment of healed bones) is a non-union modality, which is most common in fractures that require internal fixation because of multiple bone pieces and fragments. With a closed reduction and placement of a cast, the risk for bone infection is low. Impaired mobility function is not an expected outcome for most bone fractures.

PTS:

CON: Mobility

3. An older adult patient is postoperative for a total hip joint replacement. Which nursing care is inappropriate for this patient on the day of surgery? 1. Assisted out of bed the evening of surgery 2. Provided with an elevated toilet seat 3. Medicated with oral pain medications 4. Prescribed weight-bearing is maintained ANS: 3 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Plan nursing care for a patient having a total joint replacement. Page: 971 Heading: Total Hip Replacement Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Moderate Feedback 1 2

Patients with a total hip replacement will get out of bed either the evening of the surgery or in the morning after surgery. An elevated toilet seat is needed to prevent the patient from hyper-flexing the new joint.

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Initially, pain is managed by epidural analgesia, patient-controlled analgesia, or IV analgesia. Oral analgesics are most likely introduced after the first postoperative day. The health care provider (HCP) will prescribe the amount of weight-bearing that is acceptable for the patient receiving a total hip replacement.

PTS:

CON: Mobility

4. The nurse is providing care for a patient who is scheduled for joint replacement the next day. Which patient care goals are appropriate at this time? 1. Teach postoperative exercises. 2. Ask if a consent form was signed. 3. Explain the use of assistive devices. 4. Manage preoperative pain. ANS: 4 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Plan nursing care for a patient having a total joint replacement. Page: 971 Heading: Total Joint Replacement Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Comfort Difficulty: Moderate Feedback 1

2 3

The day before surgery is not the best time to be teaching postoperative exercises. This activity should occur earlier along with some preoperative strengthening exercises. The nurse can check the patient’s medical record and confirm the presence of a signed surgery consent form. Explanation of the use of assistive devices will most likely be provided as each device is introduced to the patient during recovery. The day before is not appropriate. Patients requiring total joint replacement are likely to be in severe preoperative pain. Management of pain is an important patient goal.

PTS:

CON: Comfort

5. The nurse is providing care for a patient following an open reduction of a compound fracture. Which neurologic finding does the nurse report immediately to the HCP or registered nurse (RN)? 1. The foot on the surgical limb is cool to touch. 2. Surgical pain is reported at 8 on a 0-to-10 scale. 3. There exists numbness and tingling sensations. 4. There are decreased pulses and a dusky color on the surgical limb.

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ANS: 3 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Explain the pathophysiology, signs and symptoms, and complications of fractures. Page: 951 Heading: Neurovascular Status Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Difficult Feedback 1 2 3

The foot on the surgical limb should be warm to touch. However, this is a circulatory issue and not a neurologic finding. After any surgical procedure, it is expected for the patient to report a high level of pain; however, this is not a neurologic finding. When a patient reports the presence of numbness and tingling sensations, it is indicative of a neurologic manifestation. This finding needs to be reported immediately to the HCP or RN. Decreased pulses and dusky color of the surgical limb are indications of circulatory problems. The question specifically asks for neurologic findings.

PTS:

CON: Mobility

6. A patient with gout has been instructed on the prescribed medication allopurinol (Zyloprim). Which patient statement indicates understanding of the action of this medication? 1. “It excretes proteins.” 2. “It blocks formation of uric acid.” 3. “It increases formation of purines.” 4. “It increases metabolism of purines.” ANS: 2 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Describe the pathophysiology, treatment, and nursing care for gout. Page: 963 Heading: Gout Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Integrity Cognitive Level: Application (Applying) Concept: Safety Difficulty: Moderate Feedback 1 2

Allopurinol (Zyloprim) does not excrete proteins or increase the formation or metabolism of purines. Allopurinol (Zyloprim) decreases uric acid production.

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Allopurinol (Zyloprim) does not excrete proteins or increase the formation or metabolism of purines. Allopurinol (Zyloprim) does not excrete proteins or increase the formation or metabolism of purines.

PTS:

CON: Safety

7. The nurse is contributing to the plan of care for a patient who has an upper extremity amputation. Which factor does the nurse keep in mind about this type of amputation being more debilitating than a lower extremity amputation? 1. The upper extremity is more visible. 2. Prosthetic fitting is easier for the leg. 3. The upper extremity is more specialized. 4. There is greater blood supply to the upper extremity. ANS: 3 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Explain patient teaching for a patient with a lower extremity amputation and prosthesis. Page: 974 Heading: Surgical Amputation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Mobility Difficulty: Moderate Feedback 1 2 3

Upper extremity amputations are not more debilitating because the upper extremity is more visible. Upper extremity amputations are not more debilitating because the prosthetic fitting is easier for the leg. Upper extremity amputations are usually more significant than are lower extremity amputations as the arms and hands are necessary for performing activities of daily living. Upper extremity amputations are not more debilitating because of a greater blood supply to the upper extremities.

PTS:

CON: Mobility

8. A patient who has a displaced midshaft fracture of the left femur is in balanced suspension skeletal traction with 35 pounds of weight. The patient reports calf pain with right foot dorsiflexion. Which action does the nurse take? 1. Notify the RN. 2. Check the traction setup. 3. Reduce by 5 pounds of weight. 4. Encourage dorsiflexion more frequently.

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ANS: 1 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Explain the pathophysiology, signs and symptoms, and complications of fractures. Page: 952 Heading: Venous Thromboembolitic Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Perfusion Difficulty: Moderate Feedback 1 2 3 4

Calf pain on dorsiflexion can indicate a thrombophlebitis (Homan’s sign) and is indicative of a deep vein thrombosis (DVT). The RN should be informed. The nurse should not take the time now to check the traction setup. Traction weight cannot be reduced without a physician’s order. The patient should not be encouraged to exercise the limb now since a venous thromboembolitic complication might be present.

PTS:

CON: Perfusion

9. The home-care nurse is attending to a patient with osteomyelitis in a lower extremity from a traumatic bone fracture. The patient has an open wound that is infected. Which observation prompts the nurse to provide additional information to the patient and family? 1. Clean technique is used when the dressing is changed. 2. Hand hygiene is performed correctly and appropriately. 3. Possible side effects of antibiotics are understood. 4. Children and pets are kept away from the wound. ANS: 1 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Plan nursing care for osteomyelitis. Page: 958 Heading: Osteomyelitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Infection Difficulty: Difficult Feedback 1

When a patient has osteomyelitis, sterile dressing changes are always used, even in the home environment. Osteomyelitis is difficult to treat and preventing additional infections is important. Additional teaching is required. Additional teaching is not required when the nurse validates that hand hygiene is performed correctly and at the appropriate times (before and after providing

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care). Additional teaching is not required if the patient and family understand the side effects of antibiotics. Because of the virulence of the infection, the difficulty of resolving the infection, and the possibility of transmitting the infection to others, pets and children are kept away from the wound. No additional teaching is required.

PTS:

CON: Infection

10. The nurse is providing care for a patient being treated after a complicated femur fracture. The nurse has noticed drowsiness, tachycardia, and a low-grade fever. Which additional manifestation alerts the nurse to the possibility of a fat emboli? 1. Respiratory rate of 20 breaths/min 2. Presence of a petechial rash on chest and neck 3. An oxygen saturation level of 92 percent on room air 4. Verbal complaints of nausea with vomiting ANS: 2 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Explain the pathophysiology, signs and symptoms, and complications of fractures. Page: 952 Heading: Fat Embolism Syndrome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Mobility Difficulty: Moderate Feedback 1 2 3 4

A respiratory rate of 20 breaths/min is within normal range. The presence of petechial rash is one of the classic manifestations of a fat emboli; the rash can appear on the chest, neck, axilla, and conjunctiva. An oxygen saturation level of 92 percent on room air is not necessarily an indication of a fat emboli. Verbal complaints of nausea with vomiting can be caused by multiple problems; however, it is not alone indicative of a fat emboli.

PTS:

CON: Mobility

11. The nurse is assisting with the preparation of materials for a health fair aimed at promoting health in women. Which reason does the nurse recognize as a probable cause of an increase in the incidence of osteoporosis? 1. More adults are lactose intolerant. 2. Adults tend to be more sedentary. 3. The ages of adults have increased. 4. There is an increased number of smokers.

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ANS: 3 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Describe risk factors, pathophysiology, treatment, and nursing care for osteoporosis. Page: 958 Heading: Osteoporosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Fluid and Electrolyte Balance Difficulty: Moderate Feedback 1 2 3

Increased incidence of osteoporosis is not related to an increase of adults who are lactose intolerant. The most likely cause of an increase in the incidence of osteoporosis may or may not be related to sedentary lifestyle. The population in the United State is increasing in age due to longevity related to better health care and disease management. Osteoporosis is a disease connected to aging. The number of smokers may or may not have increased. Patient education is readily available about the health risks related to smoking.

PTS:

CON: Fluid and Electrolyte Balance

12. The nurse is providing care for a patient who experienced a closed reduction to a fracture of the ulna. Which manifestation does the nurse recognize as an early symptom of acute compartment syndrome? 1. Paralysis of the affected limb 2. Lack of a distal pulse 3. Pallor with extremity warmth 4. Poikilothermia of the arm ANS: 3 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Explain the pathophysiology, signs and symptoms, and complications of fractures. Page: 954 Heading: Acute Compartment Syndrome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Moderate Feedback 1

With compartment syndrome, paralysis is a late manifestation.

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With compartment syndrome, the absence of a pulse is a late and ominous manifestation. Pallor is an early manifestation of compartment syndrome; however, there may, at this time, be warmth or redness over the area. Poikilothermia is indicative of suppressed circulation. The manifestation is coolness of the extremity. The term indicates that the limb is the same temperature as the environment.

PTS:

CON: Mobility

13. The nurse is providing care for a patient after an above-the-knee amputation because of ischemia related to diabetes mellitus complications. Which nursing care is essential for promoting ambulation? 1. Building upper body strength 2. Promoting coordination exercises 3. Maintaining residual limb elevation 4. Lying on the abdomen as prescribed ANS: 4 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Explain patient teaching for a patient with a lower extremity amputation and prosthesis. Page: 974 Heading: Amputation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Moderate Feedback 1

2 3

The patient may need upper body strength for moving about or for using crutches when a prosthesis is not worn. However, this action does not involve essential nursing care to promote ambulation. Coordination may be helpful, but it is not part of the essential nursing care for promoting ambulation. It is important to avoid the formation of hip contractures from flexing the hip for long periods of time. Sitting and the elevation of the residual limb are the most common offenders. Once contractures develop, ambulating with a prosthesis is impossible. The client will need to lie supine for 30 minutes at least four times a day. This activity will likely be prescribed by the HCP or physical therapist. Hip contractures must be avoided if ambulation is to be accomplished.

PTS:

CON: Mobility

14. A patient is being prepared for a prosthesis following surgery for an amputation. Which information will the nurse provide to the client regarding the use of a prosthesis?

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1. 2. 3. 4.

Manual massage will help shape the end of the residual limb. A prosthesis will not be fitted until the surgery site is healed. A shrinker sock is worn with the prosthesis to prevent sores. Skin inspection is performed each time the sock is removed.

ANS: 4 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Explain patient teaching for a patient with a lower extremity amputation and prosthesis. Page: 975 Heading: Prosthesis Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Mobility Difficulty: Moderate Feedback 1 2 3 4

Manual massage is not specific enough to assure the correct preparation of the residual limb for a prosthesis. A temporary prosthesis is often worn until swelling subsides. A shrinker sock is commonly worn to reduce swelling and help shape the limb for the prosthesis. The sock is worn with and without the prosthesis. It is essential that the residual limb be checked for infections and skin integrity each time the shrinker sock is removed. Neurovascular checks are performed at the same time.

PTS:

CON: Mobility

15. The nurse is providing care for a patient with external fixation for a fracture involving severe bone damage. Which is the most important focus for the nurse during care of this patient? 1. Monitoring pin and wound sites for signs of infection 2. Helping the patient achieve a desired level of mobility 3. Being aware that the patient may experience issues with body image 4. Providing a caring and supportive attitude during a challenging time ANS: 1 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Plan nursing care for a patient in a splint, cast, traction, or external fixation. Page: 952 Heading: External Fixation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Mobility Difficulty: Moderate

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Feedback 1

External fixation allows visualization and care for soft tissue injuries and holds bone pieces in place with the insertion of a pin through the skin and into the bone. Both conditions need to be monitored regularly for signs of infection. This is the most important care performed by the nurse. The nurse is aware of the patient’s desired level of mobility and can assist with meeting this goal. However, this is not the most important nursing care for this patient. The external fixation device is intimidating in appearance and may result in issues related to body image. The nurse can assist with this issue; however, it is not the most important nursing care for this patient. Providing a caring and supportive attitude is always an important nursing intervention. It especially important with a patient who has a challenging, and possibly prolonged, healing process. However, this is not the most important nursing care for this patient.

PTS:

CON: Mobility

16. The nurse is assisting with the care of a patient with rheumatoid arthritis (RA). The nurse must remember in which way RA care is different from osteoarthritis care. Which nursing care does the nurse specifically provide for the patient with RA? 1. Exercise is poorly tolerated and frequent rest is needed. 2. Acutely inflamed joints will respond best to heat therapy. 3. It is essential to monitor all body systems for effects of the disease. 4. Injury and age are the greatest contributors to disease development. ANS: 3 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Compare the care for osteoarthritis and rheumatoid arthritis. Page: 968 Heading: Rheumatoid Arthritis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1 2 3

The patient with RA will maintain a higher level of functioning with exercise and physical activity, which is balanced with rest periods. With RA, inflamed joints will respond best to ice therapy. Heat applications and hot showers will alleviate stiffness. When a patient has RA, all body systems can be affected. The nurse needs to carefully watch for changes to blood vessels, nerves, kidneys, pericardium, lungs, and subcutaneous tissue. RA is a disease of the connective tissue. Injury and age are actually the greatest contributors to osteoarthritis.

PTS:

CON: Immunity

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17. The nurse is assisting with patients on an orthopedic unit. Which is an important factor to remember when caring for patients after a total hip replacement? 1. Side-lying position is permitted with a pillow between the legs. 2. A triangular pillow is used between the legs to avoid adduction. 3. Sitting in a bedside chair is permitted if the legs are elevated. 4. Place three pillows between the legs, one distal and three proximal. ANS: 2 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Plan nursing care for a patient having a total joint replacement. Page: 971 Heading: Hip Dislocation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Mobility Difficulty: Moderate Feedback 1 2 3 4

If a patient is permitted to be in a side-lying position, the legs must be abducted by more than one pillow, which is inadequate to prevent hip dislocation. After a total hip replacement, a triangular pillow is used between the legs to avoid adduction. When sitting in a bedside chair, overflexion of the hips is prevented by using a higher chair; the lower legs are not elevated. Three pillows can be used to maintain abduction; however, one pillow is placed proximal and two are placed distal.

PTS:

CON: Mobility

18. The nurse is assisting with the care of patients who have had joint replacement surgery. Which action is unnecessary for the patient after a total knee replacement (TKR)? 1. Monitor for excessive bleeding. 2. Check for indications of a DVT. 3. Ambulate as prescribed by HCP. 4. Maintain proper joint alignment. ANS: 4 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Plan nursing care for a patient having a total joint replacement. Page: 972 Heading: Total Knee Replacement Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Mobility Difficulty: Moderate

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Feedback 1 2 3 4

As with any surgery, the patient with a TKR is monitored for excessive bleeding. Patients with total joint replacements need to be monitored for the formation of DVTs. Patients with a TKR are frequently gotten out of bed and/or ambulated for a short distance the evening of surgery or the next morning. Unlike the patient with a total hip replacement, the TKR does not require maintenance of specific joint alignment.

PTS:

CON: Mobility

MULTIPLE RESPONSE 1. A patient asks the difference between osteoarthritis and RA. Which manifestations does the nurse explain are characteristic of RA? (Select all that apply.) 1. Low-grade fever 2. Heberden’s nodes 3. Autoimmune disease 4. Pain increasing by activity 5. Early morning stiffness ANS: 1, 3, 5 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Compare the care for osteoarthritis and rheumatoid arthritis. Page: 962 Heading: Rheumatoid Arthritis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback RA is a systemic autoimmune disease with morning stiffness and low-grade fever. Heberden’s nodes are seen in osteoarthritis. RA is a systemic autoimmune disease with morning stiffness and low-grade fever. Pain increases with activity in osteoarthritis. RA is a systemic autoimmune disease with morning stiffness and low-grade fever. 1

CON: Immunity

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2. The nurse is collecting data from a patient suspected of developing a fat embolus from a fracture of the right femur. Which manifestations does the nurse expect? (Select all that apply.) 1. Petechiae 2. Migraine 3. Tachycardia 4. Mental confusion 5. Numbness in the right leg ANS: 1, 3, 4 Chapter: Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders Objective: Explain the pathophysiology, signs and symptoms, and complications of fractures. Page: 956 Heading: Fat Emboli Syndrome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Perfusion Difficulty: Difficult

2. 3.

5. PTS:

Feedback The earliest manifestation of fat emboli syndrome (FES) is altered mental status from a low arterial oxygen level. The patient then experiences tachycardia, tachypnea, fever, high blood pressure, severe respiratory distress, and petechiae. A migraine is not indicative of FES. The earliest manifestation of FES is altered mental status from a low arterial oxygen level. The patient then experiences tachycardia, tachypnea, fever, high blood pressure, severe respiratory distress, and petechiae. The earliest manifestation of FES is altered mental status from a low arterial oxygen level. The patient then experiences tachycardia, tachypnea, fever, high blood pressure, severe respiratory distress, and petechiae. Numbness in the right leg is not indicative of FES. 1

CON: Perfusion

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Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures MULTIPLE CHOICE 1. The nurse asks an older adult patient to count backward from 100 in increments of three; the patient counts correctly until the nurse stops the process. Which reason does the nurse identify as a likely cause of long periods of hesitation during the process? 1. Normal loss of neurons related to aging 2. Early manifestation of dementia 3. Normal delay in problem solving 4. Result of malnutrition and depression ANS: 3 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Identify the effects of aging on the nervous system. Page: 990 Heading: Aging and the Nervous System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 2 3 4

With age, the brain loses neurons. However, it loses only a small percentage of the total, so this is not the usual cause of mental impairment in older adults. Some forgetfulness and decreased ability to problem solve is expected with aging, but these manifestations are not indicative of dementia. The patient’s long periods of hesitation are indicative of a normal delay in problem solving. The long delays during the testing are not indicative of malnutrition and depression. However, some causes of mental changes include depression, malnutrition, infections, hypotension, and medication side effects. There is not enough information in this scenario to identify any of these causes.

PTS:

CON: Neurologic Regulation

2. The nurse is providing care for multiple patients. Which patient does the nurse decide to report immediately to the health care provider (HCP) or the registered nurse (RN)? 1. The patient admitted with dysphagia who choked on a thickened liquid 2. The patient who begins to exhibit lack of coordination and aphasia 3. The patient whose neurologic checks show slight variations over 8 hours 4. The patient who reports tingling in the fingers 1 hour after surgery on the hand ANS: 2 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: List data to collect when caring for a patient with a disorder of the nervous system.

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Page: 990 Heading: Nursing Assessment of the Neurologic System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult Feedback 1

3 4

After a stroke, a patient with dysphasia is placed on a diet that contains thickened liquids. It is possible for the patient to occasionally choke; the nurse will monitor the patient for complications and suggest that the dietitian reevaluate the patient’s diet. Any sudden change in a patient’s neurologic functioning should be reported immediately to the HCP or the RN. Rapid intervention may make the difference between chronic dysfunction and recovery, or even between life and death for the patient. When a patient is receiving neurologic checks over a period of time, some slight variations are normal and expected. One hour after surgery on a patient’s hand, it may be expected to experience tingling in the fingers as the anesthesia wears off. However, the nurse should perform additional neurologic checks to validate well-being.

PTS:

CON: Neurologic Regulation

3. The nurse is assisting with a patient who was injured in an accident and experienced head injury. The RN records the patient as exhibiting decerebrate posturing. Which condition does the nurse associate with the RN’s finding? 1. Damage to the area of the brainstem 2. Injury to the spinal cord and ascending nerves 3. Significant impairment of cerebral functioning 4. Likelihood of coma preceding brain death ANS: 1 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Identify tests used to diagnose disorders of the nervous system. Page: 991 Heading: Glasgow Coma Scale Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Neurologic Regulation Difficulty: Difficult Feedback 1 2

The patient’s posturing is indicative of damage in the area of the brainstem; the arms and legs are extended and the arms are internally rotated. Decerebrate posturing does not indicate injury to the spinal cord and ascending nerves. Damage to the spinal cord is most likely to cause paralysis and/or

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dysfunction of the descending nerves. Significant damage to the cerebral area of the brain is noted by the presence of decorticate posturing. This manifestation exhibits as flexion of the arms at the elbows, hands are raised toward the chest, and legs are extended. Neither posturing indicates the likelihood of a coma preceding brain death.

PTS:

CON: Neurologic Regulation

4. The nurse is preparing a patient for neurologic testing. Which testing does the nurse expect if the patient expresses severe pain in the lower back aggravated by movement? 1. Electroencephalogram 2. Angiogram 3. Myelogram 4. Spinal x-rays ANS: 3 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Identify tests used to diagnose disorders of the nervous system. Page: 996 Heading: Diagnostic Tests for the Neurologic System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 2 3

An electroencephalogram is performed to record brain activity; analysis of the tracings can identify areas of abnormality. An angiogram consists of an x-ray following the injection of dye to examine the structure of specific vessels as well as overall circulation to the area. A myelogram is an x-ray performed after the injection of a contrast medium to identify compressed nerve roots, herniated intravertebral disks, and blockage of cerebrospinal fluid circulation. Spinal x-rays are performed to determine the status of individual vertebrae and their relationship to each other. This testing does not help determine the involvement of nerves.

PTS:

CON: Neurologic Regulation

5. The nurse will be accompanying a patient to the radiology department for the performance of a computerized axial tomography (CAT) scan with contrast. The patient is an older adult who has pain and exhibits signs of mild agitation. Which nursing care for the patient related to the examination is inappropriate? 1. Administer prescribed sedation prior to testing. 2. Reassure sensations are not caused by incontinence. 3. Monitor closely for symptoms of allergic reactions. 4. Provide pain medication as soon as the test is done.

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ANS: 4 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Plan nursing care for patients undergoing diagnostic tests for disorders of the nervous system. Page: 996 Heading: Computed Tomography Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 2

Because the patient is mildly agitated, the nurse will administer the prescribed sedation prior to testing. Patients receiving dye may experience feelings of warmth; when the sensation is in the groin area, the patients may think they are incontinent. The nurse can reassure the patient of the sensation either before or during the procedure. The dye may cause allergic reactions, such as nausea, diaphoresis, itching, or trouble breathing. The patient is monitored closely and symptoms are reported immediately to the HCP. If the patient has pain, he or she can be given prescribed pain medication prior to the testing. However, the nurse needs to be aware of the side effects and take care not to overmedicate the patient with both a sedative and pain medication.

PTS:

CON: Neurologic Regulation

6. The nurse is providing care for a female patient who is paralyzed from a C-4 spinal cord injury. The patient is turned and repositioned every 2 hours. Which action does the nurse take when repositioning the patient in a side-lying position? 1. Place the patient’s call light within reach. 2. Ask the patient if the new position is comfortable. 3. Check that her breast is not compressed under her body. 4. Massage reddened or blanched areas on her back. ANS: 3 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Describe common therapeutic measures used for patients with disorders of the nervous system. Page: 997 Heading: Moving and Positioning Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1

With a C-4 spinal cord injury, the patient is unable to use a call light. Other

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methods of calling for assistance will be utilized. With a C-4 spinal cord injury, the patient is unable to determine if his or her body is comfortable; the nurse’s responsibility to check for potentially harmful stress and pressure is crucial. When a female with a C-4 spinal cord injury is positioned in a side-lying position, it is important to make sure that her breast is not compressed beneath her body and interrupting circulation. For the male patient, the position of the scrotum is evaluated. Reddened or blanched areas are indicative of pressure injury or an increased risk; this finding needs to be reported to the HCP or RN. Massage may cause additional injury.

PTS:

CON: Neurologic Regulation

7. An older adult patient is hospitalized for a respiratory infection. The nurses have been placing the patient’s feet into high-top tennis shoes even while in bed. Which answer does the nurse make to a family member who asks about the purpose of the shoes? 1. Instruct the family that the same practice should be continued at home. 2. Share that the practice keeps the patient ready for ambulating to the bathroom. 3. Explain that this practice keeps the sheets from placing pressure on the feet. 4. Explain that without the proper foot position, it is impossible to stand. ANS: 4 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Describe common therapeutic measures used for patients with disorders of the nervous system. Page: 996 Heading: Contractures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1

2 3 4

The patient may be perfectly able to stand and ambulate at home; there is not enough information to determine if the practice needs to be continued after discharge. The use of high-top tennis shoes while in bed is for proper foot alignment, not for readiness to ambulate to the bathroom. If a patient is not able to get out of bed, or the sheets hold the patient’s feet in a plantar flexed position, the sheets need to be loosened. It does not take long for contractures of the feet to occur if the patient is unable to ambulate or stand on a regular basis. The high-top tennis shoes will hold the feet in normal alignment to prevent those contractures. Contractures of the feet and ankles will make standing and ambulation impossible.

PTS:

CON: Neurologic Regulation

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8. The nurse is collecting data from a patient in the HCP’s office. Which statement by the patient indicates that the patient is likely to be having problems with some activities of daily living (ADLs)? 1. “I am more comfortable in slip-on shoes.” 2. “I am no longer able to carry heavy objects.” 3. “I can barely lift my arms above my shoulders.” 4. “I try to only go up and down the stairs once a day.” ANS: 3 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: List data to collect when caring for a patient with a disorder of the nervous system. Page: 997 Heading: Activities of Daily Living Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult Feedback 1 2 3

The preference for slip-on shoes is not alone a statement addressing the ability to perform ADLs. This statement needs to be explored. The inability to carry heavy objects may or may not interfere with the patient’s ability to perform ADLs. This statement needs to be explored. The inability to lift the arms above the shoulders causes serious concern about the patient’s ability to perform ADLs. This limitation can interfere with personal hygiene care, and even the ability to eat and drink. Attempting to limit trips up and down the stairs may or may not interfere with the patient’s ability to perform ADLs. This statement needs to be explored.

PTS:

CON: Neurologic Regulation

9. A patient is being admitted to a long-term care facility. Medical history includes a recent stroke with dysarthria. Which factor does the nurse consider when providing care for this patient? 1. The patient is likely to also have a cognitive deficit. 2. The patient will be able to answer yes-or-no questions. 3. A picture board will help the patient with word searching. 4. Profanity is expected due to patient frustration. ANS: 3 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Describe common therapeutic measures used for patients with disorders of the nervous system. Page: 997 Heading: Communication Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing)

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Concept: Neurologic Regulation Difficulty: Difficult Feedback 1

3 4

When a patient experiences dysarthria, it does not indicate that the patient has cognitive deficits. Treating the patient as such only increases the patient’s frustration with the inability to communicate. The nurse does not make the assumption that the patient can answer yes-or-no questions correctly. Patients with dysarthria may answer all questions with either a yes or no. For the patient with unintelligible speech or with serious word searching, a picture board with commonly used items can be useful and reduce frustration. Profanity is not necessarily a response to frustration. Some patients will use a single word as the response to all questions or communication. For some patients, that single word may be a profanity.

PTS:

CON: Neurologic Regulation

10. A patient comes to the emergency room exhibiting confusion and manifestations related to dementia. Records from previous visits indicate a history of drug and alcohol abuse along with frequent treatment for sexually transmitted infections (STIs). Which laboratory test does the nurse consider to be unnecessary? 1. Venereal disease research laboratory test (VDRL) 2. Anticholinesterase testing with antibody titers 3. Liver function and renal function tests 4. Erythrocyte sedimentation rate (ESR) and white blood cell (WBC) count ANS: 2 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Identify tests used to diagnose disorders of the nervous system. Page: 995 Heading: Laboratory Tests Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1

3 4

With a medical history of frequent treatment for STIs, a VDRL test for syphilis is expected. The manifestations of confusion and those related to dementia support this test. Anticholinesterase testing with antibody titers is testing that is performed to diagnose myasthenia gravis. This test is unnecessary given the patient’s symptoms. The patient’s history of alcohol and drug abuse may account for the patient’s behavior; liver function and renal function tests are appropriate. Without knowing the cause of the patient’s symptoms, an ESR and WBC count are appropriate to rule out infection.

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PTS:

CON: Neurologic Regulation

11. The nurse is preparing to perform a Romberg test on a client. The nurse instructs the patient to stand with the feet together and eyes closed. After 20 seconds, the patient leans to one side and exhibits a swaying motion. Which conclusion does the nurse draw from these test results? 1. The test is positive and indicates an inner ear infection. 2. The test is negative and indicates a benign cerebral tumor. 3. The test is positive and indicates cerebellar dysfunction. 4. The test is negative and indicates cochlear dysfunction. ANS: 3 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Identify tests used to diagnose disorders of the nervous system. Page: 994 Heading: Nursing Assessment of the Neurologic System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult Feedback 1 2 3 4

A positive Romberg test does not indicate an inner ear infection. A negative Romberg does not indicate a benign cerebral tumor. A positive Romberg test, when the patient sways or leans to one side during the test, can be indicative of cerebellar dysfunction. A negative Romberg test is not indicative of cochlear dysfunction.

PTS:

CON: Neurologic Regulation

12. The nurse is assisting with the care of a patient admitted following a fall resulting in a head injury. Which finding prompts the nurse to inform the RN that the patient is experiencing a negative change in the level of consciousness? 1. Verbal commands are completed as stated. 2. The patient arouses quickly from a state of drowsiness. 3. The patient falls asleep in the middle of a sentence. 4. The patient withdraws from mild pain stimulation. ANS: 3 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Identify tests used to diagnose disorders of the nervous system. Page: 989 Heading: Level of Consciousness Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction in Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate

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Feedback 1 2 3

A patient is exhibiting a normal level of consciousness when he or she is able to complete a verbal command as stated. A quick arousal from a state of drowsiness is not indicative of a negative change in the patient’s level of consciousness. The inability to remain awake or alert can be a negative change in the patient’s level of consciousness. Falling asleep in the middle of a sentence is a behavior that needs to be reported to the RN. Withdrawal from mild pain stimulus is a normal response.

PTS:

CON: Neurologic Regulation

13. The nurse is monitoring a patient who is 4 years of age who fell down a flight of steps. A Babinski response was not present during the initial assessment. The RN asks the nurse to recheck for a Babinski reflex and report abnormal responses. Which response will the nurse report to the RN? 1. The great toe extends and the other toes fan out. 2. All the toes curl toward the sole of the foot. 3. The great toe flexes when sole is stroked. 4. The foot is jerked away when the sole is stroked. ANS: 1 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Identify tests used to diagnose disorders of the nervous system. Page: 994 Heading: Nursing Assessment of the Neurologic System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1

2 3 4

After the age of 6 months, the Babinski reflex is no longer present. At 4 years of age, a positive reflex (extension of the great toe and fanning of the other toes) is indicative of neurologic dysfunction. This finding is reported to the RN. All toes curling toward the sole of the foot is not a positive Babinski reflex. After the age of 6 months, the flexion of the great toe when the sole of the foot is stroked is normal. The patient may or may not jerk the foot away when the sole of the foot is stroked; this action is not a positive Babinski reflex.

PTS:

CON: Neurologic Regulation

14. The nurse is preparing to collect data during the reassessment of a patient’s neurologic status. Which equipment is unnecessary for this procedure? 1. Clean gloves 2. Reflex hammer

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3. Cotton ball 4. Pointed object ANS: 3 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Identify tests used to diagnose disorders of the nervous system. Page: 994 Heading: Physical Examination Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 2

3 4

Clean gloves will be needed as the nurse performs the palpation actions related to a neurologic reassessment. A reflex hammer is used to assess the presence and characteristics of body reflexes; however, this procedure is not performed by the licensed practical nurse/licensed vocational nurse. A cotton ball is used to reassess if the patient can distinguish a soft-touch sensation. A pointed object is used to reassess if the patient can distinguish a sharp sensation.

PTS:

CON: Neurologic Regulation

15. The nurse is providing care for a patient who is experiencing difficulty eating due to a neurologic dysfunction. Which action by the nurse will be least helpful in promoting adequate nutritional intake for this patient? 1. Provide high-protein, high-caloric foods and supplements. 2. Position the patient to sit upright as much as possible. 3. Plan for small frequent meals to improve toleration. 4. Allow the patient adequate time and privacy to self-feed. ANS: 4 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Describe common therapeutic measures used for patients with disorders of the nervous system. Page: 998 Heading: Nutrition Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1

When a patient is diagnosed with a neurologic dysfunction, it is often difficult

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3 4

for the patient to achieve an adequate nutritional intake, a condition often compounded by the increased metabolic rate that occurs with neurologic dysfunction or illness. Nutrition should consist of high-protein, high-caloric foods and supplements. Choking and/or swallowing difficulties are often seen in patients with neurologic dysfunctions. The nurse will assist the patient to the most upright position possible. When a patient has any condition that interferes with the ability or desire to eat, small, frequent meals should be provided. When a patient has a neurologic dysfunction, the nurse needs to remain close by to be of assistance or to react to problems or complications.

PTS:

CON: Neurologic Regulation

MULTIPLE RESPONSE 1. The nurse suspects a patient is experiencing a sympathetic response. Which manifestations does the nurse expect the patient to exhibit? (Select all that apply.) 1. Relaxation of bladder 2. Decrease in peristalsis 3. Dilation of bronchioles 4. Decrease in heart rate to normal 5. Increase in salivary gland secretion ANS: 1, 2, 3 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Describe the normal structures and functions of the nervous system. Pages: 985–986 Heading: Sympathetic Division Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback The bladder muscle relaxes and the sphincter constricts to prevent urination. Relatively less important activities such as digestion (and salivation) are slowed. Vasodilation in skeletal muscles supplies them with more oxygen; the bronchioles dilate to take in more air. When the sympathetic nervous system is activated, the heart rate increases. Relatively less important activities such as digestion (and salivation) are slowed, and vasoconstriction in the skin and viscera permits greater blood flow to more vital organs such as the brain, heart, and muscles. 1

CON: Neurologic Regulation

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2. The nurse is caring for a patient scheduled for a computed tomography (CT) scan with contrast. Which actions does the nurse include in the preprocedure preparation? (Select all that apply.) 1. Check blood urea nitrogen (BUN) and creatinine levels. 2. Question the patient about allergies to dye, shellfish, or iodine. 3. Determine if the patient has aneurysm clips or metal pins in the body. 4. Explain to the patient that a sensation of warmth may be felt when the dye is injected. 5. Tell the patient to report any nausea, itchiness, or difficulty breathing during the scan. ANS: 1, 2, 4, 5 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Plan nursing care for patients undergoing diagnostic tests for disorders of the nervous system. Page: 996 Heading: Computed Tomography Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult

2. 3. 4.

PTS:

Feedback The BUN and creatinine levels should be checked before administration of contrast material because it is excreted through the kidneys. Patients with elevated BUN and creatinine or known renal disease may be unable to tolerate the contrast material. The patient should be questioned about any allergies to contrast material, iodine, or shellfish. Clips or metal pins in the body would be assessed if the patient were scheduled for an MRI. Patients who are receiving dye should be warned that they may feel a sensation of warmth following the injection; warmth in the groin area may make them feel as though they have been incontinent of urine. Nausea, diaphoresis, itching, or difficulty breathing may indicate allergy to the dye and should be reported immediately to the physician or nurse practitioner. 1

CON: Neurologic Regulation

3. The nurse is preparing a review of the neurologic system as part of a community health presentation. Which structures does the nurse identify as being part of the diencephalon? (Select all that apply.) 1. Pons 2. Medulla 3. Thalamus 4. Brainstem 5. Hypothalamus

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ANS: 3, 5 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Describe the normal structures and functions of the nervous system. Page: 985 Heading: Brain Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Teaching/Learning Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult

1. 2. 3. 4. 5. PTS:

Feedback The medulla and pons are structures within the brainstem. The medulla and pons are structures within the brainstem. The diencephalon consists primarily of the thalamus and hypothalamus. The diencephalon is superior in structure to the brainstem. The diencephalon consists primarily of the thalamus and hypothalamus. 1

CON: Neurologic Regulation

4. While observing the neurologist complete a neurologic examination, the nurse notes that a patient has an absent left patellar reflex. Which possible areas of dysfunction does the nurse consider? (Select all that apply.) 1. Spinal cord 2. Femoral nerve 3. Anterior fibula muscle 4. Posterior tibial muscle 5. Quadriceps femoris muscle ANS: 1, 2, 5 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: Describe the normal structures and functions of the nervous system. Page: 994 Heading: Normal Neurologic System Anatomy and Physiology Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult

1. 2. 3. 4.

Feedback If the patellar reflex is absent, the problem might be in the quadriceps femoris muscle, the femoral nerve, or the spinal cord itself. If the patellar reflex is absent, the problem might be in the quadriceps femoris muscle, the femoral nerve, or the spinal cord itself. The absence of a patellar reflex does not suggest that a problem exists within the anterior fibula or posterior tibial muscles. The absence of a patellar reflex does not suggest that a problem exists within

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the anterior fibula or posterior tibial muscles. If the patellar reflex is absent, the problem might be in the quadriceps femoris muscle, the femoral nerve, or the spinal cord itself. 1

CON: Neurologic Regulation

5. The nurse is using the FOUR tool to assess a patient’s neurologic functioning. In which areas does the nurse collect data when using this tool? (Select all that apply.) 1. Reflexes 2. Eye response 3. Verbal response 4. Motor movement 5. Breathing pattern ANS: 1, 2, 4, 5 Chapter: Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures Objective: List data to collect when caring for a patient with a disorder of the nervous system. Page: 991 Heading: FOUR SCALE Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult

1. 2. 3. 4. 5.

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Feedback The FOUR tool measures data from four categories: eye response, motor movement, reflexes, and breathing pattern. The FOUR tool measures data from four categories: eye response, motor movement, reflexes, and breathing pattern. A major benefit of using the FOUR tool is that no evaluation of verbal response is necessary. The FOUR tool measures data from four categories: eye response, motor movement, reflexes, and breathing pattern. The FOUR tool measures data from four categories: eye response, motor movement, reflexes, and breathing pattern. 1

CON: Neurologic Regulation

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Chapter 48. Nursing Care of Patients With Central Nervous System Disorders MULTIPLE CHOICE 1. The nurse is working in a college infirmary when a student comes in and states, “I think I have a migraine. My head hurts, I cannot stand the light, and I feel sick to my stomach.” Which additional data collected by the nurse causes concern for a different diagnosis? 1. A subnormal temperature 2. Ill college roommate 3. Positive Brudzinski’s sign 4. Positive Romberg test ANS: 3 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Explain causes, risk factors, and pathophysiology of central nervous system infections, including meningitis and encephalitis. Page: 1001 Heading: Meningitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult Feedback 1 2 3 4

A subnormal temperature can be caused by a variety of conditions; this alone does not cause the nurse concern about the diagnosis. The fact that the student’s college roommate is ill can be a concern. However, this data alone does not cause the nurse concern. Additional data are needed. A positive Brudzinski’s sign is indicative of inflammation in the meninges and spinal nerve roots. This information indicates a presence of meningitis. A Romberg test is performed to diagnose the presence of a brain lesion.

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CON: Neurologic Regulation

2. A patient is brought to the health care provider’s office with a headache, lethargy, nausea, vomiting, and a fever, which has developed over the past few days. The nurse begins collecting data about the possible causes of the symptoms. Which information indicates a possible cause for encephalitis? 1. The patient has recently exhibited flu-like manifestations. 2. The patient lives in a home where a child has chickenpox. 3. The patient has been camping within the last few weeks. 4. The patient has experienced a stiff neck for 3 days. ANS: 3 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Explain causes, risk factors, and pathophysiology of central nervous system infections, including meningitis and encephalitis.

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Page: 1003 Heading: Encephalitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 2

Having the flu may or may not initiate encephalitis; the nurse needs to look at a more specific cause. Herpes simplex virus (HSV) is the most common non-insect cause of encephalitis, and most individuals harbor HSV type 1 in a dormant state in the body. However, the patient’s exposure to chickenpox (varicella zoster virus) is not an obvious cause of the symptoms. Mosquitos and ticks are carriers of West Nile virus, a precursor to encephalitis. This information will cause the nurse to suspect the development of encephalitis. The development of a stiff neck can be a symptom of encephalitis and not a cause.

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CON: Neurologic Regulation

3. The licensed practical nurse (LPN) is assigned to assist the registered nurse (RN) in providing care for a patient admitted for an inflammatory neurologic disorder. Which reassessment finding does the LPN report immediately to the RN? 1. The patient has a consistent temperature of 101.4°F rectally. 2. The patient attempts to get out of bed to go to work. 3. A pain level of 5 on a scale of 0 to 10 is verbally reported. 4. The patient is noticed to be changing position without assistance. ANS: 2 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Plan nursing interventions for a patient with a central nervous system infection. Page: 1005 Heading: Nursing Care Plan for a Patient With a Brain Infection or Injury. Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1

The patient with an inflammatory neurologic disorder is expected to have an elevated temperature. The LPN will record the existing temperature and the RN will determine if additional nursing care is necessary. If the patient is attempting to get out of bed to go to work, the LPN recognizes the development of confusion, which can be related to cerebral edema and increased intracranial pressure (ICP); the RN needs to be notified immediately.

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The LPN will report the patient’s pain level of 5 on a scale of 0 to 10. The RN will determine if additional nursing or medical care is necessary. The patient’s ability to change positions independently is not a finding that needs reported to the RN immediately.

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CON: Neurologic Regulation

4. The nurse is providing information to a patient with migraine headaches. Which information from the patient is least likely to be useful to the HCP when prescribing treatment? 1. The effectiveness of resting in a dark, quiet environment 2. Keeping a diary about episodes including pre- and postinformation 3. Determining if there may be a genetic connection to the headaches 4. Making note of preheadache visual, speech, or sensation disturbances ANS: 1 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Provide teaching for a patient experiencing headaches. Page: 1010 Heading: Migraine Headaches Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1

2 3

Ascertaining the effectiveness of a dark, quiet environment is the least useful information to the HCP when prescribing treatment. Most patients will respond positively to this intervention. Keeping a diary about the episodes of migraines is likely to be helpful to the HCP when making decisions about prescribing treatment. Knowing about a possible genetic connection will be helpful to the HCP when prescribing treatment. It is useful to know which treatments were successful or unsuccessful with family members. Knowledge about whether patient has an aura assists the HCP to prescribe actions and behaviors that will help the patient to manage migraine headaches. Some medications are effective if taken prior to or immediately at the onset of a migraine.

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CON: Neurologic Regulation

5. The nurse is assisting with the care of a patient after a traumatic brain injury. The patient experiences a seizure and exhibits bilateral jerking of the extremities. Which type of seizure activity does the nurse recognize? 1. Partial 2. Chronic 3. Generalized 4. Traumatic

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ANS: 3 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: List the causes and types of seizures. Page: 1015 Heading: Seizure Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 2

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A partial seizure usually involves one side of the body due to the involvement of one side of the cerebral cortex. Chronic seizures are usually classified as epilepsy. This patient is at risk for acquiring epilepsy due to a traumatic brain injury. Another cause is an anoxic event. Generalized seizure involves both sides of the brain and results in the patient experiencing involvement of both sides of the body. There is no specific description or classification for traumatic seizures.

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CON: Neurologic Regulation

6. The nurse is providing care for a patient on a medical unit with a history of seizure activity. The patient exhibits the manifestations of a generalized seizure, which does not respond to prescribed treatment. Seizure activity has been continuous for over 30 minutes. Which prescription does the nurse prepare for the HCP? 1. Gathering equipment needed for mechanical ventilation 2. Administering IV lorazepam or diazepam for seizure control 3. Setting up for administration of IV phenobarbital to induce coma 4. Making immediate arrangements to transfer the patient to the intensive care unit (ICU) ANS: 4 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Describe appropriate interventions for an individual experiencing a seizure. Page: 1014 Heading: Status Epilepticus Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1

The need for mechanical ventilation is usually part of an emergency response situation. The nurse does not need to gather the equipment for mechanical ventilation. It will be brought by the emergency response team. It is unlikely that the HCP will prescribe additional medication for seizure

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control if status epilepticus is occurring; the condition is defined as seizure activity for longer than 30 minutes, which does not respond to treatment. The patient may need to have a phenobarbital coma induced to stop seizure activity; however, this treatment is not performed on a medical unit. The nurse expects the HCP to prescribe moving the patient to ICU where aggressive treatment and close monitoring can occur.

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CON: Neurologic Regulation

7. An older adult patient is experiencing the manifestation related to a neurocognitive disorder and is being transferred to a long-term care facility. Which condition will involve the nurse in reaching long-term goals related to this patient? 1. Suggesting the family attend a support group 2. Considering the patient’s input regarding care 3. Accepting the patient’s attempts at independence 4. Requesting hospitalization when symptoms worsen ANS: 1 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Plan nursing care for a patient with a neurodegenerative disorder. Page: 1012 Heading: Neurodegenerative and Neurocognitive Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1

A long-term goal is for the family to understand and accept the disease process related to neurocognitive disorders. The nurse can assist by suggesting the family attend a support group. When a patient is placed into a long-term care facility for neurocognitive decline, the patient may not be capable of providing input regarding care. However, the patient’s likes and dislikes are always considered. A long-term goal is to allow whatever independence the patient can maintain, providing safety for the patient is not compromised. Maintaining independence is not a long-term goal for the diagnosis. Hospitalization for a patient with a neurocognitive disorder is only prescribed if the patient has a physiological condition requiring acute care.

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CON: Neurologic Regulation

8. A patient is distressed to learn that a sibling is diagnosed with both neurologic and cognitive manifestations of Huntington disease. When the patient asks the nurse how to determine the incidence of the disease, which answer is most appropriate? 1. “All family members are now at risk for the disease.” 2. “You definitely need to have genetic testing for the disease.” 3. “Your children need to be tested for a genetic connection.”

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4. “If you are not diagnosed by age 20, you are considered safe.” ANS: 2 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Explain causes, risk factors, and pathophysiology associated with neurodegenerative disorders such as Parkinson, Huntington, and Alzheimer diseases. Page: 1046 Heading: Huntington Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult Feedback 1

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Huntington disease is caused by an autosomal dominant gene. All persons who carry the gene will contract the disease; however, each offspring has a 50-50 chance of inheriting the gene. It is imperative for the offspring of a parent who contracts Huntington disease to be tested. If the gene is present, the individual will contract the disease, and all offspring of that individual will have a 50-50 chance of also inheriting the gene and the disease. The patient’s children do not need to be tested unless the parent tests positive for the gene. If the parent is negative, all offspring are not at risk. The unfortunate fact about Huntington disease is that it is not symptomatic until the patient is in his or her 30s or 40s, oftentimes after children are born.

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CON: Neurologic Regulation

9. The nurse is providing care for a patient who was diagnosed with Parkinson disease 12 years prior. Which manifestation of the disease presents the nurse with the most likely risk for safety of this patient? 1. Bradykinesia 2. Muscle rigidity 3. Shuffling gait 4. Resting tremors ANS: 3 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Explain causes, risk factors, and pathophysiology associated with neurodegenerative disorders such as Parkinson, Huntington, and Alzheimer diseases. Page: 1044 Heading: Parkinson Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult Feedback

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Bradykinesia is slow movement, which can be a safety issue if the patient is trying to rebalance or prevent a fall. However, on its own, this is not the manifestation most likely to be the greatest safety risk. Muscle rigidity makes it difficult for the patient to move; however, this alone is not the manifestation most likely to be a safety risk. A shuffling gait is common in a patient with Parkinson disease, and is also the greatest risk for safety. The patient may start off slowly, but the speed of the gait increases until it is difficult for the patient to stop moving. Also, the inability to pick up one’s feet proposes an increased danger of tripping and falling. Resting tremors make it difficult to hold objects such as foods or liquids. However, this is a manifestation least likely to pose a safety issue.

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CON: Neurologic Regulation

10. The nurse is hired by a family to provide care for a family member diagnosed with stage 2 Alzheimer disease. Which action related to safety is most important for the nurse to implement? 1. Help the patient make lists for tasks to be completed. 2. Make sure that all doors are locked where potential risk exists. 3. Monitor for signs or behaviors related to the patient’s physical needs. 4. Regenerate interest in activities, acquaintances, or surroundings. ANS: 2 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Plan nursing care for a patient with a neurodegenerative disorder. Page: 1048 Heading: Alzheimer Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 2

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The patient who is most likely to benefit from lists and reminders regarding tasks is the patient with stage 1 Alzheimer disease. The patient with stage 2 Alzheimer disease is likely to wander, especially at night, because of disturbed sleep patterns. The danger is related to the patient getting into dangerous situations either in or out of the home. All doors to areas of danger must be locked. The loss of the ability to move independently, swallow, and express needs occurs during stage 3 Alzheimer disease. Diminished interest in activities, acquaintances, and surroundings occurs in stage 2 Alzheimer disease. However, these manifestations are not likely to be reversed or pose a safety risk.

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CON: Neurologic Regulation

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11. A patient is brought to the emergency department after being hit by a baseball bat during a game. Which nursing intervention is immediately reported to the HCP or RN? 1. The presence of amnesia about details before and after the injury 2. Changes in heart and respiratory rate, fever, and diaphoresis 3. Presence of head and scalp contusions with a single lesion 4. One-sided paralysis, extreme weakness, or pupil dilation ANS: 2 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Plan nursing care for a patient with an injury to the brain or spinal cord. Page: 1038 Heading: Traumatic Brain Injury Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurological Regulation Difficulty: Difficult Feedback 1

3 4

The nurse does report the presence of amnesia to the HCP and RN. Because this is a common manifestation related to a concussion, it does not warrant immediate reporting. Rapid heart and respiratory rates, fever, and diaphoresis are indicative of autonomic nervous symptoms caused by edema or hypothalamic injury. Of the given manifestations, this is the finding that the nurse reports immediately to the HCP and RN. Head and scalp contusions and a single lesion are reported to the HCP and RN; however, they do not require immediate reporting. The patient’s symptoms are indicative of an acute subdural hematoma, which generally occurs within 24 hours of injury. While the possibility of this condition warrants monitoring, it is not necessarily the symptom to report immediately.

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CON: Neurologic Regulation

12. The nurse is assisting with care for a patient in the ICU with an extreme head injury. The HCP reports that the patient has brain herniation. Which action does the nurse expect from the HCP? 1. Insertion of a shunt to reduce fluid volume in the skull 2. Emergency surgery to relieve pressure in the intracranial space 3. Medication to promote movement of fluid into the circulation system 4. Arranging for the family to be approached about possible organ donation ANS: 4 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Recognize symptoms in a patient who is developing increased intracranial pressure. Page: 1038 Heading: Brain Herniation Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 2 3 4

Brain herniation is a condition that is not compatible with life. Brain herniation is a condition that is not compatible with life. Brain herniation is a condition that is not compatible with life. Brain herniation is a condition that is not compatible with life; however, the patient is still a viable organ donor. The nurse should expect the HCP to arrange for the family to be approached about organ donation.

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CON: Neurologic Regulation

13. A patient is diagnosed with bacterial encephalopathy. Which symptoms exhibited by the patient indicate late signs of the patient’s diagnosis? 1. Short attention span and poor memory 2. Disorientation and difficulty following commands 3. Lack of involvement and lip smacking or chewing 4. Expressed fear about loud noises in the hallway ANS: 3 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Explain causes, risk factors, and pathophysiology of central nervous system infections, including meningitis and encephalitis. Page: 1003 Heading: Central Nervous System Infections Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Neurological Regulation Difficulty: Moderate Feedback 1 2 3

Short attention span and a poor memory are common mental status changes commonly seen in patients with meningitis. Disorientation and difficulty following commands are common mental status changes commonly seen in patients with meningitis. Lack of involvement can be related to lethargy, and lip smacking or chewing is a sign of partial seizures. Both manifestations are late signs of encephalopathy related to meningitis. Misinterpretation of environmental stimuli is a common mental status change in patients with meningitis.

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CON: Neurologic Regulation

14. The nurse is assisting with the care of a patient with a brain tumor who is exhibiting ICP. Which nursing intervention is specifically initiated to provide safety for this patient?

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1. 2. 3. 4.

Make sure the call light is always within the patient’s reach. Perform active or passive range of motion (ROM) at least twice each shift. Relocate environmental objects and pad the bedside rails. Follow HCP’s prescribed therapy for treatment of headache.

ANS: 3 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Identify nursing interventions that can help prevent increased intracranial pressure. Page: 1003 Heading: Increased Intracranial Pressure Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Medium Feedback 1 2

It is important for the nurse to make sure the call light is available for all patients regardless of their diagnosis. Performing active or passive ROM at least twice each shift is important to maintain the potential for mobility; however, this is not specifically related to safety or to the patient with ICP. A patient with ICP is at high risk for experiencing seizures; to promote safety, the nurse will clear the environment of objects that can cause injury and pad the side rails of the bed. Following prescribed therapy for the treatment of headaches in a patient with ICP is an important comfort measure.

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CON: Neurologic Regulation

15. The nurse is assisting the RN in providing care for a patient with a potential for ICP. Which manifestation does the nurse recognize as needing to be reported to the RN? 1. Rapid apical pulse 2. Increased systolic blood pressure (BP) 3. Shallow, even respirations 4. Narrowing pulse pressure ANS: 2 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Recognize symptoms in a patient who is developing increased intracranial pressure. Page: 1003 Heading: Increased Intracranial Pressure Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate

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Bradycardia is expected with increased ICP. Increased systolic BP while the diastolic BP remains unchanged results in a widening pulse pressure, which is a cardinal sign of ICP. Uneven respiration is expected with increased ICP. The pulse pressure widens with an increase in ICP. The systolic BP increases while the diastolic BP remains unchanged.

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CON: Neurologic Regulation

MULTIPLE RESPONSE 1. The nurse is planning care for a patient with a migraine headache. Which actions does the nurse include in this plan of care? (Select all that apply.) 1. Rest 2. White noise 3. A dark, quiet room 4. Sumatriptan (Imitrex) 5. Acetaminophen (Tylenol) ANS: 1, 3, 4 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Identify teaching to be provided for a patient experiencing headaches. Page: 1009 Heading: Migraine Headache Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult

1. 2. 3. 4. 5. PTS:

Feedback A dark room and rest help reduce stimulation during a migraine headache. Stimulation (noise and light) may worsen a migraine. A dark room and rest help reduce stimulation during a migraine headache. Sumatriptan is a medication available to be used for migraine relief. Acetaminophen may be helpful for sinus headaches. 1

CON: Neurologic Regulation

2. The nurse is caring for a patient with an acute brain injury. Which interventions does the nurse use to prevent increased intracranial pressure in this patient? (Select all that apply.) 1. Avoid hip flexion. 2. Administer stool softeners. 3. Keep head of bed elevated 30 degrees. 4. Encourage deep breathing and coughing. 5. Administer opioid analgesics for headache. ANS: 1, 2, 3

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Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Identify nursing interventions that can help prevent increased intracranial pressure. Pages: 1005–1006 Heading: Increased Intracranial Pressure Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing Concept: Neurologic Regulation Difficulty: Difficult

1. 2. 3. 4. 5. PTS:

Feedback Elevation of the head of the bed may help reduce intracranial pressure (ICP). Stool softeners prevent straining, which can increase ICP. Hip flexion may also increase ICP. Hip flexion may also increase ICP. Coughing can increase ICP. Opioid analgesics make neurological assessment difficult. 1

CON: Neurologic Regulation

3. The nurse suspects that a patient is experiencing increasing ICP. What observations cause the nurse to come to this conclusion? (Select all that apply.) 1. Headache 2. Rising temperature 3. Decreasing systolic pressure 4. Dilated pupil on affected side 5. Decreasing level of consciousness (LOC) ANS: 1, 2, 4, 5 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Recognize symptoms in a patient who is developing increased intracranial pressure. Page: 1005 Heading: Increased Intracranial Pressure Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis Concept: Neurologic Regulation Difficulty: Difficult

1. 2. 3. 4.

Feedback Headache, increasing systolic pressure, decreasing LOC, dilated pupil on affected side, and rising temperature are all signs of increased ICP. Headache, increasing systolic pressure, decreasing LOC, dilated pupil on affected side, and rising temperature are all signs of increased ICP. Decreasing systolic blood pressure is not associated with increased intracranial pressure. Headache, increasing systolic pressure, decreasing LOC, dilated pupil on

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affected side, and rising temperature are all signs of increased ICP. Headache, increasing systolic pressure, decreasing LOC, dilated pupil on affected side, and rising temperature are all signs of increased ICP. 1

CON: Neurologic Regulation

4. A patient is prescribed the dopamine agonist pramipexole (Mirapex) for Parkinson disease. Which instructions are important for the nurse to include when teaching about this medication? (Select all that apply.) 1. “Take it at noon each day.” 2. “Increase fluids and fiber in your diet.” 3. “Taking the medication with food may reduce nausea.” 4. “You may experience sudden bouts of excessive sleepiness.” 5. “Do not drive until the effects of this drug on you are fully known.” ANS: 3, 4, 5 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Plan nursing care for a patient with a neurodegenerative disorder. Page: 1043 Heading: Parkinson Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Integrity Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult

1. 2. 3. 4. 5.

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Feedback Selegiline, not pramipexole, should be given at noon. It is unknown if this medication causes constipation. Giving with meals may reduce nausea. Patients may fall asleep suddenly when taking this medication. The patient should be cautioned to avoid driving until effects are known. Patients may fall asleep suddenly when taking this medication. The patient should be cautioned to avoid driving until effects are known. 1

CON: Neurologic Regulation

5. A patient with a spinal cord injury at T3–T4 experiences a sudden increase in BP and has cool, pale, gooseflesh skin on the lower extremities. Which action does the nurse perform while awaiting physician orders? (Select all that apply.) 1. Monitor BP every 5 minutes. 2. Place the patient in supine position. 3. Place elastic stockings on the patient’s legs. 4. Check to see if the indwelling catheter is patent. 5. Perform a rectal examination to determine if impaction is present. ANS: 1, 4, 5 Chapter: Chapter 48. Nursing Care of Patients With Central Nervous System Disorders Objective: Plan nursing care for a patient with an injury to the brain or spinal cord.

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Page: 1035 Heading: Spinal Cord Injuries Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult

2. 3. 4.

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Feedback The patient is experiencing autonomic dysreflexia, which can cause hypertension and bradycardia. The nurse should monitor BP and then check for catheter patency and impaction, both of which can cause dysreflexia. The patient should be placed in high Fowler’s position, and elastic stockings should be removed to allow blood to pool and reduce BP. The patient should be placed in high Fowler’s position, and elastic stockings should be removed to allow blood to pool and reduce BP. The patient is experiencing autonomic dysreflexia, which can cause hypertension and bradycardia. The nurse should monitor BP and then check for catheter patency and impaction, both of which can cause dysreflexia. The patient is experiencing autonomic dysreflexia, which can cause hypertension and bradycardia. The nurse should monitor BP and then check for catheter patency and impaction, both of which can cause dysreflexia. 1

CON: Neurologic Regulation

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Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders MULTIPLE CHOICE 1. The nurse is providing care for a patient diagnosed with a stroke resulting in language disorder. Which type of disorder does the nurse recognize if the patient raises an arm in response to the nurse’s direction to stick out his tongue? 1. Dysarthria 2. Expressive aphasia 3. Dysphasia 4. Receptive aphasia ANS: 4 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack, ischemic stroke, and hemorrhagic stroke. Page: 1057 Heading: Language Disturbances Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 2 3

Slurred or indistinct speech (dysarthria) is caused when the stroke has caused a motor problem. Expressive aphasia is when the patient knows what he wants to say but cannot speak or make sense. Dysphasia is when the patient experiences trouble selecting the correct words, uses incomprehensible or nonsense speech, has trouble understanding other’s speech, and has trouble writing or reading. Even with this description, it is not as serious as aphasia. The patient has receptive aphasia, which is the inability to understand spoken and/or written words.

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CON: Neurologic Regulation

2. A patient arrives at the emergency department and states, “Something is wrong. I just don’t feel right.” Which objective data causes the nurse to suspect the patient is experiencing some type of stroke? 1. Symptoms have been increasing in severity for several days. 2. Ataxia is present when the patient attempts to ambulate. 3. The patient was diagnosed with hypertension managed with medication. 4. The patient appears upset and cries easily throughout assessment. ANS: 2 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders

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Objective: Identify emergency interventions for transient ischemic attack, ischemic stroke, and hemorrhagic stroke. Page: 1056 Heading: Motor Disturbances Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult Feedback 1

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The symptoms of a stroke usually have a rapid onset. However, the information that symptoms have been increasing in severity for several days is subjective data. Ataxia may occur with a stroke and includes poor balance or stumbling, and a staggering gate. This data is objective and strongly related to a stroke. Diagnosis of hypertension and treatment with medication is subjective data. However, hypertension is a major contributor to stroke. The patient appearing upset and crying easily is objective data; however, neither manifestation is unique to a stroke.

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CON: Neurologic Regulation

3. The nurse is providing care for a patient diagnosed with an ischemic stroke on the left side of the brain. The nurse notices that the patient does not easily locate items placed at the bedside. In which area does the nurse place items for easy location? 1. On the left side 2. Directly in front 3. One the right side 4. As the patient wants ANS: 3 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack, ischemic stroke, and hemorrhagic stroke. Page: 1067 Heading: Visual Disturbances Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1

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The left side is not where the nurse places items for the patient. When a stroke is diagnosed on the left side, the eye that is affected is on the same side as the affected artery. Placing items directly in front of the patient may not be convenient at all times. The patient with a stroke on the left side will have vision in the right eye. Items

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should be place on the right side. The patient may not be able to designate where items should be placed because of the effects of the stroke. The nurse knows that the best vision is on the right side.

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CON: Neurologic Regulation

4. A patient comes into the emergency department with symptoms of a stroke. Which medication does the nurse expect to be given to the patient if diagnostic testing confirms an ischemic stroke? 1. Heparin 2. Clopidogrel 3. Warfarin 4. Tissue-type plasminogen activator (tPA) ANS: 4 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Identify emergency interventions for transient ischemic attack, ischemic stroke, and hemorrhagic stroke. Page: 1060 Heading: Ischemic Stroke Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 2 3 4

Heparin can help prevent clots but is not effective in breaking up an existing clot. Clopidogrel can help prevent clots but is not effective in breaking up an existing clot. Warfarin can help prevent clots but is not effective in breaking up an existing clot. tPA is a thrombolytic agent that can break down the thrombus causing the occlusion, which can potentially prevent or completely reverse the symptoms of an ischemic stroke.

PTS:

CON: Neurologic Regulation

5. A patient comes into the emergency department with unilateral paralysis, aphasia, and inability to follow directions. Which emergency management by the health care provider (HCP) is unexpected by the nurse? 1. Maintenance of oxygen therapy to a saturation of at least 94 percent 2. Careful monitoring of changes in the patient’s level of consciousness 3. Scheduling laboratory tests, electrocardiogram (ECG), and computerized tomography (CT) scan to be performed within 45 minutes 4. Immediate treatment for temperature greater than 99.6°F

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ANS: 3 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Plan therapeutic measures for transient ischemic attack, ischemic stroke, and hemorrhagic stroke. Page: 1059 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1

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Emergency care for a patient suspected of a stroke is supportive while test results are pending. ABCs (Airway, Breathing, and Circulation) are monitored and oxygen therapy is ordered to maintain an oxygen saturation rate of at least 94 percent. The patient’s level of consciousness is carefully monitored to determine if the patient’s condition or the severity of the possible stroke is changing. Laboratory tests, ECG, and CT scan are ordered with the expectation that results will be available within 45 minutes of arrival. The HCP will want to make a decision for thrombolytic therapy within an hour of arrival. Any elevated temperature will be managed immediately because hyperthermia is associated with poorer patient outcomes.

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CON: Neurologic Regulation

6. A patient arrives in the emergency department at 0200 exhibiting the manifestations of a stroke. The patient reports going to bed at 2100 and being negative for symptoms. If the CT reveals an ischemic stroke related to a blood clot, for which reason is tPA therapy withheld? 1. The therapy is based on the time the patient went to bed. 2. The patient’s symptoms have progressed too quickly. 3. The total effects of ischemia are not currently known. 4. The patient is negative for any symptoms related to intracranial pressure (ICP). ANS: 1 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Plan therapeutic measures for transient ischemic attack, ischemic stroke, and hemorrhagic stroke. Page: 1059 Heading: Thrombolytic Therapy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1

When a patient awakens during the night with symptoms of a stroke, the time

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of the stroke is set at the time the patient went to bed. Thrombolytic therapy must be started within 3 to 4.5 hours of symptom onset to be most effective. Thrombolytic therapy is not withheld because of the rate symptoms develop. The total effects of ischemia is not a determining factor for tPA therapy; if the CT scan reveals that a blockage exists in the brain, the therapy is started if all other parameters are met. The presence or absence of ICP is not a determining factor for tPA therapy.

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CON: Neurologic Regulation

7. The patient is diagnosed with a cerebral vascular accident that has the slowest rate of recovery and the highest probability of causing extensive neurologic deficits. For which type of stroke does the nurse plan care for this patient? 1. Thrombotic stroke 2. Cerebral aneurysm 3. Subarachnoid hemorrhage (SAH) 4. Reversible ischemic neurologic deficit (RIND) ANS: 3 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack, ischemic stroke, and hemorrhagic stroke. Page: 1054 Heading: Subarachnoid Hemorrhage Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 2 3

A thrombotic stroke does not have the slowest rate of recovery. Aneurysms are often asymptomatic if they do not bleed. SAH is caused by rupture of blood vessels on the surface of the brain. This type of infarct has the slowest rate of recovery and the highest probability of leaving the patient with extensive neurologic deficits. RIND is reversible.

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CON: Neurologic Regulation

8. A patient is recovering from a stroke. The family reports to the nurse that the patient alternates between periods of crying for no given reason to periods of laughing inappropriately. Which condition does the nurse suspect the patient is exhibiting? 1. Pseudobulbar effect 2. Psychotic events 3. Bipolar disorder 4. Mood swings ANS: 1

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Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Identify outcomes that can be expected for a stroke victim. Page: 1061 Heading: Pseudobulbar Effect Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1

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A common consequence of a stroke is pseudobulbar effect in which the patient exhibits emotional lability or instability. Patients move between periods of profound sadness to euphoria and back again. Treatment is with the medication dextromethorphan quinidine. The patient is not exhibiting psychotic events. The symptoms are related to the stroke; there is no information supporting bipolar disorder. The patient is not experiencing mood swings.

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CON: Neurologic Regulation

9. A patient began experiencing manifestations of a stroke at 0800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms? 1. 0900 hours 2. 1250 hours 3. 1400 hours 4. 1660 hours ANS: 2 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Identify emergency interventions for transient ischemic attack, ischemic stroke, and hemorrhagic stroke. Page: 1059 Heading: Thrombolytic Therapy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult Feedback 1 2 3 4

A patient needs to be treated within 4.5 hours and not 1 hour. If a patient experiencing ischemic stroke symptoms receives treatment within 4.5 hours of symptom onset, medication can be provided to resolve the deficits. This is too long to wait to provide medication to treat the symptoms of a stroke. This is too long to wait to provide medication to treat the symptoms of a stroke.

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CON: Neurologic Regulation

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10. The nurse is providing care for a patient recovering from a right hemisphere infarct who now exhibits unilateral neglect. Which nursing intervention is most important at promoting safety for this patient? 1. Encourage the patient to turn her plate for ease in self-feeding. 2. Place the call light and phone on the patient’s left side. 3. Teach the patient to purposefully check the location of the left limbs. 4. Provide stimuli of all senses on the patient’s affected side. ANS: 3 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Plan nursing care for a patient with a cerebrovascular disorder. Page: 1062 Heading: Unilateral Neglect Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult Feedback 1

Because a right hemisphere infarct causes neglect on the left side of the body, the patient is unaware of the left side of her environment and possibly of the left side of her body. Turning the plate will assist with self-feeding, but it is not a safety intervention. The patient’s call light and phone are placed so that they can be easily found and used by the patient. There is another option that is more important for the patient’s safety. Because the patient can be totally unaware of the left side of the body, injury can easily occur from unsafe positioning. The patient needs to check the location of the left limbs. This intervention is most important for promoting safety. It is important to provide stimuli of all senses on the patient’s affected side. This intervention will help improve the patient’s condition, but is not necessarily related to safety.

PTS:

CON: Neurologic Regulation

11. The nurse is assisting the registered nurse (RN) in providing care for a patient who is recovering from a stroke. Which assigned intervention by the RN will the nurse question? 1. Observe the patient performing active range of motion (ROM) on the affected side. 2. Assist with maintaining correct body alignment for comfort. 3. Support affected extremities with pillows to prevent dislocation. 4. Follow the physical therapist’s (PT’s) recommendations for being up in a bedside chair. ANS: 1 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Plan nursing care for a patient with cerebrovascular disorder.

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Page: 1063 Heading: Impaired Physical Mobility related to decreased motor function Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 2 3 4

The patient is not likely to be able to perform active ROM on the affected side following a stroke. The nurse will seek clarification from the RN. The nurse will assist in maintaining correct body alignment for the comfort of the patient and to prevent contractures. The nurse will support affected extremities to promote comfort and prevent dislocations. The nurse will follow the PT’s instructions for being up in a bedside chair or for ambulation.

PTS:

CON: Neurologic Regulation

12. The nurse is preparing to assist a patient with eating who is recovering from a stroke. Which intervention is appropriate? 1. Have the patient sip liquids in small amounts with a straw. 2. Place the patient in a semi-Fowler’s position to promote swallowing. 3. Check the patient’s mouth periodically for presence of pocketed food. 4. Instruct the patient to swallow numerous times to clear food from the mouth. ANS: 3 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Plan nursing care for a patient with cerebrovascular disorder. Page: 1065 Heading: Imbalanced Nutrition Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1

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When a patient is having trouble swallowing for any reason, the use of straws is avoided. The amount of food and the rate of swallowing are not easily accomplished using a straw. The patient with swallowing issues should be placed in a high Fowler’s position or sitting upright in a chair to prevent choking. The nurse checks the patient’s mouth periodically for pocketed food, which commonly occurs in patients with swallowing issues. The nurse teaches the patient to swallow twice with each bite to make sure the food is gone from the mouth. Swallowing numerous times is not necessary.

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CON: Neurologic Regulation

13. The nurse is providing care for a patient diagnosed with a cerebral aneurysm and subarachnoid hemorrhage. Which statement by the patient indicates a need for additional information? 1. “The doctors are going to do studies to see if I can have surgery.” 2. “I know that I will be on some restrictions to prevent a rebleed.” 3. “No strenuous activity until this condition is cured by surgery.” 4. “It is very important to take my blood pressure medicine.” ANS: 3 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Plan therapeutic measures for transient ischemic attack, ischemic stroke, and hemorrhagic stroke. Page: 1054 Heading: Cerebral Aneurysm, Subarachnoid Hemorrhage, and Intracranial Hemorrhage Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 2 3

The patient has understanding about the need to perform studies to see if surgery is possible. The danger of an aneurysm is the risk for a rebleed. The patient will have restrictions about strenuous activity with or without surgical treatment. As stated above, restrictions are expected; however, the patient needs additional information about the prospect of curing the condition. Subarachnoid hemorrhage is not curable; treatment consists of stabilizing the cause if possible and preventing or managing complications. With the diagnosis of an aneurysm and a resulting subarachnoid hemorrhage, it is very important that systolic blood pressure remain between 120 and 160 mm Hg.

PTS:

CON: Neurologic Regulation

14. A patient is admitted from the emergency department to the hospital unit following the diagnosis of an ischemic stroke. The patient did not qualify for tPA therapy. The nurse is aware that which poststroke condition places the patient at greatest risk for deep vein thrombosis (DVT)? 1. The inability to be mobile and move independently 2. Hypercoagulability related to the admitting diagnosis 3. Testing that identified the cause of the stroke as ischemic 4. Laboratory tests indicating hyperlipidemia with high-density lipoprotein (HDL) at 200 ANS: 2 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders

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Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack, ischemic stroke, and hemorrhagic stroke. Page: 1059 Heading: Postemergent Care Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 2

Inability to move about and/or being restricted to bed can increase the risk of DVT; however, there is no information regarding this restriction. When an ischemic stroke occurs, it is commonly from a blood clot, a condition complicated by the inability for tPA therapy. Therefore, the patient is at greatest risk for DVT due to the hypercoagulability of the blood. Testing that identifies the cause of an ischemic stroke may or may not place the patient at risk for DVT. Ischemic strokes are caused from any condition that decreases blood flow in the brain. Hyperlipidemia with a high low-density lipoprotein (LDL) and a low HDL, can be a cause of a stroke. However, an HDL of 200 is a good test result.

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CON: Neurologic Regulation

15. The nurse is aware that children can be at risk for an embolic stroke. Which condition is least likely to cause a child to have a stroke? 1. Contact sport trauma 2. Sickle cell disease 3. Hyperlipidemia 4. Congenital heart defect ANS: 1 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack, ischemic stroke, and hemorrhagic stroke. Page: 1054 Heading: Embolic Stroke Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult Feedback 1 2

Contact sport trauma is the least likely cause of an embolic stroke, given the other more likely causes. Sickle cell disease causes the clumping of sickle-shaped red blood cells; the clumped cells can create a clot and cause occlusions of blood vessels anywhere in the body.

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Hyperlipidemia, even in children, can cause an occlusion of a blood vessel, which can create a clot if plaque deposits become dislodged. A congenital heart defect may result in inadequate pump function allowing a clot to form in the heart and travel to the brain.

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CON: Neurologic Regulation

16. The HCP is preparing to discharge a patient from the hospital after a stroke. The patient is insistent on being sent to a rehabilitation center. The nurse is aware that the patient must meet which qualification to go to rehabilitation? 1. The determination to live alone and independently 2. The willingness to commit to long-term therapy 3. The ability to participate in intensive therapy 4. The acceptance of financial responsibility ANS: 3 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Plan therapeutic measures for transient ischemic attack, ischemic stroke, and hemorrhagic stroke. Page: 1064 Heading: Rehabilitation Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Moderate Feedback 1 2 3 4

Determination alone is not a qualification to go to rehabilitation after a stroke. Rehabilitation may or may not involve long-term therapy. For a patient to qualify for rehabilitation after a stroke, the patient must have the ability to participate in intensive therapy. Some insurance programs will pay for all or part of rehabilitation. The willingness to accept financial responsibility is not a determining factor.

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CON: Neurologic Regulation

17. The nurse is reviewing the medical records of patients in an HCP’s practice. Which patient does the nurse recognize as the greatest risk for a stroke? 1. A postmenopausal patient who has type 2 diabetes mellitus (DM) controlled by diet 2. An overweight male with a 15-year smoking history, who is treated for hypertension 3. A young adult born with a heart defect causing ventricle fibrillation 4. An older female patient who has osteoporosis, a femur fracture, and hyperlipidemia ANS: 4 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders

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Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack, ischemic stroke, and hemorrhagic stroke. Page: 1052 Heading: Prevention of Stroke Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficulty Feedback 1 2 3 4

The postmenopausal patient with type 2 DM controlled by diet has three risk factors: gender, hormone change, and DM (even though controlled). The male patient has three risk factors: being overweight, smoking, and hypertension. The young patient with a serious heart defect is a high risk for a stroke. However, it is the only risk factor, which can be medically managed. The older female patient has five risks for a stroke: gender, age, fracture of a large bone, high cholesterol, and decreased activity related to a fractured femur.

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CON: Neurologic Regulation

18. The nurse is assisting with the care of a patient following an ischemic stroke who does not qualify for tPA therapy. The patient’s current blood pressure is 190/110 mm Hg. For which reason will the patient’s hypertension remain untreated? 1. The elevated blood pressure will create collateral circulation in the brain. 2. Therapeutic blood pressure needs to exceed 220/120 mm Hg to be effective. 3. Permissive hypertension is being therapeutically used to salvage brain tissue. 4. Hypertension will move the clot to an area of the brain treatable by tPA. ANS: 3 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Plan therapeutic measures for transient ischemic attack, ischemic stroke, and hemorrhagic stroke. Page: 1055 Heading: Pharmacological Management Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult Feedback 1

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The high blood pressure does not create collateral circulation in the brain; however, it does help blood to travel to the existing collateral vessels and improve blood flow to the affected area. When permissive hypertension is used, antihypertensive drugs are given if the blood pressure exceeds 220/120 mm Hg. Permissive hypertension is used when the patient does not qualify for tPA

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therapy to improve cerebral circulation. Moving the clot causing a stroke will only cause additional areas of damage. Once a patient is ruled out for tPA therapy, the decision is not reversed.

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CON: Neurologic Regulation

MULTIPLE RESPONSE 1. The nurse is providing care for a patient with expressive aphasia. Which intervention does the nurse expect to find in the patient’s plan of care? (Select all that apply.) 1. Speak loudly. 2. Use a picture board. 3. Obtain an interpreter. 4. Provide pencil and paper. 5. Speak slowly and clearly. ANS: 2, 4 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Plan nursing care for a patient with a cerebrovascular disorder. Page: 1056 Heading: Aphasia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult

1. 2. 3. 4. 5.

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Feedback Speaking loudly is not helpful unless the patient has a hearing deficit also. For expressive aphasia, pencil and paper or a picture board can help with communication. Interpreters are used for language barriers, not for aphasia. For expressive aphasia, pencil and paper or a picture board can help with communication. Speaking slowly and pantomiming may be helpful for receptive aphasia, not expressive. 1

CON: Neurologic Regulation

2. The nurse is involved in a blood pressure clinic in the community, and an individual with possible stroke symptoms is brought for evaluation. Which findings in the FAST (Face, Arms, Speech, and Time) assessment indicate the need to call emergency personnel? (Select all that apply.) 1. The patient sways when asked to stand still with eyes closed. 2. The patient is unable to follow directions during the assessment. 3. The patient is unable to repeat a stated phrase exactly as it was stated. 4. The patient’s face shows signs of uneven symmetry when asked to smile. 5. When asked to close the eyes and hold arms straight in front, one arm drifts

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downward. ANS: 3, 4, 5 Chapter: Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders Objective: Describe causes, risk factors, and pathophysiology of transient ischemic attack, ischemic stroke, and hemorrhagic stroke. Page: 1055 Heading: Warning Signs of Any Type of Stroke Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Neurologic Regulation Difficulty: Difficult

2. 3.

PTS:

Feedback Swaying when asked to stand still with the eyes closed are indicators of a possible stroke. Brain cells may be dying but is not part of the FAST assessment. Inability to follow instructions is a concern but is not part of the FAST assessment. The acronym FAST can help identify a stroke. Ask the person to say, “It is a bright and sunny day.” Any difficulty understanding or speaking is abnormal. Call 911 immediately for any abnormal findings. The acronym FAST can help identify a stroke. Ask the person to smile. If the face droops or is uneven on one side, it is abnormal. Call 911 immediately for any abnormal findings. The acronym FAST can help identify a stroke. Ask the person to close his or her eyes and hold the arms out in front of him or her. If an arm cannot be raised or drifts downward, it is abnormal. Call 911 immediately for any abnormal findings. 1

CON: Neurologic Regulation

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Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders MULTIPLE CHOICE 1. The nurse is caring for a patient experiencing an acute exacerbation of multiple sclerosis (MS). Which pathophysiological change does the nurse recognize as causing the manifestations of MS? 1. Myelin buildup in the central nervous system 2. Demyelination and destruction of nerve fibers 3. Gamma aminobutyric acid (GABA) deficiency 4. Reduced acetylcholine receptors with impaired nerve impulse transmission ANS: 2 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Explain the pathophysiology, major signs and symptoms, and complications of selected peripheral nervous system disorders. Pages: 1073–1075 Heading: Multiple Sclerosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1 2

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Myelin does not build up with a diagnosis of MS. In MS, the myelin sheath begins to break down or degenerates as a result of the activation of the body’s immune system. The nerve becomes inflamed and edematous. Nerve impulses to the muscles slow down. As the disease progresses, sclerosis or scar tissue damages the nerve. GABA is an inhibitory neurotransmitter and does not play a role in MS. Acetylcholine receptors are damaged in myasthenia gravis (MG).

PTS:

CON: Immunity

2. The nurse is assisting with care of patients diagnosed with neuromuscular disorders. Which complication does the nurse recognize as a medical emergency? 1. Evidence of severe muscle wasting 2. Indications of the development of pneumonia 3. Interruption of skin integrity over bony prominences 4. Difficulty maintaining weight due to difficulty swallowing ANS: 2 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: List common nursing diagnoses associated with peripheral nervous system disorders. Page: 1077 Heading: Neuromuscular Disorders

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Neuromuscular disorders involve a disruption of impulse transmission between neurons and the muscles they stimulate, resulting in muscle weakness. This process occurs over time and is not likely to be considered as a medical emergency. When the respiratory muscles are affected by a neuromuscular disorder, the patient is at high risk for respiratory infections and/or respiratory failure. Indications of the development of pneumonia is a medical emergency. An interruption of skin integrity over bony prominences is a concern; however, the condition will occur over a period of time and is not considered a medical emergency. When a patient has difficulty swallowing, there is a risk for choking, aspiration, or nutritional deficit. However, weight loss will occur over a period of time and is not considered to be a medical emergency.

PTS:

CON: Immunity

3. A patient who is prescribed neostigmine for newly diagnosed MG asks how the medication works. Which response does the nurse provide to the patient? 1. “It is a muscle relaxant to prevent the cramping in your muscles.” 2. “It provides potassium to your muscles so that they will contract better.” 3. “It makes more neurotransmitters available so that your muscles can contract.” 4. “It reduces the inflammation in your nerves so that they transmit signals better.” ANS: 3 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Identify therapeutic measures used for selected peripheral nervous system disorders. Page: 1080 Heading: Myasthenia Gravis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Difficult Feedback 1 2 3

This medication does not provide potassium or relax the muscles. This medication does not provide potassium or relax the muscles. Medications used to treat MG include the anticholinesterase (ACh) drugs neostigmine and pyridostigmine. These drugs improve symptoms of MG by destroying the acetylcholinesterase that breaks down ACh. Steroids reduce inflammation.

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PTS:

CON: Immunity

4. The nurse is collecting data from a patient who is diagnosed with MG. Which data is most important for the nurse to obtain? 1. Ascertain if the patient’s needs are being met by an adequate support system. 2. Ask what amount of activity causes fatigue and muscle weakness to occur. 3. Determine baseline muscle strength through the use of appropriate techniques. 4. Monitor the patient’s respiratory function and the ability to swallow effectively. ANS: 4 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Plan prioritized nursing interventions for patients with peripheral nervous system disorders. Page: 1080 Heading: Nursing Process for the Patient with Myasthenia Gravis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Moderate Feedback 1

It is important for the nurse to ascertain if a patient with MG has an adequate support system and that needs are being met. However, this is not the most important data for the nurse to collect. The nurse will have a better understanding about the patient’s condition with information about how much activity causes fatigue and muscle weakness to occur. However, this is not the most important data for the nurse to collect. The nurse needs to determine baseline muscle strength through the use of appropriate evaluation techniques. The information is useful for tracking changes in the patient’s condition; however, it is not the most important data for the nurse to collect. The patient with MG experiences muscle weakness. When the respiratory muscles are involved, there is a high risk for complications. The most important data for the nurse to collect is about the patient’s respiratory function and ability to swallow.

PTS:

CON: Immunity

5. A mother of three young children has a 3-year history of MG and recently stopped helping in the children’s classrooms because of fatigue. Which advice does the nurse give to help the patient best cope with the problem? 1. “You need to realize that you may not be able to do the things you used to do.” 2. “Time your medication so its action peaks during the time you need the most energy.” 3. “Get plenty of sleep the night before you help to give you the stamina you need.” 4. “Take your medication after you finish helping, and you may have a better energy level.”

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ANS: 2 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Identify therapeutic measures used for selected peripheral nervous system disorders. Page: 1080 Heading: Myasthenia Gravis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4

This statement may also be true, but medication is needed to get through an activity. The patient should be instructed to schedule activities at times when medication is at peak action so that muscle strength is increased. This statement may also be true, but medication is needed to get through an activity. Taking the medication after the activity will help with strength after, not during, the activity.

PTS:

CON: Immunity

6. A patient diagnosed with Guillain-Barré syndrome (GBS) asks how the disease developed since the patient rarely has an illness. Which nursing response is the most accurate? 1. “No one knows an exact cause.” 2. “It may be an autoimmune reaction to a virus.” 3. “It most often occurs as a result of a bacterial infection.” 4. “It is usually hereditary. Does anyone in your family have it?” ANS: 2 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Explain the pathophysiology, major signs and symptoms, and complications of selected peripheral nervous system disorders. Page: 1083 Heading: Guillain-Barre Syndrome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1 2 3

No one does know an exact cause; however, this statement is not the most accurate. GBS is believed to be caused by an autoimmune response to some type of viral infection or vaccination. It is believed to occur after a viral infection.

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It is not hereditary.

PTS:

CON: Immunity

7. The nurse reviews information with a patient and family members about the patient’s recent diagnosis of amyotrophic lateral sclerosis (ALS). Which comment by a family member indicates a need for clarification? 1. “When the heart muscle is affected, death will occur shortly.” 2. “We need to remember that mental functioning is intact.” 3. “A feeding tube and ventilator may need to be considered later.” 4. “We need to do some research to see if this is a familial risk.” ANS: 1 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Evaluate the effectiveness of nursing care. Page: 1081 Heading: Amyotrophic Lateral Sclerosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Moderate Feedback 1

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ALS affects the voluntary muscles of the body; the heart and gastrointestinal tract are controlled involuntarily and are not affected. Additional information is needed. The patient with ALS retains mental functioning. The patient and family will need to consider whether a feeding tube and ventilator is desired. Some patients decide on comfort care instead. However, this statement does not indicate a need for additional information. While the exact cause of ALS is unknown, it is believed to have a genetic component. The family may benefit from knowing if there appears to be a genetic risk.

PTS:

CON: Immunity

8. A patient with trigeminal neuralgia is admitted to the hospital for diagnostic testing and possible surgery. Which intervention is appropriate for this patient? 1. Provide tissues for the patient to deal with drooling. 2. Provide frequent mouth care with a firm toothbrush. 3. Provide soft foods at body temperature at mealtimes. 4. Provide a fan in the room to keep the room well ventilated. ANS: 3 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Plan prioritized nursing interventions for patients with peripheral nervous system disorders. Page: 1086

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Heading: Trigeminal Neuralgia Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1 2 3

Patients with Bell palsy may drool but not patients with trigeminal neuralgia. Gentle mouth care is provided with a soft bristle toothbrush or mouth swabs. Activities such as talking, face washing, teeth brushing, shaving, and eating can cause pain in patients with trigeminal neuralgia. Soft foods at room temperature may be better tolerated than hot or cold foods. Moving air from a fan can cause an exacerbation of pain.

PTS:

CON: Immunity

9. The nurse is assisting with the care of a patient diagnosed with postpolio syndrome. The nurse asks the registered nurse (RN) to explain the source of the disease. Which answer by the RN is correct? 1. The syndrome begins with the contraction of polio. 2. The disease is common among third-world travelers. 3. The patient must first have had a poliovirus infection. 4. The syndrome leads to development of great debilitation. ANS: 3 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Identify disorders that are caused by disruption of the peripheral nervous system. Page: 1084 Heading: Postpolio Syndrome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1

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Postpolio syndrome affects survivors of polio 20 to 40 years after they have recovered from infection caused by the poliomyelitis virus. Up to 40 percent of patients who previously had polio develop postpolio syndrome. The original infection from the poliomyelitis virus does not occur commonly among third-world travelers; there is no postpolio syndrome without a previous infection from the virus. The patient must first have had a poliovirus infection; the syndrome involves further weakening of the muscles that were affected by the initial infection. The postpolio syndrome may or may not cause great debilitation; some patients will develop lesser debilitation and fewer problems.

PTS:

CON: Immunity

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10. A patient reports to the nurse an inability to rest or sleep due to a long-term condition causing a constant urge to move the legs called restless legs syndrome (RLS). The patient expresses a need for some type of relief. Which suggestion by the nurse is most likely to help the patient? 1. Elimination of alcohol, tobacco, and caffeine 2. Pramipexole or ropinrole medication therapy 3. Using a vibrating pad (Relaxis) approved by the Food and Drug Administration (FDA) 4. Routine sleep habits and regular exercise program ANS: 2 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Identify therapeutic measures used for selected peripheral nervous system disorders. Page: 1085 Heading: Restless Leg Syndrome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Difficult Feedback 1 2

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Elimination of alcohol, tobacco, and caffeine may or may not relieve RLS symptoms. Pramipexole or ropinrole are two medications ordered to treat moderate-tosevere RLS by increasing serum dopamine levels. RLS is believed to be caused by an imbalance of dopamine and serotonin in the brain; this is the suggestion most likely to help the patient. In 2014, the FDA approved a vibrating pad (Relaxis) to aid in the relief of RLS; some RLS sufferers have been helped. Establishing routine sleep habits and a regular exercise program may or may not help alleviate the symptoms of RLS.

PTS:

CON: Immunity

11. The nurse is providing care for a patient after surgery for treatment of trigeminal neuropathy. Which nursing intervention will the nurse initiate for this patient? 1. Protect the patient’s face from any movement of air. 2. Place eye patches bilaterally while the patient sleeps. 3. Check the eye on the surgery side for corneal sensation. 4. Provide a soft diet with food served at room temperature. ANS: 3 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Plan prioritized nursing interventions for patients with peripheral nervous system disorders. Page: 1086 Heading: Trigeminal Neuralgia

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Trigeminal neuralgia can be triggered by air blowing across the effected side of the patient’s face; this should not be a concern after the corrective surgery. If the patient has no feeling or cannot completely close the eye on the side of surgery, a patch may be placed to protect the eye from injury during sleep. Bilateral patches are not necessary. It is important to check for corneal sensation after surgery for trigeminal neuralgia. If corneal sensation is lost, it is important for the patient to wear goggles and sunglasses to prevent injury to the cornea. Extreme temperatures can trigger pain with trigeminal neuralgia, and food is best served at room temperature. This will not be necessary following surgery.

PTS:

CON: Immunity

12. The nurse is preparing a patient with MG to undergo plasmapheresis. Which laboratory tests does the nurse verify and place on the medical record before the procedure? 1. Urine analysis, urine protein, blood urea nitrogen (BUN), and creatinine 2. Complete blood count, platelets, and clotting studies 3. Creatinine phosphokinase, blood type, and electrolytes 4. Electrolytes, BUN, creatinine, and albumin ANS: 2 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Identify therapeutic measures used for selected peripheral nervous system disorders. Page: 1080 Heading: Myasthenia Gravis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Moderate Feedback 1 2

3 4

Laboratory tests such as urinalysis, urine protein, BUN, creatinine, blood type, electrolytes, and albumin are not necessary before having a plasmapheresis. Plasmapheresis is used to remove the patient’s plasma and replace it with fresh plasma. Complete blood cell count, platelet count, and clotting studies are assessed prior to the procedure. Laboratory tests such as urinalysis, urine protein, BUN, creatinine, blood type, electrolytes, and albumin are not necessary before having a plasmapheresis. Laboratory tests such as urinalysis, urine protein, BUN, creatinine, blood type, electrolytes, and albumin are not necessary before having a plasmapheresis.

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PTS:

CON: Immunity

13. A patient is scheduled for a thymectomy. For which peripheral nervous system disorder does the nurse plan care for this patient? 1. MS 2. MG 3. GBS 4. ALS ANS: 2 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Identify therapeutic measures used for selected peripheral nervous system disorders. Page: 1080 Heading: Myasthenia Gravis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Moderate Feedback 1 2

3 4

A thymectomy is not indicated in the treatment of MS, GBS, or ALS. No cure has been found for MG. Treatment is aimed at control of symptoms. Removal of the thymus gland (thymectomy) can decrease production of ACh receptor antibodies and decrease symptoms in most patients. A thymectomy is not indicated in the treatment of MS, GBS, or ALS. A thymectomy is not indicated in the treatment of MS, GBS, or ALS.

PTS:

CON: Immunity

14. The nurse is collecting information from a patient in the HCP’s office. The patient is exhibiting symptoms associated with Bell palsy. Which population group does the nurse recognize as being at greatest risk for the condition? 1. Women in the third trimester of pregnancy 2. Patients who have experienced a stroke 3. Patients who have a history of sun exposure 4. Men with history of excessive alcohol abuse ANS: 1 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Identify disorders that are caused by disruption of the peripheral nervous system. Page: 1086 Heading: Bell Palsy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate

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Feedback 1

2 3 4

Bell palsy is more common in women in the third trimester of pregnancy, in people with immune disorders such as HIV, and in people with diabetes. It occurs in all ages (including children). Patients who have had a stroke may experience paralysis to one side of the face, but the condition is not Bell palsy. Sun exposure does not make a patient more susceptible to Bell palsy. Men with a history of excessive alcohol abuse are not at greater risk for Bell palsy.

PTS:

CON: Immunity

15. A patient in the plateau stage of GBS is frustrated because there has been no improvement in manifestations for 5 days. Which explanation does the nurse provide to the patient? 1. The manifestations can last up to 2 weeks. 2. The manifestations can last up to 3 weeks. 3. The manifestations can last up to 6 months. 4. The manifestations can last up to 24 months. ANS: 1 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Explain the pathophysiology, major signs and symptoms, and complications of selected peripheral nervous system disorders. Page: 1083 Heading: Guillain-Barré Syndrome Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1

2 3 4

GBS is divided into three stages. The second stage is the plateau stage, when symptoms are most severe but progression has stopped. It can last from 2 to 14 days. Patients may become discouraged if no improvement is evident. The first stage starts with the onset of symptoms and lasts until the progression of symptoms stops. This stage can last from 24 hours to 3 weeks. Axonal regeneration and remyelination occur during the third stage, recovery. This stage lasts from 6 to 24 months and symptoms slowly improve. Axonal regeneration and remyelination occur during the third stage, recovery. This stage lasts from 6 to 24 months and symptoms slowly improve.

PTS:

CON: Immunity

16. The nurse is visiting the home of a patient who is being treated for Bell palsy. Which statement by the patient indicates that care instructions need to be reviewed by the nurse? 1. “I find that I can eat better with a facial sling in place.” 2. “Gentle massage of the effected muscles reduces discomfort.”

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3. “I follow the physical therapy exercises exactly as prescribed.” 4. “Alternating heat and cold therapy is helping the swelling.” ANS: 4 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Evaluate the effectiveness of nursing care. Page: 1086 Heading: Nursing Process for a Patient With a Cranial Nerve Disorder Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Immunity Difficulty: Moderate Feedback 1

2 3 4

The patient with Bell palsy may find it difficult or painful to chew and swallow food; using a facial sling will help hold the facial muscles in a more natural position. Massage is prescribed for patients with Bell palsy; the massage should not be vigorous enough to cause tissue damage or additional pain. Physical therapy will prescribe exercises to promote the return of facial muscle tone; the patient should perform the exercises as ordered. Warm moist compresses are used to relieve pain related to Bell palsy. Cold therapy is not used.

PTS:

CON: Immunity

17. The nurse is providing care for a patient being treated for trigeminal neuropathy. The nurse is concerned about the patient’s nutritional status because of an inability to eat without experiencing severe pain. Which patient behavior indicates the nurse’s interventions are successful? 1. The patient can sip cool or warm beverages through a straw. 2. The patient can eat multiple small, soft, lukewarm meals daily. 3. The patient’s weight remains 10 pounds below the target weight. 4. The patient’s pain is managed with postprandial pain medication. ANS: 2 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Evaluate the effectiveness of nursing care. Page: 1086 Heading: Nursing Care of Patients With Peripheral Nervous System Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Moderate Feedback 1

Sipping cool or warm beverages through a straw does not indicate that nursing

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interventions are successful. Any variation of temperature of foods or liquids from room temperature will cause pain for this patient. Nursing interventions are considered to be successful if the patient is able to eat several small, soft, lukewarm meals daily. Nursing interventions are not considered to be successful if the patient remains 10 pounds below the target weight. Managing pain before and during meals indicate successful nursing interventions. Postprandial (after eating) pain management is not an acceptable goal.

PTS:

CON: Immunity

18. The nurse is collecting up-to-date data from a patient who was diagnosed with MS 15 years ago. The patient has a good understanding of the disease and manages to maintain a relatively high level of functioning. Which statement by the patient prompts the nurse to seek additional information? 1. “I am very careful to avoid sick people and crowds in the winter.” 2. “I have been attending a special yoga class for people with MS.” 3. “I love to work in my flower beds during the summer months.” 4. “I find that I do much better if I let other people run errands for me.” ANS: 3 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Plan prioritized nursing interventions for patients with peripheral nervous system disorders. Page: 1085 Heading: Nursing Care Plan for the Patient with a Progressive Neuromuscular Disorder Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Prevention of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Difficult Feedback 1 2

The nurse does not need to seek additional information if the patient expresses understanding about avoiding illnesses. Evidence-based practice supports the importance for the patient with MS to exercise; a special yoga class for MS patients is not a reason for the nurse to seek additional information. Temperature extremes are dangerous for the patient with MS and can trigger an exacerbation. The nurse needs to seek additional information about the details related to the patient’s summer gardening. The patient with MS needs to avoid stress and fatigue; having other people run errands is a good way to avoid both issues. There is no reason for the nurse to seek additional information.

PTS:

CON: Immunity

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MULTIPLE RESPONSE 1. A patient with MS has been prescribed baclofen to relax muscles. Which information is included in the nurse’s teaching about this drug? (Select all that apply.) 1. “Avoid crowds while on this medication.” 2. “Take a calcium supplement while on this medication.” 3. “Report any shortness of breath or other respiratory problems.” 4. “Avoid driving or operating machinery until the effects of the drug are known.” 5. “Prevent constipation by increasing fluids and fiber-rich foods; use suppositories when necessary.” ANS: 3, 4, 5 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Identify therapeutic measures used for selected peripheral nervous system disorders. Page: 1082 Heading: Multiple Sclerosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Difficult

3. 4. 5. PTS:

Feedback Calcium supplements are helpful with steroids, as is avoiding crowds due to infection risk; however, this information is not specifically related to the medication. Calcium supplements are helpful with steroids, as is avoiding crowds due to infection risk; however, this information is not specifically related to the medication. The patient should be monitored for respiratory depression. Patients taking antispasmodics, such as baclofen, should avoid operating machinery and driving until effects are known. Measures should be provided to prevent constipation (except dantrolene). 1

CON: Immunity

2. The nurse is teaching a patient with MG how to recognize a cholinergic crisis. Which manifestations does the nurse include in this teaching? (Select all that apply.) 1. Diarrhea 2. Salivation 3. Vomiting 4. Difficulty speaking 5. Increased bronchial secretions ANS: 1, 2, 3, 5 Chapter: Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders Objective: Explain the pathophysiology, major signs and symptoms, and complications of selected peripheral nervous system disorders.

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Page: 1084 Heading: Myasthenia Gravis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Difficult

4. 5.

PTS:

Feedback Symptoms of cholinergic crisis can be remembered with the acronym SLUDGE: salivation, lacrimation, urination, diarrhea, gastrointestinal cramping, and emesis. A severe crisis has been described as “liquid pouring out of every body orifice.” Symptoms of cholinergic crisis can be remembered with the acronym SLUDGE: salivation, lacrimation, urination, diarrhea, gastrointestinal cramping, and emesis. A severe crisis has been described as “liquid pouring out of every body orifice.” Symptoms of cholinergic crisis can be remembered with the acronym SLUDGE: salivation, lacrimation, urination, diarrhea, gastrointestinal cramping, and emesis. A severe crisis has been described as “liquid pouring out of every body orifice.” Difficulty speaking is not a manifestation of a cholinergic crisis. Symptoms of cholinergic crisis can be remembered with the acronym SLUDGE: salivation, lacrimation, urination, diarrhea, gastrointestinal cramping, and emesis. A severe crisis has been described as “liquid pouring out of every body orifice.” 1

CON: Immunity

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Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing MULTIPLE CHOICE 1. The nurse is giving instructions to a patient who is scheduled for an electronystagmogram due to a diagnosis of vertigo and ringing in the ears. Which finding regarding the patient’s medical history will cause the nurse to notify the prescribing health care provider (HCP) for cancellation of the test? 1. The patient has a history of alcohol abuse. 2. The patient has a pacemaker. 3. The patient takes tranquilizers. 4. The patient lives alone. ANS: 2 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Plan nursing care for patients undergoing diagnostic tests for sensory disorders. Page: 1108 Heading: Electronystagmogram Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1

2 3 4

A history of alcohol abuse does not indicate that the patient currently drinks alcohol; however, the nurse needs to ascertain if the patient is able to avoid alcohol intake for 1 to 5 days prior to testing. The test is contraindicated for patients with a pacemaker; the nurse will notify the prescribing HCP. Tranquilizer use will be discontinued for 1 to 5 days prior to testing. The patient will be advised to avoid tobacco and caffeine for the rest of the day after testing. It is possible that the patient may experience nausea, vertigo, or weakness after the test. However, these manifestations are not noted until after the testing and will not cause cancellation of the test.

PTS:

CON: Sensory Perception

2. The nurse is collecting information about a patient’s auditory system during a physical examination. Which process will the nurse perform first? 1. Observation 2. Inspection 3. Palpation 4. Auscultation ANS: 1

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Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: List data to collect when caring for a patient with a disorder of the sensory system. Page: 1103 Heading: Physical Examination Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Sensory Perception Difficulty: Moderate Feedback 1

2 3 4

When collecting information about a patient’s auditory system, the first action by the nurse is to observe the behaviors of the patient. Note how the patient talks and if there is any slurring of speech. Inspection of the outer ear is performed after observation. Palpitation is performed to identify areas of tenderness; special attention is paid to the mastoid bone behind the patient’s outer ear. Auscultation is not performed when assessing the auditory system.

PTS:

CON: Sensory Perception

3. The nurse is conducting an initial screening to determine a patient’s gross hearing acuity as part of a complete physical. Which test does the nurse include in the assessment? 1. Romberg 2. Calorie test 3. Whisper voice 4. Otoscopic examination ANS: 3 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Identify diagnostic tests commonly performed to diagnose disorders of the sensory system. Page: 1105 Heading: Auditory Acuity Testing Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3 4

This test does not determine gross hearing. This test does not determine gross hearing. Auditory function can be grossly evaluated using three different assessment tests: whisper voice test, Rinne test, and Weber’s test. This test does not determine gross hearing.

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PTS:

CON: Sensory Perception

4. The nurse is collecting information about the eyes from an older adult patient. Which finding is unexpected during the examination? 1. The lenses of the eyes are slightly opaque in appearance. 2. The patient states that the glare of the pen light is too bright. 3. The best color discrimination is between blue, green, and purple. 4. The patient has needed reading glasses since the age of 45 years. ANS: 3 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Explain the normal function of the sensory system. Page: 1098 Heading: Aging and the Eye Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3

It is an expected finding if the lenses of the older adult patient’s eyes exhibit some degree of opaqueness. As patients age, they become less tolerant of bright light and more glare intolerant. The ability to distinguish colors diminishes with aging. Red, yellow, and orange are the most easily identified. Blue, green, and purple are the most difficult to distinguish. Patients become more farsighted with age due to the lens losing elasticity. It is common for patients to require reading glasses around 40 years of age.

PTS:

CON: Sensory Perception

5. The nurse is explaining how the retina works to a patient who is experiencing visual changes. Which factor shared by the nurse is correct? 1. The retina reacts to chemical stimulation from rods and cones. 2. The rods and cones are stimulated by chemical stimulation of the retina. 3. The fovea centralis is located directly behind the center of the lens and contains cones. 4. The rods of the retina are most sensitive to light and are most responsible for color vision. ANS: 3 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Describe the normal anatomy of the sensory system. Page: 1099 Heading: Structure of the Eyeball

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Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Difficult Feedback 1

2 3 4

When photons strike the retina, chemical reactions are stimulated in the rods and cones, which generates nerve impulses for transmission. The retina does not react to the chemical stimulation from the rods and cones. The rods and cones are stimulated by photons, not by chemical stimulation from the retina. The fovea centralis is located on the retina directly behind the lens. The area has only cones, which is the area of most acute color vision. The cones are most sensitive to light and are most responsible for color vision. Rods are more sensitive to dim light, but only allow shades of gray vision.

PTS:

CON: Sensory Perception

6. The nurse is assisting with a patient who is having a test to measure intraocular pressure. Which equipment should the nurse expect to be used? 1. A tonometer 2. Ultrasonography 3. An ophthalmoscope 4. A slit-lamp microscope ANS: 1 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Plan nursing care for patients undergoing diagnostic tests for sensory disorders. Page: 1099 Heading: Intraocular Pressure Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3 4

Estimation of intraocular pressure is measured by using one of several types of tonometer. An ultrasound machine is not used to measure intraocular pressure. An ophthalmoscope is not used to measure intraocular pressure. A slit-lamp microscope is not used to measure intraocular pressure.

PTS:

CON: Sensory Perception

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7. A patient has an injury resulting in a major damage to the pinna of the right ear. The patient expresses fear about hearing loss in the damaged ear. Which statement by the nurse will alleviate the patient’s fear? 1. “The left ear will become over sensitive to sound.” 2. “The impulses for hearing come from the middle and inner ear.” 3. “The outside of your ear will need to be surgically restructured.” 4. “This much damage to the outer ear also indicates severe damage internally.” ANS: 2 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Explain the normal function of the sensory system. Page: 1100 Heading: Hearing Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3 4

The left ear does not become more sensitive to sound in this scenario; hearing is not lost from an injury to the pinna. The nurse will alleviate the patient’s fear by sharing information that hearing is a process of the middle and inner ear. The outside (pinna) of the ear may or may not need to be restructured, depending on the appearance of the ear and patient wishes. Damage to the outer ear is not indicative of damage to the internal part of the ear (middle and inner ear).

PTS:

CON: Sensory Perception

8. A patient is scheduled to have cataract surgery. Which structure of the patient’s eye does the nurse explain will be involved in the procedure? 1. The iris 2. The fibrous tunic 3. The ciliary body 4. The lens ANS: 4 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Describe the normal anatomy of the sensory system. Page: 1096 Heading: Structure of the Eyeball Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Sensory Perception Difficulty: Moderate

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Feedback 1 2 3 4

The iris is the circular curtain, which is anterior to the lens of the eye. It is the structure that determines the color of the patient’s eyes. The fibrous tunic (sclera and cornea) is the outer layer of the three layers of the eyeball. The ciliary body suspends the iris and the lens, and is located in the middle layer of the eyeball. The lens is the part of the eyeball where light and images enter the eye and reflect on the retina to stimulate vision. The lens can form cataracts, which interferes with visual acuity because of the associated opacity changes.

PTS:

CON: Sensory Perception

9. The nurse is attending while the HCP performs an otoscopic examination of a patient’s ears. The nurse is aware that the examination is performed primarily for which purpose? 1. To examine the eardrum 2. To look for foreign objects 3. To remove excessive earwax 4. To obtain a sample of drainage ANS: 1 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Identify diagnostic tests commonly performed to diagnose disorders of the sensory system. Page: 1103 Heading: Otoscopic Examination Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3 4

Primarily, the HCP will perform an otoscope examination to visualize the eardrum. Routinely, the HCP does not perform an otoscope examination to look for foreign objects. An otoscope examination is not performed to remove excessive earwax, which may be identified during a routine otoscope examination. An otoscope examination is not performed to obtain a sample of drainage from the ear. Drainage will be obtained through the use of a cotton-tipped swab.

PTS:

CON: Sensory Perception

10. The nurse is preparing a patient with diabetes mellitus for a fluorescein angiography. For which reason does the nurse understand the performance of this test? 1. To find leakage or damage to the blood vessels of the retina

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2. To identify the dry form of macular degeneration 3. To find the amount of vision damage related to glaucoma 4. To find abnormalities of the eye structure from hypoglycemia ANS: 1 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Identify diagnostic tests commonly performed to diagnose disorders of the sensory system. Page: 1099 Heading: Fluorescein and Indocyanine Green Angiography Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3 4

Fluorescein angiography is performed on patients with diabetes mellitus to diagnose and arrange for treatment of diabetic retinopathy. Indocyanine green angiography is performed to diagnose the wet form of macular degeneration. Fluorescein angiography and indocyanine green angiography are not used when testing to find the amount of vision damage related to glaucoma. Fluorescein angiography and indocyanine green angiography are not used when testing to find abnormalities of the eye structure from hypoglycemia.

PTS:

CON: Sensory Perception

11. The nurse performs a visual assessment on a patient and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate? 1. Palpebral angle rigid, right and left angles 2. Patient’s eyes round, regular, lively, active 3. Pupils equilateral, regular, round, little accommodation 4. Pupils equal, round, and reactive to light and accommodation ANS: 4 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Identify diagnostic tests commonly performed to diagnose disorders of the sensory system. Page: 1098 Heading: Pupillary Reflexes Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physical Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback

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1 2 3 4

This is an incorrect description for the acronym PERRLA. This is an incorrect description for the acronym PERRLA. This is an incorrect description for the acronym PERRLA. PERRLA is an acronym used to describe pupils equal, round, and reactive to light and accommodation.

PTS:

CON: Sensory Perception

12. The nurse is conducting hearing acuity evaluation on a patient using the Rinne test. The test involves the use of a tuning fork. Which test result will be validated with the documentation “AC greater than BC”? 1. The patient hears the tuning fork twice as long when it is placed on the mastoid bone. 2. The patient is unable to hear the tuning fork when it is lifted away from the mastoid bone. 3. The patient continues to hear the tuning fork for twice as long when it is lifted from the mastoid bone. 4. The patient stops hearing the tuning fork when it is moved from in front of the ear and placed on the mastoid bone. ANS: 3 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Identify diagnostic tests commonly performed to diagnose disorders of the sensory system. Page: 1105 Heading: Auditory Acuity Testing Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Difficult Feedback 1 2 3

Once the patient stops hearing the tuning fork while it is placed on the mastoid bone, it is normally heard twice as long when placed in front of the ear. It is expected that the patient will hear the tuning fork for some period of time after it is lifted from the mastoid bone and held in front of the ear. Documentation of “AC greater than BC” indicates that the patient hears the conduction of sound through the air twice as long as the conduction of sound through bone. This is considered a normal finding. If the patient stops hearing the tuning fork when it is moved away from the front of the ear and placed on the mastoid bone, this is indicative of abnormal neural conduction of sound.

PTS:

CON: Sensory Perception

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13. The nurse is preparing to administer eye medication as prescribed by the HCP after eye surgery for cataract removal. The HCP prescribes one drop with punctal occlusion. Which action will the nurse perform when administering this medication? 1. Have the nonmedicated eyelid held closed during medication administration. 2. Place the index finger on the corner of the eye and apply pressure against the nose bone. 3. Instruct the patient to squeeze the eye tightly shut once the drop is administered. 4. Tilt the head back, apply the drop, ask the patient to blink twice, and blot any leakage. ANS: 2 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Describe therapeutic measures for patients with disorders of the sensory system. Page: 1098 Heading: Punctal Occlusion Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2

3 4

There is no reason for the nurse to have the patient hold the eyelid of the nonmedicated eye closed while the other eye is being medicated. Punctal occlusion is placing the index finger against the inner corner of the eye and applying pressure against the nose bone. The action will help to keep the medication in the eye longer and reduce systemic absorption and side effects. Some eye medications can have serious cardiac or respiratory effects. Squeezing the eye tightly shut will force the medication out of the eye; closing the eye shut normally for 1 minute has the same effect as punctal occlusion. Tilting the head back and applying the drop is appropriate. However, blinking will allow the medication to leave the eye and limit medication effects.

PTS:

CON: Sensory Perception

14. A patient’s Snellen chart findings are 20/60. Which explanation does the nurse provide to the patient regarding this finding? 1. “Your vision is better than normal.” 2. “You must be at 60 feet to see what normal vision sees at 20 feet.” 3. “You must be at 20 feet to see what normal vision sees at 60 feet.” 4. “You are considered legally blind, even though with prescription glasses you’ll be able to see.” ANS: 3 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Identify diagnostic tests commonly performed to diagnose disorders of the sensory system. Page: 1095

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Heading: Visual Acuity Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3 4

Normal vision is 20/20, which means the patient can read at 20 feet what the normal eye can read at 20 feet. This is an inaccurate explanation of the finding of 20/60. For 20/60, the patient has less acute vision and must be at 20 feet to see what normal vision sees at 60 feet. Visual impairment occurs at 20/70 and legal blindness at 20/200 or more with correction.

PTS:

CON: Sensory Perception

15. The nurse is assisting with the preparation of a patient for a cochlear implant due to profound deafness. Which teaching will the nurse reinforce for this patient? 1. Preparation instructions for surgery 2. Care of the external equipment 3. The impact of hearing for the first time 4. Physical limitations after the procedure ANS: 1 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Describe therapeutic measures for patients with disorders of the sensory system. Page: 1105 Heading: Assistive Hearing Devices Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3 4

A cochlear implant requires a surgical procedure; the nurse needs to reinforce the instructions that are part of the surgical preparation. The care of the external equipment will need to be taught, but at this point, preparation for the procedure needs to be reinforced. The impact of hearing for the first time is likely to be addressed by the HCP. At this time, instructions for surgery will be reinforced by the nurse. The physical limitations after the procedure will be provided by the HCP; postsurgical review will be appropriate. At this time, the patient needs instructions for surgery preparation.

PTS:

CON: Sensory Perception

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16. The nurse is working at a summer camp for preadolescent children. One of the children comes to the nurse rubbing an eye and stating pain from getting sand in the eye. After the child is effectively treated, which teaching is the nurse prompted to provide to all the attendees? 1. It is dangerous to throw sand at each other. 2. Wear sunglasses if it is windy at the beach. 3. Do not rub your eye if it has something in it. 4. Remove the sand with any available fluid. ANS: 3 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Describe therapeutic measures for patients with disorders of the sensory system. Page: 1100 Heading: Eye Hygiene Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3

There is no indication in the question about how the sand got into the child’s eye. Another topic should be covered with all attendees. Sunglasses may or may not help keep blowing sand out of the eyes. The nurse is prompted to provide information about why it is dangerous to rub your eye if it has something in it. The real danger is scratching the delicate surfaces of the eye, such as the cornea. The eye should be allowed to water freely to remove any debris safely. The upper lid is pulled down to wash out the debris and then the eye is gently wiped from the inner to the outer canthus.

PTS:

CON: Sensory Perception

17. The nurse in an HCP’s office is providing assistance with a patient who has purulent drainage from the ear. Which action by the HCP does the nurse expect? 1. Flushing of the drainage from the ear canal 2. Packing the ear lightly to absorb the drainage 3. Excising the eardrum to promote drainage 4. Obtaining a swab of the drainage for culture ANS: 4 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Describe therapeutic measures for patients with disorders of the sensory system. Page: 1106 Heading: Laboratory Tests Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential

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Cognitive Level: Application (Applying) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3

When the ear is draining, flushing presents a risk of pushing the exudate deeper into the ear. The ear may or may not be packed lightly to absorb the drainage; the amount of drainage will be the determining factor. When the ear is currently draining, if the middle ear is involved, the eardrum is already perforated. If the drainage source is in the ear canal, the eardrum should be kept intact to avoid infecting the middle ear. When an ear is draining, a swab sample needs to be obtained and sent to the laboratory immediately for culture. Identifying the causative microbe will assist in prescribing the most effective antibiotic.

PTS:

CON: Sensory Perception

18. During a physical examination of a patient, pupillary reflexes are checked. A light is shone into the right eye while it is observed. Pupillary reaction and pupil size are noted. Then a light is shone into the left eye as the right eye is still observed. Which response occurs during the second step of the test? 1. Direct response 2. Indirect response 3. Consensual response 4. Accommodation response ANS: 3 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Identify diagnostic tests commonly performed to diagnose disorders of the sensory system. Page: 1098 Heading: Pupillary Reflexes Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3 4

The direct response is what is noted during the first part of the test when the light is shone into the right eye and the responses of that eye are noted. There is no pupillary response labeled “indirect.” Consensual response is the second part of this test; the light is shone into the left eye and the right eye is observed for response. There is no pupillary response labeled “accommodation.”

PTS:

CON: Sensory Perception

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19. While checking a patient’s pupils, the nurse notes that the left pupil constricts when a light is shone into the right eye. Which information does this finding suggest to the nurse? 1. Tropia present 2. Esotropia absent 3. Accommodation absent 4. Consensual response present ANS: 4 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Identify diagnostic tests commonly performed to diagnose disorders of the sensory system. Page: 1098 Heading: Pupillary Reflexes Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3 4

Tropia is a deviation of the eye away from the visual axis. Esotropia is deviation of the eye toward the nose. Accommodation is the ability of the pupil to respond to near and far distances. A consensual response occurs when the pupil of one eye constricts when the other eye has a light shone into it.

PTS:

CON: Sensory Perception

20. The National Eye Institute has performed research regarding the impact of nutrition on eye diseases. Which factor does the nurse recognize as an incorrect conclusion from this research? 1. A diet high in green, leafy vegetables lowers the risk of age-related macular degeneration (AMD). 2. With intensive glycemic control, patients with diabetes mellitus do not experience retinopathy. 3. Supplements containing vitamins and minerals will reduce the risk of developing advanced AMD. 4. There is no benefit of supplemented omega-3 fatty acids on AMD; eating fish lowers the rate. ANS: 2 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Describe therapeutic measures for patients with disorders of the sensory system. Page: 1095 Heading: Nutrition and Eye Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential

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Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Difficult Feedback 1 2 3 4

A diet high in green, leafy vegetables is high in the antioxidants lutein and zeaxanthin, which lowers the risk for AMD. Patients with diabetes mellitus can reduce the progression of retinopathy by one-third by maintaining intensive glycemic control. Supplements with vitamins and minerals will reduce the risk of developing AMD. Research validates that there is no benefit from omega-3 fatty acid supplements, but eating fish high in omega-3 fatty acids is effective in reducing the rates of AMD.

PTS:

CON: Sensory Perception

MULTIPLE RESPONSE 1. The nurse determines that a patient is experiencing common age-related changes in vision and hearing. Which findings does the nurse identify in the patient? (Select all that apply.) 1. Presbycusis 2. Yellowing of the lens 3. Distorted depth perception 4. Decreased lacrimal secretions 5. Increased pupil size and response to light ANS: 1, 2, 3, 4 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: List data to collect when caring for a patient with a disorder of the sensory system. Page: 1098 Heading: Age-Related Changes in Vision and Age-Related Changes in Hearing Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Difficult

1. 2. 3. 4.

Feedback Age-related changes in vision and hearing include presbycusis, yellowing of the lens, distorted depth perception, and decreased lacrimal secretions. Age-related changes in vision and hearing include presbycusis, yellowing of the lens, distorted depth perception, and decreased lacrimal secretions. Age-related changes in vision and hearing include presbycusis, yellowing of the lens, distorted depth perception, and decreased lacrimal secretions. Age-related changes in vision and hearing include presbycusis, yellowing of

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5. PTS:

the lens, distorted depth perception, and decreased lacrimal secretions. Pupil size and response to light decreases with aging. 1

CON: Sensory Perception

2. The nurse places eyedrops for a patient with an injured eye and covers the eye with a patch as prescribed. Discharge instructions are given to the patient. Which patient statements indicate further instruction is needed? (Select all that apply.) 1. “I should exercise my patched eye four times daily.” 2. “I can watch television without moving my eye too much.” 3. “I should apply pressure to the tear duct of the eye every 5 minutes.” 4. “I should try to open my eyelid under the patch hourly while awake.” 5. “I can listen to music or an audiotaped book, but should not read or watch television.” ANS: 1, 2, 3, 4 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Describe therapeutic measures for patients with disorders of the sensory system. Page: 1100 Heading: Eye Patching Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback The patient should not exercise the patched eye, watch television, apply pressure to the tear duct, or open the eye under the patch. The patient should not exercise the patched eye, watch television, apply pressure to the tear duct, or open the eye under the patch. The patient should not exercise the patched eye, watch television, apply pressure to the tear duct, or open the eye under the patch. The patient should not exercise the patched eye, watch television, apply pressure to the tear duct, or open the eye under the patch. Listening to an audio book and taping the patch securely indicate teaching has been effective. 1

CON: Sensory Perception

3. The nurse has reinforced teaching with a patient about diagnostic tests that evaluate eye muscle balance. Which tests identified by the patient indicate teaching has been effective? (Select all that apply.) 1. Cover test 2. Corneal light reflex 3. Tonometer readings 4. Electroretinography 5. Computed tomography

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6. Fluorescein angiography ANS: 1, 2 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Identify diagnostic tests commonly performed to diagnose disorders of the sensory system. Page: 1099 Heading: Muscle Balance and Eye Movement Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Difficult

1. 2. 3. 4. 5. 6. PTS:

Feedback The cover test is used in conjunction with an abnormal corneal light reflex test to evaluate muscle balance. The cover test is used in conjunction with an abnormal corneal light reflex test to evaluate muscle balance. Tonometer readings do not evaluate eye muscle balance. Electroretinography does not evaluate eye muscle balance. Computed tomography does not evaluate eye muscle balance. Fluorescein angiography does not evaluate eye muscle balance. 1

CON: Sensory Perception

4. During a health history, the nurse suspects that a patient is at risk for a vision problem. Which information within the family history does the nurse use to make this decision? (Select all that apply.) 1. Asthma 2. Diabetes 3. Cataracts 4. Blindness 5. Glaucoma ANS: 2, 3, 4, 5 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: List data to collect when caring for a patient with a disorder of the sensory system. Page: 1096 Heading: Nursing Assessment of the Eye and Visual Status Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Difficult

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1. 2. 3. 4. 5.

PTS:

Feedback Asthma does not affect vision. Family history that affects vision includes glaucoma, diabetes mellitus, and cataracts. Family history that affects vision includes glaucoma, diabetes mellitus, and cataracts. Family history that affects vision includes glaucoma, diabetes mellitus, and cataracts. Family history that affects vision includes glaucoma, diabetes mellitus, and cataracts. 1

CON: Sensory Perception

5. Prior to measuring a patient’s hearing, the nurse obtains a tuning fork. Which hearing tests is the nurse preparing to conduct? (Select all that apply.) 1. Rinne test 2. Weber test 3. Caloric test 4. Tympanometry 5. Electronystagmogram ANS: 1, 2 Chapter: Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing Objective: Identify diagnostic tests commonly performed to diagnose disorders of the sensory system. Page: 1107 Heading: Diagnostic Tests for the Ear and Hearing Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback The Rinne test is performed with a tuning fork and is useful for differentiating between conductive and sensorineural hearing loss. The Weber test is also performed using a tuning fork. The caloric test is used to test the function of the eighth cranial nerve and to assess vestibular reflexes of the inner ear that control balance. Tympanometry is a test used to measure compliance of the tympanic membrane and differentiate problems in the middle ear. The electronystagmogram is used to diagnose the causes of unilateral hearing loss of unknown origin, vertigo, or ringing in the ears. 1

CON: Sensory Perception

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Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing MULTIPLE CHOICE 1. The nurse is collecting information from a patient who reports difficulty seeing the print in the newspaper. The patient is 50 years of age and does not have any condition that requires medical management. Which vision condition does the nurse suspect the patient is experiencing? 1. Myopia 2. Presbyopia 3. Astigmatism 4. Emmetropia ANS: 2 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Explain the etiologies, signs, and symptoms of each sensory disorder. Page: 1119 Heading: Refractive Errors Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1

Myopia (nearsightedness) is when items up close can be seen clearly and distant objects are unclear. It is caused when the eyeball is elongated and light rays focus in front of the retina. Presbyopia is a condition related to aging and occurs when the lens of the eye loses elasticity. The lens is less able to focus light onto the retina to see close objects. The condition occurs around age 40 and is likely this patient’s visual difficulty. Astigmatism is caused by uneven curvatures on the cornea causing the light rays to be focused on two different points of the retina. The person with astigmatism will experience blurred vision with distortion. The cause can be from trauma, inflammation, or an autosomal dominant trait. Emmetropia is the term used to define good vision.

PTS:

CON: Sensory Perception

2. The nurse is visiting the home of a patient diagnosed with visual impairment related to macular degeneration. Which observation indicates to the nurse the patient is adjusting to the condition? 1. The patient is in nightclothes in the middle of the afternoon. 2. The patient is moving about in the apartment without problems. 3. The patient’s refrigerator contains only condiments, eggs, and milk. 4. The patient has stacks of unopened mail on the kitchen table.

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ANS: 2 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Plan nursing care for patients with disorders of the eye or ear. Page: 1127 Heading: Nursing Process for the Patient With Visual Impairment Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1

With a visually impaired patient, the goal is for independence in performing the activities of daily living. The nurse needs to determine the reason that the patient is not dressed in the middle of the afternoon. When the nurse observes the patient’s ability to move about the apartment without difficulty, it is an indication that the patient can be safe and independent in the patient’s environment. The nurse expects to see more in the patient’s refrigerator than condiments, eggs, and milk. The nurse needs to determine how the patient is meeting nutritional needs. When the nurse sees piles of unopened mail on the patient’s kitchen table, the nurse needs to explore the patient’s ability to read and care for personal matters.

PTS:

CON: Sensory Perception

3. A patient with acute angle glaucoma and a fractured femur that is scheduled for surgery is prescribed the preoperative medications morphine 10 mg intramuscularly (IM) and atropine 0.4 mg IM. Which action does the nurse take? 1. Hold the morphine. 2. Contact the physician. 3. Give medications as ordered. 4. Collect data on patient’s pain. ANS: 2 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Identify medications contraindicated for patients with acute angle-closure glaucoma. Page: 1124 Heading: Glaucoma Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1

There is no reason to hold the morphine.

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2 3 4

Atropine is contraindicated for patients with acute angle glaucoma. It can cause blindness if given so the physician must be notified. Giving the medications could cause blindness in the patient. The morphine is not being given for pain but rather for preoperative preparation.

PTS:

CON: Sensory Perception

4. The nurse is reinforcing teaching provided to a patient with open-angle glaucoma. What is most important for the nurse to include in the patient teaching? 1. Regardless of treatment, peripheral vision will be eventually lost. 2. Compliance with drug therapy is essential to prevent loss of vision. 3. Damage to the eye caused by glaucoma is reversible in early stages. 4. Eye pain is experienced until the optic nerve atrophies, causing blindness. ANS: 2 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Explain the etiologies, signs, and symptoms of each sensory disorder. Page: 1124 Heading: Glaucoma Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3 4

It is not definite that the patient will lose peripheral or any vision. Lifelong compliance with drug therapy is essential to prevent loss of vision. Vision changes cannot be corrected with eyeglasses. Eye pain and optic nerve damage is associated with acute angle glaucoma. PTS:

CON: Sensory Perception

5. The caregiver of a patient with macular degeneration voices being increasingly frustrated because of food spills on the patient’s clothing. Which explanation does the nurse give to help the caregiver understand what the patient is experiencing? 1. “The patient’s vision is blurred.” 2. “There is total blindness in one eye occurring.” 3. “The central vision is gone and only peripheral vision remains.” 4. “There are black dots in the field of vision that cause confusion.” ANS: 3 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Explain the pathophysiology of each of the disorders of the sensory system. Page: 1127 Heading: Macular Degeneration Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation

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Cognitive Level: Application (Applying) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3 4

This statement does not correctly describe macular degeneration. This statement does not correctly describe macular degeneration. In macular degeneration, central vision is gone, and only peripheral vision remains, so it is hard to see things in front of oneself. This statement does not correctly describe macular degeneration.

PTS:

CON: Sensory Perception

6. A patient is diagnosed with otosclerosis and is scheduled for a stapedectomy. Which postoperative finding does the nurse report to the health care provider (HCP) or the registered nurse (RN) immediately? 1. The patient remains positioned with the surgical ear positioned upward. 2. The side rails of the bed are up in response to the patient feeling dizzy. 3. The patient received an antiemetic for nausea, but vomits after the medication. 4. The earplug placed in the surgical ear is found on the floor next to the patient’s bed. ANS: 3 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Plan nursing care for patients with disorders of the eye or ear. Page: 1137 Heading: Stapedectomy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2

The patient is positioned correctly if the surgical ear is positioned upward while the patient is lying in bed. It is expected that the patient may feel dizzy following surgery for a stapedectomy; the side rails of the bed need to be in the up position to promote safety and prevent falls. After a stapedectomy, the patient may experience nausea; however, an antiemetic is given to prevent vomiting. If the patient vomits, the HCP or RN needs to be notified immediately. Vomiting can displace the prosthesis. The nurse needs to report if the earplug in the surgical ear is no longer in the ear canal. The earplug is placed to keep the area aseptic. However, there is another issue that requires immediate action.

PTS:

CON: Sensory Perception

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7. The nurse in an HCP’s office is assisting with the removal of impacted cerumen from the ear canal of an older adult patient. The patient presented with decreased hearing and a sensation of fullness. Which reason does the nurse identify as the most likely cause of the patient’s condition? 1. Improper cleaning of the ear canal 2. The presence of hair growth in the ear canal 3. Dryness of secretions from shrinking ear canal glands 4. Exposure to dirt and dust in the working environment ANS: 3 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Explain the etiologies, signs, and symptoms of each sensory disorder. Page: 1134 Heading: Impacted Cerumen Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1

Improper cleaning of the ear canal can cause cerumen to be shoved and impacted into the ear canal. However, there is no information in the question to support this cause. Cerumen can become compacted due to an abundant amount of hair growth in the ear canal. However, there is no specific information in the question to support this cause. Because of the patient being older, the most likely cause of the impacted cerumen is related to age. In the older adult, cerumen is drier as secretions decrease because of shrinking ceruminous glands; keratin continues to collect causing an impaction in the ear canal. Exposure to dirt and dust in the environment can contribute to impacted cerumen; however, there is no information in the question to support this cause.

PTS:

CON: Sensory Perception

8. A patient is diagnosed with Ménière disease. Which therapeutic measures does the nurse expect the HCP to prescribe? 1. A minimum of 8 hours of sleep nightly to prevent fatigue 2. A salt-restricted diet and prescribed antihistamines and vasodilators 3. Prophylactic antiemetic medications prescribed for nausea and vomiting 4. Meclizine, tranquilizers, and vagal blockers prescribed to prevent symptoms ANS: 2 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Identify therapeutic measures for each sensory disorder. Page: 1140 Heading: Ménière Disease Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation

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Cognitive Level: Application (Applying) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3 4

Ménière disease is not associated with fatigue; a minimum of 8 hours of sleep nightly is not a therapeutic measure for the disorder. Therapeutic management of Ménière disease involves a salt-restricted diet, diuretics, antihistamines, and vasodilators during prophylactic treatment. Nausea and vomiting are manifestations of an acute attack of Ménière disease; antiemetic medications are not prescribed prophylactically for the condition. Meclizine, tranquilizers, and vagal blockers are used to manage the manifestations of an acute attack of Ménière disease, and not prescribed for symptom prevention.

PTS:

CON: Sensory Perception

9. The nurse is providing care for a school-age patient at a community clinic. The patient exhibits redness and crusting exudate on the lids and corners of each eye, and reports pain and itching. A culture was taken of the exudate and antibiotic drops were prescribed. Which action does the nurse take if the eye culture returns as positive for Neisseria gonorrhoeae? 1. Review the importance of medication administration with the patient’s parent. 2. Mail the patient’s household literature about prevention of infecting family members. 3. Ask a family member to bring the patient back to the clinic for a follow-up evaluation. 4. Notify the HCP and RN about a possible situation involving sexual abuse of a minor. ANS: 4 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Plan nursing care for patients with disorders of the eye or ear. Page: 1121 Heading: Conjunctivitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Difficult Feedback 1 2

The infective organism is bacterial and should respond to the prescribed antibiotic therapy. However, this action is not specific to culture results. The infective organism is contagious and the family needs to know methods of preventing cross contamination to other persons. However, mailing literature does not necessarily meet the needs of prevention. It may be necessary for the patient to be brought back to the clinic for a followup evaluation; however, this can be arranged after the nurse notifies the HCP or the RN.

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The infective organism is responsible for gonorrhea, which is a sexually transmitted infection. When a minor is infected in any way with an organism that is sexually transmitted, the HCP and/or RN should be notified of possible sexual abuse of a minor. All medical professionals are legally required to report such instances.

PTS:

CON: Sensory Perception

10. An adolescent patient is diagnosed by the HCP with keratitis from a herpes simplex infection of the eye. Which patient teaching does the nurse reinforce as a method for pain management? 1. The importance of finishing all the prescribed antiviral medication 2. Wearing sunglasses indoors and outdoors to decrease effects of photophobia 3. Disposing of all eye cosmetics that were used at the time of becoming infected 4. Refraining from using contact lenses until all signs of inflammation are gone ANS: 2 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Identify therapeutic measures for each sensory disorder. Page: 1114 Heading: Keratitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Sensory Perception Difficulty: Moderate Feedback 1

3 4

It is important for the patient to understand the necessity of completing all antiviral medication; however, this information is related to management of the condition and is not specifically focused on pain management. Keratitis causes photophobia due to the irritation of the cornea. The pain of photophobia can be managed by wearing sunglasses while indoors and outdoors until the condition is resolved. The patient will be advised to dispose of all eye cosmetics that were used up until the time of becoming infected; the purpose is to prevent reinfection. Because keratitis causes an irritation to the cornea, contact lenses are not used until the conjunctiva and surrounding tissues are no longer inflamed.

PTS:

CON: Sensory Perception

11. The nurse is conducting hearing tests in a neighborhood clinic. The nurse is concerned about the number of young adult patients who exhibit signs of sensorineural hearing loss. For which reason does the nurse suspect this type of hearing loss in this population? 1. High exposure to ototoxic drugs 2. Prolonged exposure to loud noise 3. Trauma from physical contact sports 4. Increased incidences of meningitis

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ANS: 2 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Explain the etiologies, signs, and symptoms of each sensory disorder. Page: 1129 Heading: Sensorineural Hearing Loss Integrated Process: Clinical Problem-Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2

3 4

Ototoxic drugs are not routinely taken by young adult patients; it is unexpected that this population would experience sensorineural hearing loss for this reason. Young adults have grown up in a time when loud music is popular and often listened to at a high volume with or without earphones. Prolonged exposure to loud noise can cause sensorineural hearing loss. Not all persons in the young adult age category are involved in contact sports. A percentage of young adults have a higher incidence of meningitis, but this is not a condition most closely related to sensorineural hearing loss in this population.

PTS:

CON: Sensory Perception

12. A patient presents with vertigo, tinnitus, and sensorineural hearing loss and is diagnosed with labyrinthitis. Which patient teaching does the nurse reinforce with this patient? 1. Instruct to not turn the head quickly. 2. Emphasize the importance of taking antihistamines. 3. Use proper methods for cleaning the ear. 4. Hearing will return with rest and medication. ANS: 1 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Plan nursing care interventions for the patient with a hearing impairment. Page: 1129 Heading: Labyrinthitis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3

The patient with labyrinthitis should be reminded not to turn the head quickly to avoid vertigo. Antihistamines may or may not be effective in relieving dizziness; there is no specific medication to alleviate this manifestation. Proper ear cleaning is not necessary for the nurse to reinforce with a diagnosis of labyrinthitis; the infection is in the inner ear.

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Hearing may or may not return when labyrinthitis is resolved; an audiologist will test the patient for the extent of hearing loss.

PTS:

CON: Sensory Perception

13. The nurse is assisting in the evaluation of the effectiveness of teaching for a patient who has severe visual impairment. Which statement by the patient indicates additional teaching is needed? 1. “I can do all my self-care if no one moves my hygiene items.” 2. “Cooking is still impossible and I am just eating cold foods.” 3. “My family helped move everything out of my pathways.” 4. “I have someone come weekly for cleaning and laundry.” ANS: 2 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Plan nursing care for patients with disorders of the eye or ear. Page: 1123 Heading: Nursing Care Plan for the Patient With Visual Impairment Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3 4

When a patient with severe vision impairment is able to perform self-care independently, patient teaching is effective. The patient needs additional teaching about methods and/or agencies that can be helpful in supplying adequate nutrition. When the patient enlists the help of family to make the environment safer, teaching is effective. When the patient understands the need for help with chores that cannot be performed independently, teaching is effective.

PTS:

CON: Sensory Perception

14. The nurse is collecting data from a patient with diabetes mellitus. The patient’s medical history reveals multiple episodes of hyperglycemia requiring medical management. The patient tells the nurse, “I just got new glasses, but I still do not see very well.” Which condition does the nurse suspect? 1. Preproliferative retinopathy 2. Background retinopathy 3. Proliferative retinopathy 4. Incomplete retinal detachment ANS: 2 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Explain the etiologies, signs, and symptoms of each sensory disorder. Page: 1123

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Heading: Diabetic Retinopathy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1

Preproliferative retinopathy is the second stage of diabetic retinopathy, which is characterized by swollen and irregularly dilated veins. There are no symptoms related to this stage. Background retinopathy is the first stage of diabetic retinopathy when microaneurysms form in the retina capillary walls. The patient may notice decrease in color discrimination and visual acuity. Proliferative retinopathy is the third state of diabetic retinopathy characterized by the formation of new blood vessels, which are fragile and leak blood into the vitreous and retina. During this stage, retinal detachment may occur. The patient’s statement does not support the presence of any type of retinal detachment.

PTS:

CON: Sensory Perception

15. The nurse is providing care for an older adult client. The nurse notices the patient appears to be having difficulty understanding her and asks that questions and comments be repeated. If the nurse suspects presbycusis, which action does the nurse take to promote better hearing for the patient? 1. Ask the patient if he is having difficulty hearing. 2. Sit closer to and directly in front of the patient. 3. Speak to the patient in a lower tone of voice. 4. Use a slightly louder and slower talking rate. ANS: 3 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Plan nursing care interventions for the patient with a hearing impairment. Page: 1129 Heading: Sensorineural Hearing Loss Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Basic Care and Comfort Cognitive Level: Application (Applying) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2

The nurse can ask the patient to confirm problems with hearing, but should expect the answer to be positive given the patient’s actions. Sitting closer and directly in front of the patient may or may not help the patient to hear better; depending on the patient, it may be culturally contraindicated to make this change. Older patients are inclined to develop presbycusis and have difficulty in

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deciphering higher pitched sounds, like the female voice. The nurse should lower the tone of her voice to promote better hearing. Talking slightly louder and slower will not improve the patient’s ability to hear.

PTS:

CON: Sensory Perception

16. The nurse is reinforcing teaching provided to a patient with primary open-angle glaucoma (POAG) about symptoms to report. Which patient statement regarding symptoms indicates a correct understanding of the teaching? 1. “Hypotension and bradycardia” 2. “Fever and reddened conjunctiva” 3. “Loss of central vision and dizziness” 4. “Headache and seeing halos around lights” ANS: 4 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Explain the etiologies, signs, and symptoms of each sensory disorder. Page: 1125 Heading: Glaucoma Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3 4

Hypotension and bradycardia are not symptoms of POAG. Fever and reddened conjunctiva are not symptoms of POAG. Loss of central vision and dizziness are not symptoms of POAG. POAG develops bilaterally. The onset is usually gradual and painless, so the patient may not experience noticeable symptoms or, after time, may experience mild aching in the eyes, headache, halos around lights, or frequent visual changes that are not corrected with eyeglasses.

PTS:

CON: Sensory Perception

17. The nurse is reinforcing teaching provided to a patient recovering from a stapedectomy. Which patient statement indicates teaching has been effective? 1. “I will avoid airplane travel for 6 months.” 2. “I will cough or sneeze with my mouth open.” 3. “I will gently blow my nose with both sides open.” 4. “I will keep the ear moist by packing it with cotton balls.” ANS: 2 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Plan nursing care for patients with disorders of the eye or ear. Page: 1137 Heading: Middle Ear, Tympanic Membrane, and Mastoid Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3 4

There is no need for the patient to avoid airplane travel for 6 months. It is important to prevent increased pressure to protect the graft site, so the mouth should be open when coughing or sneezing. The nose should be gently blown one side at a time. The ear does not need to be kept moist; there is no need to pack the ear with cotton balls.

PTS:

CON: Sensory Perception

18. The nurse is assisting with the care of a patient being prepared for emergency intervention for a detached retina. If the nurse asks the patient about the ability to maintain a reclining position for 16 hours, which procedure is planned for this patient? 1. Laser surgery 2. Cryopexy 3. Pneumatic retinopexy 4. Scleral buckling ANS: 3 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Identify therapeutic measures for each sensory disorder. Page: 1124 Heading: Retinal Detachment Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1 2 3

Laser surgery does not require the patient to recline for 16 hours prior to the procedure. Cryopexy does not require the patient to recline for 16 hours prior to the procedure. Pneumatic retinopexy is a procedure that involves injecting air or gas into the eyeball to hold the retina in place. Reclining for about 16 hours before the procedure is required to allow the retina to fall back toward the choroid. Three weeks of specific positioning is required to complete the process of healing. Scleral buckling does not require the patient to recline for 16 hours prior to the procedure.

PTS:

CON: Sensory Perception

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19. The nurse is preparing to assist the HCP with the incision of a carbuncle in the ear canal of a patient. Which specific manifestation does the nurse associate with the patient’s diagnosis? 1. Necrotic tissue spreading toward the auricle 2. An absence of protective earwax in the canal 3. Several hair follicles that have formed an abscess 4. Fungus in the ear canal causing an infection ANS: 3 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Explain the pathophysiology of each of the disorders of the sensory system. Page: 1133 Heading: External Ear Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Moderate Feedback 1

2 3

Perichondritis is an infection of the auricle that can result in necrosis of the ear cartilage. Necrotic tissue spreading toward the auricle is not associated with a carbuncle. The absence of protective earwax in the ear canal is swimmer’s ear and is not associated with a carbuncle in the ear canal. When several hair follicles in the ear canal become infected and form an abscess, it is a carbuncle. Many carbuncles will rupture on their own; some will need to be incised and drained. Otomycosis is an infection of the ear canal caused by a fungus growth.

PTS:

CON: Sensory Perception

20. The nurse in the emergency department is assisting with the care of a patient with a penetrating wound to the eye. The patient keeps crying out and asking that the uninjured eye be uncovered. Which answer by the nurse provides understanding? 1. “It is less stressful if you cannot see anything about the other eye.” 2. “Covering your uninjured eye will keep anything from getting into it.” 3. “Being able to see will allow you to look around and get more upset.” 4. “Covering the uninjured eye stops ocular movement in the injured one.” ANS: 4 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Identify therapeutic measures for each sensory disorder. Page: 1129 Heading: Trauma Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Sensory Perception Difficulty: Moderate

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Feedback 1 2 3 4

The nurse needs to help keep the patient calm; however, it is not the reason the uninjured eye is covered. The uninjured eye is not necessarily covered to keep anything from getting into it; the goal is to prevent ocular movement in the injured eye. Telling the patient that the ability to look around will just upset them more and does not help to keep the patient calm. The primary reason for covering the uninjured eye when there is a penetrating injury to the other eye is to stop ocular movement that can cause additional damage.

PTS:

CON: Sensory Perception

MULTIPLE RESPONSE 1. The nurse is providing care for a patient with a sensorineural hearing loss. Which prescribed medications does the nurse question before administering medications to this patient? (Select all that apply.) 1. Gentamicin 2. Furosemide 3. Indomethacin 4. Acetaminophen 5. Warfarin sodium ANS: 1, 2, 3 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: List three ototoxic drugs. Page: 1129 Heading: Hearing Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Difficult

4. 5.

Feedback Gentamicin, furosemide, and indomethacin are all ototoxic medications. For the patient with sensorineural hearing loss, the nurse should question these medications before providing. Gentamicin, furosemide, and indomethacin are all ototoxic medications. For the patient with sensorineural hearing loss, the nurse should question these medications before providing. Gentamicin, furosemide, and indomethacin are all ototoxic medications. For the patient with sensorineural hearing loss, the nurse should question these medications before providing. This medication is not considered ototoxic. This medication is not considered ototoxic.

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PTS:

CON: Sensory Perception

2. The nurse is collecting data from a patient with a detached retina. Which findings does the nurse expect in this patient? (Select all that apply.) 1. Severe pain 2. Blurred vision 3. Flashing lights 4. Loss of peripheral vision 5. Loss of acuity in the affected eye ANS: 3, 4, 5 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Explain the etiologies, signs, and symptoms of each sensory disorder. Page: 1124 Heading: Retinal Detachment Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Difficult

1. 2. 3.

4. 5.

PTS:

Feedback There is no pain because the retina does not contain sensory nerves. Blurred vision does not occur with a detached retina. Patients experiencing a retinal detachment report a sudden change in vision. Initially, as the retina is pulled, patients report seeing flashing lights and then floaters. The flashing lights are caused by vitreous traction on the retina, and the floaters are caused by hemorrhage of vitreous fluid or blood. On visual examination, the patient typically has a loss of peripheral vision when the visual fields are tested and a loss of acuity in the affected eye. On visual examination, the patient typically has a loss of peripheral vision when the visual fields are tested and a loss of acuity in the affected eye. 1

CON: Sensory Perception

3. A patient with acute ear pain and drainage comes into the community clinic. Which diagnostic tests does the nurse expect to be performed prior to beginning treatment for this patient? (Select all that apply.) 1. Biopsy 2. Audiometric testing 3. Complete blood count (CBC) 4. Rinne and Weber tests 5. Culture of ear discharge ANS: 3, 4, 5 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Plan nursing care for patients with disorders of the eye or ear. Page: 1133 Heading: External Ear

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1. 2. 3.

4. 5.

PTS:

Feedback A biopsy would be indicated for an ear mass. Audiometric testing would be appropriate for the patient with impacted cerumen. For an external ear infection diagnostic tests include a CBC, specifically white blood cell count, and cultures of discharge. This will help diagnose the infection. The Rinne and Weber tests can indicate conductive hearing impairment. Culture and sensitivity tests isolate the specific infective organism and determine which antibiotics would be most effective to treat the infection. 1

CON: Sensory Perception

4. A patient with otitis media is experiencing severe ear pain. Which nonpharmacological measures does the nurse apply to help relieve this patient’s discomfort? (Select all that apply.) 1. Offer a massage. 2. Apply heat to the area. 3. Offer liquid or soft diet. 4. Apply an ice pack to the area. 5. Dim the lights and reduce environmental noise. ANS: 1, 2, 3 Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Plan nursing care for patients with disorders of the eye or ear. Page: 1133 Heading: Middle Ear, Tympanic Membrane, and Mastoid Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Basic Care and Comfort Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback Nonpharmacological methods, such as relaxation, massage, music, guided imagery, or distraction techniques help to relieve ear pain. Apply heat as ordered to the area to promote comfort. Offer liquid or soft foods to relieve pain when chewing. Ice to the area could cause additional pain. Dimming the lights and reducing environmental noise would be helpful for a patient with an eye injury or condition. 1

CON: Sensory Perception

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COMPLETION 1. After surgery for a detached retina, a patient is experiencing nausea and is prescribed prochlorperazine (Compazine), 10 mg IM prn every 6 hours. Compazine is available as 5 mg/mL. The nurse administers mL in each dose. ANS: 2, two 2 two 2, two Chapter: Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing Objective: Plan nursing care for patients with disorders of the eye or ear. Page: 1133 Heading: Retinal Detachment Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Analysis (Analyzing) Concept: Sensory Perception Difficulty: Difficult Feedback: The solution is found by mathematical process. 10 mg

PTS:

1 mL 5 mg 1

= 2 mL

CON: Sensory Perception

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Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures MULTIPLE CHOICE 1. The nurse is assisting with a skin examination for a patient. The patient asks, “I love the sun, why is everyone so concerned about sun exposure?” Which answer by the nurse is best? 1. “Sun exposure will cause the skin to age and wrinkle.” 2. “The sun gives off ultraviolet (UV) rays that destroy vitamin D.” 3. “Melanin pigment is a barrier against UV exposure.” 4. “UV rays are mutagenic and can cause skin cancers.” ANS: 4 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Explain normal structures and functions of the integumentary system. Page: 1147 Heading: Epidermis, Dermis, and Hypodermis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3

Sun exposure can contribute to skin aging and the development of wrinkles; however, this is not the best answer regarding sun exposure. The sun gives off UV rays, but UV rays are not involved in the destruction of vitamin D. When melanin cells are stimulated by exposure to the sun, more pigment is produced to form a barrier against UV exposure to living cells in the stratum germinativum. The visible result is a tan. The best answer about concern related to sun exposure is that UV rays are mutagenic and can damage the DNA in cells, create mutations, and cause skin malignancies.

PTS:

CON: Tissue Integrity

2. The nurse in a health care provider’s (HCP’s) office is reassessing a patient’s skin and making a comparison with the information from the patient’s last visit. For which reason does the nurse focus on any changes noted in the patient’s skin? 1. Detection of skin cancer early can improve chances of a cure. 2. The skin is a good communicator regarding the patient’s health. 3. Skin lesions are seen as solid predictors of general health state. 4. The patient’s psychological health is best predicted by the skin. ANS: 2

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Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: List data to collect when caring for a patient with an integumentary system disorder. Page: 1148 Heading: Nursing Assessment of the Integumentary System Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2

3 4

Skin cancer can be detected early with regular skin inspections; however, the nurse’s focus on changes is not just related to skin cancer. The nurse knows the condition of the skin can be caused by underlying systemic conditions or manifestations of issues just related to the skin. Both situations make it important for the nurse to focus on changes from the last examination. Skin lesions are not solid predictors of a patient’s general health issues. Some skin lesions are just indications of skin problems. Psychological stress can contribute to a patient’s skin condition; however, this connection varies among individuals.

PTS:

CON: Tissue Integrity

3. The nurse is preparing to reexamine the skin of a patient who has a history of malignant skin growths. Which preparation by the nurse is incorrect? 1. Allow the patient to leave on underwear and socks. 2. Plan to use the techniques of inspection and palpation. 3. Include the hair, nails, scalp, and mucous membranes. 4. Explain the need for a penlight and magnifying glass. ANS: 1 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: List data to collect when caring for a patient with an integumentary system disorder. Page: 1149 Heading: Physical Examination Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Tissue Integrity Difficulty: Moderate Feedback 1

The patient needs to completely undress for a thorough inspection, especially with a history of malignant skin growths. The feet and genitalia are not immune

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2 3 4

to skin lesions or cancers. When reassessing the patient’s skin, the nurse will use the techniques of inspection and palpation. The body skin is not the only area inspected during a skin examination; the hair, nails, scalp, and mucous membranes are also inspected. The nurse needs to explain the need for a penlight and magnifying glass during a skin inspection; some areas of concern may be very small or in areas hidden by other parts of the body.

PTS:

CON: Tissue Integrity

4. The nurse is applying wet dressings as ordered to a patient who has a crusted skin lesion. Which assessment finding causes the nurse the most concern? 1. Edema formation 2. Dry, macerated skin 3. Increased lesion oozing 4. Excessive skin oiliness ANS: 2 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Describe therapeutic measures that are used for patients with integumentary disorders. Page: 1150 Heading: Open Wet Dressings Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3 4

Edema is not a common reaction to wet dressings. Wet dressings should not be prescribed for more than 72 hours, because the skin may become too dry or macerated. Oozing is not a common reaction to wet dressings. Oiliness is not a common reaction to wet dressings.

PTS:

CON: Tissue Integrity

5. The nurse works in an extended-care facility and is assisting in the development of a policy and procedure addressing foot care of the residents. Which intervention does the nurse identify as needing to be reconsidered in regard to routine foot care? 1. Soak the residents’ feet briefly in warm water and wash with gentle soap. 2. Use gauze or pads to reduce pressure where toes lie across each other. 3. Use a pumice stone to remove dry skin from heels or callused areas. 4. Apply an alcohol-free lotion to massage and perform range of motion (ROM) on feet and ankles.

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ANS: 3 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Identify the effects of aging on the integumentary system. Page: 1181 Heading: Care of Older Patients’ Feet Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Difficult Feedback 1 2 3

Soaking the feet of residents in warm water for a brief period of time before washing the feet with a gentle soap is appropriate care. Placing a gauze or commercial pad between toes that overlap each other is an appropriate action to prevent skin breakdown in pressure areas. The nurse needs to identify and question the suggestion to gently remove dry skin from heels and callouses with a pumice stone. Many residents will be older adults and the diagnosis of diabetes mellitus is common. A pumice stone is used on the feet of a patient with diabetes only under the direction of a podiatrist. Massage and ROM performed on the feet and ankles are relaxing and therapeutic. Alcohol-free lotion is used, but the lotion is not applied or allowed to remain between the toes.

PTS:

CON: Tissue Integrity

6. A patient presents with skin lesions that appear reddened, with seeping areas partially crusted over. The HCP orders a viral culture to be performed. Which action by the nurse is inappropriate when collecting the culture specimen? 1. An intact vesicle is gently squeezed to obtain fluid. 2. A sterile cotton swab is used to acquire culture material. 3. The collected fluid is evenly distributed over a glass slide. 4. The specimen is immediately transported to the laboratory. ANS: 3 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Identify laboratory and diagnostic tests commonly performed to diagnose integumentary disorders. Page: 1152 Heading: Cultures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Tissue Integrity Difficulty: Moderate

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Feedback 1 2 3

If an intact vesicle is available, it is gently squeezed to obtain fluid. If the area is crusted over, the crusts are removed or punctured to obtain culture fluid. A sterile cotton swab is used to obtain the material for a culture; care is taken to not contaminate the specimen. When obtaining a specimen for a virus culture, the cotton swab is placed in a special collection tube and placed on ice. The nurse does not distribute the collected fluid over a glass slide. For viral cultures, the collected specimen is placed inside a special tube, which is placed on ice and transported to the laboratory immediately.

PTS:

CON: Tissue Integrity

7. The nurse is preparing to assist the HCP in obtaining a full-thickness skin biopsy. Which information from the nurse is most appropriate? 1. Explain that the surface of the biopsy area will be shaved off. 2. Inform the patient that a thick area of skin will be punched out. 3. Tell the patient that the most pain will be in numbing the area. 4. Instruct the patient to expect considerable bleeding to occur. ANS: 3 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Identify laboratory and diagnostic tests commonly performed to diagnose integumentary disorders. Page: 1152 Heading: Biopsy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Cognitive Level: Application (Applying) Concept: Tissue Integrity Difficulty: Difficult Feedback 1 2 3 4

If the HCP plans a full-thickness biopsy, the technique will not involve shaving off the surface of the lesion. It is true that a thick area of skin will be punched out; however, this description may cause the patient anxiety or fear. The most important information for the nurse to give the patient is the most pain associated with obtaining the biopsy involves numbing the area. Bleeding or the amount of bleeding is expected, although it is unnecessary for the nurse to convey this information prior to the procedure.

PTS:

CON: Tissue Integrity

8. The nurse is assisting with a patient who has a suspected diagnosis of tinea capitis (ringworm). For which diagnostic test does the nurse prepare the patient? 1. Patch test 2. Scratch test 3. Skin biopsy

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4. Wood’s light examination ANS: 4 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Identify laboratory and diagnostic tests commonly performed to diagnose integumentary disorders. Page: 1177 Heading: Wood Light Examination Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3

A patch test is performed when allergic contact dermatitis is suspected. A scratch test is performed when allergic contact dermatitis is suspected. A skin biopsy is indicated for deeper infections to establish an accurate diagnosis or for the evaluation of current treatment. A biopsy is an excision of a small piece of tissue for microscopic assessment. Wood’s light examination is the use of UV rays to detect fluorescent materials in the skin and hair present in certain diseases such as tinea capitis (ringworm).

PTS:

CON: Tissue Integrity

9. While changing the dressing on a burned arm, the patient informs the nurse of feeling cold and having extreme pain. However, the patient asks the nurse to not apply so much pressure when wrapping gauze around the limb. Which conclusion does the nurse draw from the patient’s statements? 1. All nerves in the limb are damaged. 2. Free nerve endings in the arm are injured. 3. Encapsulated nerve endings in the arm are intact. 4. Encapsulated nerve endings in the arm are injured. ANS: 3 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Explain normal structures and functions of the integumentary system. Page: 1203 Heading: Receptors Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1

This is an incorrect interpretation of the patient’s response and extent of injury

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2 3

to the nerve endings in the burned arm. This is an incorrect interpretation of the patient’s response and extent of injury to the nerve endings in the burned arm. Sensory receptors for the cutaneous senses reside in the dermis. Receptors for heat, cold, and pain are free nerve endings; encapsulated nerve endings are specific for touch and pressure. The sensitivity of an area of skin is determined by the density of receptors present. This is an incorrect interpretation of the patient’s response and extent of injury to the nerve endings in the burned arm.

PTS:

CON: Tissue Integrity

10. The nurse works in an office with a dermatologist. When preparing to assist with a patch test for a client with suspected allergic contact dermatitis, which nursing action is unnecessary? 1. Cleanse the patient’s upper back and arms with alcohol. 2. Instruct the patient to keep areas dry and free from moisture. 3. Place resuscitation equipment in the vicinity of the testing. 4. Arrange for the final reading of the testing in 2 to 5 days. ANS: 3 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Identify laboratory and diagnostic tests commonly performed to diagnose integumentary disorders. Page: 1153 Heading: Skin Testing Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3

With a patch test, the skin needs to be oil free to promote adhesion of the patch; alcohol is an acceptable prep for the skin. The patient needs to keep the tested area(s) dry and free from moisture for the prescribed length of time. Resuscitation equipment is not needed for patch testing. However, due to the risk for anaphylaxis, the equipment is kept in a close location for scratch testing, which elicits an immediate reaction. With a patch test, the patches remain in place for 2 days and final reading or evaluation of the reactions take place within 2 to 5 days.

PTS:

CON: Tissue Integrity

11. A patient is admitted for treatment for a severe ulcerated pressure injury exhibiting signs of infection. The HCP prescribes open wet dressings to be applied every 6 hours for a period of 30 minutes. For which part of the prescription does the nurse consult with the registered nurse (RN)?

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1. 2. 3. 4.

Treatment is to continue for 7 days. The procedure is performed with clean technique. Room temperature normal saline is prescribed. The appearance of the area is to be documented.

ANS: 1 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Describe therapeutic measures that are used for patients with integumentary disorders. Page: 1165 Heading: Open Wet Dressings Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Tissue Integrity Difficulty: Moderate Feedback 1

Open wet dressings are not prescribed for longer than 72 hours; the skin may become too dry or macerated if treatment is extended. The nurse needs to consult with the RN about the prescribed period of 7 days. The procedure can be ordered as sterile or clean, depending on the tendency for an infection to develop. Because the patient already has an infection at the site, there is no need to consult with the RN since sterile technique is not necessary. Room temperature normal saline is an appropriate soaking solution to use on an open wet dressing. Other solutions include cool tap water, aluminum acetate solution, or magnesium sulfate. There is no need to consult with the RN. Documentation is always considered a part of nursing care.

PTS:

CON: Tissue Integrity

12. A patient with widely distributed chronic eczema is prescribed to receive medicated tar baths. Which important detail does the nurse acknowledge during this procedure? 1. The patient will need to be kept in the bath for 1 hour. 2. Old medications will need to be removed prior to the bath. 3. The room needs to have good ventilation because of volatility. 4. Slow addition of hot water will keep the bath temperature stable. ANS: 3 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Describe therapeutic measures that are used for patients with integumentary disorders. Page: 1153 Heading: Balneotherapy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Tissue Integrity

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Difficulty: Moderate Feedback 1 2

3 4

Balneotherapy is prescribed for 15 to 30 minutes. Balneotherapy is prescribed to apply medications to large areas of the body, for debridement and removing old crusts, to remove old medications, and to alleviate inflammation and itching. Medication does not need to be removed prior to the bath. When a medicated tar bath is prescribed, the room must be well ventilated because tars are volatile. During balneotherapy, hot water is not added to the bath to prevent skin burns. The temperature of the bath should be comfortable.

PTS:

CON: Tissue Integrity

13. The nurse is providing care for a patient with a large skin abrasion to the outer thigh. The HCP has ordered a daily dressing change without disturbance of the healing crusts that have formed in the area. Which dressing material will the nurse select? 1. Gauze 4 × 4s with paper tape to seal the edges of the dressing. 2. A nonadherent dressing for cover and gauze for wrapping. 3. Thick abdominal pad for protection with an elastic wrap. 4. A thin dressing wrapped around the thigh and taped securely. ANS: 2 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Describe therapeutic measures that are used for patients with integumentary disorders. Page: 1166 Heading: Dressings Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3 4

Gauze of any size will stick to the wound and pull away the crusts when the dressing is removed. Tape should be avoided. This wound requires a nonadherent dressing (Xeroform) held in place with a gauze wrapping; this selection will protect the healing crusts on the wound. A thick abdominal pad is not necessary and the material of the pad is not nonadherent. An elastic wrap has the potential of being too tight. The wound needs to have a dressing and wrapping a dressing around the entire thigh is not necessary. Tape should be avoided.

PTS:

CON: Tissue Integrity

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14. A patient has an open skin lesion and the HCP wants the area covered with a dressing after application of an antibiotic ointment. The patient asks the nurse the purpose of covering the area. Which reason does the nurse provide? 1. The dressing is solely for the purpose of retaining moisture. 2. The dressing will prevent the evaporation of the medication. 3. The dressing will reduce pain in the lesion and prevent itching. 4. The dressing will enhance the absorption of the topical medication. ANS: 4 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Describe therapeutic measures that are used for patients with integumentary disorders. Page: 1166 Heading: Dressings Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3 4

There is no information to validate the need for a dressing to retain moisture at the site of the lesion. Ointment is not likely to evaporate; this is not a valid reason for the dressing. There is no information provided to indicate that the patient has pain or itching at the site of the wound. When the lesion is open and an antibiotic ointment is applied, the purpose of the dressing is to enhance the absorption of the topical medication.

PTS:

CON: Tissue Integrity

15. The nurse is assisting in the care of a patient with second-degree burns to the arm. The blisters are not intact. The HCP prescribes an antibiotic ointment to be applied to the open areas twice daily. Which method will the nurse use for applying the prescribed medication? 1. A soft bristle brush 2. A cotton tipped swab 3. A wooden tongue depressor 4. A small surgical sponge ANS: 3 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Describe therapeutic measures that are used for patients with integumentary disorders. Page: 1196 Heading: Topical Medications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Pharmacological Therapies Cognitive Level: Application (Applying)

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Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3 4

Sometimes a soft brush can be used to apply thin or watery medications. A cotton swab is so small it may not be time effective to apply ointment in this manner. Ointment is thick and will spread well with the use of a wooden tongue depressor. A small surgical sponge may not be solid enough to spread an ointment.

PTS:

CON: Tissue Integrity

16. The nurse is providing care for a patient diagnosed with a fungal infection in the skinfolds beneath the breasts. The HCP has prescribed the application of an antifungal powder to the affected areas. For which reason does the nurse contact the RN for validation of the prescribed treatment? 1. The area of treatment has developed open sores. 2. The patient has an allergy to cornstarch. 3. The breasts are heavy and pendulant. 4. The patient has a chronic respiratory disease. ANS: 4 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Describe therapeutic measures that are used for patients with integumentary disorders. Page: 1149 Heading: Topical Medications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2

With a fungal infection in skinfolds, open sores are not unusual or a reason to validate the prescribed treatment. Antifungal powders come in a variety of bases (cornstarch, zinc oxide, talc), so if an allergy exists, a different product can be ordered. However, there is no information in the question to indicate an allergy to cornstarch. The patient is likely to have the fungal infection because the breasts are heavy and pendulant; fungus is most common in warm moist areas. After the application of the powder, the area can be covered with gauze dressings. Powder medications are contraindicated for patients with respiratory disorders or a tracheotomy. This is the reason the nurse needs the RN to validate the medication.

PTS:

CON: Tissue Integrity

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17. The nurse is assisting in the care of a patient presenting with painful psoriatic lesions. The HCP is preparing for intralesional therapy using a sterile suspension of corticosteroid. Which side effect does the nurse recognize as a possibility with this therapy? 1. Thinning of the skin at the site of the injection 2. Infection from invasive administration of medication 3. Local atrophy if the injection is in subcutaneous tissue 4. Interference with healing if an infection occurs ANS: 3 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Describe therapeutic measures that are used for patients with integumentary disorders. Page: 1150 Heading: Topical Medications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3 4

Thinning of the skin can occur with prolonged use of topical corticosteroids. It is uncommon for an infection to develop because of the injection of medication; the procedure is performed using aseptic technique. If the intralesional injection is not placed deeply beneath the lesion and is injected into subcutaneous tissue, local atrophy can occur. Intralesional injections of a corticosteroid will not interfere with healing if an infection occurs. However, the infection at the site may be masked by the medication.

PTS:

CON: Tissue Integrity

18. The nurse is collecting data on an older adult patient with a generalized rash. The patient reports severe itching and the nurse notes open lesions from scratching. Which additional finding causes the nurse the least concern? 1. The patient has uncut fingernails. 2. The patient is wearing soft-soled slippers. 3. The patient has thin hair with seborrhea. 4. The patient has an odor of urine and feces. ANS: 2 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: List data to collect when caring for a patient with an integumentary system disorder. Page: 1150 Heading: General Integrity and Cleanliness Integrated Process: Clinical Problem-Solving Process (Nursing Process)

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Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1

2 3

Because of the reported itching and open lesions, the nurse is concerned that the patient has uncut fingernails, which enables skin damage with scratching. Longer nails also harbor pathogens that can cause infections. The nurse’s least concern is the patient wearing soft-soled slippers. It is not unusual for older adult patients to have thin hair. Seborrhea can cause itching and provide an environment on the scalp that promotes the growth of bacteria. When the patient has the odor of urine and feces, general cleanliness is in question. Unclean skin allows for the growth of bacteria that can cause infections.

PTS:

CON: Tissue Integrity

MULTIPLE RESPONSE 1. The nurse is caring for a patient in a wound clinic who is treated with plastic wrap dressings. Which findings indicate complications related to prolonged application of the dressings? (Select all that apply.) 1. Cyanosis 2. Folliculitis 3. Maceration 4. Skin atrophy 5. Lichenification ANS: 2, 3, 4 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Describe therapeutic measures that are used for patients with integumentary disorders. Page: 1154 Heading: Dressings Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Difficult

1. 2.

Feedback Properly applied occlusive dressings do not cause cyanosis or lichenification. Continued use of occlusive dressings can cause skin atrophy, folliculitis, maceration, erythema, and systemic absorption of the medication. To prevent some of these complications, the dressing is removed for 12 out of every 24

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5. PTS:

hours. Continued use of occlusive dressings can cause skin atrophy, folliculitis, maceration, erythema, and systemic absorption of the medication. To prevent some of these complications, the dressing is removed for 12 out of every 24 hours. Continued use of occlusive dressings can cause skin atrophy, folliculitis, maceration, erythema, and systemic absorption of the medication. To prevent some of these complications, the dressing is removed for 12 out of every 24 hours. Properly applied occlusive dressings do not cause cyanosis or lichenification. 1

CON: Tissue Integrity

2. The nurse is assisting with the presentation about skin for a group of senior citizens in a community center. Which normal changes associated with aging does the nurse include? (Select all that apply.) 1. Fibroblasts in dermis die. 2. Subcutaneous fat increases. 3. Epidermal cell division slows. 4. Hair follicles become inactive. 5. Sweat glands become more active. ANS: 1, 3, 4 Chapter: Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures Objective: Identify the effects of aging on the integumentary system. Page: 1155 Heading: Gerontological Issues Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Difficult

1. 2. 3. 4. 5. PTS:

Feedback In normal aging, cell division slows, hair follicles become inactive, and fibroblasts in the dermis die. Subcutaneous fat decreases, not increases. In normal aging, cell division slows, hair follicles become inactive, and fibroblasts in the dermis die. In normal aging, cell division slows, hair follicles become inactive, and fibroblastsin the dermis die. Sweat glands become less, not more, active. 1

CON: Tissue Integrity

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Chapter 54. Nursing Care of Patients With Skin Disorders MULTIPLE CHOICE 1. The nurse is participating in a unit program aimed at preventing pressure injuries to residents in a long-term care facility. Which intervention does the nurse anticipate will be least effective? 1. Thoroughly dry all skin-to-skin surfaces after bathing. 2. Position patients at a 45-degree angle when on their side. 3. Place a pillow lengthwise under the calves of the legs. 4. Ensure an adequate intake of protein, calories, and fluid. ANS: 2 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: Recognize the role of the nurse in preventing pressure injuries. Page: 1160 Heading: Pressure Injuries Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1

3 4

It is important to keep the skin clean and dry for a patient who is at risk for pressure injuries. Places like under the breasts, the groin, and between the toes are suitable for the growth of bacteria. When positioning a patient on the side, the angle should not be more than 30 degrees to prevent pressure on the trochanter, a bony prominence, which is particularly subject to ischemia and pressure injury. The suggestion of 45 degrees is least helpful. The heels need to be elevated off any surface to prevent pressure injuries; placing a pillow lengthwise under the calves is an effective intervention. Good nutrition and hydration will promote healthy skin and assist in preventing pressure injuries, along with many other problems.

PTS:

CON: Tissue Integrity

2. The nurse is monitoring a patient’s stage 3 pressure injury for healing during treatment. Which finding indicates the nursing interventions have been effective? 1. There is a hard crust over the wound. 2. The patient states that pain is minimal. 3. The wound drainage is serosanguinous. 4. The wound has a grainy, spongy texture. ANS: 4 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders

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Objective: Explain how you will know whether your nursing interventions have been effective. Page: 1167 Heading: Pressure Injuries Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3 4

A hard crust indicates eschar, which must be removed for healing to occur. Minimal pain is a good outcome, but is not a measure of healing. Serosanguinous drainage indicates absence of infection, not healing. Granulation tissue is a sign of healing and has a budding appearance, from the development of tiny new capillaries. If the granulations are healthy, they have a slightly spongy texture.

PTS:

CON: Tissue Integrity

3. The nurse is providing care for a patient with limited mobility. The nurse notes that the head of the patient’s bed is frequently at 45 degrees of elevation and the patient is slouched in the bed. Which area of the patient needs to be inspected carefully? 1. The coccyx and buttocks 2. The buttocks and the hips 3. The shoulder blades and coccyx 4. The heels and the back of the head ANS: 1 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: Recognize the role of the nurse in preventing pressure injuries. Page: 1153 Heading: Reduce Pressure, Friction, and Shear Damage Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1

2 3 4

The shearing and friction forces that occur when the patient slides down in bed will increase the possibility of pressure injury to the coccyx and buttocks. The nurse needs to check these areas carefully and lower the head of the bed to 30 degrees. The hips are prone to pressure injuries if the patient is not positioned correctly in a side-lying position. The shoulder blades are not at risk for pressure injuries unless the patient is left in a supine position. The heels and the back of the patient’s head are at risk for pressure injury if the

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patient is left in a supine position. PTS:

CON: Tissue Integrity

4. The nurse is providing care for a patient who has a stage 4 pressure injury that is 2 cm in diameter and 2 cm deep. Bone is visible in the wound. Which patient assessment finding does the nurse communicate to the registered nurse (RN) immediately? 1. Patient report of pain 2. Yellow wound drainage 3. A reddened area adjacent to the injury 4. Pink grainy appearance at wound edges ANS: 3 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: List data to collect when caring for patients with disorders of the integumentary system. Page: 1153 Heading: Pressure Injuries Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3 4

Pain is not unexpected and can be treated by the licensed practical nurse (LPN). Yellow drainage may indicate colonization and not true wound infection. A reddened area adjacent to the injury can indicate extension of the injury or infection and should be reported. Pink grainy appearance is a sign of healing.

PTS:

CON: Tissue Integrity

5. The nurse is providing care for a patient with an open pressure injury on the right hip. The bed of the wound is covered with thick, black eschar and the tissue around the wound is red and warm to the touch. Which action does the nurse take in anticipation of the type of debridement used for this pressure injury? 1. Obtain sterile forceps and scissors for the health care provider (HCP) to use for mechanical debridement. 2. Read the instructions about how to apply and manage the use of a proteolytic enzyme. 3. Expect that the patient will be taken to surgery to remove any nonviable tissues. 4. Bring gauze and normal saline to the bedside for application of wet-to-dry dressings. ANS: 3 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders

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Objective: Describe current therapeutic measures that are used for each of the skin disorders. Page: 1165 Heading: Debridement Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Difficult Feedback 1

Mechanical debridement can be performed to selectively remove nonviable tissue. However, the debridement of the described wound may be more extensive than a bedside procedure. Proteolytic enzymes will selectively digest necrotic tissue; however, the described wound is covered with thick eschar and the borders may be exhibiting manifestations of becoming infected. A more aggressive and timely procedure may be needed. The nurse needs to anticipate that the patient will require surgical debridement to remove the eschar and explore the border tissues and the areas underneath for the possibility of infection. The procedure is likely to be painful and the patient will need some type of anesthesia and monitoring. Because of the presence of the eschar, and the possibility of a developing infection, wet-to-dry dressings are not the appropriate initial treatment; the method may be used as needed after surgical debridement.

PTS:

CON: Tissue Integrity

6. A patient is admitted with a recent surgical wound that is infected and exhibits an open suture line. The HCP prescribes negative pressure wound therapy (NPWT). Which step in setting up the treatment does the nurse anticipate? 1. Moist gauze is placed into the open wound. 2. The wound is packed loosely with a sterile sponge. 3. Pressure is applied and increased until drainage appears. 4. The wound is covered completely with thick, absorbent pads. ANS: 2 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: Describe current therapeutic measures that are used for each of the skin disorders. Page: 1166 Heading: Negative Pressure Wound Therapy Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Tissue Integrity Difficulty: Moderate Feedback

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1 2 3

Moist gauze is not placed into the open wound when NPWT is prescribed. The nurse should anticipate loosely packing the wound with a sterile sponge. Gentle negative pressure is applied to allow excess drainage and infectious material to be removed. The result is less pressure on delicate new tissue and better circulation to promote healing. The wound is covered with an occlusive dressing to maintain the negative pressure required for the procedure.

PTS:

CON: Tissue Integrity

7. A patient comes into the HCP’s office and reports a rash. The nurse notices a red rash on the patient’s chest, back, arms, and legs. The patient describes an intense itching. Which question does the nurse ask to determine the type of dermatitis displayed by the patient? 1. “Have you changed any of your laundry products?” 2. “Did you have any swelling of your lips or mouth?” 3. “Are you still using your usual grooming products?” 4. “Does anyone in your family have the same rash?” ANS: 1 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: List data to collect when caring for patients with disorders of the integumentary system. Page: 1170 Heading: Inflammatory Skin Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Difficult Feedback 1

2 3 4

Because of the distribution of the rash, which is underneath clothing, the nurse needs to ask about a change in laundry products. The patient probably has contact dermatitis. If the rash were more generalized or specifically on the patient’s head or face, the nurse needs to ask about swelling of the lips or mouth. The nurse would ask about grooming products if the rash were in areas such as the hands, face, or scalp. The nurse will need to ascertain if other members of the patient’s family has the same rash after a probable cause can be identified.

PTS:

CON: Tissue Integrity

8. A patient in the emergency department has bright red edematous plaques along an uneven line that runs from under the right arm toward the chest. The patient states that the breakout was sudden and is very painful. Which information does the nurse need to obtain first? 1. Ask if the patient was around anyone with the chickenpox. 2. Attempt to discover where the patient was during the last 3 weeks. 3. Inquire if the patient has ever received a vaccine for herpes zoster.

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4. Verify if the patient is aware of ever having a case of chickenpox. ANS: 4 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: Explain the pathophysiology of each of the skin disorders listed in this chapter. Page: 1176 Heading: Herpes Zoster (Shingles) Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2

3 4

A person is unable to get herpes zoster (shingles) from someone who has chickenpox or shingles. The patient is not likely to be able to recall specifically where he or she was during the last three 3. Exposure to either chickenpox or shingles does not cause shingles. It may be good to know if the patient has received a vaccine for herpes zoster; however, it is still possible to get shingles after receiving the vaccine. To have herpes zoster (shingles), the patient must have had chickenpox. The virus will lay dormant in the patient’s nerve tissue near the brain and spinal cord. Herpes zoster (shingles) is a reactivation of the latent varicella virus.

PTS:

CON: Tissue Integrity

9. The nurse works in a clinic that specializes in the care of patients diagnosed with psoriasis. Which patient does the nurse identify as being the greatest challenge for management of the disease? 1. An adult male with a family history of the skin disease 2. An adult female who is postmenopausal and smokes 3. A school-age patient who frequently has strep throat 4. An adult patient who has a stressful occupation ANS: 3 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: Describe the etiologies, signs, and symptoms of each of the skin disorders. Page: 1172 Heading: Psoriasis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1

The exact cause of psoriasis is unknown; however, it is autoimmune in nature. Often there is a family history of the condition. The management is not

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2 3

impacted by a familial connection. Hormone changes and smoking can be aggravating factors for psoriasis. The patient needs to stop smoking to prevent exacerbations of the disease. The average age for contracting psoriasis is 27 years; the condition can be severe if it develops in childhood. If the patient also has a tendency to have streptococcal pharyngitis, the condition is worsened by this aggravating factor. This patient will present the greatest challenge for the management of the disease. Stress can be an aggravating factor for the patient with psoriasis. The nurse needs to present the patient with stress management techniques to avoid exacerbations.

PTS:

CON: Tissue Integrity

10. The nurse in a high school clinic is aware of an unusually high incidences of cold sores among the student population. Which information from the nurse will be the most helpful in controlling the spread of the causative virus, HSV-1? 1. Infected students need to stay out of school until the lesion is crusted over. 2. Students with an active lesion need to eat at a specific isolation table. 3. All students need to sustain from sharing lip products, drinks, and foods. 4. Any student who has not been infected needs to get immunized immediately. ANS: 3 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: Explain the etiologies, signs, and symptoms of each of the skin disorders. Page: 1174 Heading: Herpes Simplex Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1

It is true that the HSV-1 virus is contagious for 2 to 4 days before the crusts form; however, there is no reason for the infected student to stay home from school until crusting occurs. Students do need to avoid direct contact with a known blistering lesion to prevent developing a primary lesion. Isolating infected students is not necessary; students need to understand that the condition is contagious and direct contact with a blistered lesion needs to be avoided. The most helpful information from the nurse is that the HSV-1 virus can be spread by sharing lip products, drinks, or foods. The students need to avoid direct contact with a blistering lesion (no kissing or touching). There is no immunization for HSV-1. The best management is to avoid contracting a primary lesion from another person.

PTS:

CON: Tissue Integrity

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11. The community nurse is working with a family who has had multiple infestations of pediculosis capitis over a period of several months. Which comment by the parent indicates that nursing information is now likely to be effective? 1. “I have washed all hats and linens in hot soapy water.” 2. “We are all using a medicated bath soap to kill the lice.” 3. “I frequently check the scalps of the children for reinfection.” 4. “We are no longer attending school, I am home schooling now.” ANS: 1 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: Explain how you will know whether your nursing interventions have been effective. Page: 1181 Heading: Pediculosis Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1

3 4

All clothing and linens need to be washed in hot soapy water to kill lice and prevent reinfestation. Until this action is taken, the family will not be rid of the problem. Pediculosis capitis is head lice and will not be managed by bathing with a special soap. A special shampoo or treatment must be used on the hair and scalp. Checking the scalp is a good way to monitor for reinfection; however, other actions are needed to kill the lice that are currently present. School children are most susceptible to infestations of pediculosis capitis. However, the condition is not necessarily associated with cleanliness. The parent can home school the children but must still manage the current infestation.

PTS:

CON: Tissue Integrity

12. The nurse is assisting with preparation for cryosurgery for a patient diagnosed with a lentigo maligna melanoma lesion on the forehead. Which information will the nurse provide regarding the events related to this surgery? 1. Explain that pain medication is given for expected severe pain. 2. A hemorrhagic blister will form immediately after the procedure. 3. The area will be cleaned as ordered and a prescribed ointment applied. 4. The lesion is likely to reappear and follow up treatment is expected. ANS: 3 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: Describe current therapeutic measures that are used for each of the skin disorders. Page: 1182 Heading: Malignant Skin Lesions

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2 3 4

With cryosurgery, minor discomfort is expected. After the procedure, the patient may experience some swelling and local tenderness. It is unlikely that the patient will require pain medication. A hemorrhagic blister will appear at the site of cryosurgery within 1 to 2 days. After cryosurgery, the area is to be cleansed as ordered and a prescribed ointment is applied. After cryosurgery, the lentigo maligna melanoma lesion is not expected to return and require additional treatment.

PTS:

CON: Tissue Integrity

13. The nurse is preparing to begin a position in an extended-care facility. The RN shares that the administration is interested in research that guides the skin care of the residents. Which information does the nurse discover about best practices? 1. The importance of assessing for risk factors monthly 2. The practice of bathing residents with dry skin weekly 3. The cleaning of moist areas with gentle synthetic soaps 4. The need to use moisture wicking adult diapers at night ANS: 3 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: Plan nursing care for patients with each of the skin disorders. Page: 1179 Heading: Evidence Based Practice Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Tissue Integrity Difficulty: Moderate Feedback 1

3 4

It is important that residents of long-term care be assessed for skin-related risk factors; the timing is not designated, but monthly may not be frequently enough for residents who are at high risk. Research does report that residents with dry skin should not be bathed frequently. However, a specific schedule is not indicated and weekly seems inadequate. Research supports that moist areas (between the toes, skinfolds, and under the breasts) be cleansed daily with gentle synthetic detergent soaps. Research supports protecting the residents’ skin from exposure to urine or stool. It is not advised to place the residents in any kind of adult diaper at any time.

NURSING TEST BANK

PTS:

CON: Tissue Integrity

14. The nurse is providing care for a patient with an open pressure injury, which exhibits the manifestations of an infection. The HCP prescribes wound cleansing with normal saline at a pressure of 4 to 15 pounds per square inch. Which method of cleansing does the nurse use? 1. A 30-mL syringe with an 18-gauge needle attached 2. A whirlpool bath in warm water and antiseptic soap 3. A hand-held showerhead directed at the open area 4. A needleless 30- to 60-mL syringe and normal saline ANS: 1 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: Describe current therapeutic measures that are used for each of the skin disorders. Page: 1164 Heading: Wound Cleansing Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Application (Applying) Concept: Tissue Integrity Difficulty: Moderate Feedback 1

2 3 4

When an open pressure injury is infected, the area needs to be cleansed by a method that removes bacteria and dead tissue. A pressure of 4 to 15 pounds per square inch can be achieved using a 30-mL syringe with an 18-gauge needle. The pressure is changed by the force exerted on the plunger of the syringe. A whirlpool bath will not supply the prescribed pressure. A hand-held showerhead directed at the open area may or may not provide the prescribed pressure. A needleless 30- to 60-mL syringe will provide gentle pressure for cleaning an open pressure injury exhibiting signs of healing.

PTS:

CON: Tissue Integrity

15. The nurse is assisting at a community health fair by performing skin checks. Which characteristic is unexpected by the nurse when screening participants who are dark skinned? 1. Keloid formation 2. Multiple birthmarks 3. Mongolian spots 4. Nevi ANS: 4 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: Describe the etiologies, signs, and symptoms of each of the skin disorders. Page: 1166 Heading: Cultural Considerations Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation

NURSING TEST BANK

Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1

2 3 4

Persons with dark skin color are more likely to form an overgrowth of connective tissue at the site of an injury or infection. The formation of a keloid is an example. Persons with dark skin color are more likely to have multiple birthmarks. Persons with dark skin color are prone to Mongolian spots, which may be mistaken for bruising. Mongolian spots will fade with the passage of time. Nevi, which are freckles and skin discolorations, are seen in persons of lighter skin color. Nevi are a result of sun exposure and can increase the incidence of skin cancer.

PTS:

CON: Tissue Integrity

16. The nurse at an HCP’s office is interviewing a patient presenting with a skin infection. Which question by nurse will provide the least important information? 1. “How long have you had the infection?” 2. “Do you think you are contagious?” 3. “What aggravates or alleviates symptoms?” 4. “What do you think caused your infection?” ANS: 2 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: List data to collect when caring for patients with disorders of the integumentary system. Page: 1165 Heading: Nursing Process for the Patient With a Skin Infection Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3

Asking how long the patient has had the infection will provide important information; the infection may be either acute or chronic. The question that provides the nurse with the least information about the patient’s condition is asking if the patient thinks the infection is contagious. It is important for the nurse to know what aggravates or alleviates the symptoms of the patient’s infection. This information can guide diagnosis and treatment. Sometimes the most information is obtained by just asking the patient what he or she thinks about his or her condition and any possible causes.

PTS:

CON: Tissue Integrity

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17. A patient with an infected skin lesion is prescribed oral antibiotics, daily dressing changes with topical antibiotic ointment, and acetaminophen with codeine for pain. Which patient statement indicates to the nurse additional teaching is necessary? 1. “Once the swelling and redness are gone, I can stop taking the antibiotics.” 2. “I should wash the area gently with antibacterial soap before applying a new dressing.” 3. “Covering my pillow with plastic and cleaning it every day will help prevent additional infection.” 4. “I will need to increase my fluid and fiber intake to prevent constipation from the pain medication.” ANS: 1 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: Plan nursing care for patients with each of the skin disorders. Page: 1166 Heading: Infectious Skin Disorders Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3 4

Antibiotics should be taken for the complete course as ordered. It is important to cleanse surrounding skin with antibacterial soap, followed by application of antibacterial ointment. Cover mattress and pillows with plastic and wipe daily with a disinfectant to prevent spread of infection. Constipation is a potential complication of the prescribed pain medication and preventive measures such as increased fluid and fiber intake are important.

PTS:

CON: Tissue Integrity

18. A patient is diagnosed with dermatomycosis. Which statement by the patient gives the nurse an idea of where the infection was acquired? 1. “I wash my hair every day.” 2. “I work out and shower at a club.” 3. “I have never owned any pet.” 4. “I always buy the organic foods.” ANS: 2 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: Explain the pathophysiology of each of the skin disorders listed in this chapter. Page: 1168 Heading: Fungal Infections Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Difficult

NURSING TEST BANK

Feedback 1

3 4

Dermatomycosis is a fungal infection of the skin occurring when there is an impairment of skin integrity in a warm moist location. Washing the hair daily is an unlikely contributor to the development of tinea capitis. Working out and showering at a club puts the patient at risk for picking up the fungus that causes tinea pedis (athlete’s foot). The infection is acquired with direct contact with infected humans, animals, or objects. Feet are prone to small skin openings and are primarily located in warm moist environments. Dermatomycosis can be acquired from infected animals, but the patient has never owned a pet. Eating only organic food does not protect the patient from dermatomycosis.

PTS:

CON: Tissue Integrity

MULTIPLE RESPONSE 1. The nurse is providing care for a patient who is immobile and being treated for diabetes mellitus and a urinary tract infection. Which intervention is included in a plan of care to prevent pressure injuries in this patient? (Select all that apply.) 1. Apply moisturizer to the skin after bathing. 2. Reposition the patient at least every 2 hours. 3. Elevate the head of the bed no more than 30 degrees. 4. Place the patient on a donut-shaped cushion when sitting. 5. Assure that skin is dried carefully and completely after washing. ANS: 1, 2, 3, 5 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: Recognize the role of the nurse in preventing pressure injuries. Page: 1160 Heading: Pressure Injuries Integrated Process: Clinical Problem-Solving Process Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Difficult

1. 2.

Feedback After bathing, lubricate the skin with moisturizers to prevent dryness. If patients are on bedrest, turn and reposition them at least every 2 hours, but preferably more often because ischemia development begins after 20 to 40 minutes of pressure. The head of the bed should not be elevated more than 30 degrees to reduce pressure on the coccyx and to reduce friction and shear damage from sliding down in the bed. Avoid massaging bony prominences or reddened skin areas; research has shown that blood vessels are damaged by massage when ischemia is present or when they lie over a bone.

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PTS:

Because the patient is diabetic, good skin care is essential, especially with a urinary infection. Drying the skin carefully will prevent maceration due to moisture. 1

CON: Tissue Integrity

2. The nurse is completing the Braden scale to predict risk for pressure ulcer development with a patient on bedrest. Which findings does the nurse score as increasing this patient’s risk? (Select all that apply.) 1. Patient eats half of offered foods. 2. Patient responds only to painful stimuli. 3. Linen must be changed at least once per shift. 4. Patient makes body position changes with assistance only. 5. Patient walks independently outside of the room twice a day. ANS: 1, 2, 3, 4 Chapter: Chapter 54. Nursing Care of Patients With Skin Disorders Objective: List data to collect when caring for patients with disorders of the integumentary system. Page: 1160 Heading: Pressure Injuries Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback Limited nutritional intake by only eating half of offered foods put the patient at risk for development of pressure injuries. Responding only to painful stimuli indicates the patient is at risk for development of pressure injuries. If moisture necessitates linens needing to be changed at least once per shift, the patient is at risk for development of pressure injuries. The inability to change body positions without assistance places the patient at risk for development of pressure injuries. Walking independently outside of the room twice a day would reduce the patient’s risk of developing a pressure injury. 1

CON: Tissue Integrity

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Chapter 55. Nursing Care of Patients With Burns MULTIPLE CHOICE 1. The nurse is assisting with the care of an older adult patient who is hospitalized for seconddegree burns of the legs and feet acquired when a deep fryer tipped over. Which factor has the least impact on the condition and recovery of the patient? 1. The normal condition of the patient’s skin 2. The nature of the substance causing the burns 3. The patient history of having diabetes mellitus 4. The patient wearing light-weight cotton pajamas ANS: 4 Chapter: Chapter 55. Nursing Care of Patients With Burns Objective: List data to collect when caring for patients with burns. Page: 1192 Heading: Burn Injury and the Older Adult Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Difficult Feedback 1 2

3 4

An older adult patient normally has skin that is thinner, which is more easily damaged and more difficult to heal. The fact that a deep fryer tipped over is indicative that the burn was caused by hot oil, which is likely to have adhered to the skin surface and caused deeper burns. With a medical history of diabetes mellitus, the patient is at risk for poor healing and the increased possibility of infection. Of all the factors, the fact that the patient was wearing light-weight cotton pajamas is the condition of least concern. The client would have been at greater risk if the clothing had been heavy and retained both heat and the oil or made of a synthetic material that would “melt” into the burn areas.

PTS:

CON: Tissue Integrity

2. The nurse is providing care for a patient with burns covering the entire surface of both arms and the anterior trunk. Approximately what percentage of the patient’s body surface area has been affected? 1. 18 percent 2. 27 percent 3. 36 percent 4. 45 percent ANS: 3 Chapter: Chapter 55. Nursing Care of Patients With Burns

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Objective: List data to collect when caring for patients with burns. Page: 1193 Heading: Evaluation of Burn Injuries Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3 4

This is an inaccurate calculation using the Rule of Nines. This is an inaccurate calculation using the Rule of Nines. According to the Rule of Nines, each arm is 9 percent and the anterior trunk is 18 percent for a total of 36 percent. This is an inaccurate calculation using the Rule of Nines.

PTS:

CON: Tissue Integrity

3. The nurse is providing care for a patient in the emergent stage of treatment for a partialthickness burn. The patient has been stabilized, with blood pressure 140/88 mm Hg, pulse 78 beats/min, respirations 22 breaths/min, and temperature 97.4°F (36.3°C) orally. Which new assessment finding does the nurse immediately communicate to the health care provider (HCP)? 1. Report of increasing pain 2. Temperature 99°F (37.2°C) 3. Serum-filled blister formation 4. Blood pressure 122/74 mm Hg ANS: 4 Chapter: Chapter 55. Nursing Care of Patients With Burns Objective: Plan nursing care for patients with burns. Page: 1190 Heading: Emergent Stage Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3 4

Pain is a concern, but is not immediately life threatening. Temperature is a concern, but is not immediately life threatening. Blister formation is expected. A patient with a burn is at risk for fluid volume deficit, and a dropping blood pressure, even though it is still within normal limits, could be an early sign.

PTS:

CON: Tissue Integrity

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4. A child is brought to the emergency department with burns from hot liquid pulled from the stove. Which information is most important for the nurse to acquire from the accompanying adult? 1. If the adult is a parent or legal guardian 2. Identification of the substance causing the injury 3. An estimation of the temperature of the burning liquid 4. If any measures were taken at the scene of the accident ANS: 2 Chapter: Chapter 55. Nursing Care of Patients With Burns Objective: List data to collect when caring for patients with burns. Page: 1192 Heading: Pathophysiology and Signs and Symptoms Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Difficult Feedback 1

3 4

Identifying the person bringing a minor to the emergency department is needed; however, if the adult is not a parent or legal guardian, emergency care will be provided for the patient immediately. The identification of the substance causing the injury is the most important information for the nurse to acquire; the nature of the substance can contribute to the intensity of the burn and how initial care will be determined. An estimation of the temperature of the burning liquid is important, but knowing the substance is most important. An awareness of any measures taken at the scene of the accident may be helpful, but it is not the most important information.

PTS:

CON: Tissue Integrity

5. The nurse is providing care for a patient who is receiving fluid replacement after being burned on 37 percent of the body. Nursing assessment reveals a blood pressure of 80/60 mm Hg, pulse of 120 beats/min, and urine output of 10 mL over the past hour. After reporting these findings, which order does the nurse expect to be prescribed for this patient? 1. Discontinue the IV fluid infusion. 2. Change the IV fluid to dextrose and water. 3. Increase the amount of IV fluid administered per hour. 4. Decrease the amount of IV fluid administered per hour. ANS: 3 Chapter: Chapter 55. Nursing Care of Patients With Burns Objective: Describe current therapeutic measures used for burns. Page: 1190 Heading: Emergent Stage Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing)

NURSING TEST BANK

Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3

Decreasing or discontinuing fluids is inappropriate. Dextrose and water are hypotonic and will not maintain circulating volume. In the first 48 hours after a burn, fluid shifts lead to hypovolemia and, if untreated, hypovolemic shock. Low blood pressure, elevated pulse, and low urine output indicate hypovolemia, so the nurse should anticipate increasing IV fluids. Decreasing or discontinuing fluids is inappropriate.

PTS:

CON: Tissue Integrity

6. The nurse is providing care for a patient who received synthetic dressings over partialthickness burns. Which comment by the patient indicates to the nurse that additional information is needed about the procedure? 1. “This is just a temporary method of covering the burns.” 2. “This material is used until my own skin can be grafted.” 3. “If these grafts begin to grow, I won’t need more surgery.” 4. “The purpose of this process is to reduce the risk of infection.” ANS: 3 Chapter: Chapter 55. Nursing Care of Patients With Burns Objective: Describe current therapeutic measures used for burns. Page: 1192 Heading: Acute Stage Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3

Synthetic dressings are used in the management of partial-thickness burns and donor sites. They are used as temporary wound coverings. Synthetic dressings are used to help maintain the wound surface until healing occurs, a donor site becomes available, or the wound is ready for autografting. Synthetic grafts do not grow; they can be used until healing occurs or until other methods of grafting are performed. This statement indicates a need for additional teaching. A major purpose of using a synthetic dressing is to help prevent infection.

PTS:

CON: Tissue Integrity

7. The nurse is providing care for a patient admitted to the burn unit with burns to 45 percent of the body. After 3 days, the nurse notes that the patient’s temperature is newly elevated at 100.2°F (37.9°C), and the patient exhibits new-onset agitation and confusion. Which action does the nurse take first?

NURSING TEST BANK

1. 2. 3. 4.

Increase oral fluids to 3,000 mL/day. Notify the registered nurse (RN) or HCP. Monitor the patient for further changes in mental status. Administer a prn dose of acetaminophen (Tylenol) for the fever.

ANS: 2 Chapter: Chapter 55. Nursing Care of Patients With Burns Objective: Explain the pathophysiology of burns. Page: 1191 Heading: Complications Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2

3 4

Fluids may also be appropriate, but only after the HCP determines the cause of the change and provides recommendations. The nurse should continually assess for and report signs and symptoms of sepsis: temperature elevation, change in sensorium, changes in vital signs and bowel sounds, decreased output, and positive blood and wound cultures. A rise in temperature should be reported. Further monitoring may also be appropriate, but only after the HCP determines the cause of the change and provides recommendations. Tylenol may also be appropriate, but only after the HCP determines the cause of the change and provides recommendations.

PTS:

CON: Tissue Integrity

8. The nurse is assisting in the care of a patient with a circumferential burn to the leg. The health care provider determines that an escharotomy is necessary. Which action does the nurse recognize as the most important nursing intervention? 1. Checking for the return of distal pulses 2. Padding the bed for copious amounts of drainage 3. Monitoring for unlabored respiratory function 4. Medicating as prescribed for pain management ANS: 1 Chapter: Chapter 55. Nursing Care of Patients With Burns Objective: Plan nursing care for patients with burns. Page: 1195 Heading: Acute Stage Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback

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2 3

Burned tissue can act as a tourniquet with a circumferential burn and cut off circulation. The most important intervention following an escharotomy on a leg is to monitor for the return of distal pulses, which indicates adequate circulation. Prior to the performance of an escharotomy, the bed should be well padded due to the expectation of copious amounts of drainage. If the circumferential burn is on the trunk of the body, respiratory function can be compromised. However, respiratory function is not affected by an escharotomy performed on an extremity. Pain management will be a part of the postprocedure care; however, it is not the most important intervention.

PTS:

CON: Tissue Integrity

9. The nurse notes that a patient with full thickness burns has an increase in hematocrit level. What does the nurse realize is causing this change in laboratory value? 1. Loss of intravascular fluid 2. Destruction of blood vessels 3. Increased function of platelets 4. Migration of white blood cells ANS: 1 Chapter: Chapter 55. Nursing Care of Patients With Burns Objective: Explain the pathophysiology of burns. Page: 1190 Heading: Diagnostic Tests Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1

2 3 4

A burn is followed by an initial decrease in cardiac output, which is further compromised by the loss of circulating plasma volume. In the first 48 hours after a burn, fluid shifts lead to hypovolemia and, if untreated, hypovolemic shock. Loss of intravascular fluid causes a relative increase in hematocrit. The increase in hematocrit level is not caused by destruction of red blood cells. The increase in hematocrit level is not caused by increased function of platelets. The increase in hematocrit level is not caused by migration of white blood cells.

PTS:

CON: Tissue Integrity

10. The nurse is assisting with the care of a patient with second-degree burns to 35 percent of the body. Five hours after the burn occurs, the HCP prescribes nasogastric (NG) enteral feedings. For which reason does the nurse understand the value of the NG feedings and the importance of the time frame?

NURSING TEST BANK

1. 2. 3. 4.

Metabolic demands are increased by injury, interventions, and stress. Enteral feedings will help replace proteins lost from the burn. Nutritional status is maintained until oral intake resumes. Incidence of mortality and infectious morbidity are reduced.

ANS: 4 Chapter: Chapter 55. Nursing Care of Patients With Burns Objective: Describe current therapeutic measures used for burns. Page: 1195 Heading: Nutrition Notes Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Difficult Feedback 1

3 4

The increase in metabolic demands is caused by the burn injury, surgical interventions, and stress. However, the demands are ongoing and do not specifically relate to the time frame provided in the question. A goal of nutritional support for the patient with burns is to reduce the protein lost from the injury. However, the need is ongoing and the time frame is not specifically important to meeting this need. Enteral feedings may continue even after the patient is able to resume oral intake. Early (within 4 to 6 hours of injury) use of NG enteral feeding has been shown to reduce the incidence of mortality and infectious morbidity.

PTS:

CON: Tissue Integrity

11. The nurse is working on the rehabilitation unit in a burn facility. The nurse has been reinforcing the importance of returning the patient to an optimal level of physical functioning. Which statement by the patient indicates a lack of understanding? 1. “I am trying to accept that this recovery is full of pain.” 2. “I just keep hoping that someday I will be able to be normal.” 3. “I can now feed myself and that makes me independent enough.” 4. “I am tired of the pain and time that it is taking to move past this.” ANS: 3 Chapter: Chapter 55. Nursing Care of Patients With Burns Objective: Explain how you will know whether your nursing interventions have been effective. Page: 1197 Heading: Rehabilitation Stage Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Difficult

NURSING TEST BANK

Feedback 1 2 3

When the patient acknowledges that rehabilitation is painful, it does not show a lack of understanding, it indicates acceptance of the work that is required. When the patient expresses a hope to return to a state of normalcy, it indicates that the patient is motivated to achieve rehabilitation. When the patient expresses satisfaction about partial rehabilitation, it indicates a lack of understanding. The goal or rehabilitation is to return the patient to an optimal level of physical functioning. Expressing disappointment about the pain and time involved in rehabilitation does not indicate that the patient lacks understanding about the process.

PTS:

CON: Tissue Integrity

12. A patient receives extensive burns to the face, chest, and hands from a random act of violence. The patient states, “I was doing so well, but I will never fit in again with my family, friends, or coworkers.” The nurse identifies which need for this patient? 1. Reinforcement from people who are close to the patient 2. Professional psychiatric counseling to regain self-esteem 3. Identification of a support group that focuses on victims of crime 4. Information from medical specialists about reconstructive surgery ANS: 2 Chapter: Chapter 55. Nursing Care of Patients With Burns Objective: Plan nursing care for patients with burns. Page: 1198 Heading: Psychosocial Effects of Burn Injury Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2

3 4

Reinforcement from people who are close to the patient may be helpful, but it may not restore the self-esteem of the patient. The biggest need of this patient is to regain self-esteem. Professional psychiatric counseling will be best suited to assist the patient to regain an acceptable level of psychosocial functioning. Due to the nature of the patient’s injuries, a support group with other victims of crime may or may not be helpful. The patient may or may not be a candidate for plastic reconstruction surgery. When burn injuries are extensive, the patient is not always pleased with the options or the results.

PTS:

CON: Tissue Integrity

13. The nurse on a burn rehabilitation unit presents information addressing the incidence of postburn itching. Which information from researching the topic will the nurse identify as incorrect?

NURSING TEST BANK

1. 2. 3. 4.

Scratching the opposite part of the body will stop the itching. Itching is a problem because it interferes with daily activities. There are pharmacological and nonpharmacological interventions. Some techniques may include massage with a soothing lotion.

ANS: 1 Chapter: Chapter 55. Nursing Care of Patients With Burns Objective: Plan nursing care for patients with burns. Page: 1198 Heading: Evidence-Based Practice Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Application (Applying) Concept: Tissue Integrity Difficulty: Moderate Feedback 1 2 3 4

There is no support in the evidence-based practice information supplied in this chapter for the use of counterpart scratching to stop the itching of a burn site. The nurse in a postburn unit needs to understand that itching is a problem because of the interference with the activities of daily living. There are both pharmacological and nonpharmacological interventions that can be helpful with postburn itching. Many nonpharmacological techniques can be done at home and can be very soothing.

PTS:

CON: Tissue Integrity

MULTIPLE RESPONSE 1. The nurse is assisting with the care of a patient admitted to the emergency department with chemical burns across the chest and hands. Which actions are included in the plan of care? (Select all that apply.) 1. Apply ice packs to burn sites. 2. Remove all contaminated clothing. 3. Cover the patient with a clean sheet. 4. Obtain a history of the event and burning agent. 5. Provide copious tepid water lavage for 20 minutes. ANS: 2, 3, 4, 5 Chapter: Chapter 55. Nursing Care of Patients With Burns Objective: Plan nursing care for patients with burns. Page: 1194 Heading: Therapeutic Measures Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Reduction of Risk Potential Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Difficult

NURSING TEST BANK

1. 2. 3. 4. 5.

PTS:

Feedback Ice is not applied when a patient has a chemical burn. Initiate immediate copious tepid water lavage for 20 minutes for all chemical burns, along with simultaneous removal of contaminated clothing. Cover the patient with a clean sheet and obtain a history of the burning agent. Cover the patient with a clean sheet and obtain a history of the burning agent. Initiate immediate copious tepid water lavage for 20 minutes for all chemical burns, along with simultaneous removal of contaminated clothing. 1

CON: Tissue Integrity

2. The nurse is preparing a patient with 46 percent total body surface area burned for graft placement. Which anatomical locations does the nurse expect to have a lower rate of graft success than other areas of the body? (Select all that apply.) 1. Axillae 2. Buttocks 3. Perineum 4. Forearms 5. Joint areas ANS: 1, 2, 3, 5 Chapter: Chapter 55. Nursing Care of Patients With Burns Objective: Describe current therapeutic measures used for burns. Page: 1196 Heading: Skin Grafts Integrated Process: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity—Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Tissue Integrity Difficulty: Difficult

1. 2. 3. 4. 5.

PTS:

Feedback The perineum, axillae, buttocks, and joints are generally poor areas for graft success. The perineum, axillae, buttocks, and joints are generally poor areas for graft success. The perineum, axillae, buttocks, and joints are generally poor areas for graft success. Factors promoting graft success are smooth contoured areas, adequate hemostasis, and good nutritional status. The perineum, axillae, buttocks, and joints are generally poor areas for graft success. 1

CON: Tissue Integrity

NURSING TEST BANK

Chapter 56. Mental Health Function, Assessment, and Therapeutic Measures Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is caring for a patient with a suspected mental health disorder who is having blood drawn to check electrolyte levels. The patient says, “What does my blood work have to do with my mental health?” Which response by the nurse is correct? a. “Electrolyte imbalances are the cause of certain mental health disorders.” b. “Some mental health disorders cause the electrolytes to be out of balance.” c. “The doctor wants to make sure your symptoms are not caused by a physical problem.” d. “People with mental illnesses frequently take illicit drugs that can cause electrolyte imbalances.” 2. What is the best general definition of “coping”? a. The way one adapts to a stressor b. The use of specific mechanisms to reduce anxiety c. The development of unconscious behaviors to reduce psychological distress d. The adaptation to mental health problems 3. A student feels anxious about being unprepared for an upcoming test. Which of the following is a positive response to this anxiety? a. Choosing not to worry about studying because grades have been good so far b. Staying up all night the night before the test to study c. Canceling nonessential activities for 3 days to study d. Borrowing notes from another student who has had the class in the past 4. A patient who has been diagnosed with a mental illness tells the nurse about plans to find a voodoo doctor. How should the nurse respond? a. “You know voodoo doctors can’t really help you. Don’t waste your money.” b. “Be sure to mention your plan to your psychiatrist. It is important to follow up with that treatment plan also.” c. “Research has shown that voodoo can effectively treat many mental health disorders. That decision is up to you.” d. “I do not think using voodoo is safe. I would recommend you think about it carefully before contacting a voodoo doctor.” 5. The nurse is caring for a patient with a history of schizophrenia who is admitted to a surgical unit for a cholecystectomy. The patient becomes extremely agitated when other patients are around and says, “They are going to kill me. Get me out of here.” Which of the following interventions should the nurse assist with implementing in order to provide a therapeutic milieu for the patient? a. Help the patient clarify the meaning of the feelings b. Request an order for antipsychotic medications c. Suggest the patient be scheduled for a psychotherapy session d. Place the patient in a private room 6. The nurse is caring for a patient who has had electroconvulsive therapy (ECT) for severe depression. During the recovery period, the patient says to the nurse, “Where am I? What have you done to me?” What action by the nurse is best? a. Encourage the patient to go back to sleep until the preprocedure medication has worn off. b. Administer a sedative to help calm the patient.

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c. Call the physician and report the patient’s response. d. Explain that the patient is in the hospital and has just had ECT. 7. A student is angry about failing a test at school and accuses the teacher of trying to fail everyone. This is an example of what type of response? a. Anger b. Repression c. Projection d. Denial 8. After talking with a patient being evaluated for a mental health disorder, the nurse says, “It sounds as if you are feeling angry.” Which therapeutic communication technique is the nurse employing? a. Offering a general lead b. Reflecting c. Restating d. Giving recognition 9. During initial assessment of mental health status, the nurse asks a patient to interpret a familiar proverb and explain what it means. The nurse is assessing which area/aspect of the patient’s mental status? a. Level of awareness and orientation b. Judgment c. Memory d. Mood and affect 10. A young mother is angry with the mess her son has made in his room. She yells at him and tells him to stay in his room until it is cleaned up. About 20 minutes later, the mother enters the boy’s room offering him milk and cookies. The mother is using which ego defense mechanism? a. Regression b. Restitution c. Reaction formation d. Conversion reaction 11. A patient with schizophrenia states, “I’m going to the fribity to see a megnat.” What term should the nurse use to describe this language? a. Neologisms b. Conversions c. Imagery d. Soliloquy 12. The nurse is providing care for a teenage mother expressing ambivalence about her new role as a parent. Which of the following responses by the nurse is best? a. “Parenthood is certainly not for everyone, you shouldn’t feel guilty about that.” b. “I’ll call the social worker so you can discuss adoption.” c. “Tell me more about how you feel when you hold the baby.” d. “I’m sure your own parents felt the same way when you were small, you should talk to your mom.” Multiple Response Identify one or more choices that best complete the statement or answer the question. 13. Which of the following qualities are considered essential in any nurse–patient relationship? (Select all that apply.)

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a. b. c. d. e. f.

Friendship Sympathy Empathy Respect Humor Honesty

14. Which of the following beliefs or techniques are associated with person-centered/humanistic therapy? (Select all that apply.) a. It stresses rethinking situations. b. It focuses on the whole person. c. It focuses on insights and finding the cause of problems. d. It works in the present. e. It is the basis of many nursing principles. 15. The nurse is caring for a patient who is verbalizing concerns related to a difficult relationship. Which of the following responses by the nurse will block communication and should therefore be avoided? (Select all that apply.) a. Using silence b. Asking “why” c. Changing the subject d. Agreeing or disagreeing e. Verbalizing the implied 16. Which neurotransmitters may be decreased in a patient experiencing depression? (Select all that apply.) a. Norepinephrine b. Dopamine c. Serotonin d. Acetylcholine e. Substance P

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Chapter 56. Mental Health Function, Assessment, and Therapeutic Measures Answer Section MULTIPLE CHOICE 1. ANS: C Some mental health symptoms can be caused by physical illness. Laboratory tests are done to rule out problems such as electrolyte imbalances, hypothyroidism, infections, dehydration, drug toxicity, or pregnancy. Electrolyte imbalances can cause symptoms but do not cause mental illness. There is no evidence in the question that the patient takes illicit drugs. PTS: 1 DIF: Medium REF: Page 1359 KEY: Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | Integrated Processes: Teaching and Learning | Question to Guide Your Learning: 3 2. ANS: A Coping is the way one adapts psychologically, physically, and behaviorally to a stressor. This may encompass B, C, and D, but A is the best general definition. PTS: 1 DIF: Easy REF: Page 1361 KEY: Client Need: Psychosocial Integrity | Cognitive Level: Knowledge | Question to Guide Your Learning: 1 3. ANS: C Canceling nonessential activities to study helps the student reach the goal of knowing the information and passing the test. Not worrying will not help the student pass the test. Staying up all night will cause the student to be tired and not think clearly. Borrowing notes may help but is not as reliable as a book or other good study habits. PTS: 1 DIF: Easy REF: Page 1362 KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application | Integrated Processes: Clinical Problem-Solving Process | Question to Guide Your Learning: 7 4. ANS: B Giving advice is not the role of the nurse. The nurse can help the patient to explore options or focus thinking. In this instance, the nurse can refer the comment to the psychiatrist, who is licensed to make treatment recommendations. PTS: 1 DIF: Medium REF: Page 1364 KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application | Integrated Processes: Clinical Problem-Solving Process | Question to Guide Your Learning: 7 5. ANS: D A therapeutic milieu is an environment that provides containment, support, structure, involvement, and validation during the patient’s stay. In this case, it will help keep the patient psychologically safe while undergoing care for a physiological problem. The patient is likely already receiving antipsychotic agents; psychotherapy and exploring feelings are not the priority at this time—keeping the patient safe for surgery is the priority. PTS: 1 DIF: Hard REF: Page 1363 KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application | Integrated Processes: Clinical Problem-Solving Process | Question to Guide Your Learning: 5 6. ANS: D

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The patient may feel confused and forgetful immediately after ECT. This can be from a combination of the ECT and the medication that was used before the treatment. The nurse should be truthful in responding to the patient’s questions. A, B, and C avoid, and do not answer, the patient’s question. PTS: 1 DIF: Medium REF: Page 1366 KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application | Integrated Processes: Caring | Question to Guide Your Learning: 7 7. ANS: C Projection is blaming others. It is a mental or verbal “finger-pointing” at another for the patient’s own problem. Repression is an unconscious “burying” or “forgetting” mechanism. Denial is an unconscious refusal to see reality. Anger is a response, usually to a perceived threat. PTS: 1 DIF: Easy REF: Page 1363 KEY: Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | Integrated Processes: Clinical Problem-Solving Process | Question to Guide Your Learning: 4 8. ANS: C Restating is a therapeutic communication technique that repeats the main idea of what the patient has verbalized. A general lead is a statement such as “I see . . .” or “Go on . . .” Reflecting refers a statement or question back to the patient. Giving recognition acknowledges something the patient has done. PTS: 1 DIF: Easy REF: Page 1364 KEY: Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | Integrated Processes: Communication and Documentation | Question to Guide Your Learning: 7 9. ANS: B Judgment refers to a patient’s ability to make appropriate decisions about his or her situation or to understand concepts and is often tested by asking the meaning of a proverb. Awareness and orientation are assessed by asking questions related to person, place, and time. Memory is tested by asking the patient to recall recent or remote events. Mood and affect are assessed by determining if the patient’s expression, body language, and emotional condition match the patient’s circumstances. PTS: 1 DIF: Easy REF: Page 1361 KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application | Integrated Processes: Clinical Problem-Solving Process | Question to Guide Your Learning: 2 10. ANS: B Restitution attempts to make amends for a behavior one thinks is unacceptable, to reduce feelings of guilt. Regression is turning to an earlier, less stressful time in life. Reaction formation involves developing a trait or belief that is opposite to something the patient cannot have (overcompensation). A conversion reaction channels psychological discomfort into physical symptoms. PTS: 1 DIF: Easy REF: Page 1363 KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application | Integrated Processes: Clinical Problem-Solving Process | Question to Guide Your Learning: 4 11. ANS: A Words that the patient makes up are called neologisms. PTS: 1 DIF: Easy REF: Page 1360 KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application | Integrated Processes: Clinical Problem-Solving Process | Question to Guide Your Learning: 2 12. ANS: C

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Therapeutic communication is accomplished through the deliberate use of verbal and nonverbal techniques. The technique of focusing involves concentrating on a single idea or event, in this instance, how the young woman feels when she holds the infant. The other responses are not patient focused, are closed-ended, and do not exemplify therapeutic communication techniques. PTS: 1 DIF: Medium REF: Page 1364 KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application | Integrated Processes: Communication and Documentation | Question to Guide Your Learning: 7 MULTIPLE RESPONSE 13. ANS: C, D, F Three qualities are essential for caregivers: empathy, which is the ability to identify with the patient’s feelings without actually experiencing them with the patient; unconditional positive regard (respect); and genuineness or honesty. Friendship and sympathy (feeling sorry for the patient) are not necessarily therapeutic. Humor may not be perceived as intended by patients with mental health disorders and is best used cautiously. PTS: 1 DIF: Easy REF: Page 1366 KEY: Client Need: Psychosocial Integrity | Cognitive Level: Knowledge | Integrated Processes: Caring | Question to Guide Your Learning: 7 14. ANS: B, D, E Person-centered therapy focuses on the whole person and works in the “present.” It is not important in humanistic treatment to understand the cause of the problem or what happened in the person’s past; what is important is the here-and-now. With this therapy, the patient learns to see himself or herself as a person who has value and who is respected by others. Nursing is very strongly centered in person-centered principles. PTS: 1 DIF: Medium REF: Page 1366 KEY: Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | Integrated Processes: Caring | Question to Guide Your Learning: 6 15. ANS: B, C, D Asking why, changing the subject, and agreeing or disagreeing can block communication. Appropriate use of silence and verbalizing the implied are therapeutic. PTS: 1 DIF: Medium REF: Page 1364 KEY: Client Need: Psychosocial Integrity | Cognitive Level: Comprehension | Integrated Processes: Communication and Documentation | Question to Guide Your Learning: 7 16. ANS: A, B, C Norepinephrine, dopamine, and serotonin may be decreased in depression. Acetylcholine and substance P may be increased. PTS: 1 DIF: Medium REF: Page 1366 KEY: Client Need: PHYS—Physiological Adaptation | Cognitive Level: Comprehension | Integrated Processes: Clinical Problem-Solving Process | Question to Guide Your Learning: 6

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Chapter 57. Nursing Care of Patients With Mental Health Disorders Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A patient with schizophrenia has not bathed recently and a family member states that the patient has not been out of the house for 10 days. The patient tells the nurse, “They are trying to hurt me; don’t let them hurt me.” Which symptom is this patient demonstrating? a. Paranoid delusions b. Grandiose delusions c. Auditory hallucinations d. Persecutory hallucinations 2. A patient is diagnosed as having a phobia. Which fear should the nurse expect to observe in this patient? a. Fear of poisonous spiders b. Fear of leaving the house during the day c. Fear of failing a test that one has not studied for d. Fear that a child playing in the street might get hurt 3. A patient who is a war veteran states, “It should have been me that died. I’ll never forgive myself for leaving my buddy when he needed me.” The nurse recognizes this statement is most associated with which diagnosis? a. Bipolar depression b. Generalized anxiety c. Obsessive-compulsive disorder d. Post-traumatic stress disorder (PTSD) 4. The spouse of an older male patient is concerned because since retiring the patient sits around the house, avoids eating, naps, and refuses to participate in sporting activities. Which disorder should the nurse recognize as being associated with these manifestations? a. Depression b. Bipolar disorder c. Conversion disorder d. Post-traumatic stress disorder (PTSD) 5. A patient hospitalized for bipolar disorder is sitting in the corner of the room with the lights off, staring into space. Three hours later, the patient is in the same position. What should the nurse say to the patient? a. “Cheer up! Come on out and join us in a game!” b. “Come with me. I’d like you join our group for a while.” c. “You won’t make any progress if you stay in your room all the time.” d. “What’s the matter? Don’t you know you should be in your group right now?” 6. The nurse is assisting with medication teaching for a patient who is prescribed lithium carbonate (Eskalith) for bipolar disorder. Which instruction by the nurse is most important? a. Instruct the patient to discontinue other antidepressant agents. b. Teach the patient that the lithium will help stabilize mood swings. c. Teach the patient side effects to report, such as nausea or weight gain. d. Explain to the patient and significant other the importance of regular blood tests. 7. The nurse is caring for an older adult patient with a history of depression. Which comment by the patient indicates an immediate need for further assessment? a. “I am so old; all my friends have died.” b. “I am useless now; there is no reason to be alive.”

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c. “I retire in 6 months, and it will be all downhill from there.” d. “I am looking forward to seeing my husband in heaven someday.” 8. A patient who has schizophrenia has a dull facial expression and speaks in a monotone voice, even though a visitor is making an effort to be jovial. What terminology should the nurse use to document this observation? a. Bored b. Depressed c. Flat affect d. Ambivalent attitude 9. A patient with schizophrenia calls the nurse into the room and says, “Help me! The books are on fire!” Which response by the nurse is best? a. “I’ll get some water and put it out.” b. “That’s crazy; you know the books are not on fire!” c. “You don’t have any books; how could they be on fire?” d. “I do not see any fire. Here is your supper; it’s time to eat.” 10. A patient with a mental illness says, “I have to go to the bank. The voices are telling me to go there.” Which response by the nurse is best? a. “Do you need money?” b. “I will call you a cab later. Right now, it is time for therapy.” c. “Why do you think the voices are telling you to go to the bank?” d. “I want to help you focus away from the voices. I am real, they are not.” 11. A patient who experienced injuries from a motor vehicle crash 6 months ago continues to request prescriptions for an opioid analgesic. When assessing this patient for opioid dependency which finding is the nurse least likely to observe? a. The patient drops out of a Saturday night Bingo group. b. The patient continues to manage to get to work each day. c. The patient tried to quit using the opioid but couldn’t stop thinking about it. d. The patient has been to three or four physicians to obtain new prescriptions for the drug. 12. The nurse is cautiously avoiding the temptation to take unused or wasted doses of narcotic medications when providing patient care. What percentages of nurses in the United States are chemically impaired? a. 0% to 5% b. 6% to 15% c. 25% to 35% d. 49% to 50% 13. The nurse notes that another nurse colleague has been acting differently lately. The nurse often has red watery eyes and a runny nose. Today, the nurse was unhappy with the patient assignment and screamed, “Someone is going to pay for this!” What should the nurse who has observed this behavior do? a. Nothing; all nurses have stressful days sometimes. b. Tell the clinical manager exactly what was observed. c. Tell the clinical manager that the nurse is abusing drugs. d. Confront the nurse with the behavior and provide information about counseling. 14. The nurse is providing care for a patient with symptoms of tardive dyskinesia from major tranquilizers. What treatment should the nurse anticipate? a. Use of anticholinergic agents b. Use of muscle relaxant agents c. Discontinuance of the tranquilizers d. Addition of rational emotive therapy to the treatment plan

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15. The nurse is completing a mental status examination for a newly admitted patient. In which part of the nursing process is the nurse functioning? a. Assessment b. Planning c. Implementation d. Evaluation 16. The nurse is assisting with teaching a patient who has been started on fluphenazine (Prolixin). About which side effect should the nurse focus this teaching? a. Weight loss b. Hypoglycemia c. Photosensitivity d. Elevated blood pressure 17. A patient cannot leave home without checking the coffee pot numerous times. This behavior makes the patient late to many functions. Which anxiety disorder should the nurse suspect the patient is experiencing? a. Phobia b. Generalized anxiety disorder (GAD) c. Post-traumatic stress disorder (PTSD) d. Obsessive-compulsive disorder (OCD) 18. A patient who is withdrawing from alcohol is restless and reports seeing snakes on the ceiling. Vital signs are blood pressure 180/100 mm Hg, pulse 92 beats/min, and respirations 22 breaths/min. What should the nurse do first? a. Teach the patient a relaxation technique. b. Administer a dose of lorazepam (Ativan). c. Search the patient’s room for hidden alcohol. d. Administer an antihypertensive agent as ordered. 19. The nurse assists with admission of a patient to the hospital with pancreatitis and a history of alcohol abuse. Why should the nurse observe the patient for agitation, tremors, and hallucinations? a. These are symptoms of alcohol withdrawal. b. These symptoms indicate possible cirrhosis of the liver. c. The patient may be using alcohol in the hospital setting. d. Patients with a history of alcohol abuse are at risk for mental illness. 20. A patient is newly diagnosed with a trauma related disorder. Which medication should the nurse expect to be prescribed for this patient? a. Paroxetine (Paxil) b. Sertraline (Zoloft) c. Buspirone (Buspar) d. Alprazolam (Xanax) 21. A patient with extreme anxiety is arriving for out-patient chemotherapy. What should the nurse do to help reduce the patient’s anxiety during this current treatment? a. Play a CD with nature sounds. b. Select a television station with a sporting event. c. Close the door to the room during the treatment. d. Remind the patient that anxiety is not going to make the treatment effective. 22. A patient with depression is prescribed duloxetine (Cymbalta). What should the nurse instruct the patient about this medication?

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a. b. c. d.

Take with fruit juice. Do not take with St. John’s wort. Stop the medication if experiencing adverse effects. Expect blood pressure to drop with this medication.

Multiple Response Identify one or more choices that best complete the statement or answer the question. 23. The nurse is assisting with teaching a patient who is to begin taking a monoamine oxidase inhibitor (MAOI). Which foods should the nurse teach the patient to avoid? (Select all that apply.) a. Fish b. Wine c. Bread d. Pastas e. Aged cheese 24. The nurse is assisting in the preparation of an educational seminar on anxiety disorders. Which anxiety disorders should the nurse make sure are included in this presentation? (Select all that apply.) a. Phobia b. Panic disorder c. Schizophrenia d. Unipolar depression e. Post-traumatic stress disorder f. Obsessive-compulsive disorder 25. The nurse is assisting with data collection on a patient newly diagnosed with schizophrenia. Which observations should the nurse consider as being positive symptoms of schizophrenia? (Select all that apply.) a. Alogia b. Apathy c. Delusions d. Hallucinations e. Social isolation f. Disorganized behavior 26. A patient has been prescribed fluoxetine (Prozac) to treat depression. What should be included in the nurse’s teaching about the drug? (Select all that apply.) a. “You need to take this drug only once a week.” b. “Take the prescribed dose in the early evening.” c. “A decreased interest in sexual activity may occur with this medication.” d. “You should not consume red wine, aged cheese, or other tyramine-rich foods.” e. “Do not expect immediate results; it usually takes 6 to 8 weeks for therapeutic effects to be felt.” f. “You may experience some nausea, vomiting, and anorexia, but these side effects will subside in time.” 27. The nurse is reviewing the causes of anxiety with a patient diagnosed with an anxiety disorder. Which neurotransmitter abnormalities should the nurse include as causing symptoms of anxiety? (Select all that apply.) a. Increased substance P b. Increased epinephrine c. Increased somatostatin

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d. Decreased norepinephrine e. Decreased gamma-aminobutyric acid (GABA) 28. The nurse is reviewing potential patient teaching needs. For which prescribed medications should the nurse plan to instruct patients to follow a tyramine-free diet? (Select all that apply.) a. Phenelzine (Nardil) b. Buspirone (Buspar) c. Isocarboxazid (Marplan) d. Valproic acid (Depakote) e. Lithium carbonate (Eskalith) 29. A patient comes into the emergency department experiencing chest pain and feelings of impending doom. Which assessment findings should the nurse use to determine if this patient is experiencing a panic attack? (Select all that apply.) a. Shaking b. Neck pain c. Dissociation d. Vomiting brown emesis e. Occurs at 3 p.m. every day 30. A patient with schizophrenia is returning from a CT scan of the brain followed by an electroencephalogram. Which diagnostic test findings should the nurse identify as supporting this patient’s diagnosis? (Select all that apply.) a. Enlarged ventricles b. Reduced amount of gray matter c. Areas of nerve de-myelinization d. Aneurysms of the cerebral vessels e. Diminished prefrontal cortex activity 31. The nurse is assisting in planning care for a patient with extreme anxiety. Which interventions should the nurse include in this patient’s plan of care? (Select all that apply.) a. Maintain a calm environment. b. Encourage verbalization of feelings. c. Model and encourage positive self-talk. d. Encourage participation in competitive activities. e. Permit the patient to have time alone during acute anxiety events.

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Chapter 57. Nursing Care of Patients With Mental Health Disorders Answer Section MULTIPLE CHOICE 1. ANS: D Patients with paranoid schizophrenia tend to have delusions of persecution or grandeur. Patients experiencing persecutory delusions state that they feel tormented and followed by people. B. In delusions of grandeur, patients may state that they are God or the President of the United States. C. Hallucinations often accompany delusions but are not the same as delusions. The hallucinations can affect any of the five senses but are most commonly auditory followed by visual. A. Patients with paranoid schizophrenia talk about hearing “voices.” PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 2. ANS: B A phobia is an irrational fear of an object or situation—it is not normal to fear leaving the house. A. C. D. The fear of poisonous snakes, failing a test when unprepared, and a child getting hurt when playing in the street are reasonable things to fear. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 3. ANS: D A behavior associated with PTSD is survivor guilt, which is the feeling of guilt expressed by those who have survived a tragedy. A survivor of an airline crash may say, “Why me? Why did I make it? I should have died too!” A. B. C. Survival guilt is not associated with bipolar depression, generalized anxiety, or obsessivecompulsive disorder. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 4. ANS: A According to the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V), symptoms of major depression include either a depressed mood or anhedonia which is the loss of pleasure in things that are usually pleasurable along with additional symptoms such as change in appetite and sleep patterns. B. Bipolar disorder is also characterized by periods of mania as well as depression. C. Conversion disorder involves the conversion of a mental health problem into physical symptoms. D. PTSD occurs after a major trauma. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 5. ANS: B Saying “Come with me. I’d like you to join our group for a while,” removes the patient from the situation and does not give him or her a choice. A is inappropriate. If the patient could cheer up, he or she would not be in the hospital. D. Asking what is the matter is also inappropriate—the patient does not likely know. C. Telling the patient he or she will not make any progress will cause feelings of guilt, which is not helpful. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 6. ANS: C

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Lithium is an antimanic medication with a very narrow therapeutic range so toxic drug levels can easily develop. Lithium levels must be drawn regularly to assess that serum levels are in the therapeutic range. C. Reporting of side effects is important, but nausea and weight gain are not life-threatening. A. The patient should not discontinue other antidepressants unless instructed to do so by the physician. B. Lithium will stabilize mood swings, and it is important to tell the patient this, but not as important as advising the patient to have regular levels checked to avoid toxicity. PTS: 1 DIF: Moderate KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application 7. ANS: B Comments by any older adult referring to hopelessness or desire to die must be explored to assess suicide risk. A. C. These comments may require further assessment however is not as hopeless sounding as the statements about having no reason to be alive. C. Looking forward to seeing a spouse in heaven someday is a positive comment. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 8. ANS: C Affect is the outward expression of mood—a patient who speaks in a monotone voice and has a dull expression has a flat affect. B. Depression is a medical diagnosis. A. D. Documenting boredom or ambivalent attitude is subjective and should be verified with additional assessment. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 9. ANS: D The nurse needs to validate that the patient’s comment was heard but then needs to bring the patient back to reality by saying that it is time for a meal. A. Putting water on it is inappropriate—there is no fire. B. Telling a mental health patient he or she is crazy is inappropriate. C. The nurse cannot use logic such as saying that the patient does not have any books. A patient with schizophrenia may be unable to see logic. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 10. ANS: D The nurse needs to validate the patient’s concern without exploring and focusing on the delusion. The patient needs to know what is real and what is not. B. Calling a cab and focusing on therapy does not validate the patient’s concern. C. Asking the patient about the voices encourages the patient to focus on the delusion. D. Asking about money might be appropriate for an older person with dementia, but a patient with schizophrenia needs to be brought back to reality. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 11. ANS: B Being able to work each day is not an observation associated with opioid addiction. A. C. D. The patient with an addiction gives up important social or professional functions to use the substance, has tried at least once to quit but still obsesses about the substance, spends significant time obtaining the substance, and is unable to fulfill major role obligations at work, school, or home. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis

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12. ANS: B According to the National Council of State Boards of Nursing, between 6 and 15 percent of nurses in the United States are chemically impaired. A. More than 5% of nurses are chemically impaired. C. D. The percentage of nurses who are chemically impaired is not above 15%. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 13. ANS: B The nurse should document the behavior and inform the supervisor. A. Doing nothing could lead to harm to the nurse’s patients. C. Telling the manager that the nurse is using drugs is making an assumption. D. Confronting the nurse is not the role of a coworker. It is the job of the manager to follow up and ensure that the nurse is safe to provide patient care. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 14. ANS: A Anticholinergic medications such as benztropine (Cogentin) or trihexyphenidyl (Artane) are used to combat the extrapyramidal side effects of the typical antipsychotics by helping return balance between dopamine, acetylcholine, and other neurotransmitters. B. D. Addition of rational emotive therapy or muscle relaxants will not affect the cause of the symptoms. C. Discontinuing the tranquilizers may help but may not be realistic if the patient needs them to control symptoms. PTS: 1 DIF: Moderate KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application 15. ANS: A A mental status examination is part of the assessment phase, though it may be done again during the evaluation phase to determine progress toward goals. B. C. An examination is not completed during the planning or implementation phases of the nursing process. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 16. ANS: C Prolixin can cause photosensitivity, so the patient should be cautioned about sun protection. D. It can cause hypotension, not hypertension. A. B. It is not associated with weight loss or hypoglycemia. PTS: 1 DIF: Moderate KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application 17. ANS: D Repeatedly checking the coffee pot is an example of a compulsion which is a part of obsessive compulsive disorder (OCD). A. B. C. Compulsions are not manifestations associated with GAD, phobias, or PTSD. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 18. ANS: D According to Maslow’s hierarchy, physiological symptoms must be attended to first. The patient’s blood pressure is at an unsafe level. A. B. Once the patient’s blood pressure is under control, then Ativan and relaxation may be helpful. C. Searching the room for alcohol is occasionally necessary, but a patient who has withdrawal symptoms is not likely using alcohol.

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PTS: 1 DIF: Moderate KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application 19. ANS: A Patients who are actively using drugs or alcohol when admitted to an inpatient setting, or who are cut off from their alcohol abruptly, can experience a condition called delirium tremens (DTs). In DTs, hyper-excitability can cause visual hallucinations, tremors, and possibly tonic-clonic seizures. B. These are not symptoms of cirrhosis. D. Patients with alcohol histories are at risk for cognitive changes, but not necessarily mental illness. C. If the patient were using alcohol in the hospital, he or she would not be experiencing DTs. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 20. ANS: D Psychopharmacology for trauma related disorders may involve benzodiazepines which are antianxiety medications. Alprazolam (Xanax) is commonly used and is effective in most cases. Benzodiazepines are used for short-term treatment because of the strong potential for chemical dependency. A. B. C. Individuals who need longer term therapy for anxiety or who have chemical dependency tendencies may be treated with buspirone (Buspar), selective serotonin reuptake inhibitors (SSRIs) paroxetine (Paxil) or sertraline (Zoloft). PTS: 1 DIF: Moderate KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application 21. ANS: A A study was done that looked at the effect of nature based sounds to reduce agitation, anxiety level and physiological signs of stress in patients. The experimental group had significantly lower systolic blood pressure, diastolic blood pressure, anxiety and agitation levels than the control group. The use of music or nature based sounds incorporated into nursing care may help reduce anxiety. B. Selecting a program televising a sporting event might be too stressful for the patient. C. Closing the door to the treatment room might cause the patient to feel abandoned. D. Reminding the patient that anxiety is not going to make the treatment effective is threatening and is a negative statement. The patient should be counseled in positive self-talk. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 22. ANS: B Many people take St. John’s wort, an OTC herbal supplement, for depression. Although it may be effective for some people with mild depression, it can interact with many prescribed medications that influence serotonin levels. If combined with prescription serotonin-type antidepressants, it can cause serotonin syndrome, an excess of serotonin resulting in agitation, confusion, diarrhea, muscle spasms, and even death. A. This medication does not need to be taken with fruit juice. C. This medication should not be abruptly stopped. D. This medication can cause systolic hypertension. PTS: 1 DIF: Moderate KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application MULTIPLE RESPONSE 23. ANS: B, E

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When a patient taking a monoamine oxidase inhibitor (MAOI) consumes foods high in tyramine, the drug prevents the normal breakdown of tyramine, leading to excessive epinephrine levels. Hypertension can occur which can be severe enough to cause intracranial hemorrhage. Foods to be avoided include wine and aged cheese. A. C. D. Breads, pastas, and fish do not need to be restricted because of tyramine content. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 24. ANS: A, B, E, F Phobias are the most common of the anxiety disorders. Additional disorders are panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. D. Depression is a mood disorder. C. Schizophrenia is a brain disorder that is a group of illnesses, not one of the anxiety disorders. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 25. ANS: C, D, F Positive symptoms of schizophrenia can be thought of as those symptoms that reflect an “excess” or distortion of normal functioning. Positive symptoms include hallucinations, delusions, disorganized thinking, and disorganized behavior. A. B. E. Negative symptoms include affective blunting or flattening, alogia, avolition, apathy, anhedonia, and social isolation. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 26. ANS: C, F Teach patient who is taking a selective serotonin reuptake inhibitor (SSRI) that it will take 6 to 8 weeks for therapeutic effects to occur, and possibly longer with Prozac. Possible side effects include excitation, nausea and vomiting, decreased libido, anorexia, and weight loss. B. SSRIs should be administered before 3 p.m. to prevent excitation from affecting sleep. A. They are taken daily. D. Aged foods are avoided with monoamine oxidase inhibitors (MAOIs), not SSRIs. PTS: 1 DIF: Moderate KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application 27. ANS: B, E Anxiety, as explained by biological theory, is associated with increased epinephrine and norepinephrine, and decreased GABA. A. C. Increased substance P is associated with depression, and increased somatostatin is associated with Huntington’s disease. D. Anxiety is associated with increased and not decreased norepinephrine. PTS: 1 DIF: Moderate KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application 28. ANS: A, C Tyramine-free diet is required for patients taking monoamine oxidase inhibitor (MAOI) antidepressants including phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan). B. D. E. A tyraminefree diet is not required for patients taking buspirone (Buspar), valproic acid (Depakote), or lithium carbonate (Eskalith). PTS: 1 DIF: Moderate KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application 29. ANS: A, C, E

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Panic is a state of extreme fear that cannot be controlled; it may be referred to as a panic attack. Panic episodes are recurrent and occur unpredictably. Patients may present themselves at the emergency room because they believe they are having a heart attack or other significant physical illness. Patients must exhibit several episodes within a specified time frame to be given the diagnosis of panic disorder. Additional symptoms associated with panic disorder include dissociation and shaking. B. D. Neck pain and vomiting brown emesis are not manifestations of a panic disorder. PTS: 1 DIF: Moderate KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application 30. ANS: A, B, E The brains of patients with a diagnosis of schizophrenia show a significant loss of gray matter, enlarged ventricles, and diminished prefrontal cortex functioning. C. Nerve de-myelinization would not be visible through a CT scan or electroencephalogram. D. Aneurysms are not a normal finding in the patient with schizophrenia and would be considered an emergency. PTS: 1 DIF: Moderate KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application 31. ANS: A, B, C Nursing care for the patient with extreme anxiety includes maintaining a calm environment, encouraging verbalization of feelings, and encouraging positive self-talk. D. Activities should be encouraged however the patient should not be placed in a competitive situation since it can produce anxiety. E. The nurse should stay with the patient during an acute anxiety event because feeling abandoned can increase anxiety. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

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